Chapter 2The Pre-Travel ConsultationCounseling & Advice for Travelers
“Medical tourism” is the term commonly used to describe people traveling outside their home country for medical treatment. Traditionally, international medical travel involved patients from less-developed countries traveling to a medical center in a developed country for treatment that was not available in their home country. In the United States, the term “medical tourism” generally refers to people traveling to less-developed countries for medical care. Medical tourism is a worldwide, multibillion-dollar phenomenon that is expected to grow substantially in the next 5–10 years. However, little reliable epidemiologic data on medical tourism exist. Studies using different definitions and methods have estimated there are 60,000–750,000 medical tourists annually from around the world.
The most common categories of procedures that people pursue during medical tourism trips are cosmetic surgery, dentistry, cardiology (cardiac surgery), and orthopedic surgery. Common destinations include Thailand, Mexico, Singapore, India, Malaysia, Cuba, Brazil, Argentina, and Costa Rica. The type of procedure and the destination need to be considered when reviewing the risk of travel for medical care.
Most medical tourists rely on private companies or “medical concierge” services to identify foreign health care facilities, and they pay for their care out of pocket. Some insurers and large employers have alliances with overseas hospitals to control health care costs, and several major medical schools in the United States have developed joint initiatives with overseas providers, such as the Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Center, and the Duke-National University of Singapore. Whether these joint ventures will increase the number of US citizens who go overseas for health care is unknown.
Travel health providers should advise prospective medical tourists to determine if health care facilities they are considering are accredited by the Joint Commission International (JCI). JCI is the international division of the Joint Commission Resources, a US-based, not-for-profit affiliate of the Joint Commission that certifies health care facilities in the United States. As of March 2012, JCI has accredited 368 international hospitals in 46 countries. These can be found at www.jointcommissioninternational.org/JCI-Accredited-Organizations. As more facilities are accredited, more providers will likely offer incentives for their patients to travel overseas for care.
PRE-TRAVEL ADVICE FOR MEDICAL TOURISTS
As discussed in Chapter 1, Planning for Healthy Travel: Responsibilities & Resources, patients who elect to travel for medical reasons should consult a travel health provider for advice tailored to individual health needs, preferably ≥4–6 weeks before travel. In addition to other considerations for healthy travel related to their destination, medical tourists should consider the risks associated with surgery and travel, either while being treated or while recovering from treatment. Air pressure in an aircraft is equivalent to the pressure at an altitude of about 6,000–8,000 ft (1,829–2,438 m). Patients should not travel for 10 days after chest or abdominal surgery to avoid risks associated with this change in pressure. Flying and surgery both increase the risk of the development of blood clots and the formation of pulmonary emboli. The American Society of Plastic Surgeons advises people who have had cosmetic procedures of the face, eyelids, or nose, or who have had laser treatments, to wait 7–10 days before flying. Patients are also advised to avoid “vacation” activities such as sunbathing, drinking alcohol, swimming, taking long tours, and engaging in strenuous activities or exercise after surgery. The Aerospace Medical Association has published medical guidelines for airline travel that provide useful information on the risks of travel with certain medical conditions (www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf).
One controversial form of medical tourism is “transplant tourism,” which is travel for the purpose of receiving an organ purchased from an unrelated donor for transplant. An estimated 5%–10% of all kidney transplants in 2007 were from commercial living donors or vendors (although most of these were not transplant tourism). In 2004, the World Health Assembly Resolution 57.18 encouraged member countries to “take measures to protect the poorest and vulnerable groups from ‘transplant tourism’ and the sale of tissues and organs.” A meeting in 2008 in Istanbul addressed the issue of transplant tourism and organ trafficking, which resulted in a call for these activities to be prohibited. In view of those events, the World Health Organization revised the Guiding Principles on Human Cell, Tissue and Organ Transplantation and released those revised principles in March 2009. A 2007 report on the international organ trade found that China, the Philippines, and Pakistan were the largest organ-exporting countries. Several studies have indicated potential problems that travelers and clinicians need to be aware of when considering transplantation overseas: the donor and the procedures lacked documentation, most patients received fewer immunosuppressive drugs than is current practice in the United States, and most patients did not receive antibiotic prophylaxis. However, it is not clear if these issues are representative of the issues faced by all patients who travel for transplants.
Box 2-05. Guiding principles on medical tourism1
The American Medical Association advocates that employers, insurance companies, and other entities that facilitate or promote medical care outside the United States adhere to the following principles:
(a) Medical care outside the United States must be voluntary.
(b) Financial incentives to travel outside the United States for medical care should not limit the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options.
(c) Patients should be referred for medical care only to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
(d) Prior to travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
(e) Coverage for travel outside the United States for medical care must include the costs of necessary follow-up care upon return to the United States.
(f) Patients should be informed of their rights and legal recourse prior to agreeing to travel outside the United States for medical care.
(g) Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
(h) The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
(i) Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
1 From American Medical Association. New AMA guidelines on medical tourism. Chicago: AMA; 2008. Available from: http://www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.
GUIDELINES FOR TRAVELERS SEEKING MEDICAL CARE ABROAD
Several professional organizations have developed guidelines that include questions useful for travelers when discussing medical or dental care abroad, either with the facility providing the care or with the group facilitating the trip. When considering a trip overseas for medical care, travelers should be aware of the guiding principles developed by the American Medical Association (Box 2-05). For cosmetic surgery, the American Society for Plastic Surgery (ASPS) developed a briefing paper that includes a patient safety checklist (Box 2-06). Similarly, the American Dental Association provides informational documents, including “Traveler’s Guide to Safe Dental Care” through the Global Dental Safety Organization for Safety and Asepsis Procedures (Box 2-07). Although the dental guidelines were not developed for medical tourists, they provide useful information for travelers to consider when selecting a facility or planning a trip for medical or dental care. These 3 guides are targeted for specific groups; however, they provide an indication of the types of questions that people considering travel for medical care should discuss with their regular health care provider. In addition to these guidelines, the European Union is working to establish harmonized standards of care for professional services such as plastic or aesthetic surgery. These standards, released for comment in early 2012, will provide additional guidance for medical tourists in evaluating facilities and services.
Box 2-06. Patient safety checklist for cosmetic surgery1
To help ensure optimal results and to limit risks and complications, the American Society for Plastic Surgery (ASPS) offers the following tips to anyone considering cosmetic surgery in the United States.
Do Your Homework: Research the procedure, the benefits, and the risks. Refer to www.plasticsurgery.org for the latest information on plastic surgery procedures.
Have Realistic Expectations: Ask your plastic surgeon questions about how the surgery will work for you: identify expectations and understand side effects and recovery time.
Be Informed: Talk to patients who have had your procedure so you know what to expect.
Require a Medical Evaluation: Consult with your plastic surgeon for an evaluation and discuss your full medical history to determine the most appropriate treatment.
Choose an ASPS Member Surgeon: Why? ASPS Member Surgeons are qualified, trained, properly certified, experienced in your procedure, and operate only in accredited facilities.
- Are you an ASPS Member Surgeon?
- Are you certified by the American Board of Plastic Surgery?
- Do you have hospital privileges to perform this procedure? If so, at which hospitals?
- How many procedures of this type have you performed?
- Am I a good candidate for this procedure? What will be expected of me to get optimal results?
- Where and how will you perform my procedure?
- Is the surgical facility accredited?
- What are the risks involved with my procedure?
- How long a recovery period can I expect, and what kind of help will I need during my recovery?
- Will I need to take time off work? If so, how long?
- How much will my procedure cost? Are financing options available?
- How are complications handled?
1 Excerpt from American Society of Plastic Surgeons. Cosmetic surgery tourism briefing paper. Arlington Heights, IL: American Society of Plastic Surgeons; 2010. Available from: http://www.plasticsurgery.org/News-and-Resources/Briefing-Papers/Cosmetic-Surgery-Tourism.html.
Box 2-07. Patient checklist for obtaining safe dental care during international travel1
Before you leave:
- Visit your dentist for a check-up to reduce the chances you will have a dental emergency.
- See a health care provider to receive any needed vaccinations, medications, and advice related to your travel destination.
When seeking treatment for a dental emergency during your trip:
- Consult hotel staff or the American Embassy or consulate for assistance in finding a dentist.
- If possible, consider recommendations from Americans living in the area or from other trusted sources.
If the answers to any of the asterisked (*) items below are “No,” you should have reservations about the office’s infection control standards. If the answer to a two-star item (**) is “No,” consider making a swift but gracious exit.
When making the appointment, ask:
- Do you use new gloves for each patient?*
- Do you use an autoclave (steam sterilizer) or dry heat oven to sterilize your instruments between patients?**
- Do you sterilize your handpieces (drills)?* (If not, do you disinfect them?)**
- Do you use new needles for each patient?**
- Is sterile (or boiled) water used for surgical procedures?** (In areas where drinking water is unsafe, the water also may cause illness if used for dental treatment.)
Upon arriving at the office, observe the following:
- Is the office clean and neat?
- Do staff wash their hands, with soap, between patients?**
- Do they wear gloves for all procedures?**
- Do they clean and disinfect or use disposable covers on surfaces touched during treatment?
1 Excerpt from Organization for Safety and Asepsis Procedures. Traveler’s guide to safe dental care. Annapolis, MD: Organization for Safety and Asepsis Procedures; 2001. Available from: http://www.osap.org/?page=TravelersGuide.
- Aerospace Medical Association. Medical Guidelines for Airline Travel. 2nd ed. Alexandria, VA: Aerospace Medical Association; 2003.
- American Medical Association. New AMA Guidelines on Medical Tourism. Chicago: AMA; 2008 [cited 2012 Sep 18]. Available from: http://www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.
- American Society of Plastic Surgeons. Cosmetic Surgery Tourism Briefing Paper. Arlington Heights: American Society of Plastic Surgeons; 2010 [cited 2012 Sep 18]. Available from: http://www.plasticsurgery.org/News-and-Resources/Briefing-Papers/Cosmetic-Surgery-Tourism.html.
- Bookman MZ, Bookman KR. Medical Tourism in Developing Countries. New York: Palgrave MacMillan; 2007.
- Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant. 2008 May;8(5):925–9.
- Ehrbeck T, Guevara C, Mango PD. Mapping the market for medical travel. McKinsey Quarterly. 2008(May).
- Einhorn B, Arnst C. Outsourcing the patients: more US health insurers are slashing costs by sending policyholders overseas for pricey procedures. Businessweek News. 2008 Mar 13.
- Galland Z. Medical tourism: the insurance debate: most insurers balk at covering medical procedures performed overseas, but some are exploring the option Businessweek News. 2008 Nov 9.
- Gill J, Madhira BR, Gjertson D, Lipshutz G, Cecka JM, Pham PT, et al. Transplant tourism in the United States: a single-center experience. Clin J Am Soc Nephrol. 2008 Nov;3(6):1820–8.
- Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: globalization of the healthcare marketplace. MedGenMed. 2007;9(4):33.
- JointCommissionInternational.org [Internet]. Oak Brook, IL: Joint Commission International; c2002–2011 [cited 2012 Sep 18]. Available from: http://www.jointcommissioninternational.org/.
- Keckley PH, Underwood HR. Medical Tourism: Consumers in Search of Value. Washington, DC: Deloitte Center for Health Solutions; 2008.
- Merion RM, Barnes AD, Lin M, Ashby VB, McBride V, Ortiz-Rios E, et al. Transplants in foreign countries among patients removed from the US transplant waiting list. Am J Transplant. 2008 Apr;8(4 Pt 2):988–96.
- Organization for Safety and Asepsis Procedures. Traveler’s guide to safe dental care. Annapolis, MD: Organization for Safety and Asepsis Procedures; 2001 [cited 2012 Sep 18]. Available from: http://www.osap.org/?page=TravelersGuide.
- Reed CM. Medical tourism. Med Clin North Am. 2008 Nov;92(6):1433–46, xi.
- Sajjad I, Baines LS, Patel P, Salifu MO, Jindal RM. Commercialization of kidney transplants: a systematic review of outcomes in recipients and donors. Am J Nephrol. 2008;28(5):744–54.
- Sanford C, Merck. Air travel. Whitehouse Station, NJ: Merck Sharp & Dohme Corp; 2009 [cited 2012 Sep 18]. Available from: http://www.merck.com/mmpe/sec22/ch333/ch333b.html#CBBIEDEH.
- Shimazono Y. The state of the international organ trade: a provisional picture based on integration of available information. Bull World Health Organ. 2007 Dec;85(12):955–962.
- US Department of Commerce. 2008 United States resident travel abroad. Washington, DC: US Department of Commerce; 2008 [cited 2012 Sep 18]. Available from: http://tinet.ita.doc.gov/outreachpages/download_data_table/2008_US_Travel_Abroad.pdf.
- US Department of Health and Human Services. 2007 annual report of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: transplant data 1997–2006. Rockville, MD: US Department of Health and Human Services; 2007 [cited 2012 Sep 18]. Available from: http://www.ustransplant.org/annual_reports/current/ar_archives.htm.
- World Health Organization. Guiding principles on human organ transplantation. Geneva: World Health Organization; 2010 [cited 2012 Sep 18]. Available from: http://www.who.int/ethics/topics/transplantation_guiding_principles/en/index1.html.
- World Health Organization. Human organ and tissue transplantation. Geneva: World Health Organization; 2009 [updated 2012 Sep 18]. Available from: http://apps.who.int/gb/ebwha/pdf_files/A62/A62_15-en.pdf.