Nikol Kvasnickova

Four years ago, thirty years old Patricia Melo had a car accident that left her with agonizing back pain preventing her from walking upright and finally putting her in a wheelchair. Doctors told her she was not eligible for a surgery and treated her pain with morphine. She had to quit her job and felt hopeless about her situation, until a friend recommended a treatment in India, which she decided to pay for out of her own pocket. Melo's surgery went well and she was slowly recovering under the supervision of her Indian doctor (Prashad). Canadian Business featured Melo's story in September 2009 as an example of medical tourism, a phenomenon that has been on a steady rise in the past decade.

Hundreds of thousands of patients have been travelling mostly to developing and newly industrialized countries in a search for affordable treatments. This trend can be attributed to the fact that a growing number of Western countries, including Canada and the United States, are facing serious problems regarding their health care systems, above all endless waiting lines. Unfortunately, not all patients have been as lucky as Patricia Melo. In November 2010, The Gazette reported on a death of an MS patient from Ontario, who died after travelling to Costa Rica for an experimental surgery that has not been approved in Canada (Fitzpatrick). Canadian Federal Health Minister then discouraged patients from following the man's example (ibid).

 This patient's case illustrates that medical tourism is still a problematic issue when it comes to legal or financial issues. The fact that patients are not satisfied with the health care they are getting for their money is today's reality and governments should realize that medical tourism is a direct consequence. Although medical tourism is not entirely risk-free, with the help of protective measures such as accreditation of foreign medical facilities, effective legal framework safeguarding patients' rights and government reimbursement plans, it can help reduce the strain on current health care systems.

History

Medical tourism might seem like a new idea due to the media attention it has been receiving lately, but a closer look reveals that the roots of medical tourism go back to Ancient Greece. Ben-Natan et al. write that "[t]he first recorded case of medical tourism describes Greek pilgrims who traveled from the Mediterranean Sea to Epidaurus ... [to meet] the healing God" (8). The authors further mention 15th century India with its yoga masters and 18th and 19th century Europe with its spas as medical travel destinations (ibid). Modern medical tourism as we know it today dates back to the 1980's (qtd. in Ben-Natan, Ben-Sefer and Ehrenfeld 8).

Meanwhile, medical tourism is booming in all corners of the planet. An estimated number of 150,000 foreigners underwent treatments in India in 2004, another 400,000 were treated in Malaysia in 2005 and the numbers have been increasing, generating considerable revenues in the countries of destination (qtd. in Cohen 1472).

Reasons for Medical Tourism, Types of Procedures and Principal Destinations

Medical tourism, also called medical travel or health tourism "denotes ... typically elective procedures driven by patients being more able ... to travel to overseas destinations for specialised surgical treatments and other forms of medical care" (Lunt, Hardey and Mannion 1). Among the principal reasons why patients seek treatment abroad are dissatisfaction with existing care, long waiting times, cost and unavailability of certain procedures.

The vast majority of medical tourists are Americans - 750,000 of them traveled in 2007 and since then, this number has multiplied (Pickert). Patients most often travel for plastic surgery, orthopaedic and cardiac procedures and dental or eye surgeries; particular cases include stem cell, transplant and reproductive tourism. Bookman and Bookman add detox tourism for Islamic patients with alcohol problems and suicide tourism to countries where euthanasia has been legalized to the list of treatments (42).

Medical tourism is practiced all over the world. Several Asian countries receive the majority of patients travelling for heart or orthopaedic surgery. The most important country that is becoming prominent in providing cardiac surgeries and hip replacements is India (Bookman and Bookman 59). Other countries from this region include Thailand, Malaysia and Singapore. Central and South America are equally popular, with Mexico, Costa Rica and Brazil, thanks to its proximity to the United States, and Argentina as a destination for fertility treatments, being on the top of the list (Keckley et al. 6; Smith). In Europe, Hungary stands out as a country where many Europeans seek dental treatments.

The European Union Case

European countries are a particular case in the context of the European Union. Patients from the older member states often visit former Eastern European countries that have joined the EU in 2004 and where health care is usually much cheaper. To illustrate this, German patients only have to travel a short distance across the border to reach the Czech Republic or Poland and obtain a treatment, which is then reimbursed in their home country. This practice is possible thanks to the directive accepted in June 2010 by the Council of the European Union. The directive specifies, among other things, the accessibility of health care in other EU member states:

[A]s a general rule, patients will be allowed to receive healthcare in another member state and be reimbursed up to the level of reimbursement applicable for the same or similar treatment in their national health system if the patients are entitled to this treatment in their country of affiliation... [M]ember states may manage the outgoing flows of patients also by asking a prior authorisation for certain healthcare... (Council of the European Union 1)

The directive is yet to be approved by the European Parliament. Even though these rules have clearly better chances to function in a community like the European Union, we could imagine a system in place facilitating medical tourism worldwide, inspired by these principles.

Marketing Medical Tourism

Various resources are available to health tourists. The Medical Tourism Association is a non-profit organisation promoting medical tourism and providing information for patients. The association organizes conferences and publishes Medical Tourism Magazine that focuses on the different issues such as legal matters, information for insurance companies, etc. Patients can also use the service of several travel agencies specializing in organizing medical tours and consult a number of websites, such as medicaltourism.com.

Risks of Medical Tourism

Medical procedures, whether they are performed in one's home country or abroad, always involve certain risks. It is true that travelling thousands of kilometres poses additional potential problems; however, these do not necessarily have to present an insurmountable obstacle. Among the risks associated with medical tourism are patient's health complications, ethical and legal concerns and questions related to financing.

Many are worried about the standards of medical facilities in developing countries and the dangers that insufficient health care quality or poor sanitation could bring about. Potential risks include post-operation complications or infections that could be brought back to one's home country. These are certainly valid concerns, addressed by such organizations as the Joint Commission International (JCI). JCI is an American non-profit organization that provides accreditation to medical facilities in the United States and abroad. Similar institutions exist in Canada, United Kingdom and Australia. By choosing a facility that has been certified by one of the above mentioned organizations, patients significantly reduce the risk of being affected by a treatment of poor quality in the destination country.

Medical tourism could also create certain ethical concerns. Queue jumping is usually mentioned as a big challenge. While we would all agree that it is unethical to try to push one's way to the top of a waiting list, we are now in a situation where some doctors in Montreal are receiving bribes from patients to jump the queue, as was reported in The Gazette (Fidelman). Montreal is hardly the only place where envelopes full of money are being offered to doctors by desperate patients who have been waiting for months for their treatments. We could imagine an institution parallel to JCI whose role would be to set standards for patients' rights and oversee that these are upheld. Governments of developed countries should also make an effort and cooperate with the JCI-like organizations to establish legal framework and so preventing cases of queue jumping and other unethical behaviour.

Government involvement is also crucial to resolve controversies about who is going to pay for medical procedures performed abroad. There are cases where patients successfully claimed cost reimbursements in their home country, but this is not yet the rule. Including out-of-country treatments in medical insurance plans would eliminate most of the financial difficulties.

Many commentators focus on the risks associated with medical tourism, but few of them acknowledge the potential it has and the possibilities for heath care improvement it offers.

Benefits of Medical Tourism

Both developed and developing countries could benefit greatly from medical tourism. Better access to health care, affordability and positive effects on job situation in destination countries are some of the possible benefits. Medical tourism could be an important aspect in improving health care and increasing patients' satisfaction. By having certain procedures performed abroad, we would see the waiting lists shrinking and doctors having more time for patients, which would lead to their greater satisfaction.

            Furthermore, we know that a major factor in deciding to undergo a medical treatment abroad is its affordability. Since medical costs are so much lower in developing countries, governments would save large amounts of money by promoting and encouraging medical tourism. The National Center for Policy Analysis estimates the US insurers' costs of a heart bypass at $94,277, while the same operation in India costs $10,000 and is available in Thailand for $20,000 (qtd. in Cohen 1473). This means that nine operations in India could be performed for the price of one operation in the United States. Even after adding the cost of plane tickets and fees related to travelling, health care budgets would still profit from sending patients abroad for treatments.

Just as medical tourism would economize government resources of developed countries, it would bring revenues and boost the economies of destination countries, creating thousands of jobs for qualified medical staff, as well as work opportunities in the hospitality and tourism sectors. These would be important incentives for foreign economies that would be felt by larger population, as demand for workers providing infrastructure needed for the industries would increase.

When we consider all the different aspects of medical tourism, it is evident that despite some uncertainties, medical travel offers numerous advantages. As quoted by Crooks et al., "...if the industry is properly regulated, medical tourism can provide a viable means by which developing countries can gain access to needed revenue and developed countries can lessen 'bottlenecks' in their health systems" (2). Medical tourism could thus be one of the solutions for existing health care problems, although certainly not an easy one. It is a complex issue that requires time for implementing all the necessary measures to make it functional. Nevertheless, governments should direct their attention to the phenomenon of medical tourism and try to incorporate out-of-country health care into their nationwide policies in an effort to improve their citizens' access to dynamic health care.

Works Cited

Ben-Natan, Merav, Ellen Ben-Sefer, and Malka Ehrenfeld. "Medical Tourism: A New Role for Nursing?" Online Journal of Issues in Nursing 14.3 (2009): 8. Academic Search Complete. EBSCO. Web. 25 Nov. 2010.

Bookman, Milica Zarkovic, and Karla R. Bookman. Medical Tourism in Developing Countries. New York, NY: Palgrave Macmillan, 2007. Print.

Cohen, I. Glenn. "Protecting Patients with Passports: Medical Tourism and the Patient-Protective Argument." Iowa Law Review 95.5 (2010): 1467-1567. Academic Search Complete. EBSCO. Web. 2 Dec. 2010.

Council of the European Union. "Council Agrees on New Rules for Patients' Rights in Cross-Border Healthcare." Council of the European Union. 8 Jun. 2010. Web. 2 Dec. 2010.

Crooks, Valorie A., et al. "What Is Known About the Patient's Experience of Medical Tourism? A Scoping Review." BMC Health Services Research 10.(2010): 266-277. Academic Search Complete. EBSCO. Web. 30 Nov. 2010.

Fidelman, Charlie. "College of Physicians to Probe Bribery Report." The Gazette. 30 Nov. 2010. First Ed.: A12. Print.

Fitzpatrick, Meagan. "MS Patients Should Not Go Abroad: Minister." The Gazette. 20 Nov. 2010. First Ed.: A18. Print.

Keckley, Paul H., et al. "Medical Tourism: Consumers in Search of Value." Deloitte Center for Health Solutions. 2008. Web. 2 Dec. 2010.

Lunt, Neil, Mariann Hardey, and Russell Mannion. "Nip, Tuck and Click: Medical Tourism and the Emergence of Web-Based Health Information." Open Medical Informatics Journal 4.(2010): 1-11. Academic Search Complete. EBSCO. Web. 25 Nov. 2010.

Pickert, Kate. "A Brief History of Medical Tourism." Time. 25 Nov. 2008. Web. 2 Dec. 2010.

Prashad, Sharda. "Medical Tourism: The World Is Your Hospital." Canadian Business. 11 Aug. 2008. Web. 25 Nov. 2010.

Smith, Elise, et al. "Reproductive Tourism in Argentina: Clinic Accreditation and Its Implications for Consumers, Health Professionals and Policy Makers." Developing World Bioethics 10.2 (2010): 59-69. Academic Search Complete. EBSCO. Web. 2 Dec. 2010.