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Can Fam Physician. Oct 2007; 53(10): 1639–1641.
PMCID: PMC2231416

Medical tourism

Family medicine and international health-related travel

Delays for medical interventions such as hip and knee replacements, spinal surgery, and ophthalmologic procedures are a serious problem in Canada. Federal and provincial governments are struggling to shorten waiting lists and provide timely care. Patients often wait months to obtain appointments with specialists, undergo diagnostic tests, and receive treatment. Lack of access to family physicians can make obtaining care particularly difficult.

Recognizing that many Canadians are unable to obtain prompt treatment, medical tourism companies promote travel to medical facilities in other countries.1 Customers of these companies can purchase anything from cosmetic procedures and diagnostic examinations to kidney transplants, in vitro fertilization, cancer therapies, and orthopedic procedures. The cost of medical tourism packages varies greatly. Prices depend on the procedures clients select, where they travel, how long they intend to stay, and whether they choose postoperative accommodations in budget hotels or luxury resorts.

At least 15 medical tourism companies operate in Canada. One such company is located in Alberta, 1 is located in Manitoba, 7 are located in British Columbia, 3 in Ontario, and 3 in Quebec. This list does not include more traditional travel agencies advertising medical tourism packages: a Vancouver-based travel agency arranges trips to Bumrungrad International Hospital in Bangkok, Thailand; a Quebec travel agency markets travel to hospitals and clinics in India.

Canadian medical tourism companies send their clients to such countries as Argentina, Brazil, China, Costa Rica, Cuba, France, Germany, India, Malaysia, Mexico, Pakistan, Poland, Russia, Singapore, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, the United Arab Emirates, and the United States. Some companies send their clients to a single medical facility in a particular country, while others advertise a choice of destinations.

The health care travel packages typically include air and ground transportation, travel visas, hotel accommodations, assistance from a local company representative in the destination country, transfer of medical records to treating physicians, and negotiated rates for whatever medical procedures clients decide to purchase.

Wealthy Canadians have always had the option of traveling outside Canada for treatment.24 Medical tourism companies “democratize” the international health care option. Recent news media coverage tracked the journeys of a chaplain who sought cancer treatment in the state of New York, a high school biology teacher who traveled to India for treatment, and a cab driver who visited Belgrade for surgery.57

With some treatments unavailable in Canada and other medical interventions available only after long delays, medical tourism companies use problems with Canada’s provincial health care systems to promote out-of-country health care. Though few Canadians can afford the high price of care at US medical centres, the international facilities offer less expensive access to private health care.

The number of medical tourism companies in Canada is growing. At present, however, these businesses are relatively small, have few employees, and appear to have a limited client base. As these companies become better known, standardize their operations, and benefit from considerable media coverage, it is possible that more Canadians will travel to other countries for treatment. Interest in the medical tourism option will likely decline if Canadians gain improved local access to elective surgical procedures, such as hip and knee replacements. If waiting lists persist or lengthen, however, medical tourism companies might succeed in “outsourcing” treatment for more Canadians seeking immediate care.

Advocates of medical tourism

Supporters of international health-related travel argue that medical tourism promotes patient choice, gives consumers access to treatment alternatives not found in their local communities, permits expedited access to care, fosters global competition, and puts pressure on more expensive health care facilities to lower their prices. As well, say advocates, the practice promotes economic and social development by building health care economies in developing societies.

Within the United States, advocates of medical tourism characterize travel to such places as India and Thailand as a safety net for uninsured and underinsured Americans who cannot afford to purchase expensive medical procedures at local hospitals.8 Many American companies have out-of-country travel options in their health insurance plans.9 West Virginia is considering legislation that will provide financial incentives to state employees willing to travel outside the United States for health care.10,11 In Canada, supporters of medical tourism argue that the practice promotes improved access to care for patients able to pay for treatment and helps citizens who cannot afford to travel abroad by shortening waiting lists at home.

Proponents of medical tourism note that internationally accredited health care facilities are located around the world. Supporters emphasize the high quality of care at private hospitals and clinics in Asia, the Caribbean, Eastern Europe, and South America.

Critical perspectives

Critics of medical tourism have several powerful arguments on their side. Medical tourism raises concerns about health equity. Wealthy citizens can afford to buy immediate access to care, while poorer citizens wait in queues.

Quality of care is a serious concern. Though medical tourism companies typically broker arrangements through internationally accredited hospitals, quality of health care around the world is variable. Some Canadian patients who travel abroad for care will likely receive excellent treatment. Other patients will be at increased risk of receiving substandard care. The modest body of scholarship on patients traveling to China, India, and Pakistan for organ transplants suggests that commercial out-of-country transplantation substantially increases morbidity and mortality rates.1214 Quality of care and patient safety could be serious concerns with other medical procedures.

Continuity of care is another problem associated with medical tourism. Within Canada, family physicians ideally interact with specialists and remain involved in patient care throughout the course of treatment. Continuity of care is likely to be disrupted when patients travel to other countries for treatment. Some medical tourism companies link family physicians to specialists in the countries where care is to be provided. In other cases, patients travel for hip and knee replacements, kidney transplants, cataract surgery, and other procedures, and return to their family physicians with no documentation concerning the care they received outside Canada. The task of the family physician is made far more difficult when continuity of care is disrupted and patients offer little information about the treatments they received outside Canada.

Legislation, professional codes, and institutional policies place strict legal and ethical duties upon Canadian physicians to disclose risks, benefits, treatment alternatives, and the consequences of not receiving medical care. Physicians in other countries are, of course, not bound by Canadian law. It is possible that Canadian patients will not be fully informed of risks and benefits when they arrange medical care outside Canada. Family physicians might sometimes find themselves providing postoperative care to patients who overestimated benefits and underestimated risks associated with treatment outside Canada.

Finally, Canadian physicians are governed by laws containing standards for determination of negligence and medical malpractice. Canadian courts provide a forum where patients can seek legal redress if they are harmed while receiving care. Patients who leave Canada and receive negligent medical care might find they cannot obtain legal remedies in the countries where they obtained treatment. Furthermore, the medical tourism companies that arrange out-of-country care insist that patients sign waivers of liability. These documents state that medical tourism agencies have no legal obligations if patients are harmed while receiving care at destination sites. Companies will presumably try to use these documents to shield themselves from litigation if their clients are harmed while receiving care outside Canada.

Conclusion

Travel for treatment outside Canada might remain a minor, idiosyncratic option for Canadian patients. Many patients will not want to leave their family members and other loved ones to receive a hip replacement in India, for example. Furthermore, some patients will prefer the frustration of waiting for treatment over whatever risk they associate with traveling abroad for care.

It is also possible, however, that avoiding treatment delays by leaving Canada for care will become increasingly common. If medical tourism companies expand their clientele, family physicians will find themselves treating increasing numbers of patients willing to leave Canada for medical care. Family physicians will have to decide whether they should mention this option when patients face lengthy waits for treatment. They will have to consider to what extent they should help their patients explore risks and benefits associated with traveling elsewhere for care.

If international health-related travel remains a marginal phenomenon, few family physicians will have to face such questions. Some Canadian patients, however, are becoming decidedly impatient. Tired of waiting for treatment, afraid of the suffering they will have to endure if they do not receive the therapies they require, or concerned about the harm they might experience by failing to receive health care in a timely fashion, they are willing to pay for prompt access to care. Therefore, it is possible that family physicians might soon find themselves encountering increasing numbers of patients contemplating traveling abroad for care.

What should family physicians say in such circumstances? What role should they play in facilitating or discouraging out-of-country care? How might continuity of care be undermined in a world in which patients travel to Pakistan for kidney transplantation or India for orthopedic surgery? Should family physicians provide patient records to medical tourism companies? Should family physicians in Canada help their patients arrange care in destinations such as Cuba and India? Will continuity of care suffer if travel in search of treatment becomes common?

Having answers to such questions might soon become important.

Footnotes

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

References

1. Eggertson L. Wait-list weary Canadians seek treatment abroad. CMAJ. 2006;174:1247. [PMC free article] [PubMed]
2. Johnston C. US ad uses lure of prompt treatment to entice Canadians needing joint replacement. CMAJ. 1996;154:1071–2. [PMC free article] [PubMed]
3. Katz SJ, Cardiff K, Pascali M, Barer ML, Evans RG. Phantoms in the snow: Canadians’ use of health care services in the United States. Health Aff (Millwood) 2002;21:19–31. [PubMed]
4. Korcok M. Excess demand meets excess supply as referral companies link Canadian patients, US hospitals. CMAJ. 1997;157:767–70. [PMC free article] [PubMed]
5. Alcoba N, Patrick K. Ontario agrees to pay $52,000 cancer bill. National Post. 2007. Jan 31, Sect. A:13.
6. Priest L. Panel orders Ontario to pay for hip surgery. The Globe and Mail. 2007. Feb 3, Sect. A:6.
7. Priest L. Long wait forces cancer patient to buy operation in land he fled. The Globe and Mail. 2007. Jan 31, Sect. A:1.
8. Roth M. Surgery abroad an option for those with minimal health coverage. Pittsburgh Post-Gazette. 2006. Sept 10. [Accessed 2007 Aug 28]. Available from: www.post-gazette.com/pg/06253/719928-37.stm.
9. Yi D. Overseas surgery a clamp on costs. Los Angeles Times. 2006. Jul 30, Sect. A:1.
10. Appleby J, Schmit J. Sending patients packing. USA Today. 2006. Aug 9. Accessed 2007 Aug 27Available from: www.usatoday.com/money/industries/health/2006-07-26-travel-surgery-usat_x.htm.
11. Anderson J. Hospitals oppose ‘medical tourism’ bill. Charleston Daily Mail. 2007 Feb 16
12. Canales M, Kasiske B, Rosenberg M. Transplant tourism: outcomes of United States residents who undergo kidney transplantation overseas. Transplantation. 2006;82:1658–61. [PubMed]
13. Kennedy S, Shen Y, Charlesworth J, Mackie J, Mahony J, Kelly J, et al. Outcome of overseas commercial kidney transplantation: an Australian perspective. Med J Aust. 2005;182:224–7. [PubMed]
14. Prasad GV, Shukla A, Huang M, D’A Honey RJ, Zaltzman JS. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation. 2006;82:1130–5. [PubMed]

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