November 13, 2019
The Inside Story: Medical Tourism...it's a gamble with high stakes for health
Sun, surf, and we’ll throw in a knee replacement with that…
Now that’s certainly a twist on all-inclusive. But is it travel or is it health care? The answer is both; it’s medical tourism, which these days is taking a range of shapes and forms including various locations and health services. Although medical tourism is on the rise, it’s risky business. And even if (and that’s a big “if”) plan members think that out-of-country treatments are of comparable quality—or even better quality—than in Canada, how would they know for sure? It’s like rolling the dice.
Exotic sunsets aren’t the only thing on the horizon…
The government of Canada defines medical tourism as “travelling to another country to receive medical care” (not to be confused with inbound medical tourism, which means people coming to Canada for medical care).1 But medical tourism is not emergency out-of-country medical care, rather it is the intentional pursuit of elective treatments across borders. So just how prevalent is medical tourism?
Only a few countries produce reliable data on the incidence of medical tourism. However, from the limited data available, the Conference Board of Canada has been able to pull together some estimates. In 2012, approximately 80,000 Canadians travelled to other countries for procedures that cost more than $1,000.2 Also, Statistics Canada estimates that in 2017, Canadians spent $1.9 million per day on health care trips to other countries—up from $1.2 million per day in 2013.3
Although the incidence of Canadian medical tourism estimated for 2012 is relatively small—at just 0.2% of the total population—the Conference Board reports in 2015, that during recent years, medical tourism is one of the fastest growing industries in the world.4 And growth is estimated to continue at a rate of 15%-25% annually.5
In addition, within medical tourism, dental procedures—or dental tourism continues to be on the rise globally. Although, as with medical tourism, the incidence of dental tourism isn’t well-defined, estimates include that it is the dominant form of medical tourism, accounting for 60% of some countries’ medical tourism revenue.6
Accordingly, if medical tourism isn’t already on your plan members’ horizon, it may be in their future. And more medical tourism can equal more risk to plan member health.
GSC PLAN MEMBERS INCREASINGLY TAKING FLIGHT…
As you may recall from the August edition of The advantage, GSC is seeing an increase in non-emergency foreign medical claims. For example, regarding claims reimbursed for dental work received outside of Canada:
- 2016 – 2017: 1.8% increase
- 2017 – 2018: 7.45% increase
- 2018 – 2019: 15.5% increase
Could your plan members become medical tourists?
Holiday Instagram posts don’t usually include pics from hospital beds and dental chairs. But given the projected growth rate for medical tourism, more recovering on-the-beach selfies may be in our future. Whether travelling outside of Canada solely to receive medical care—or to take advantage of the chance to have a massage on the beach while on vacation—the type of medical care and range of destinations varies.
In 2009, the top destinations for Canadian medical tourists were countries with investments in medical infrastructure like large hospitals in China, India, and Thailand.7 Their motivation to treat medical tourists? To use excess capacity while generating revenue. However, over the last five or six years, more Canadian medical tourists report travelling to places like the Caribbean and Central America to access smaller facilities purposefully built for medical tourists.8 Conditions that Canadians travel for include orthopaedic surgeries, dentistry, cardiac procedures, weight loss surgery, and cosmetic surgery—to name a few.9
So just who becomes a medical tourist? The motivation to seek medical care elsewhere is as varied as the services they seek and the destinations they travel to. For example, many are motivated by the desire to overcome perceived barriers to accessing care in their home country like…
Cost jumps out as an obvious motivation for American medical tourists, given no universal coverage, the high cost of care, and costs 30%-65% lower in many countries.10 Indeed, research indicates that lack of health insurance—or coverage that does not include certain conditions—are main motivators for American medical tourists. This illustrates that how a country’s health care is structured can influence the demand for medical tourism.
So what about Canada with universal health care and employer-sponsored private health plans? Cost can also be a motivator for low-income and unemployed Canadians or for those who don’t have a private plan. Even with coverage, cost can be an issue regarding deductibles, co-payments, and benefit maximums (think dental procedures like expensive bridgework). Motivation can also come from not wanting to pay out-of-pocket for treatments that aren’t covered—or aren’t fully covered—by a provincial or private plan. For example, research shows that lack of dental coverage—or perceived inadequate coverage—can increase demand for getting dental care elsewhere. Elsewhere like China where the cost of dental work is estimated to be 20%-30% lower than in Canada.11 A wide-ranging combination of factors can drive down costs in some places, this includes everything from lower salaries and lower cost of supplies to more competition.
Long wait times
In a 2016 survey of 11 comparator developed countries, Canada has the longest wait times to see a specialist and longer than average wait times for all elective surgeries.12 For example, in Calgary, the average wait time is one year for knee replacements and approximately 10 months for hip replacements.13 And maybe longer—in 2018, 30% of Canadians didn’t get their replacements done within the recommended wait times.14 Accordingly, some Albertans avoid the wait by heading to Mexico, Singapore, India, and the United States for the surgery.15
Unavailability of care
A range of issues—like lack of expertise or limited technology or high costs—limits availability of treatment in various countries, prompting medical tourists to seek care elsewhere. For example, medical tourists from Saudi Arabia come to Canada, the United States, and Europe for certain highly specialized surgeries.16 Even here, Canadian doctors indicate unavailability of treatment as a main motivator, after long wait times.17 For example, a mayor in Ontario travelled to Germany for a pancreatic cancer procedure considered experimental in Canada.18
In addition, Canadians travel for controversial treatments not offered here, such as going to Mexico, Costa Rica, Egypt, India, Bulgaria, and Poland to treat multiple sclerosis with “liberation therapy” (a process of widening veins in the neck).19 And some Canadians seek illegal services like travelling to China, Pakistan, and India to pay for an organ on the black market, known as “transplant tourism.”20
“Medical returns” refers to immigrants returning to their country of origin solely to get medical care.21 Also, visiting family and friends may provide an opportunity to access care at the same time. Either way, the motivation may be wanting to overcome cultural barriers like language. Ease of communication and a similar cultural identity can go a long way to building trust and a comfort level. And the draw for some is seeking culturally specific care not widely available here, like travelling to India for Ayurveda (an ancient practice that includes detoxification, a special diet, herbal remedies, massage therapy, yoga, and meditation).22
Although barriers to care exist for many Canadians, most would agree (in our humble opinion) that plan members have it pretty good. They are covered by their provincial plan and their private plan. This points out that sometimes motivation isn’t just in the form of wanting to overcome barriers, but also in the form of wanting to gain some advantages.
‘Sun, sea, and a new knee’
This is a hospital’s advertising slogan targeting medical tourists, including Canadians.23 The hospital promises “a tranquil setting that alleviates stress and encourages healing.”24 No kidding, as it’s located in the Cayman Islands. With sales pitches that include soaking up the sun while getting some treatment done, even going to the dentist can be appealing.
Plus, of course, the internet means that promotional messages know no borders. The Conference Board of Canada identifies the internet as a catalyst for medical tourism because it gives a platform for all kinds of players promoting and facilitating various services.25 For example, numerous medical tourism planner operate in Canada. This is in addition to traditional travel agencies that advertise medical tourism packages. Plus, of course, patients can directly research and connect with treatment providers in other countries with just a click of the keyboard (not to mention, bargain hunt online for cheap flights from budget airlines).
With all this buzz, if plan members haven’t already heard about medical tourism, they’re bound to as the buzz gets louder. The surgeon and entrepreneur who founded that hospital in the Cayman Islands plans to make it the “capital of medical tourism for the western hemisphere.”26 Similarly, a Canadian entrepreneur in Armenia whose company helps Canadians access dental work and plastic surgery abroad is striving to become the expedia.com of medical tourism.27 However, regardless of the motivation behind becoming a medical tourist, the risks are many.
Too good to be true
The old adage, “if it sounds too good to be true, it probably is” are words of wisdom— or more like words of warning—for plan members regarding medical tourism. No matter what the motivation, the cost/benefit—or more broadly, the risk/reward—is high on risk and questionable on reward. The main risk being quality of care.
The Canadian government heeds this warning: “Although Canadians may seek medical care in other countries, they need to be aware of the risks involved. It is important to remember that medical practices, health standards, and infection control measures in other countries may differ from those in Canada and could result in lower quality medical care.”28
Remember just how complex it is to understand the regulation of health professionals in Canada, as discussed in the February/March 2019 and April 2019 editions of The Inside Story? If it’s exceedingly difficult to understand the situation in our very own country, imagine trying to figure out quality assurance issues like training, oversight, and accountability—in a foreign country. And although there has been some international accreditation—for instance, hospitals meeting international standards—some experts feel that this represents a fairly low bar and that it gives potential medical tourists a false sense of security.29
Accordingly, the Canadian government gets right to the crux of the issue by stating that “even if you research the facility and staff thoroughly, there is no guarantee that what you experience will match the information that you found.”30 Bingo!
So the sales pitch of “our medical innovations include minimally invasive surgery, which results in faster recovery and reduced pain for our patients” may be nothing but a sales pitch.31 But how would plan members know? The answer is, they wouldn’t. Consequently, the Canadian government also cautions…
“Be aware of the implications of receiving medical care in other countries and be
prepared. For example:
- Some countries’ medical services may not test blood for blood-borne infections like HIV or hepatitis B. There can also be a risk of acquiring malaria from local blood banks in areas where malaria is present. Avoid injections or blood transfusions except in an emergency.
- Be aware that there are multi-drug resistant bacteria in hospitals and other health care facilities around the world.
- Vulnerable people may be coerced into donating their organs without their full consent. As a result, ‘transplant tourism’ and selling organs are illegal in many countries.”32
- Makes you think twice (hopefully, more than twice) because ultimately, the result of substandard or no oversight and accountability is poor treatment and in some cases, over treatment—or worse, the wrong treatment. Like the patient who got a root canal done in Mexico, but on the wrong tooth.33
If words of warning are “if it sounds too good to be true, it probably is,” then words to live by are “buyer beware” because the quality issue has far-reaching consequences. Such as, what happens when the dream vacation—with medical care to boot—results in health complications back in Canada? And some complications can be very serious given the increasing spread worldwide of antimicrobial-resistant infections.
This may sound familiar as earlier this year, the Public Health Agency of Canada warned that 30 Canadians may be at risk of a potentially deadly infection after having weight loss surgery at a clinic in Mexico. Some of the clinic’s patients contracted an antibiotic-resistant strain of bacteria. In addition, the agency is warning of the risk of hepatitis B, hepatitis C, and HIV.34 Complications back in the home country certainly lead to their share of more complications, like needing to:
- Get remedial care: Whether treatment complications or completely botched treatments, is it the responsibility of our Canadian doctors to “make it better”? And if so, what about potential legal action against Canadian doctors if the issues become more severe? Plus, is it the responsibility of our public health care system to cover the costs of “fixing”?
- Take legal action: Is it possible to take legal action for negligent care against a foreign doctor, dentist, hospital, or clinic? And if so, in addition to legal costs, what is the cost of the time and stress involved in trying to work through the foreign country’s legal system?
All risks with no clear answers. And even when all goes well, will continuity of care back home be high quality? For example, Canadian doctors voice concerns about their ability to effectively provide follow-up care because of poor or non-existent documentation of treatments. Even if documentation exists, it’s not necessarily shared across borders.35 Canadian doctors are also concerned about the many ways that medical tourism can influence the doctor/patient relationship, like when patients go against doctor’s “orders” and pursue medical tourism. Some doctors are also concerned about potential malpractice risk to themselves.36
Medical tourism is a losing proposition
Clearly, plan members have a lot riding on their decision to pursue medical care elsewhere—they are gambling with their health. And although in some instances they may hit the jackpot with good health outcomes, it’s the luck of the draw. This Canadian expert on the growing trend of medical tourism warns, “there’s often no way to predict from the outset if someone’s going to have a wholly positive or wholly negative experience.”37
In fact, the inability to effectively assess medical tourism options has led Canadian professionals to raise concerns about “whether or not medical tourists can provide informed consent to medical procedures abroad. This is because most information sources consulted during the decision-making process are marketing-focused and do not provide adequate insight into risks.”38
Fortunately, provincial plans and private plans hold a lot of aces—all the scientific evidence, rigour, and oversight that goes into coverage decisions protects plan member health. Multiple layers of oversight also help deter fraud because if the provincial or private plan can’t even find out whether a foreign provider exists—let alone whether or not it’s a legit provider—it opens up the plan to increased fraud.
As for GSC, as always, we’re data-driven and with the poor value proposition of medical tourism, we say (…just in case you haven’t had enough gambling lingo): medical tourism is rolling the dice with plan member health.