Medical Tourism (MT): A Passport to Souvenirs our Patients Didn’t Bargain for

Linda MacConnell, PA-C, MPAS, MAEd

Many thanks to Stephanie Fortuna, PA-C

Why Medical Tourism?

Well…..

I love love love medicine Honored to be a PA for 35

years (counting the 2 years as a PA-S)

AND

I love to travel!

AND

The world fascinates me

ENT and aesthetic medicine

Introduced to medical tourism by Stephani Fortuna, PA-C

Why do WE need to know this?

Medical tourism has been increasing worldwide

Expected to grow in the next 5-10 years, especially cosmetic procedures Additionally for necessary medical procedures, meds & elective

surgeries

The global health marketplace is booming and we need to be able to educate, inform “consent” and

be advocates for our patients who choose this path

We always start with the HX:

MT not a new concept; not initially financial Medieval ages in Greece; sacred healing baths

Tourists would travel to Greek temples

Early 1700’s Bath in England Covered sewers allowed for Spa services

Then up into the 20th century, US became the MT magnet Technology and therapeutics

Then India; initially for interest in Ayurvedic medicine Late 20th C. travel to save $

First Cuba and Central America

Then Asian countries marketed themselves

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-SA

WHAT and WHO?What: Medical tourism = pts travel to obtain medical services;

typically procedures; World Health Organization (WHO) likes the term medical “travel/er” Doesn’t count expats and emergency care obtained by touristsOutbound* Inbound!

Intrabound

Who? *Travel all over the world, usually from developed to developing countries ! More traditionally low income to high income

We’ve asked for Years about travel in the hx and here is another reason to ask

WHY, WHERE and WHOWhy:

Reasons include seeking quality care; to US, SwitzCosts of care, long waiting times (esp Europe and

Canadians) Limited availability of desired procedure (insurance

authorization, regulations, legality)all-inclusive vacation packages

Where: Mexico, Dominican Republic, Costa Rica, India, Malaysia, South Korea, Taiwan, Thailand, Jordan

Some MT pts obtaining services legal both at home and their destination Hip replacements, cardiac bypass, cosmetic surgery

More Who and Why? Some seek services illegal @ home & destination, other country

“looks the other way” Terminally ill pts: experimental tx not approved in the US Transplant tourism—travel to a country where organ purchase or sale is

illegal, but it happens—is one of the best examples of this

Travel to obtain procedures legal from a place where they are illegal or strictly regulated = “circumvention tourism”. Examples = travel to obtain abortion, assisted suicide, reproductive

technology Stem cell tourism also circumvention travel, not illegal but represents a

technology restricted at home via control of biomedical therapies Terminally ill pts: experimental tx not approved in the US

U.S. vs. the world: costs of major procedures in major medical tourism locations*:

Procedure U.S Costa Rica

India Malaysia Mexico South Korea

Taiwan Thailand

Average savings

45%-65% 65-90% 60-80% 40-60% 25-45% 40-65% 50-75%

Coronary artery bypass

92,000 31,500 9,800 20,800 34,000 29,000 27,000 33,000

Valve replace-ment & bypass

87,000 28,000 11,900 15,000 26,500 38,000 22,000 19,000

Total hip 31,000 15,300 9,400 12,500 14,200 21,600 14,000 16,500Total knee 28,000 14,200 7,200 7,800 12,300 16,200 13,400 13,200Gastric bypass 23,000 10,500 6,800 9,250 11,500 14,500 12,700 12,6004 implant por-celain bridge

21,500 9,350 6,850 7,700 9,300 9,900 8,700 9,300

Full Facelift 11,500 4,900 2,800 3,300 4,750 5,900 5,250 3,700Rhinoplasty 4,800 2,600 1,400 2,800 3,100 3,800 3,200 1,600

*February 2017. All values in US dollars. U.S. costs vary due to location, materials/equipment used, and pts’ requirements and are averages based on most common costs. International travel and lodging not included.Source: Patients Beyond Borders

Who wouldn’t want to recover:

In Malaysia In Costa Rica In IndiaMany medical

tourists spend recovery vacationing

What’s out there? Cosmetic and dental surgery*Cardiovascular (angioplasty, CABG, transplantsOrthopedic (joint and spine; sports medicine) Bariatric surgery (lap band; bypass)Organ and tissue transplantationCancer (esp last resort) Reproductive health

IVF treatment Abortion

Assisted suicide * Most Common

Why is it NOT the best thing in the WORLD

Infections: Commensals: “Nl Flora” carried on skin, mouth, digestive tracts, etc. Pathogens: harmful disease causing bacteria

One’s commensal bacteria may = another's pathogen

MT pts take commensals and pathogens to the foreign hospitals where they travel AND:

Exposure to commensals and pathogens of foreign providers, hospitals, and general folks

Dx and tx difficult for Locals and travelers who are exposed to foreign “nl flora”

Health Care Associated and other Infections

MT countries like Thailand & India = places where infections like TB and Malaria are endemic

World Health Organization (WHO) data from many countries estimates hundreds of millions of patients around the world are affected by Health Care Associated Infections (HCAI)Low-middle-income countries > high-income onesNosocomial infections: ~10–15% of pts in hosp in low-income

countries vs 7–8% in higher income countries

Case presentation

American patient with hx of obesity underwent gastric bypass surgeryApproved and paid for by insuranceSuccessful & pt lost a large amount of weight resulting in large

amount of redundant tissue Insurance would not cover abdominoplasty

Pt traveled to Mexico; underwent abdominoplasty

These photos are not our patient:

Abdominoplasty = one of the MC aesthetic surgical procedures worldwide. Estimated > 800,000 people undergo each year; 6th MC cosmetic procedure

See why abdominoplasty is desired Redundant tissue Infection after abdominoplasty

Case Presentation

Post procedure, could only afford to stay 3 days in Mexico

Drains were removed too soon and allowed a large 18 cm x 10 cm hematoma to form.

46 year old female presents w/ fever, chills, nausea and abdominal pain

ExaminationErythema, edema and ecchymosis of the surgical siteCT showed large hematomaTemperature >100.4

Wound exploration, evacuation and packing or primary closure with sutures or staples

Literature Review Post op infections not uncommon

Hygiene procedures

Commensals and pathogens

Recent study1 reported 42 infections in MTs 39/42 in Dominican Republic

MC procedures abdominoplasty, mastoplexy and lipo Referred to as “lipotourists”

Rapidly growing mycobacteriua: Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium chelonae M. abscessus in 74%

Clinical take home: Think of this is a pt who traveled w/ Postop infection resistant to Rx Multiple acid fast bacilli cultures

Clarithromycin, amikacin, moxifloxicin

• 44-year-old woman went to the DR for mastopexy/ abdominoplasty April 20154 weeks post-op presents w/ M. abscessus infectionResolution of the infection after surgical drainage and appropriate antibiotic treatment 14 weeks after diagnosis with RGM wound infection.

What’s the cause?WHO says: Medical procedures often occur in multiple

steps; may need tx over a longer period of timeW/ foreign travel steps may be squeezed into a shorter period

of time

F/U care might be needed after pt returns Breaks the link in continuing care:

Problematic for the individual and local health system Health care providers may hesitate to fix a problem caused by

malpractice abroad; patients then turn to $$ emergency services

Consider the travel involved: e.g. a long flight from Asia to US after ortho surgery

Therefore:MT may undergo less expensive procedures of

questionable quality: complications post-op can cost the pt’s health and

pocketbookTransparency: Difficult in the US; more so in other

countriesCredible outcomes information on foreign procedures is

difficultCommon methodology for data collection is lacking; Statistics ltd. on MT available & not comparable country to

country

Can OFFER“HighQuality” Care

But says who? UnmonitoredGenerally, international

hospitals/facilities don’t release outcomes data, adverse events, errors, nosocomial infection rates Hard to make “data-based

judgment” and substanciate safety claims

Difficult to research and find data

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-NC-ND

Disclaimer: At one point it was thought that medical tourism would

SKYROCKET Predicted by 2017: 25 million Americans would travel for

care 2016: 12-15 million traveled WORLDWIDE

Affordable Care Act (ACA) made foreign travel less necessary particularly for needed but elective procedures

Still many travel for cosmetic procedures and from other countries

Ethical considerationsMT raises many ethical issues.

May cause division in health care policies: ensuring the access of health care for every citizen vs promoting cutting-edge technologies for foreign pts Assets move toward offering care to foreigner w/$$$$

Concerns re: changes in pt-provider relationship: healthcare moves from patient care activity toward health care as a commodity: MT involving human body resources e.g. organs

Ethical concerns raise debate Scarcity of human body resources = concerns about obtaining and

using

MT Ethical Concerns

Many countries w/ restrictive/prohibitive legislation re: policies governing donation & access (organ procurement)

Big international variation in legislation and enforcement trigger international flows of pts attempting to take advantage of legal differences

Estimates in 2005 total # of recipients who underwent commercial organ transplants overseas ~5% of all recipients.MT for transplantation is MC way of receiving transplants in some places Human body resources typically more available where poor and vulnerable

population groups will jeopardize their health for a small financial rewardOften, standards of health care for donors = poor and w/o f/u care

On the plus side

The Joint Commission (The US' main hospital accrediting agency) opened an international accrediting office in 1994 w/ growth of medical tourism from the US Involved International accrediting groups to raise standard

of care due to lack of regulation Joint Commission routinely accredits foreign hospitals using the

same standards as the US. Joint Commission International increased # of approved

foreign sites from 76 (2005) to 985 (2017) Refer pts to: https://www.jointcommissioninternational.org/about-jci/jci-accredited-organizations/ Malaysia, Dubai, Mumbai, and China Possibly, Medicare could become the single largest

purchaser of tourism medicine? https://medicaltourismassociation.com/en/about-

us.html

Countries with JCI-Accredited Organizations

Insurance and Medical Tourism Insurance companies in several countries have started

offering plans covering international medical careOffered at a lower price than domestic plans, expected that tx

and rx are less expensive in a foreign country In the US, several plans, such as Access Baja, have developed in

CA Offer options w/ lower premium and co-pays for employees of

American companies wanting to obtain health services in Mexico Regulators have also become aware of the challenges of the

availability of insurance coverage for medical treatment abroad EU travelers seeking acute or ambulatory care another EU country

are covered directly by their home insurance arrangements

MT & Insurance

US pts w/ private insurance may participate in MT paid for by insurer

For private insurers & pts; cost = major motivator

US health insurers pay less for a hip replacement than a pt. pays out of pocket; insurer pays 2.5 X less if the procedure done in Thailand

MT and Insurance

Cost savings add up Insurers w/ large numbers of covered pts & = dramatic

cost savings Pt traveling to Costa Rica from North Carolina for gastric sleeve

surgery could save $3,000 out of pocket in the US ANDGet a bonus check for $2500 from her employer; which is only a

%age of the corporate savings in insurance costs The employer could afford to do this as outsourcing medical care has saved

the employer nearly $10 million in health care costs over the past five years

Conclusions: Take homes and talking points Pts desire cosmetic procedures (CP) and foreign travel for CP will As clinicians in a border state, our pts may be more likely to engage in MT The global health marketplace is booming and we need to be able to educate, inform

“consent,” and be advocates for our patients who choose this path Patients must be made aware of risks and benefits

Patients must understand that f/u care will be necessary US clinicians may be reluctant to provide care for those who received foreign care

Patients must know that negative outcomes are not well documented in other countries There is a risk for infection There is JCI accreditation https://medicaltourismassociation.com/en/about-us.html https://www.jointcommissioninternational.org/about-jci/jci-accredited-organizations/

References

1. Padilla P, Ly P, Dillard R, et al. Medical tourism and postoperative infections: A systematic literature review of causative organisms and empiric treatment. American Society of Plastic Surgeons. January 24, 2018. Published online: www.PRSJournal.com

Cohen I. Medical tourism, medical migration, and global justice: Implications for biosecurity in a globalized world. Medical Law Review. Vol. 25, No. 2, pp. 200–222 http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=6&sid=06bcca7b-066f-4d47-8c7c-56e42844b9f2%40pdc-v-sessmgr01.