Medical Tourism: Globalization of the Healthcare Marketplace

Abstract
The citizens of many countries have long traveled to the United States and to the developed countries of Europe to seek the expertise and advanced technology available in leading medical centers. In the recent past, a trend known as medical tourism has emerged wherein citizens of highly developed countries choose to bypass care offered in their own communities and travel to less developed areas of the world to receive a wide variety of medical services. Medical tourism is becoming increasingly popular, and it is projected that as many as 750,000 Americans will seek offshore medical care in 2011. This phenomenon is driven by marketplace forces and occurs outside of the view and control of the organized healthcare system. Medical tourism presents important concerns and challenges as well as potential opportunities. This trend will have increasing impact on the healthcare landscape in industrialized and developing countries around the world and this has an increasing medical tourism towards india.

Introduction
Medical tourism has captured the interest of the media. Articles, guidebooks, and broadcasts on medical tourism are being published and produced with increasing frequency. A Google Internet search using the term medical tourism performed on July 29, 2007, returned 1,100,000 results an increase of 300,000 in the preceding 62 days. Individual practitioners and medical organizations must be able to provide accurate information about this rapidly evolving trend. There is a compelling need for all parties involved in healthcare to become familiar with medical tourism and to understand the economic, social, political, and medical forces that are driving and shaping this phenomenon. In medical tourism, citizens of highly developed nations bypass services offered in their own communities and travel to less developed areas of the world for medical care. Medical tourism is fundamentally different from the traditional model of international medical travel where patients generally journey from less developed nations to major medical centers in highly developed countries for medical treatment that is unavailable in their own communities. The term medical tourism does not accurately reflect the reality of the patient's situation or the advanced medical care provided in these destinations. Nevertheless, this phrase has come into general usage and it provides an unambiguous way of differentiating the recent phenomenon of medical tourism from the traditional model of international medical travel.

The Increasing Popularity of Medical Tourism

Although there are no verifiable statistics regarding the magnitude of medical tourism, the available information suggests that a substantial number of patients travel to developing nations for healthcare. In 2004, 1.2 million patients traveled to India for healthcare and 1.1 million medical tourists traveled to Thailand. One source projects that 750,000 Americans will go offshore for medical services in 2007, with this number increasing to 6 million in 2010. It is estimated that medical tourism to Asia could generate as much as $4.4 billion by 2012, with approximately half of this revenue going to India. It has been estimated that the global medical tourism industry currently generates annual revenues up to $60 billion, with 20% annual growth. However, another valuation suggests that the industry is somewhat smaller, with growth to $40 billion projected by 2010.

Medical Tourism Destinations

The medical tourism marketplace consists of a growing number of countries competing for patients by offering a wide variety of medical, surgical, and dental services .Many of these destinations boast modern facilities with advanced technology and appealing accommodations. A substantial number of the physicians in medical tourism destinations received postgraduate training in industrialized nations, have board certification (or equivalent), and may have practiced in the country where they completed their training. Medical tourists are presently traveling to faraway countries for cosmetic surgery, dental procedures, bariatric surgery, assisted reproductive technology, ophthalmologic care, orthopaedic surgery, cardiac surgery, organ and cellular transplantation, gender reassignment procedures, and even executive health evaluations .A number of countries in Central and South America have developed strong reputations for cosmetic and plastic surgery, bariatric procedures, and dental care. India, Malaysia, Singapore, and Thailand are well-established medical tourism destinations that have become popular for patients seeking cardiac surgery and orthopaedic surgery. Medical services in India are particularly affordable, with prices as low as 10% of those in the United States. Several highly developed nations including Belgium, Canada, Germany, Israel, and Italy are attracting foreign patients under the banner of medical tourism, offering sophisticated modern care with careful attention to patient preference, service, and satisfaction.

Table 1

Cost Comparison of Selected Surgeries:

Procedure United States ($) Heart bypass 130000 Heart valve 160000 replacement Angioplasty 57000 Hip replacement 43000 Hysterectomy 20000 Knee replacement 40000 Spinal fusion 62000 Source: AMA, June 2007

Thailand ($) 11000 10000 13000 12000 4500 10000 7000

Singapore ($) 18500 12500 13000 12000 6000 13000 9000

India ($) 10000 9000 11000 9000 3000 8500 5500

Cost Comparison between US, UK and India: Procedure Open Heart Surgery (CABG) Total Knee Replacement Hip Resurfacing LA Hysterectomy Lap Cholcystectomy Spinal Decompression Fusion Obesity Surgery (Gastric Bypass) Source: Wockhardt Hospitals USA ($) 100000 48000 55000 22000 18000 60000 65000 UK ($) 43000 52000 48000 24000 20000 65000 70000 India ($) 7500 6300 7000 4000 3000 5500 9500

Cosmetic Surgery (Costs in US$) Procedure United States ($) Face-lift 20000 Breast 10000 Augmentation Breast Reduction 10000 Eyelid Surgery 7000 Liposuction 10000 Nose Surgery 7300 Tummy Tuck 8500 Thailand ($) 4800 3150 3900 1400 2100 3850 4050 Singapore ($) 6250 8000 8000 3750 5000 4400 6250 India ($) 3100 2200 3000 2200 2500 1800 3400

Table 2 International Price Comparisons: Selected Surgeries

Procedure Heart Bypass Heart Valve Replacement Angioplasty Hip Replacement Hysterectomy Knee Replacement Spinal Fusion

US Cost India

Thailand Singapore $18,500 $12,500 $13,000 $12,000 $6,000 $13,000 $9,000

$130,000 $10,000 $11,000 $160,000 $9,000 $57,000 $43,000 $20,000 $40,000 $62,000 $10,000

$11,000 $13,000 $9,000 $3,000 $8,500 $5,500 $12,000 $4,500 $10,000 $7,000

The Global Healthcare Marketplace

The international healthcare marketplace emerged in the late 19th century when patients from less developed parts of the world with the necessary resources to do so began to travel to major medical centers in Europe and the United States to have diagnostic evaluation and treatment that was unavailable in their own countries. The situation is very different in the medical tourism model, where patients from highly developed nations travel to less developed countries, bypassing medical care that is offered in their own community but is inaccessible or undesirable to them. Medical tourists would prefer to have major surgery in their hometown hospital or regional referral center if they felt that was a feasible or reasonable option. However, these patients feel pressed to balance their health needs against other considerations, and medical concerns may be subordinated to other issues. Modern technology enables potential medical tourists to investigate and arrange healthcare anywhere in the world from their home computer directly or with the advice and assistance of a medical tourism agency. For patients from highly industrialized nations, the primary reason to have medical services in less developed countries is attractively low cost. Such cost-conscious patients choose to accept the inconvenience and uncertainties of offshore healthcare to obtain service at prices they can more comfortably afford. The opportunity to conserve limited financial resources and protect the equity in their home mollifies their uncertainties. A patient from the United States is likely to be a middle class adult requiring elective surgical care who has no health insurance or who has

inadequate coverage. Milstein and Smith describe these patients as middle-income Americans evading impoverishment by expensive, medically necessary operations. The other group pursuing medical tourism are people seeking cosmetic surgery, dental reconstruction, fertility treatment, gender reassignment procedures, and other treatments not covered by health insurance. The common feature in both groups is that their resources are adequate to purchase healthcare in low-cost medical tourism destinations but insufficient for them to comfortably have the same services in their local market. For patients from countries where a governmental healthcare system controls access to services, the major reason to choose offshore medical care is to circumvent delays associated with long waiting lists. National health programs do not typically pay for cosmetic surgery and similar type services; therefore, patients from Canada and the United Kingdom desiring these procedures pursue medical tourism for the same economic reasons as those from the United States. Patients also travel to offshore medical destinations to have procedures that are not widely available in their own countries. For example, stem cell therapy for any one of a number of problems may be unavailable or restricted in industrialized countries but may be much more available in the medical tourism marketplace. Some patients, particularly those undergoing plastic surgery, sex change procedures, and drug rehabilitation, choose to go to medical tourism destinations because they are more confident that their privacy and confidentiality will be protected in a faraway setting. Finally, some patients have medical care abroad for the opportunity to travel to exotic locations and vacation in affordable luxurious surroundings. Although medical tourism agents and travel professionals may promote the tourism aspect of offshore care, the recreational value of travel has decreasing importance to patients with complex, serious medical problems. The primary reason that medical centers in developing countries are able to provide healthcare services inexpensively is directly related to the nation's economic status. Indeed, the prices charged for medical care in a destination country generally correlate with that nation's per capita gross domestic product, which is a proxy for income levels. Accordingly, the charges for healthcare services are appropriate for the level of economic development in which the services are provided. Low administrative and medicolegal expenses for overseas practitioners also contribute to the affordability of offshore medical care. For example, the professional liability insurance premium for a surgeon in India is 4% of that for a surgeon in New York. An important consideration in medical tourism is the potential impact on the residents of destination countries. Mattoo and Rathindran suggest that revenue generated by developing countries providing medical services to foreign patients creates opportunities to improve the access and quality of care available to the citizens of these countries. Bookman and Bookman emphasize that the government of destination countries must implement and enforce appropriate macroeconomic redistributive policies to ensure that the local residents of these nations actually realize the potential benefits of the medical tourism industry. Chinai and Goswami have expressed concerns that medical tourism may seriously undermine the care of local residents by adversely impacting workforce distribution.

Quality and Safety in Medical Tourism

Faced with the choice of many medical institutions in diverse countries, medical tourists may find it very difficult to identify well-trained physicians and modern hospitals that consistently provide high-quality care. Some medical tourism agents, particularly those with backgrounds in healthcare, may be a helpful resource for patients in making appropriate choices. Accreditation

by the Joint Commission International, which has accredited more than 125 facilities in 24 countries, and/or the International Organization of Standardization may provide a useful point of reference for patients selecting offshore medical facilities. Concerns have been voiced regarding the risk of complications resulting from travel and vacation activities in the postoperative period. The management of postoperative complications that occur after a patient returns from an offshore medical facility, and the consequent costs of this care, are difficult issues that remain unresolved.

Medical Tourism in India

Indian corporate hospitals excel in cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. The various specialties covered are Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Pediatrics, Pediatric Surgery, Pediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery The various facilities in India include full body pathology, comprehensive physical and gynecological examinations, dental checkup, eye checkup, diet consultation, audiometry, spirometry, stress & lifestyle management, pap smear, digital Chest X-ray, 12 lead ECG, 2D echo colour doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, carotid colour doppler, spiral CT scan and high strength MRI. Each test is carried out by professional M.D. physicians, and is comprehensive yet pain-free. There is also a gamut of services ranging from General Radiography, Ultra Sonography, Mammography to high end services like Magnetic Resonance Imaging, Digital Subtraction Angiography along with intervention procedures, Nuclear Imaging. The diagnostic facilities offered in India are comprehensive to include Laboratory services, Imaging, Cardiology, Neurology and Pulmonology. The Laboratory services include biochemistry, hematology, microbiology, serology, histopathology, transfusion medicine and RIA. All medical investigations are conducted on the latest, technologically advanced diagnostic equipment. Stringent quality assurance exercises ensure reliable and high quality test results. As Indian corporate hospitals are on par, if not better than the best hospitals in Thailand, Singapore, etc there is scope for improvement, and the country may become a preferred medical destination. In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals. In fact, priority treatment is provided today in Indian hospitals. The Apollo Group, Escorts Hospitals in New Delhi and Jaslok Hospitals in Mumbai are to name a few which are established names even abroad. A list of corporate hospitals such as Global Hospitals, CARE and Dr L.V. Prasad Eye Hospitals in Hyderabad, The Hindujas and NM

Excellence in Mumbai, also have built capabilities and are handling a steadily increasing flow of foreign patients. India has much more expertise than say Thailand or Malaysia. The infrastructure in some of India's hospitals is also very good. What is more significant is that the costs are much less, almost one-third of those in other Asian countries. Medical tourism can be broadly defined as provision of 'cost effective' private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public. Medical or Health tourism has become a common form of vacationing, and covers a broad spectrum of medical services. It mixes leisure, fun and relaxation together with wellness and healthcare. The idea of the health holiday is to offer you an opportunity to get away from your daily routine and come into a different relaxing surrounding. Here you can enjoy being close to the beach and the mountains. At the same time you are able to receive an orientation that will help you improve your life in terms of your health and general well being. It is like rejuvenation and clean up process on all levels - physical, mental and emotional. Many people from the developed world come to India for the rejuvenation promised by yoga and Ayurvedic massage, but few consider it a destination for hip replacement or brain surgery. However, a nice blend of top-class medical expertise at attractive prices is helping a growing number of Indian corporate hospitals lure foreign patients, including from developed nations such as the UK and the US. As more and more patients from Europe, the US and other affluent nations with high medicare costs look for effective options, India is pitted against Thailand, Singapore and some other Asian countries, which have good hospitals, salubrious climate and tourist destinations. While Thailand and Singapore with their advanced medical facilities and built-in medical tourism options have been drawing foreign patients of the order of a couple of lakhs per annum, the rapidly expanding Indian corporate hospital sector has been able to get a few thousands for treatment. But, things are going to change drastically in favour of India, especially in view of the high quality expertise of medical professionals, backed by the fast improving equipment and nursing facilities, and above all, the cost-effectiveness of the package. As Indian corporate hospitals are on par, if not better than the best hospitals in Thailand, Singapore, etc there is scope for improvement, and the country may become a preferred medical destination. In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals. In fact, priority treatment is provided today in Indian hospitals The Apollo Group, Escorts Hospitals in New Delhi and Jaslok Hospitals in Mumbai are to name a few which are established names even abroad. A list of corporate hospitals such as Global Hospitals, CARE and Dr L.V. Prasad Eye Hospitals in Hyderabad, The Hindujas and NM Excellence in Mumbai, also have built capabilities and are handling a steadily increasing flow of

foreign patients. India has much more expertise than say Thailand or Malaysia. The infrastructure in some of India's hospitals is also very good. What is more significant is that the costs are much less, almost one-third of those in other Asian countries.

The Response to Medical Tourism

The medical community in developed countries has started to recognize medical tourism as a real phenomenon that involves the profession, practitioners, and patients. Peer-reviewed medical and health journals began publishing papers on this topic in 2006. Medical organizations have addressed medical tourism in articles and other documents posted on their Web sites. The United States Senate Special Committee on Aging held hearings on the issue of medical tourism in June 2006 and called for a task force of experts to explore the impact and safety of lower-cost healthcare abroad. The insurance industry has become an active participant in medical tourism. In several states, Blue Cross Blue Shield sells insurance policies that enable or encourage patients to have expensive surgical procedures at low-cost offshore medical facilities. In an effort to reduce the financial burden of employee healthcare, several fortune 500 corporations are evaluating the feasibility of outsourcing expensive medical procedures to offshore healthcare destinations. Insurance provider networks are currently being expanded to include physicians around the globe, and it is anticipated that within a decade a majority of large employers' health plans will include offshore medical centers. Insurance companies are able to use a portion of their substantial savings to offer incentives to beneficiaries willing to have care in medical tourism destinations, including waiving deductible and out-of-pocket health expenses and paying for travel for the patient and even a family member. A particularly interesting response to the migration of patients to offshore healthcare destinations is that some US medical facilities are now accepting referrals from medical tourism agencies and providing highly discounted services to American patients. In nations that have long waiting lists for certain procedures, medical tourism provides a mechanism to clear backlogs by sending patients to foreign countries without expanding local capacity. Currently, the British National Health System is sending patients to nearby countries for this purpose, and more distant medical tourism destinations may be used in the future. Although this idea has not been explored, there may be novel opportunities to use low-cost offshore medical destinations to provide care for unfunded low-income patients while simultaneously relieving the burden on domestic healthcare facilities and philanthropic organizations.

The Continuing Evolution of Medical Tourism

The medical tourism industry is fueled and driven by patients who feel disenfranchised by the healthcare system in their home country. These informed patients shop outside the organized medical system to find services that are affordable, timely, or simply available. Millstein and Smith emphasize that the flight of American patients to foreign destinations for lifesaving operations is a symptom of an affordability problem that is symbolically important and must be addressed by physician leaders. These leaders must recognize that patients, like all consumers, will search for providers who offer them maximal value, and medical tourism is an explicit declaration about what patients value most. Physicians and hospitals in medical tourism destinations recognize that they must provide high-quality care to develop a sustainable competitive advantage in the international marketplace. In an article on medical tourism in Time, Princeton University healthcare economist Uwe Reinhardt stated: This has the potential of doing to the US health-care system what the Japanese auto industry did to American carmakers. It is increasingly apparent that medical tourism is changing the healthcare landscape in industrialized and developing countries around the world, and there is every reason to believe that this trend will continue to evolve.