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    September 22, 2021

    Off Hold from the Pandemic: Global Medical Travel Set to Again Gain Momentum, Offer Multiple Benefits to Employers, Patients, and Providers

    By David Boucher, MPH, FACHE, Aster DM Healthcare, UAE

    Introduction

    Until COVID-19 hit, global medical travel had been growing as an industry for the last few decades.1 Defined as the practice of seeking medical treatment and care in another state, region, or country, people travel to gain greater, more timely access to care, take advantage of procedures not available in their home country, and save money. Pent-up demand for elective and sometimes needed surgery following COVID-19 will also prompt increased adoption in countries where the variants aren’t surging and shutting down borders. While tourism is an attractive aspect of medical value travel, it is certainly not the main driver of destination medical care. 

    According to the Centers for Disease Control & Prevention (CDC), the most common types of treatment include dental care, orthopedic surgery, cardiac and neurological care, cosmetic surgery, organ and tissue transplantation, fertility treatments, and oncology treatments. Each year, millions of U.S. residents travel abroad for healthcare.2 In the reverse, U.S. doctors and hospitals are encouraging foreign patients to come to the United States for care and treatment.

    Safety, service, quality, accessibility, and financial savings for care are the main concerns surrounding medical value travel. Destinations and providers that can meet expectations for care excellence will be successful in this burgeoning marketplace. As the value in medical travel becomes too compelling to ignore, even U.S.-based Medicare Advantage plans may begin taking advantage of the opportunities for offering members an international option, and there is nothing in the Medicare guidelines that prevents medical value travel for Medicare Advantage members.3

    The Growing Demand for Global Medical Travel 

    The last decade saw medical travel boom with the top countries being Thailand, Turkey, and India.4 In the Middle East, the countries of Oman, Israel, and the United Arab Emirates, which includes the city of Dubai, are emerging as world leaders among healthcare market destinations.5

    The industry’s growth was related to increased awareness of patients in higher-income countries that they could save money on treatments while they seek destination healthcare.

    During the pandemic, medical travel suffered a big hit because countries were closed. In addition, countries had to limit the number of nonessential surgeries because they had to focus on taking care of COVID-19 patients.6

    As the pandemic subsides, healthcare experts expect to see a surge in global medical travel. One of the factors in the United States is the significant reduction in elective surgeries and procedures during the pandemic, as patients deferred non-COVID-19 related treatment.7 This trend has prompted built-up demand for care, and in response, costs are expected to rise. Rising medical care prices will surely ensue in the United States as the result of significantly higher than expected general inflation in the overall economy.8 This, combined with the growing number of states increasing their minimum wages to $15 per hour, will pressure hospitals to sharply increase charges to commercial insurers like BlueCross, Aetna, Cigna, and United Healthcare to cover the increased costs. As usual, governmental programs like Medicare and Medicaid will be slow to increase reimbursement and they comprise the largest percentage of patients in most American hospitals. So combined, sharply increasing prices accompanied by pent-up demand create the perfect storm for medical value travel.  The situation in Canada and Great Britain is similar, especially with more restricted access to elective care – mainly in orthopedics and gastroenterology.9

    Beginning the Medical Travel Journey 

    When medical tourists begin their treatment journey, they need to consider the marketing and advertising packages announced by the destination hospitals to get the best returns. Many locations in the United States and outside the country dedicate considerable resources to promotion, and consumers can now search online for information about specific clinicians and clinics as well as the intermediaries – medical travel facilitators and concierge services – who may help with this search.

    Patients also must think about what treatments to purchase and whether to use a broker, take out travel insurance, and opportunities for pretreatment consultation. Finally, medical tourists need to explore what is a surgeon or clinic’s legal duty for longer-term aftercare.10 Other options include all-inclusive transparent pricing with no add-on surprises later and covered treatment for procedure-caused complications or readmissions within a certain period after discharge. 

    Avoiding Patient Travel Risks

    In the world of healthcare, mitigating risk is essential to keep patients and staff safe.11 It starts with policies and procedures to protect everyone involved in the patient’s care. These policies need to be regularly reviewed and updated to reflect changes in healthcare delivery and more. This also applies to medical travel. 

    Data analysis is essential in a successful risk management program because it can catch high-risk patients, track quality issues, and assess monitors used by patients.12 For instance, although a patient may be deemed “fit to fly” by a local physician in his/her home country, the presence of comorbidities that may render the patient a bit more vulnerable in a relatively COVID-safe country could result in the receiving hospital, which is more restrictive, requesting that the patient delay the elective surgery. Another example of the risks of patient travel is that of a morbidly obese patient wishing to fly a long distance for gastric bypass surgery offered by a physician/hospital which requires a minimum one-month stay for nutritional counseling and more treatment. If patients can only stay for a week’s vacation time, they will probably be denied by the physician/hospital due to the increased risk. 

    Quality of Care and JCI Accreditation 

    The Joint Commission (JC) is an independent, not-for-profit organization founded in 1951 to evaluate and accredit healthcare organizations in the United States plus U.S. territories and military bases. Currently about 20,000 hospitals and other healthcare facilities have JC accreditation, which helps them provide safe and effective care of the highest quality and value.13 The JC’s 250 standards focus on patient safety and quality care, and they are updated regularly to coincide with the changes in healthcare and medicine.

    In the 1990s, the Joint Commission International (JCI) became an extension of the JC to survey and accredit healthcare facilities in Asia, Europe, the Middle East, and South America.14  In 2006, there were only 83 international hospitals accredited by the JCI; today there are nearly 1,000 JCI-accredited facilities, and more are on the way.15 The JCI’s International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety. For instance, Goal #1 is “Identify Patients Correctly,” and Goal #2 is “Improve Effective Communication.”

    Unannounced surveyors visit healthcare facilities a minimum of once every three years (two years for laboratories) to evaluate their standards compliance and conduct an on-site survey. They trace and document a patient’s experience in the facility. Hospitals must submit data on how they treat conditions and publish data quarterly and make it publicly available.

    Legal Issues Affecting U.S. Residents Traveling Abroad

    Informed Consent & Privacy

    Informed consent occurs when permission is granted in full knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with knowledge of the possible risks and benefits. Most JCI-accredited hospitals routinely inform patients of the medical and clinical risks for procedures the patients are considering.16

    Medical Malpractice May Not Be a Concern 

    There is widespread misunderstanding of the facts surrounding medical malpractice in foreign countries.17 The process to address medical malpractice in a foreign country is different from what is available in the United States, but in many countries, patients have a mechanism to address issues of safety and quality.

    Medical malpractice insurance is required in many countries, including, China, Canada, and Australia.18 It is also prevalent in Thailand,19 India,20 and the UAE.21

    Some insurance companies have developed no-fault insurance which doesn’t exist in the United States.  It can however be purchased by individual patients or hospitals which can buy a policy for all of their medical travelers.  Moreover, some countries have moved to no-fault medical systems that replace medical malpractice litigation.22 

    However, there is still significant legal uncertainty surrounding medical malpractice overseas.23

    Payment and Insurance

    There are about 30.4 million Americans without health insurance, and that number has grown since 2017 when individuals were no longer penalized for not having health coverage.24

    The swelling ranks of the uninsured will be scrambling to find truly affordable quality care and may choose to go abroad. There are several IRS-approved programs, including health savings accounts (HSAs), which give people tax advantages to offset healthcare costs, especially people who have a high deductible health plan (HDHP).25

    Technically, Americans aren’t barred from using medical value travel to another country under their commercial healthcare plans.

    If patients have original fee-for-service Medicare, they can only have surgeries in the United States and U.S. territories. However, if they have Medicare Advantage, which is insurance coverage through commercial payors, they may be eligible for medical travel outside the United States.26

    On the employer side, self-funded employers must have enough capital to cover the expenses associated with self-insurance. These employers pay for claims out-of-pocket instead of a pre-determined premium to an insurance carrier and assume the financial risk of providing healthcare benefits to their employees. Self-funded plans provide many benefits to employers, including the freedom to work with providers and provider networks that work well for their employees’ healthcare needs.27  As a result, self-insured employers seek to lower healthcare costs and increase financial margins.28 To do so, some of them have turned to medical tourism for their employees.

    Employers typically prefer to send workers to overseas hospitals that have become Centers of Excellence.  Many of these hospitals participate in knowledge-transfer programs and training offered by U.S. institutions and providers. These collaborative efforts are bringing American ingenuity, sophisticated technology, and advanced levels of care to hospitals outside of the United States.29

    Conclusion

    Medical travel has become a viable way for people to receive safe, affordable, and quality healthcare no matter where they live. Patients need to sit down with their employers and do their own research as they figure out the best international option based on their health status and what they can financially manage. There are many benefits to medical travel, but not all locations and providers are the same, so patients need to be fully informed in their decision-making. 

    Footnotes

    1. Government roles in regulating medical tourism: evidence from Guatemala (nih.gov) (Sept. 20, 2018).
    2. Medical Tourism: Travel to Another Country for Medical Care | Travelers' Health | CDC (last reviewed Apr. 19, 2021).
    3. Medicare Interactive: Traveling with Medicare, https://www.medicareinteractive.org/get-answers/medicare-covered-services/medicare-coverage-overview/traveling-with-medicare
    4. Top 10 countries for medical tourism — best destinations for treatment,Top 10 medical tourism destinations | Bookimed (updated Dec. 16, 2020).
    5. Covid-19 and medical tourism: is a recovery on the cards? | Thailand 2021 | Oxford Business Group (Feb. 4, 2021).
    6. Yeginsu, C., Why Medical Tourism Is Drawing Patients, Even in a Pandemic - The New York Times (nytimes.com) (Jan. 19, 2021).
    7. Reed, T., Expert: Hospitals should prepare for pent-up demand from non-COVID-19 patients | FierceHealthcare June 1, 2020).
    8. Medical cost trend: Behind the numbers 2022: PwC
    9. Health Care Wait Times By Country 2021 (worldpopulationreview.com)
    10. Legal dimensions of outward medical travel - Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches - NCBI Bookshelf (nih.gov) (2014).
    11. 3 Surefire Ways to Mitigate Risk in Healthcare | PolicyMedical
    12. Risk Mitigation Planning for Healthcare Organizations | Study.com
    13. World Hospital Search, “The Value of JCI Accreditation,” https://www.worldhospitalsearch.org/the-value-of-jci-accreditation/where-are-the-us-hospitals/
    14. Joint Commission International, www.jointcommissioninternational.org.
    15. JCI accredited hospitals and medical centers, A list of JCI accredited hospitals and medical centers (health-tourism.com)
    16. Joint Commission, “Quick Safety Issue #21: Informed Consent, https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-21-informed--consent-more-than-getting-a-signature/
    17. International locum tenens: How malpractice works in other countries (gmedical.com) (June 10, 2019).
    18. Medical Malpractice Around the World - eQuoteMD (Jan. 7, 2019).
    19. Medical Malpractice in Thailand: How Common is it? Chiangrai Times (Feb. 8, 2021), https://www.chiangraitimes.com/learning/legal-learning/medical-malpractice-in-thailand-how-common-isit/#:~:text=Thai%20courts%20allow%20medical%20malpractice%20claims%20to%20be,to%20provide%20for%20possible%20and%20known%20h
    20. Goel, S., Medical Practice in India, Medical malpractice in India (legalserviceindia.com)
    21. Sarah, Details Do Matter! Medical Malpractice In Dubai, UAE | Law Firms Dubai (lawyersuae.com)
    22. Coppolo, G & Spigel, S., Medica Malpractice No-Fault Systems, Connecticut General Assembly (Dec. 8, 2003), Medical Malpractice-No-Fault Systems.
    23. Mirer-Singer, P, Medical Malpractice Overseas: The Legal Uncertainty Surrounding Medical Tourism, Journal of Law and Contemporary Problems (2007), Medical Malpractice Overseas: The Legal Uncertainty Surrounding Medical Tourism on JSTORNote that concerns about medical malpractice are not unique to U.S. residents traveling abroad; foreign nationals traveling to the United States can also bring lawsuits against U.S. providers. To avoid such legal action brought by an international travel patient, the Centers for Disease Control and Prevention recommends that U.S. providers focus on three areas: good communication between the traveling patient and provider; strong documentation of all consultations among clinics, patients and providers; and the need for providers to identify potential problems with patients and consult with their risk management personnel or legal team. Henao-Martinez, A. & Franco-Paredes, C., Perspectives: Legal Issues in Travel Medicine - Chapter 2 - 2020 Yellow Book | Travelers' Health | CDC
    24. Number of Americans without health insurance, (Apr. 15, 2021), Americans without health insurance U.S. 2010-2020 | Statista
    25. Publication 969 (2020), Health Savings Accounts and Other Tax-Favored Health Plans | Internal Revenue Service (irs.gov)
    26. Traveling with Medicare - Medicare Interactive
    27. What is Self Funding? - Health Care Administrators Association (HCAA)
    28. How self-funded employers can shrink health care costs--instead of benefits--in 2020 | BenefitsPRO (Sept. 12, 2019).
    29. Carabello, L., Hospital Impact: ACA repeal could have major impact on medical travel | FierceHealthcare (Feb. 6, 2017).
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    David Boucher

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    David Boucher has worked in healthcare for over 40 years and currently serves as Chief of Service Excellence at the corporate level for Aster DM Healthcare in Dubai. In this capacity, he is guiding the 26-hospital chain through its service excellence journey. Prior to Aster, Mr. Boucher served for two years as Chief Business Transformation Officer at Bumrungrad International Hospital in Bangkok, Thailand. Mr. Boucher previously served 18 years as an executive of BlueCross & BlueShield of South Carolina.  From 2006 through 2016, Mr. Boucher also served as President of Companion Global Healthcare, Inc. – the world’s only medical tourism facilitator owned by a major health insurer. Prior to 2000, he served as CEO at several hospitals in the United States.

    Mr. Boucher earned his BS degree from Slippery Rock University (PA) and a Master of Public Health degree (MPH) from the University of South Carolina; he has been named a distinguished alumnus by both institutions.

    He has been quoted in over 250 newspapers and journals, including The Wall Street Journal, New York Times, The Economist, and U.S. News & World Reports. He has been interviewed on NBC Nightly News and Fox Business News.  Mr. Boucher has delivered lectures on disruptive innovation in healthcare at Harvard Business School, Yale School of Management, and Harvard Medical School. He currently resides in Dubai, UAE. He may be reached at [email protected].