What is Medical Tourism?

Medical tourism is the practice of traveling across international borders to access healthcare systems or physician services that are not available or less attractive in a person’s native country. Although medical tourism is not a new concept, high health care cost, long wait times, availability of relatively inexpensive worldwide travel, and increasing number of countries catering to medical tourism have led to an increase in this practice throughout the last decade. Today, facilities catering to medical tourism may involve either locally trained staff and physicians or sometimes may involve physicians trained and employed in the U.S. who travel to these facilities part time to participate in the care of patients. These facilities offer surgical procedures at costs that are 40 – 80 percent less than the cost in the U.S.

While the term medical tourism is most often used to describe travel across international borders to obtain medical care as part of a pre-arranged package, this term does not fully or accurately describe all of the issues or concerns related to bariatric surgery. The ASMBS has therefore adopted the term “global bariatric healthcare” to encompass all of the scenarios in which patients travel long distances for bariatric surgery (including medical tourism packages).

Global bariatric healthcare is defined as travel to undergo bariatric surgery across any distance that precludes routine follow-up and continuity of care with the surgeon or program. No specific type of border or distance of travel can universally apply as regional differences in surgeon availability and expertise vary greatly throughout the world. While this practice commonly involves travel across international borders, travel across long distances within a country, region, or state involves the same risks and challenges for continuity of care as does long distance travel to another country and these situations should also be included in this concept of global bariatric healthcare or medical tourism.

In addition to increased interest in medical travel among insurance companies, many corporations and other payers are taking advantage of this growing market by offering global health care coverage and providing incentives for patients to seek less expensive health care in other countries. Some U.S. employers have “outsourced” medical travel programs as a way to cut the cost of health care. This typically involves a relationship with certain medical facilities abroad that are approved to provide services by the insurance carrier of the employer. Incentives such as paying for airfare, for example, may be used to encourage employees to seek out medical tourism opportunities. In the U.S., three-quarters of a million people received health care abroad in 2007. More recent figures report an exponential rise in the number of people seeking health care in other countries.1

How is Quality Monitored for Bariatric Surgery in Other Countries?

There are many countries around the world that participate in medical tourism; however, accreditation and other measures of quality control vary widely depending on the country in which the services are being provided. There is no worldwide standard of care, and therefore, there is no way of ensuring that the same safeguards are in place that we are accustomed to in the U.S. Certain countries may offer unproven therapies to patients outside true clinical trials, and it can be difficult to differentiate between acceptable medical innovation and unacceptable patient exploitation.3-4  Additionally, the equivalent of the Food and Drug Administration (FDA) either does not exist or is not as stringent in most of the countries that serve as major medical tourism sites for bariatric surgery; therefore, even the medical supplies that are used may not be as closely regulated.

Several organizations including The Joint Commission International (JCI), Trent International Accreditation Scheme (U.K.), the International Society for Quality in Healthcare, the International Organization for Standardization (ISO) and the International Bariatric Surgical Review Committee (IBSRC) have responded to the growth in medical travel by establishing accreditation procedures for international medical facilities. In the last five years, the number of JCI accredited public and private hospitals around the world has increased by nearly 1,000 percent. Currently, more than 250 facilities in 36 countries are accredited by the JCI, up from 27 hospitals in 2004. Establishing this high standard of accreditation instills a higher level of confidence in citizens seeking affordable health care alternatives abroad and many foreign hospitals seek this type of accreditation to attract American patients to their facility. Despite these attempts at standardization, though, there are often regional or local variations in accreditation standards, based on cultural, societal or religious differences.

The Medical Tourism Association is an international non-profit organization comprised of international hospitals, insurance companies and affiliates with a common goal of promoting the highest level of quality healthcare to patients in the global environments. They are devoted to transparency in quality and pricing, communication and education.2

What are the Risks of Having Bariatric Surgery as Part of a Medical Tourism Package?

When a person is considering traveling to another country to receive healthcare, there is more to consider than just the cost and quality of the surgery that is performed. Peri-operative care presents an enormous challenge for bariatric procedures. Preoperative education, continuity of care and long-term follow-up are proven essential components for successful outcomes in bariatric surgery and these are not necessarily provided in the setting of medical travel. Some of the facilities participating in medical tourism may not have the capability, such as a modern Intensive Care Unit, imaging capabilities and interventional radiology, etc., to optimally care for major post-operative complications. Additionally, although many programs involved in medical tourism include a short stay post-operatively, this does not ensure that a complication will not develop upon returning to the US.

Unfortunately, this is further complicated by the fact that some surgeons may be reluctant to care for patients that have had surgery in another country. Often an operative report is not available, there may be uncertainty of what was done, and there are concerns whether assuming the care of the patient will make them liable for any complications the patient may have in the future. The cost of treating complications for patients returning from a procedure performed abroad may be substantial, particularly if the patient self-referred outside their insurance system or is uninsured when he or she develops the complication

Long-term success in bariatric surgery depends on lifelong compliance with dietary habits, nutritional guidelines and exercise as part of a multi-disciplinary bariatric program.  Facilities outside the U.S. that participate in medical tourism may not have the time or staff to adequately prepare and educate the patients once they arrive for care. Additionally, patients who have surgery outside the U.S. may have difficulty finding bariatric programs willing to accept them for ongoing routine care after they return home. This has been particularly problematic for many patients who have had an adjustable gastric band procedure outside the U.S. and need band adjustments and long-term follow-up.

Traveling a long distance after surgery can also increase the risk of complications such as deep venous thrombosis and pulmonary embolisms. One must also consider the endemic disease of the area in which they are traveling. Infectious disease-related epidemiology, for example, is a substantial concern. Patients from North America may not have built up a natural immunity to certain pathogens widespread in other continents. This can lead to severe and complicated gastrointestinal illness, influenza and even tuberculosis. Coming home with such an ailment may confuse local physicians, delay therapy and increase the morbidity and mortality of certain problems.

What is the American Society for Metabolic and Bariatric Surgery’s Position on Medical Tourism?

Based on the limited available data, guidelines published by other medical societies, expert opinion, and a primary concern for patient safety, the American Society for Metabolic and Bariatric Surgery supports the following statements and guidelines regarding bariatric surgical procedures and global bariatric healthcare:

  1. Based on the unique characteristics of the bariatric patient, the potential for major early and late complications after bariatric procedures, the specific follow-up requirements for different bariatric procedures, and the nature of treating the chronic disease of obesity, extensive travel to undergo bariatric surgery should be discouraged unless appropriate follow-up and continuity of care are arranged and transfer of medical information is adequate.
  2. The ASMBS opposes mandatory referral across international borders or long distances by insurance companies for patients requesting bariatric surgery if a high quality bariatric program is available locally.
  3. The ASMBS opposes the creation of financial incentives or disincentives by insurance companies or employers that limit patients’ choices of bariatric surgery location or surgical options and, in effect, make medical tourism the only financially viable option for patients.
  4. The ASMBS recognizes the right of individuals to pursue medical care at the facility of their choice. Should they choose to undergo bariatric surgery as part of a medical tourism package or pursue bariatric surgery at a facility a long distance from their home, the following guidelines are recommended:
  • Patients should undergo procedures at an accredited JCI institution or preferably a bariatric center of excellence.
  • Patients should investigate the surgeon’s credentials to ensure that the surgeon is board eligible or board certified by a national board or credentialing body. Individual surgeon outcomes for the desired procedure should be made available as part of the informed consent process whenever possible.
  • Patients and their providers should ensure that follow-up care, including the management of short and long-term complications, are covered by the insurance payer or purchased as a supplemental program prior to traveling abroad.
  • Surgical providers should ensure that all medical records and documentation are provided and returned with the patient to their local area. This includes the type of band placed and any adjustments performed in the case of laparoscopic adjustable gastric banding, as well as any postoperative imaging performed.
  • Prior to undergoing surgery, the patient should establish a plan for postoperative follow-up with a qualified local bariatric surgery program to monitor for nutritional deficiencies and long-term complications, and to provide ongoing medical, psychological and dietary supervision.
  • Patients should recognize that prolonged traveling after bariatric surgery may increase the risk of deep venous thrombosis, pulmonary embolism, and other perioperative complications.
  • Patients should recognize that there are risks of contracting infectious diseases while traveling abroad that are unique to different endemic regions.
  • Patients should recognize that travel over long distances in a short period of time for bariatric surgery may limit appropriate preoperative education and counseling regarding the risks, benefits, and alternatives for bariatric operations. This also significantly limits the bariatric surgery program’s ability to medically optimize the patient prior to surgery.
  • Patients should understand that compensation for complications may be difficult or impossible to obtain.
  • Patients should understand that legal redress for medical errors for procedures performed across international boundaries is difficult.

References

  1. Linda A. Johnson,”Americanslookabroadtosaveonhealthcare: Medicaltourism couldjumptenfoldinnextdecade,” TheSanFranciscoChronicle, August 3, 2008
  2. MedicalTourism – Medical & HealthtravelAssociation – GlobalHealthcareManagementCompany”. Medicaltourismassociation.com.http://www.medicaltourismassociation.com/. Retrieved 2010-09-15.
  3. USA (2011-10-03).”LindvallO, HyunI. Medicalinnovationversusstemcelltourism. Science. 2009 Jun 26;324(5935):1664-5″. Ncbi.nlm.nih.gov.http://www.ncbi.nlm.nih.gov/pubmed/19556497. Retrieved 2011-10-29.
  4. ISSCRGuidelinesfortheClinicalTranslationofStemCells. 2008
  5. Manuel Roig-Franzia,DiscountDentistry, SouthofTheBorder, Washingtonpost.com,June 18, 2007. Retrieved October 15, 2008.