This report originally appeared in the December 2010 issue of DOTmed Business News

When Jean S. of Long Island, New York decided to undergo Lasik eye surgery, she felt more comfortable traveling across the border to Canada where doctors had performed several thousand procedures. Local New York doctors had only done a few hundred because in 2002, the surgery was fairly new to the area, said Jean.

Living at the time in Central New York, Jean and her husband traveled about two hours north into Ontario, Canada for the procedure. She wasn't covered by insurance but was able to use her medical Flex account to cover the costs.

"[My experience abroad] was excellent," Jean told DOTmed News by e-mail. "The doctors and offices were incredibly efficient and kept us very well-informed of everything related to the surgery. The procedures and recovery were exactly as we had been told."

Lasik surgery is a relatively minor procedure in terms of recovery and travel limitations. Jean drove into Canada on a Friday, underwent the operation the next morning and drove back to New York with her husband Sunday afternoon.

Jean's major concern was regarding post-surgery complications, she said.

"But we were assured that a local doctor would be able to assist in an emergency situation," she said.

Traveling abroad for medical services is a growing trend and a multi-billion dollar industry. In 2007, an estimated 750,000 Americans traveled abroad for medical care. It was predicted that in 2010 that number would jump to 6 million. But experts say it's difficult to measure how many people actually travel abroad for medical services, especially because countries seemed to stop reporting during 2008 and 2009, when presumably, numbers fell and predictions were not met.

"Even the handful now issuing figures are often at great pains to give encouraging news for 2010, while referring back to 2007 or earlier for comparisons. It is as though 2008 and 2009 figures have been wiped from the collective memory," according to an article published in the International Medical Travel Journal.

The industry was worth $60 billion in 2006, and according to a report from McKinsey & Company, a global management consulting firm, it may hit $100 billion by 2012. But when it comes to numbers in medical tourism, some experts say they're a hard thing to judge.

"It's a very difficult question to answer," says Wouter Hoeberechts, CEO of WorldMed Assist, when asked how much the medical tourism industry is worth. "Large consulting companies looked into this, and estimates vary widely. It's partially a definition problem. It's partially a methodology problem. Some people include outpatient, others do not. Some research includes close to the border, between Texas and Mexico, some do not."

WorldMed Assist is a company that helps patients through the process of traveling abroad for medical services.

As the demand for cross-border and overseas medical services escalates, there is an increase in health care facilities and insurance providers catering to the millions of people who will travel abroad for surgeries and procedures every year.

Rx: International travel
The biggest driver in going abroad is the significant cost-savings - medical tourism offers savings up to 70 percent after travel expenses, according to a report from Deloitte Center for Health Solutions, an international accounting and consulting firm. Other reports have cited savings of 85 percent.

Almost 39 percent of respondents in the Deloitte report said they would consider going abroad for an elective procedure if they could save half the cost and be assured quality was comparable. And 88 percent said they 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 are many reasons why health care abroad is so much cheaper than in the United States, says Hoeberechts.

He points out that because the cost of living in some parts of the world is much lower, a doctor in India, for example, only needs to make a sixth of what an American doctor brings home to enjoy the same quality of living.

Another factor keeping the cost of international medicine low is the fact that defensive medicine is rarely practiced.

"The legal system is based on getting the patient better rather than punishing the medical team," says Hoeberechts.

To understand how significant cost-savings are from medical tourism, it's necessary to look at numbers. In the United States, knee replacement surgery costs $40,000. The same surgery performed in India costs only $8,500. And in Malaysia the surgery is even cheaper at $8,000. The amounts include the surgery and hospital stay. But even after factoring in the price of a roundtrip flight, this option remains attractive to many.

"Medical tourism is definitely growing," says Hoeberechts. "Health care reform isn't going to reduce the cost [of U.S. health care] anytime soon...I don't believe that medical travel is the solution to the U.S. health care crisis, but it's one of the components to the solution."

Paula Wilson, president and CEO of The Joint Commission subsidiary, Joint Commission Resources (also known as JCI) shares a similar opinion about medical tourism.

"It's not that big of a deal to get on a plane and go somewhere [for medical services]," she says. "Twenty years ago, this was unthinkable. That says something about the cost of health care in the United States."

Passport to surgery
Most commonly, patients travel abroad for elective surgeries. Orthopedic, spine and cardiac surgeries make up the bulk of the procedures, says Hoeberechts. But there is a fair share of general surgeries as well.

"The biggest reason [people travel abroad] is cost," he says. "In other cases, it's purely a matter of quality. People are willing to pay more than the U.S. [charges] for some procedures."

Countries don't necessarily specialize in certain procedures, says Hoeberechts, but in some cases patients may choose one country over another because of its reputation for a procedure or surgery. Most often, where a certain procedure is best executed boils down to individual hospitals.

India is a popular choice for major surgeries, not something small like a hernia repair, which is common in Mexico.

"The savings related to hernia repair [in India] are somewhat negated by the additional cost of travel and lodging," says Hoeberechts. "It probably doesn't make sense to go to India for hernia repair."

But, Mexico is perfect for that type of surgery, he says. Even with the cost of travel, the expense is much less.

Mexico has become a top medical tourism destination for U.S. patients due to its proximity, with 40,000 to 80,000 American seniors spending their retirement there, many receiving home health care.

Other countries attractive to Americans due to their proximity include Costa Rica and Panama for dental services or cosmetic surgeries.

For orthopedic and cardiovascular cases, Southeast Asian countries are becoming popular destinations, due to high-quality health care infrastructure and the number of U.S.-accredited hospitals and physicians.

For example, in 2004, Singapore had 270,000 medical tourists. It's expected that the country will see 410,000 tourists by 2012. Malaysia is becoming a famous medical tourism destination, with 300,000 tourists in 2006. India saw 150,000 tourists in 2002 and that number tripled in 2007.

But the medical tourism destination that sees the most foreign patients annually is Thailand, with 900,000 to 1.2 million patients. The country's Bumrungrad International Hospital has made headlines for treating foreign patients, with 58,000 U.S. patients in 2005 and 64,000 in 2006.

The health care facility, located in Bangkok, was the first hospital to win the Award of Excellence in the health care tourism category, in the Thailand Tourism Awards in 2008. It is also the world's first internationally accredited hospital.

World-renowned for its top-rated service to both domestic and international patients, the Thai hospital is a go-to facility for many travelers. The hospital treats more than 1.1 million patients annually, with more than 407,000 international patients from more than 190 countries.

Bumrungrad has an average of 180 Americans visit daily; half still reside in United States and half are expatriates who use the Thai hospital as their regular health care facility. The hospital also has more than 200 doctors who are U.S.-board certified, as well as an American management team.

Florida resident Bruce Pearson, 64, said in prepared remarks that visiting Bumrungrad is "like coming home."

He chose to continue receiving his health care at the hospital and forgo his Medicare benefits in the United States.

Ensuring safety, insuring coverage abroad
The Medical Tourism Association, also known as the Global Healthcare Association, is a non-profit organization dedicated to promoting high-quality health care to patients all around the world. It comprises international hospitals, health care providers, medical travel facilitators and insurance companies.

In order to educate patients, health care providers and doctors worldwide, MTA publishes Health Tourism Magazine and Medical Tourism Magazine. The latter focuses on quality of care, choosing an international hospital, accreditation issues, integrating medical tourism into a health insurance plan and other legal issues.

"Patients must educate themselves on the destination they choose and take the time to understand the culture as well," said Renee-Marie Stephano, MTA's president, in an e-mail interview with DOTmed News.

The American Medical Association, in an effort to promote safe medical tourism, released guidelines for patients and health care providers alike. Among the guidelines, the AMA recommends that patients only be referred to health care institutions that have been accredited by recognized international accrediting bodies, including JCI and the International Society for Quality in Health Care.

The physician group also advises that patients undergoing medical services abroad should have access to physician licensing and outcome data, as well as facility accreditation and outcome data. In order to address concerns regarding travel after surgery, the AMA recommends that patients should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.

"Though Medical Tourism [Association] suggests that the patient and perhaps their companion may take the opportunity to enjoy the destination where treatment is sought, any tourism activity must be appropriate for the patient's condition and evaluated on a case by case basis," said Stephano.

The JCI is one of the groups responsible for accrediting hospitals abroad. To date, the organization has accredited some 360 international hospitals, says Wilson. The accrediting body has noted an increase in hospitals overseas seeking JCI-accreditation, a trend possibly driven by medical tourism, she says.

"The thing I find heartening, due to medical tourism or otherwise, is the increased number of hospitals around the world asking to have someone to take a look at them and decide whether they are providing quality care and protecting their patients," says Wilson. "That's a good trend. If the motivation is medical tourism, I'm neutral on that."

JCI-accredited hospitals, explains Wilson, offer a sense of safety and security to medical tourists.

"For the most part, individuals who need a procedure done, whether it's cosmetic surgery or a hip replacement and there isn't enough insurance to cover it in the United States, they don't want to do it blindly," she says. "They want some proof that the place they're going to has a good standard quality of patient care...[JCI-accreditation] provides assurance to international patients that somebody [objective] looked at this organization and it meets certain standards."

"With the transparency of facilities, in terms of pricing and quality of services, increase in the number of internationally accredited facilities and the proliferation of information on the Internet, it is expected more patients will have the tools they need to make educated choices for value in health care service delivery," said Stephano.

As medical tourism becomes more popular, health insurers are beginning to include global coverage in their plans.

"A lot of companies are taking a closer look at [medical tourism]," says Robert Zirkelbach, spokesman for America's Health Insurance Plans.

Health insurance providers need to look into issues such as ensuring safety and quality care and how best to follow up with patients whose caregivers are overseas.

"If someone is getting a complex procedure overseas...follow-up care is necessary," says Zirkelbach. "One [question] is how do you ensure follow-up with the primary [doctor] or surgeon? If the surgery is overseas, how do you ensure that?"

It is not the policy of Blue Cross Blue Shield of Texas to cover members who travel abroad only for elective procedures at a lower cost. But the agency will cover certain procedures if they have been preapproved by the employer paying for the care. However, if a surgery or procedure is not approved by the U.S. Food and Drug Administration, the insurance company will not pay for the care, regardless of employer permission.

"Our members travel all over the world. That means BCBSTX has always had a need to cover members traveling outside the U.S....but not specifically for the purpose of seeking lower-cost, routine or non-emergency health care," Margaret Jarvis, spokeswoman for the agency, said in an e-mail interview.

While there are often cost-savings in undergoing medical service abroad, Jarvis warns against assuming that is so in all cases.

"It's often a [misconception] that medical services are cheaper in a foreign country," she said. "Knowing which procedures are covered and whether they are less expensive in other countries is challenging and one needs to be quite familiar with their group's coverage and reimbursement policy on foreign claims."

The United Group Program in Florida is actively promoting medical tourism to more than 200,000 individuals covered through self-funded health plans and fully insured mini-med plans. The insurance agency has medical sites at India's Apollo Hospitals and hospitals in Thailand.

Bumrungrad, Blue Cross Blue Shield of South Carolina and Blue Choice Health Plan of South Carolina created an alliance of sorts to promote medical tourism to more than 1 million of its members. Through a subsidiary, Companion Global Healthcare and BCBSSC will help members who are interested in overseas medical treatment, by providing information and access to the Thai hospital.

"Corporations and insurers alike are looking for new solutions to drive down the cost of health care, and we are part of the solution," said Ruben Toral, Bumrungrad's group marketing director, in prepared remarks, e-mailed to DOTmed News.

"More and more third-party payers will offer international health care service reimbursement," said MTA's Stephano.

How medical tourism will affect U.S. health care is still up for debate, with both positive and negative effects presented. According to the Deloitte Center for Health Solutions report, the expansion of medical tourism creates opportunities for health insurers. For example, the low-cost option available abroad allows insurers to develop plans that provide incentives for patients willing to travel for certain procedures and surgeries.

"As the cost of health care continues to rise in the United States, leveraging low-cost care abroad can help health insurers to increase profitability," the report said.

Highly regarded
Despite it being difficult to pinpoint exact numbers for the medical tourism business, it's clear that it is growing - by about 35 percent a year.

Experts point to a variety of reasons for the rapid growth, including a significant increase in outpatient procedures - which account for 75 percent of medical tourism procedures - an increased acceptance of medical tourism by employers and health plans, and a rise in demand for dental and cosmetic surgeries, according to the Deloitte Center for Health Solutions report.

Often, the response to overseas surgeries is positive. For Sue Nagy of Illinois, seeking emergency angioplasty in Mexico saved her more than $30,000.

"I remembered an article a few years back about medical tourists going abroad for medical care," she wrote in a testimonial for WorldMed Assist, who helped plan her procedure. "At first, I was a little hesitant about going to Mexico, and my friends thought I was crazy. But now, I'd tell anyone in my situation, 'Go for it.'"

Allen Miller of Washington was able to spend three days vacationing in San Diego after a gallbladder surgery in Mexico. His surgery was a third of the cost it would have been in the United States, as Miller did not have health insurance.

"Medical tourism is a good option for anyone who can't get insurance," he wrote in a WorldMed Assist testimonial.
Jean, who underwent eye surgery in Canada, would recommend traveling abroad for medical procedures, also noting that it is a case-by-case decision.

"For the circumstances we were in, the additional expertise and the cost-savings at the time, I would recommend it," she said. "It would depend on the comfort level of the person with their destination."