Helping medical tourists make informed decisions by Sharon Kleefield Introduction This chapter focuses on the number one issue of concern for medical tourism: quality, safety and potential harm for patients who travel abroad for treatment. While medical tourists seek shorter waiting times and lower costs abroad, we have limited knowledge about the factors that determine their decisions regarding quality and safety. As the number of medical tourists continues to increase and the availability of surgical and experimental treatments increases in more and more countries, limited studies from telephone interviews suggest that medical tourists choose destination hospitals based on proximity to home, affordability, physician experience and training, advertising and testimonials on social media. Although there is some indication that hospital accreditation may also influence the decision-making process, the level of healthcare understanding necessary to make an informed decision and what constitutes ‘informed’ are yet to be standardized in this evolving industry (Crooks et al., 2010). Hospital providers and facilitators may offer a range of unverified claims about the quality of care and expected outcomes; however, the medical tourist is unable to assess and compare international hospitals for quality and safety. Other than accreditation, which is voluntary, there are no international regulatory standards for this industry. Hospitals that advertise themselves as ‘centers of excellence’ should provide evidence that they are knowledgeable and responsible for promoting safety and reducing preventable harm for their patients and staff. Currently, this obligation is ‘marketed’ but not sufficiently substantiated. Closing this quality chasm for the medical tourism industry will be addressed here with a modest proposal for establishing an initial set of safety ‘markers’ that are cross-cultural and evidence-based. While accreditation sets the necessary basic standards, there is a need to meet the quality concerns with these ‘markers’. With evidence from landmark studies during the 1990s in the USA and onward internationally, we’ve learned to identify and measure quality and safety risks in the hospital, in particular, with proven strategies to reduce preventable harm for patients. These will be identified in this chapter with the intent of informing medical tourists and those who assist them in medical travel about how to compare hospitals based on more specific measures. Personal experience As a faculty member of Harvard Medical School for 15 years, I served as the Director of International Health Care Quality Programs and our mission was to establish long-term collaborations with international hospitals to continuously improve the delivery of patient care. In this capacity I provided training, education and design of hospital quality systems in more than 12 countries. Early entries into medical tourism began in 2004-2005. While working in a private hospital in Bangalore, India, I had the opportunity to interview 3 patients who had come for procedures from the USA and UK. This hospital became an early hub for medical tourism, providing direct marketing and communication with patients abroad and later with medical travel companies in India. The hospital had a dedicated, well-managed office for international patients that provided direct communication between patients and physicians. Physicians were transparent about their particular specialty training and the volume of patients treated for specific procedures. The hospital was clean, equipment and operating theatres were new and the staff was eager to care for all patients, local and international. At this hospital, which was newly designed in 2003, six large suites were dedicated to international patients, with nurses and ancillary staff specifically focused on service and patient satisfaction. The suites were equivalent to four- or five-star hotels with all amenities. The first patient I interviewed, Jane, was a 24-year-old dancer from Britain who had injured her knee in a minor car accident that prevented her from dancing – threatening both her current livelihood and her advancement to a career as a professional dancer. The waitlist for the procedure on the NHS was several months, but waiting several months would risk her position in the dance troupe. When I saw her, she was out of bed, doing her post-op exercises with the physical therapist, and stated that she had no pain in her knee just 2 days post-surgery. She had a big smile on her face and thanked everyone for their ‘brilliant’ care. Her surgery appeared to have been a success. The surgeon encouraged her to continue physical therapy when she returned home, but did not rush her out of the hospital, as they had started her on specific exercises to strengthen the muscles around her knee. The suite next door was occupied by two middle-aged women from the USA, Jill and Mary. Jill had been a waitress at the same Kansas City restaurant for 29 years, a career she enjoyed and relied upon. She had no other means of income and was underinsured, making a hip procedure unaffordable in the USA. She could not continue to work with her increasing hip pain. This hospital offered her an affordable hip-resurfacing procedure that was affordable at one-tenth the cost of the procedure offered in the USA. This would be a less invasive approach to a complete hip replacement, with shorter recovery time. Hip resurfacing is typically not performed in the USA. The day after surgery, Jill reported that she had little to no pain and that she was sure that she would be able to resume her waitress job. While describing her stay at this hospital, her tears of gratitude were obvious, as were her optimistic feelings that she would be able to return to work. While staying in the suite with her sister for the 5 days, Mary decided to have a minor cosmetic procedure on her eyelids. This, too, was very affordable and went well. She was thrilled to ‘look younger’ and recommended this procedure to her friends. This hospital had just received the third Joint Commission International (JCI) accreditation in all of India. For these patients and many who followed, the quality and safety of care were presented as evidence of the hospital’s continued success. Patients were able to speak with the Indian physicians prior to travel and this hospital also required evidence of a follow-up plan when the patient returned home so that any problems could be properly addressed. All patient records were available electronically, allowing for appropriate screening and identification of pre-existing and post-treatment risks before and after surgery. After my visit to Bangalore, I also visited Bumrungrad International Hospital, a multi-specialty hospital in Bangkok, Thailand, whose medical staff included more than 200 US Board Certified physicians. This hospital treated the largest number of medical tourists and had already received the first JCI accreditation. In 2007, it reported 520,000 foreign patients, including 55,000 from the USA and 190 countries. The facility was welcoming and patients were guided by trained personnel who provided specific directions and support throughout their care process. The first floor had several restaurants offering both Western and Asian food. I sat in the lobby and watched the international traffic of people in many different kinds of dress, from Asian and African countries. While sitting with my coffee, a middle-aged man sat down next to me wearing a Boston Red Sox (my home team!) baseball cap. We chatted and I asked him what he was doing so far from home. John said that he had come for a knee replacement. He was an underinsured private contractor who could not afford to have this procedure in the USA. He also said that his brother had come to Bumrungrad for the same procedure a year ago and was doing well. He was optimistic that he, too, would be walking out with a painless new knee. Compared to the new hospital in Bangalore, these international patients had somewhat less elaborate rooms; however, the occupancy was consistently near 100 per cent and there was a continuous flow of foreign patients. (Bumrungrad International Hospital, 2015). It was these early interviews that first enlightened me about the possible advantages of medical tourism. Fancy new facilities designed to provide all the amenities of the finest hotels with high-tech medicine at lower costs could be available to the medical consumer, thus positioning health services within the global marketplace (Turner, 2011). The term ‘touristification’ of healthcare is now associated with the business and commerce of tourism and linking it to the transnational provision of high-technology-led expert medical treatment (Botterill et al., 2013). Patients, as medical tourists, become tourist consumers – now having a variety of healthcare systems and cultures to choose from (Botterill et al., 2013). These example hospitals have a significant number of foreign-educated physicians who would be qualified to practise in the USA. Bumrungrad International Hospital is an example of what is considered a reputable medical facility, comparable to ‘the best’ in industrial countries (Mattoo and Rathindran, 2006). This hospital has maintained international accreditation for more than 10 years and tracks success rates in specific surgeries that are comparable to the USA. It is also comparable in its low rate of surgical site infections, medication errors and high patient satisfaction (Bumrungrad International Hospital, 2015). The new landscape of medical tourism By 2006 an estimated 150,000 Americans travelled to India and Latin America for cosmetic surgery and dentistry. Thailand and Singapore became early healthcare destinations for other procedures. By 2007, the number of US medical travelers increased to 300,000, including patients seeking more advanced procedures, such as joint replacement; cardiac, spine and bariatric surgeries; liposuction; breast augmentation; and regenerative therapies such as experimental stem cell treatments and fertility treatments, including in vitro fertilization (IVF) and surrogacy. By 2009, India, Thailand and Singapore served a majority of medical tourists in Asia. More recent reports extrapolate that more than 3 million patients will travel overseas for treatment, representing a growth rate of 20-30 per cent, with a market size predicted to be US$100 billion (Frost & Sullivan, 2012). It is estimated that as many as 7 million patients seek healthcare outside their home country annually (Woodman, 2014). More than 50 countries, including the USA, Central and South America, Asia, Africa and Eastern Europe, are providing care to medical travelers. Currently, the Malaysian government is aggressively promoting its medical tourism through its Ministry of Tourism, hoping to make Malaysia an international hub for healthcare. Both Penang and Kuala Lumpur are advertising low-cost cosmetic, dental and dermatology procedures. Many of their physicians have postgraduate training in the UK or the USA and several of their hospitals have JCI accreditation. India has been aggressively promoting itself as an international healthcare destination with high-tech cardiac and orthopaedic procedures at one-tenth the cost of the USA. The Indian government is planning to launch a single-window portal listing hospitals with accreditation to promote medical tourism as the destination of choice as well as to address patients’ concerns directly (BusLine, 2016). The Korean government is also promoting its growing medical tourism industry, seeking to compete with other Asian countries. The United Arab Emirates is expanding its Health Care City and forming international partnerships, hoping to become a hub for inbound medical tourists and to reduce the costly outbound travel by its own citizens. Partnering with Western universities and clinics alludes to co-branding for quality, but typically is marketed too broadly (Cohen, 2015; Runnels and Carrera, 2012). A recent article in International Living listed ‘4 countries with the best healthcare in the world’ – Colombia, Costa Rica, Panama and Malaysia. No measures of quality were referenced (International Living, 2016). More than 50 countries currently offer a variety of established and experimental treatments to international patients, including the European Union Directive that allows EU residents to seek healthcare within its member countries with limited restrictions. Germany is attracting foreign patients from Russia and Central European countries. Jordan is a popular destination for Middle Eastern and North African medical tourists because of its sophisticated infrastructure and low costs. Cuba offers medical treatment for nearby countries. Barbados is known for fertility treatments and Panama offers orthopaedic surgery, dental care and cardiac surgery. Costa Rica offers advanced and affordable dental treatment; it also offers the controversial ‘liberation’ therapy to treat multiple sclerosis. Mexico attracts at least 1 million Californians for dental and medical care and cheaper prescription drugs (Lunt et al., 2011). Brazil has long provided affordable plastic surgery by experienced physicians (NaRonong and NaRanong, 2011). The total number of medical tourists is difficult to ascertain, but the estimated number in 2013 was greater than 7 million across 11 countries and the USA. Top destinations in 2013 were Thailand, the USA, Malaysia, Europe, Singapore, Mexico and India. Major procedures include cardiac, hip/knee, eye and spinal surgeries, IVF, gastric bypass, dental implants and full face lift. Some experimental procedures are also performed, such as stem cell or other regenerative medical treatments (Woodman, 2014); however, these treatments carry considerable risks and questionable outcomes and lack US Food and Drug Administration approval (Mattoo and Rathindran, 2006). Stay tuned for Part Two, which will appear in February’s issue of MTT.