The term "medical tourism" seems to be cropping up everywhere these days. From trade and business journals to the popular press, traveling to another country specifically to obtain medical care is a significant new trend. In this challenging economy, where the cost of healthcare continues to spiral up and hundreds of thousands have lost their health insurance along with their jobs, it's not surprising to see keen interest in less expensive resources, especially because the savings are often substantial. Today a $250,000 heart surgery in the United States costs approximately US$15,000 in India, including airfare and accommodations. As a result, a number of major U.S. insurance agencies and provider companies are offering coverage for a range of medical procedures performed internationally. It is easy to imagine how this could lay the foundation for a growing treatment alternative and possibly, depending on variables such as the future of Medicare and the concept of universal coverage, a sea change in the U.S. healthcare industry. But important factors such as hospital reporting, medical residency requirements, the use of evidence-based medical guidelines, and even pharmaceutical nomenclature vary worldwide, and so a critical component remains unsolved: how to standardize the way patients, providers, and payers assess and manage the risks associated with this new medical frontier.

Americans go abroad

In 2007, an estimated 750,000 Americans travelled abroad to receive medical treatment.¹ While these "medical holidays" traditionally have conjured images of the well-to-do pairing vacations with tummy tucks, financial necessity is a growing force behind the trend. An estimated 47 million Americans lack health insurance, and millions more are underinsured or face deductibles too high to manage. While the costs at home have grown increasingly out of reach for many, a burgeoning, highly competitive medical industry serving foreigners has been taking root worldwide. This summer, the Boston Globe followed a "tourist of the medical variety" through his healthcare experience in Thailand,² where hundreds of thousands of visitors make similar trips each year. The Chicago Tribune explored a son's decision to "outsource" his parents' assisted living care to India,³ where they receive daily massages and 24-hour nursing care. These countries, and others such as Argentina, Hungary, Mexico, Singapore, and South Africa, have built medical centers that cater to "medical tourists," many employing advanced technologies and U.S.-trained physicians. As a result, obtaining both elective and necessary treatment abroad is becoming increasingly appealing.

Particularly in light of the seriousness of some surgeries and procedures being sought abroad, the term "medical tourism" seems a misnomer. A better term is "cross-border care," because it encompasses both the phenomena of traveling to an out-of-country destination to receive medical treatment as well as traveling to in-country locations for specialized care. This, too, is a growing trend. A recent study found that 88% of respondents would consider going out of their community or local areas to get care or treatment for a condition if they knew the outcomes were better and the costs were no higher there.⁴

While Americans have been willing for some time to travel within the United States to seek care from medical experts, and a growing number of individuals cross U.S. borders to the north and south to buy less expensive drugs and services, the number who would now travel for treatment is substantial. What also is new is the distance many are willing to travel. As Americans become more active healthcare consumers, and as information about treatment options and resources becomes increasingly available via the Internet, attitudes about travel and healthcare seem to be shifting. Today almost 39% of respondents to a recent survey said they would go abroad for an elective procedure if they could save half the cost and be assured that the quality was comparable.⁵

In addition to the shift in consumer attitudes and the increasing range of healthcare resources, there is the growing necessity for many to find affordable options. A few years ago, the U.S. Senate Special Committee on Aging investigated medical outsourcing as a means of responding to the rapidly rising costs of care in the U.S. system. The current economic situation has only served to exacerbate the challenge many Americans face in affording medical care and may escalate the burgeoning trend of seeking care abroad. With the considerable number of job layoffs around the country, the percentage of the population that is un- or underinsured is growing even more rapidly.

Many of the recently unemployed qualify for COBRA, but a significant percentage struggle to pay the premiums and often lose their coverage. In fact, the Commonwealth Fund reports that under COBRA, unemployed workers would have to pay four to six times their current contribution. It reports that, because of the high premiums, only 9% of unemployed workers have COBRA coverage.⁶

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At the same time, economic pressure is causing more businesses to take a hard look at their rising healthcare-benefits costs. Even individuals with employer-sponsored healthcare coverage are finding themselves facing significantly rising costs through higher copayments and/or deductibles. Many employers are offering high-deductible health plans with a health savings account, and the trend is expected to grow. The increasing financial stresses on premiums in the United States stand in stark contrast to the lower medical costs in countries like India, Thailand, and Singapore, where an individual can pay as little as 10% of the cost for the same treatment in the United States. As plan deductibles and copayments increase and more and more Americans lose their coverage entirely, the appeal of purchasing lower-cost healthcare services abroad will grow.

The business of healthcare outsourcing

In response to this market demand, insurance agencies and provider companies have begun covering the outsourcing of medical treatment in out-of-country facilities, and it is an expanding business. This year, the nation's second-biggest health insurer, Indianapolis-based WellPoint, included an outsourcing benefit for employees of Wisconsin-based Serigraph Inc. The target country for care is India, and employees will have the option of receiving certain nonemergency care there. Serigraph will waive the deductibles and coinsurance, as well as pay all medical costs and travel for the patient and a companion.⁷

A few major insurance providers offer low-cost policies that encourage members to seek care abroad. Blue Shield and Health Net of California encourage members to seek care in Mexico, while United Group Programs, a Florida third-party administrator, offers a program that refers patients to Bumrungrad Hospital in Thailand as a preferred provider.

Blue Cross of South Carolina has created an international arm, Companion Healthcare,⁸ which manages health and dental care provided outside of the United States. Aetna now manages a self-insured group of 27,000 members that introduced a medical-tourism benefit for hip and knee surgery for U.S. employees who want an option to reduce the $3,000 deductible on elective surgery.⁹

In addition to insurance companies' covering lower-cost options abroad, at least one U.S. business, Blue Ridge Paper Products in North Carolina, is offering employees incentives to obtain major medical care overseas, providing up to $10,000 for undergoing expensive U.S. procedures in select hospitals in India.

Even closer to home, Aetna has a program for small businesses that provides for immigrant workers to receive all of their care—not just selected procedures—in "network" hospitals in Mexico, through Vitalidad México con Aetna. This option lets individuals seek care in venues and within a culture they understand, presumably for a commensurate premium point.

But covering outsourced healthcare opens the door to a number of administrative and liability issues. There currently are no standard insurance codes or quality measurements across country lines. What if complications arise when the patient returns home? Is the procedure covered if non-FDA-approved materials or drugs were used? Most important, who is responsible if something goes wrong? Some insurers are outsourcing international claims to third-party administrators or travel claims companies outside the United States, but because these are new practices, it is unclear whether they have the infrastructure and focus to assess and manage these types of cases in the way the U.S. market expects. With no governing or legislative body overseeing international healthcare, how will malpractice or challenged claims be handled?

U.S. hospitals abroad

Major U.S. hospital associations have not overlooked the trend toward cross-border care, and many are expanding their presence internationally. Hospital Corporation of America (HCA)in Tennessee is poised to purchase hospitals in China.¹⁰ Johns Hopkins has acquired facilities globally and established affiliate relationships with hospitals in more than 30 countries. A who's-who list of other top-tier U.S. hospitals is making the move abroad, including Duke, Harvard, the Mayo Clinic, Memorial Sloan-Kettering, Cleveland Clinic, University of Texas, and University of Pittsburgh.

But because a facility bears affiliation with a well-respected name, does that ensure the same caliber of care? How can patients and families decipher the relationship between the familiar U.S. respected-name hospital and its overseas presence?

There are essentially three ways an AMC institution or a U.S. hospital does business abroad:

• Ownership—The U.S. hospital actively operates and manages the international hospital.
• Affiliation—The U.S. hospital affiliates for care delivery with the international hospital.
• Relationship—The U.S. hospital consults to support running the international hospital.

There is a broad range of differences in these business arrangements, such as whether they include in-country physician-training programs, U.S.–domestic physician rotations, and medical director assignments. Some relationships require strict onsite examination of services such as water-source purity, sanitation, sewage, laboratories, and food preparation; others do not, providing only question-and-answer checklists without direct inspection. Because it is difficult for patients, payers, and referral agencies to differentiate the kind of relationship existent between a U.S. facility and its out-of-country collaborator, quality and risk assessments are currently challenging.

Setting international standards

In response to the rise in international medicine, a number of regulatory agencies have begun establishing standards for care. Most notably, the Joint Commission International (JCI) has accredited more than 100 facilities in 34 countries, ranging from Austria and Bangladesh to Turkey and the United Arab Emirates.¹¹ Australia and Canada are extending their accreditation programs into the international arena. The Australian Council on Healthcare Standards (ACHS) focuses on four major topics: safe management of blood, infection control, falls prevention, and continuity of care among healthcare providers.¹²  The Canadian Council on Health Services Accreditation (CCHSA) promotes quality by providing education to medical staff to build Western-style capacity, working with 30 clients in four geographical areas: the Caribbean, Latin America, Europe, and the Middle East combined with North Africa.¹³

As the international medical market expands, so do the number of accreditation groups. Beyond the United States, Australia, and Canada, there are accrediting groups from numerous countries, the standards and judgment criteria of which are less known or even unknown to the U.S. healthcare market. How is a patient or provider to determine the differences in standards among hospitals that are accredited through one of these groups? How will the level of care measure up to a hospital accredited through the JCI?

As consumers and medical professionals seek to ascertain quality and standards in the fast-emerging international marketplace, the guideposts are not always clear. For instance, another regulatory body, the Center for Healthcare Planning and Quality (CPQ), states its mission as "ensuring outstanding world-class service provision."¹⁴ However, the CPQ is located in Dubai's Healthcare City, so it appears that CPQ is regulating standards within its own medical facility.

While gains are being made in establishing international standards, the question remains: Who is assessing the accrediting agencies for independence, accountability, and transparency?

Travel agents as medical facilitators

To navigate the labyrinth of outsourced healthcare, many patients now depend on "medical facilitators." They serve a host of roles, including acting as facilitators between patients and foreign physicians and hospitals, scheduling surgeries, buying airline tickets, reserving hotel rooms, and even planning sightseeing tours for recovering patients. Medical facilitators are introduced through several sources—travel agencies, trip planners, hotel chains, and international-minded doctors' offices. In response to the need for direct liaison with patients traveling abroad, business is booming in this field. But there is no regulatory body that qualifies medical facilitators in their capacity to help plan medical care. The International Medical Tourism Journal reports that "hospitality stakeholders" in at least one country—the Philippines—are seeking to have medical-travel facilitators reclassified as professionals so they can make referrals to physicians directly.¹⁵ Another large network, the Medical Tourism Association (MTA), which identifies itself as a nonprofit group of hospitals, insurers, and tourist groups interested in expanding the role of medical tourism, has introduced a facilitator certification program. It certifies participants to coordinate patient care for individuals who travel from one country to another for healthcare purposes.¹⁶ Applicants are not required to have any clinical background. However, they are required to provide biannual payments of $2,500 to the MTA and to refer patients to the facilities and partners in the MTA network. This means that their customers are being asked to trust MTA facilitators, who are marketed as certified to coordinate the "patient journey" but have no clinical training, and who will refer them to MTA-certified facilities, which have no known certification standards.

Across the board, there are no licensing requirements for medical travel or tourism agencies, either in the United States or overseas, which is likely part of the appeal of this rapidly growing piece of the international healthcare industry. A Business 2.0 article reported on MedRetreat, based in Odenton, Md., noting that its customers' average length of stay in hospitals abroad is 17 days and that the company makes most of its money through commissions for booking hotel rooms and by pocketing the 20% discount on treatment costs that its partner hospitals grant in exchange for referrals.¹⁷

The need for informed, unbiased advocacy

An estimated six million Americans will be traveling abroad to receive care by 2010,¹⁸ which makes the need for transborder healthcare monitoring a growing priority. International case managers (ICM) and knowledgeable patient advocates could help provide more comprehensive, unbiased information about current conditions and practices, as well as facilitate care appropriate to individual patients' needs.

Not all health economies are equal, and expertise must be developed in the quality and risk factors associated with care on a regional and countrywide basis. These include determining standards for drugs and medical technology, as well as the quality of practitioner education. What if a given culture does not promote collaboration? Is that a skill set that hospitals can "turn on" to meet the needs of different clients? How can political instability in a region be weighed as a potential risk factor in patient care? And what about ethical concerns? What role should human rights issues play in the selection of an international care facility?

Critical components of any risk analysis should include an assessment of an individual's medical history and known complications that could arise. For example, if an individual seeks medical care in a country affected by dengue, malaria, or foodborne illnesses; has evidence of counterfeit medication; or learns that high levels of corruption exist—what impact could any of that have on the care pathway? And how might the patient advocate proactively plan for problems if they arise?

These risks can be assessed in broad strokes, but qualified advocates have the ability to work "on the ground" on behalf of individual patients to secure culture-sensitive connections, promote clear communications, and determine the reliability of services. ICM practitioners possess the ability and skill to reach first, beyond the periodic, system-level accreditation reviews and business-brand affiliations and second, through the curtain of in-country customs, in order to provide critical assessments of quality and risks. They and qualified advocates would have the ability to respond to patients' day-to-day, real-world concerns.

Evaluating care at the facility level

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Standards set by the JCI serve as a valuable road map to ICMs, patient advocates, and anyone interested in evaluating standards of care at the facility level. They include care pathways that dovetail well with the Milliman Care Guidelines®, which deliver internationally recognized evidence-based best medical practices at the bedside.

The JCI standards¹⁹ focus on two areas: patient-centered standards and healthcare-organization-management standards. The use of clinical pathways or evidence-based medical protocols map out as follows:

The Milliman Care Guidelines offer practitioners, patients, payers, and patient advocates a common language for evaluating standards of care. By providing clinical-treatment pathways based on scientifically researched evidence, the Guidelines help ensure continuity of care and provide important education and discharge-planning information, whatever the setting. They also deliver tools for measuring outcome variances and can help facilitate collaboration among practitioners to understand and determine treatment courses. 

The use of evidence-based protocols serves as a real-time quality gauge. Used correctly, these protocols ensure that the hospital is aware of international evidence of best practices, is working to apply them, and will communicate with the patient, insurer, or third-party administrator when it deviates from that course. Delivery of quality care through clearly defined pathways, assessed by unbiased international monitors, provides the best opportunity to set accountable standards in cross-border care.

Potential impacts to the U.S. market

Today the most common procedures Americans seek abroad are dental, cosmetic, orthopedic, and cardiovascular.²⁰ There is every indication that the trend toward cross-border care will grow substantially. What does this mean to U.S. hospitals and practitioners, who earn significant margins from these types of cases? At what point will it affect the bottom line? Can U.S. hospitals compete with the international market when the cost of care and labor is significantly higher in the United States than abroad? Could this change the landscape of medical delivery?

While this article has focused on the potential risks associated with international care, it also should be noted that many international hospitals deliver exceptionally high-quality care and customer-focused service. Quality varies dramatically in U.S. hospitals, and evidence-based best medical practices are not delivered with consistency. By comparison, Singapore medical facilities today reportedly are providing outcome data that sets new international standards in measurements and accountability. As a U.S. benefits director noted in hearings held by the U.S. Senate Special Committee on Aging, "We do not get commensurate value for our healthcare dollar, are not seen as customers, must pay for medical errors and hospital acquired infections, and are patronized by being constantly told by healthcare leaders that American healthcare is the best in the world."²¹

To compete effectively, a possible scenario is that U.S. hospitals will capitalize on the growing willingness among healthcare consumers to travel to receive cost-effective, high-quality care by establishing themselves as hubs for practice specialties. Less expensive rural areas within the United States may become hotbeds of state-of-the-art medical facilities that cater to cardiac or orthopedic patients. With the potential for public policy shifts and a focus on healthcare reform, combined with increasing market pressures, it is unlikely that the U.S. medical model will remain unaffected by international competition.

Minimizing risk

While the future of cross-border healthcare is an unknown, it is clear that there is great opportunity for capturing more accurate information and working to develop a standardized approach to identify the risks and benefits of receiving care abroad. Because there currently is no oversight of cross-border care, it is vital that patients, providers, and payers have access to unbiased information with which to measure risk, assess quality, and inform better decisions.

Lisa Beichl is an international health specialist with Milliman Care Guidelines. She has worked for healthcare organizations in Germany, Nigeria, Switzerland, and the United States. Her main focus at the Care Guidelines is on methodology design and the development of strategies for U.S. medical guideline introduction in international markets.

1 Medical tourism: Consumers in search of value, Deloitte Center for Health Solutions, 2008.

2 Conway, Alicia B., "Medical tourism," Boston Globe, July 2, 2008.

3 Goering, Laurie, "Made in India: Low-cost care for ailing parents. American facing unpleasant alternatives finds novel solution with outsourcing," Chicago Tribune, July 29, 2007.

4 Medical Tourism: Consumers in search of value, Deloitte Center for Health Solutions, 2008.

5 Ibid.

6 Doty, M. M., Rustgi, S. D., Schoen, C., and Collins, S. R., Maintaining health insurance
during a recession: Likely COBRA eligibility, The commonwealth fund, January 2009.

7 "WellPoint soon will offer some medical travel benefits," StarTribune.com, November 20, 2008.

8 www.companionglobalhealthcare.com/.

9 McGinley, Laurie, "Health matters: The next wave of medical tourists might include you," Wall Street Journal, February 16, 2008.

10 "First family looks to China for new hospital venture," July 28, 2008, www.tennessean.com (accessed August 6, 2008).

11 www.jointcommissioninternational.org/ (accessed August 6, 2008).

12 "International Expansion," The International Medical Travel Journal, Issue 04 2006.

13 Interview with Wendy Nicklin, President and CEO of the Canadian Council on Health Services Accreditation; The International Medical Travel Journal, Issue 04 2008.

14 International Medical Travel Journal, Issue 04 2008; full-page advertisement for "Dubai Healthcare City."

15 "The Philippines: Makati promotes," International Medical Travel Journal, Issue 04 2008.

16 www.medicaltourismassociation.com/certification.html (accessed January 2, 2009).

17 Crawford, K., "An Rx for Clever Start-ups: Taking Operations Overseas," Business 2.0, August 2006.

18 Medical Tourism: Consumers in search of value, Deloitte Center for Health Solutions, 2008.

19 Joint Commission International 3rd Edition, 2008. 20 Medical Tourism: Consumers in search of value, Deloitte Center for Health Solutions, 2008.

20 Medical Tourism: Consumers in search of value, Deloitte Center for Health
Solutions, 2008.

21 "The Globalization of Health Care: Can medical tourism reduce health care costs?"
U.S. Senate Special Committee on Aging hearings, June 27, 2006