It is a powerful statement when American patients feel so disenchanted with local healthcare that they abandon the US healthcare system and go abroad.
Pippa Wysong
Published: 10/14/2009
Increasing numbers of patients travel outside of the United States for medical treatments, including cosmetic surgery. At the same time, many people from other countries travel to the United States for healthcare. Michael D. Horowitz, MD, MBA, studies global medical tourism and investigates what this means to physicians both here in the United States and worldwide. He began his career as a cardiothoracic surgeon but now concentrates on researching and analyzing medical tourism. Dr. Horowitz received his master of business administration from the Goizueta Business School of Emory University, and is founder and president of Medical Insights International. An afterword is provided by James Wells, MD, who is past president of the American Society of Plastic Surgeons (ASPS) and sits on the board of the American Board of Plastic Surgery (ABPS).
Medscape: As a physician, how did you become interested in medical tourism?
Dr. Horowitz: I went to business school and heard of medical tourism in the context of offshoring and outsourcing of healthcare (offshoring and outsourcing are similar terms for the rapidly growing practice of seeking medical treatment in another country). In the United States, many businesses send services offshore because they are cheaper. Some Americans are now outsourcing their own healthcare. I had not heard of medical tourism and did a research project on the topic. This became the focus of my professional activities.
Medscape: How did medical tourism become so popular?
Dr. Horowitz: Historically, patients came from developing countries to the United States and other industrialized countries to access specific healthcare services that were not available at home. That continues to a significant degree, but the last decade has seen a general trend toward globalization, with better transportation, better communication, and information access through the Internet. All of these advances have made offshoring healthcare easier for patients in the United States.
Medscape: Where does cosmetic or plastic surgery fit in?
Dr. Horowitz: It was for plastic and cosmetic surgery that people first recognized they could go abroad for a procedure and have a vacation simultaneously -- for lower cost than they could have the procedure done at home. The ASPS was the first medical professional organization to respond to this trend and posted a briefing paper on its Website in 2005.
Cosmetic surgery behaves more like a "true market" than many other healthcare services. A true market industry follows the rules of supply and demand more than does, say, treatment for a heart attack. When someone has a heart attack, they are not in a position to shop around, and hospitals are not in a position to say, "You don't have enough money to buy our product." Patients looking for a face-lift are in a better position to shop, and plastic surgeons are in a better position to accept or decline their business. That is true market behavior.
Medscape: How many people leave the United States for medical services?
Dr. Horowitz: Nobody knows the exact numbers. In 2003, approximately 350,000 American patients went abroad for healthcare, and in 2007, it was an estimated 750,000 patients. Some project the numbers might hit 6 million by 2010.
Medscape: That is for everything from going to a spa to going for a face-lift?
Dr. Horowitz: Or heart surgery, or kidney transplant, whatever. One problem is that there are no standards for what is meant by medical services. People going for Ayurvedic therapy in India might be included in some data sources. If someone goes overseas for surgery, then goes back 3 months later, is that patient counted once or twice? Nobody knows what is being counted.
Medscape: Why do people go offshore for medical care?
Dr. Horowitz: The primary driver is cost. For the same amount of money that patients pay for a procedure in the United States, they can stay in a luxurious resort hotel and have a tour of the Costa Rican jungle included. In any marketplace, when consumers go to somebody else's store, it is because you are not offering what they want, or the price is not right.
Medscape: How big are the price differences?
Dr. Horowitz: It varies from country to country and from procedure to procedure. Plus, the services offered vary. For instance, if you live in Miami and go to a local plastic surgeon, the cost would cover just the procedure. If you go to Costa Rica, the price may include travel, the procedure, a jungle tour, and accommodations. For most of the successful medical tourism destinations, the overall cost is probably 50% less than the medical costs alone charged in the United States.
Medscape: Does the fact that cost is the main driver reflect something about the US healthcare system?
Dr. Horowitz: The US healthcare system is expensive, mostly because the cost of living is high. Although American patients may spend less money to get care abroad, it does not mean that other countries are offering a discounted or bargain price. If the cost of plastic surgery is X dollars in the United States, and the cost in another country is less, that is the market price where the care is provided. American patients actually pay a premium price because they may get premium services. Nevertheless, they end up spending less money for the care because of the substantial differential in prices between the United States and many developing nations.
Medscape: Apparently, the odd insurance company covers patients going abroad for treatments. What is that all about?
Dr. Horowitz: Some insurance plans -- particularly employer benefit plans --are developing networks that include offshore providers. Companies such as Hannaford Brothers, Grocers in New England, and Serigraphics in Indianapolis have benefit plans that include an offshore network. If somebody goes abroad, they save out-of-pocket money on deductibles and copays. The plan even covers travel and other expenses. They will incentivize patients to travel, but they are not pushing people.
Medscape: Are there specific conditions insurers offer this for?
Dr. Horowitz: Primarily orthopaedics and some cardiac conditions. These procedures are expensive in the United States but less costly to the insurance company offshore. In cosmetic surgery, it is not an issue because there generally is not insurance coverage for that.
Medscape: Is this increasing trend of people leaving the States to go elsewhere for cheaper procedures something that is bad for US healthcare? Is it a problem economically?
Dr. Horowitz: Yes and no. On one hand, many patients who go abroad cannot pay hospital bills anyway. In that respect, it is not really hurting the local hospital. On the other hand, when patients go abroad, they pay real money. In plastic surgery, it is an issue because this is lost revenue.
Would these people undergo cosmetic surgery in Minneapolis if they could not travel? Or would these people simply say, "Oh well, forget it"? No one knows. Some patients are not truly lost to the international marketplace.
Medscape: How commonly do people come back with a bad result?
Dr. Horowitz: Bad results can happen in the best of hands. It is a concern and it occurs, but it is probably less common than most people believe. US plastic surgeons tend not to see the patients with good outcomes.
There are people abroad who are working to develop international referral patterns, and they are extremely diligent in providing the best care that they can. Some centers abroad keep patients around longer for follow-up to make sure that things are okay.
Sometimes patients do return with real problems, though. There is no good answer to that. The same thing can happen in the United States. For example, a patient from New York City could go to Los Angeles for cosmetic surgery and return home with a problem that has to be treated in New York.
Medscape: Don't patients fresh out of surgery have trouble traveling?
Dr. Horowitz: This is an important issue and a particular concern in regard to venous thromboembolism and pulmonary embolism. It is a good idea to get patients to stay longer after their surgeries. Some practitioners use deep venous thrombosis prophylaxis for patients who must travel long distances. Of interest, you do not hear that argument when patients are travelling to the United States for care. It is not that physicians here do not think of it, but they rarely use the patient's need to travel home as a reason not to do the procedure. The ASPS has a briefing paper that will likely discourage some patients from going offshore. The American College of Surgeons (ACS) and the American Medical Association (AMA) have more recently published position papers or guidelines regarding medical tourism.
Medscape: What should physicians say to patients who are considering going abroad for a procedure?
Dr. Horowitz: Most practitioners in the United States discourage patients from going offshore for care and provide them a good list of reasons. Part of their motivation is that they do not want the liability if patients go offshore. Plus, most US practitioners do not know what is available offshore. Physicians should explain some of the advantages and disadvantages and advise patients to research this very carefully. There is no clear script on what physicians should say.
Medscape: Any final comments on the topic?
Dr. Horowitz: Yes. There is some very good quality care available in unlikely sounding destinations. It is naive to think that just because someone practices elsewhere they are not as well trained, or qualified, or artistic as a physician in the United States.
When practitioners encounter patients who have gone abroad, try to understand what it was they were looking for. Sometimes patients shopped for a price that may have been at a level the local practitioner could have met -- had the patient asked. Maybe there is something else the physician could be doing; maybe it is something they cannot.
It is a powerful statement when American patients feel so disenchanted with local healthcare that they abandon the US healthcare system and go abroad.
Medscape: You have made a lot of really intriguing points today. Thanks for sharing your thoughts about medical tourism with Medscape.
Afterword From Dr. Wells
Medscape: Dr. Wells, what does medical tourism mean to the specialty of plastic surgery?
Dr. Wells: Certainly, some patients look only for the best cost. Remember, a number of international members are part of our society and are board certified. Many trained in the United States, and some patients may go to them. Many countries currently do not have credentialing processes like the American Board of Medical Specialty (ABMS) system, but various places are working to establish accreditation programs. Also, many patients come to the United States for procedures. In fact, some US physicians market their services outside the United States. It is not a one-way street.
Medical tourism is a phenomenon worth watching and understanding. If medical tourism is so good that patients leave the country, then maybe we as a healthcare system need to look at what we are putting out as a product, particularly in elective procedures, and make sure that we are offering a comparable product. We certainly think that we are, as far as the quality of care, quality of surgery, and the medical experience, but we may not be competing as well when it comes to cost.
Pippa Wysong
Published: 10/14/2009
Increasing numbers of patients travel outside of the United States for medical treatments, including cosmetic surgery. At the same time, many people from other countries travel to the United States for healthcare. Michael D. Horowitz, MD, MBA, studies global medical tourism and investigates what this means to physicians both here in the United States and worldwide. He began his career as a cardiothoracic surgeon but now concentrates on researching and analyzing medical tourism. Dr. Horowitz received his master of business administration from the Goizueta Business School of Emory University, and is founder and president of Medical Insights International. An afterword is provided by James Wells, MD, who is past president of the American Society of Plastic Surgeons (ASPS) and sits on the board of the American Board of Plastic Surgery (ABPS).
Medscape: As a physician, how did you become interested in medical tourism?
Dr. Horowitz: I went to business school and heard of medical tourism in the context of offshoring and outsourcing of healthcare (offshoring and outsourcing are similar terms for the rapidly growing practice of seeking medical treatment in another country). In the United States, many businesses send services offshore because they are cheaper. Some Americans are now outsourcing their own healthcare. I had not heard of medical tourism and did a research project on the topic. This became the focus of my professional activities.
Medscape: How did medical tourism become so popular?
Dr. Horowitz: Historically, patients came from developing countries to the United States and other industrialized countries to access specific healthcare services that were not available at home. That continues to a significant degree, but the last decade has seen a general trend toward globalization, with better transportation, better communication, and information access through the Internet. All of these advances have made offshoring healthcare easier for patients in the United States.
Medscape: Where does cosmetic or plastic surgery fit in?
Dr. Horowitz: It was for plastic and cosmetic surgery that people first recognized they could go abroad for a procedure and have a vacation simultaneously -- for lower cost than they could have the procedure done at home. The ASPS was the first medical professional organization to respond to this trend and posted a briefing paper on its Website in 2005.
Cosmetic surgery behaves more like a "true market" than many other healthcare services. A true market industry follows the rules of supply and demand more than does, say, treatment for a heart attack. When someone has a heart attack, they are not in a position to shop around, and hospitals are not in a position to say, "You don't have enough money to buy our product." Patients looking for a face-lift are in a better position to shop, and plastic surgeons are in a better position to accept or decline their business. That is true market behavior.
Medscape: How many people leave the United States for medical services?
Dr. Horowitz: Nobody knows the exact numbers. In 2003, approximately 350,000 American patients went abroad for healthcare, and in 2007, it was an estimated 750,000 patients. Some project the numbers might hit 6 million by 2010.
Medscape: That is for everything from going to a spa to going for a face-lift?
Dr. Horowitz: Or heart surgery, or kidney transplant, whatever. One problem is that there are no standards for what is meant by medical services. People going for Ayurvedic therapy in India might be included in some data sources. If someone goes overseas for surgery, then goes back 3 months later, is that patient counted once or twice? Nobody knows what is being counted.
Medscape: Why do people go offshore for medical care?
Dr. Horowitz: The primary driver is cost. For the same amount of money that patients pay for a procedure in the United States, they can stay in a luxurious resort hotel and have a tour of the Costa Rican jungle included. In any marketplace, when consumers go to somebody else's store, it is because you are not offering what they want, or the price is not right.
Medscape: How big are the price differences?
Dr. Horowitz: It varies from country to country and from procedure to procedure. Plus, the services offered vary. For instance, if you live in Miami and go to a local plastic surgeon, the cost would cover just the procedure. If you go to Costa Rica, the price may include travel, the procedure, a jungle tour, and accommodations. For most of the successful medical tourism destinations, the overall cost is probably 50% less than the medical costs alone charged in the United States.
Medscape: Does the fact that cost is the main driver reflect something about the US healthcare system?
Dr. Horowitz: The US healthcare system is expensive, mostly because the cost of living is high. Although American patients may spend less money to get care abroad, it does not mean that other countries are offering a discounted or bargain price. If the cost of plastic surgery is X dollars in the United States, and the cost in another country is less, that is the market price where the care is provided. American patients actually pay a premium price because they may get premium services. Nevertheless, they end up spending less money for the care because of the substantial differential in prices between the United States and many developing nations.
Medscape: Apparently, the odd insurance company covers patients going abroad for treatments. What is that all about?
Dr. Horowitz: Some insurance plans -- particularly employer benefit plans --are developing networks that include offshore providers. Companies such as Hannaford Brothers, Grocers in New England, and Serigraphics in Indianapolis have benefit plans that include an offshore network. If somebody goes abroad, they save out-of-pocket money on deductibles and copays. The plan even covers travel and other expenses. They will incentivize patients to travel, but they are not pushing people.
Medscape: Are there specific conditions insurers offer this for?
Dr. Horowitz: Primarily orthopaedics and some cardiac conditions. These procedures are expensive in the United States but less costly to the insurance company offshore. In cosmetic surgery, it is not an issue because there generally is not insurance coverage for that.
Medscape: Is this increasing trend of people leaving the States to go elsewhere for cheaper procedures something that is bad for US healthcare? Is it a problem economically?
Dr. Horowitz: Yes and no. On one hand, many patients who go abroad cannot pay hospital bills anyway. In that respect, it is not really hurting the local hospital. On the other hand, when patients go abroad, they pay real money. In plastic surgery, it is an issue because this is lost revenue.
Would these people undergo cosmetic surgery in Minneapolis if they could not travel? Or would these people simply say, "Oh well, forget it"? No one knows. Some patients are not truly lost to the international marketplace.
Medscape: How commonly do people come back with a bad result?
Dr. Horowitz: Bad results can happen in the best of hands. It is a concern and it occurs, but it is probably less common than most people believe. US plastic surgeons tend not to see the patients with good outcomes.
There are people abroad who are working to develop international referral patterns, and they are extremely diligent in providing the best care that they can. Some centers abroad keep patients around longer for follow-up to make sure that things are okay.
Sometimes patients do return with real problems, though. There is no good answer to that. The same thing can happen in the United States. For example, a patient from New York City could go to Los Angeles for cosmetic surgery and return home with a problem that has to be treated in New York.
Medscape: Don't patients fresh out of surgery have trouble traveling?
Dr. Horowitz: This is an important issue and a particular concern in regard to venous thromboembolism and pulmonary embolism. It is a good idea to get patients to stay longer after their surgeries. Some practitioners use deep venous thrombosis prophylaxis for patients who must travel long distances. Of interest, you do not hear that argument when patients are travelling to the United States for care. It is not that physicians here do not think of it, but they rarely use the patient's need to travel home as a reason not to do the procedure. The ASPS has a briefing paper that will likely discourage some patients from going offshore. The American College of Surgeons (ACS) and the American Medical Association (AMA) have more recently published position papers or guidelines regarding medical tourism.
Medscape: What should physicians say to patients who are considering going abroad for a procedure?
Dr. Horowitz: Most practitioners in the United States discourage patients from going offshore for care and provide them a good list of reasons. Part of their motivation is that they do not want the liability if patients go offshore. Plus, most US practitioners do not know what is available offshore. Physicians should explain some of the advantages and disadvantages and advise patients to research this very carefully. There is no clear script on what physicians should say.
Medscape: Any final comments on the topic?
Dr. Horowitz: Yes. There is some very good quality care available in unlikely sounding destinations. It is naive to think that just because someone practices elsewhere they are not as well trained, or qualified, or artistic as a physician in the United States.
When practitioners encounter patients who have gone abroad, try to understand what it was they were looking for. Sometimes patients shopped for a price that may have been at a level the local practitioner could have met -- had the patient asked. Maybe there is something else the physician could be doing; maybe it is something they cannot.
It is a powerful statement when American patients feel so disenchanted with local healthcare that they abandon the US healthcare system and go abroad.
Medscape: You have made a lot of really intriguing points today. Thanks for sharing your thoughts about medical tourism with Medscape.
Afterword From Dr. Wells
Medscape: Dr. Wells, what does medical tourism mean to the specialty of plastic surgery?
Dr. Wells: Certainly, some patients look only for the best cost. Remember, a number of international members are part of our society and are board certified. Many trained in the United States, and some patients may go to them. Many countries currently do not have credentialing processes like the American Board of Medical Specialty (ABMS) system, but various places are working to establish accreditation programs. Also, many patients come to the United States for procedures. In fact, some US physicians market their services outside the United States. It is not a one-way street.
Medical tourism is a phenomenon worth watching and understanding. If medical tourism is so good that patients leave the country, then maybe we as a healthcare system need to look at what we are putting out as a product, particularly in elective procedures, and make sure that we are offering a comparable product. We certainly think that we are, as far as the quality of care, quality of surgery, and the medical experience, but we may not be competing as well when it comes to cost.