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Maturitas 73 (2012) 300 304
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Maturitas
jo ur n al hom ep age : www.elsev ier .com/
Review
Why do patients engage in medical tourism?
Vivien Rua Globalizationb Health Techn
a r t i c l
Article history:Received 23 AAccepted 25 A
Keywords:Medical tourisUnmet needMedical decisiChoiceHealth inform
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3001.1. The global market for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3011.2. Fullling the (unmet) need for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
2. On the decision for medical tourism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3012.1. Should I stay or should I go? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3022.2.
3. . . .(Ex3.1.
4. ConclContrCompProveAcknoRefere
1. Introdu
In ordetourism offa patients ucial for info
CorresponE-mail add
pm.carrera@ya
0378-5122/$ http://dx.doi.oShopping for medical care abroad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302pensive) deal? Confronting quality issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302Vetting providers of services abroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
uding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302ibutors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303eting interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303nance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303wledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303nces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
ction
r to take advantage of the opportunities medicalers as well as address and contain attendant threats,nderstanding of medical tourism is necessary and cru-rming a decision. This paper aims at extending current
ding author. Tel.: +31 53 489 5657; fax: +31 53 489 2159.resses: [email protected],hoo.com (P.M. Carrera).
knowledge on the increasingly popular and complex form ofaccessing and providing medical care, that is, medical tourism bydistinguishing the focal content of the decisions that patients make.Based on the existing literature, the paper proposes a theoreti-cal sequence of decision-making to engage in medical tourism,which includes considerations of the required treatments, locationof treatment, and the quality and safety issues that are attendantto seeking care. Correspondingly, it indicates improved ways toaccess health information online and refers to the current regu-latory mechanisms which impact on medical tourism.
see front matter 2012 Elsevier Ireland Ltd. All rights reserved.rg/10.1016/j.maturitas.2012.08.011nnelsa, P.M. Carrerab,
and Health Equity Research Unit, Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, ON K1N 6N5, Canadaology and Services Research Department, School of Management and Governance, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands
e i n f o
ugust 2012ugust 2012
m
on-making
ation
a b s t r a c t
Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the systemand individual levels. The decision to engage in medical tourism, however, is more complex, driven bypatients unmet need, the nature of services sought and the manner by which treatment is accessed. Inorder to benecially employ the opportunities medical tourism offers, and address and contain possiblethreats and harms, an informed decision is crucial. This paper aims to enhance the current knowledgeon medical tourism by isolating the focal content of the decisions that patients make. Based on theexisting literature, it proposes a sequential decision-making process in opting for or against medical careabroad, and engaging in medical tourism, including considerations of the required treatments, locationof treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on theimperative of access to health information and the current regulatory environment which impact on thisincreasingly popular and complex form of accessing and providing medical care.
2012 Elsevier Ireland Ltd. All rights reserved.locate /matur i tas
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V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304 301
Source: Adapte
1.1. The glo
Medicalas an econoa major drtures beingcompanies elsewhere tto vote witcal touristspatients preing economadvanced e[4,5].
Among medical carby the Unitto US$660 mUnited StatUS$2.3 billiwith exporrespectivelytion of movalone, whildo not drive
1.2. Fulllin
At the hspur that dviduals for simplistic nthe individuover and abity for persassessmentsurgeries incoronary arthe develop
As illustbeyond thoavailable anmay be for
equence of a typical decision-making process to engage in medical tourism.
tically (i.e. resulting from lack of/insufcient health insur-overage) or rationed according to urgency (in the case ofly funded elective treatment), to one that does not resolveh problem but may improve an individuals sense of well-Fig. 1. Hierarchy of Health Care Needs.d from [10].
bal market for health care
tourism is commonly perceived and popularly depictedmic issue, with high costs of domestic health care beingiver of individual demand, and with these expendi-
a major driver on the supply side for countries andwho feel they can offer signicant cost advantageso large numbers of potential patients who are willingh their feet [1,2]. As such, although ows of medi-
are multidirectional [3], the direction of movement ofdominantly present as out of OECD countries to emerg-ies such as India, Malaysia and Thailand as patients ofconomies hedge the cost of medical services at home
OECD countries, for example, the largest importer ofe is Germany with US$1.5 billion in imports followeded States and the Netherlands with imports amounting
illion and USD$618 million, respectively [6]. That thees is the largest exporter of health care, reporting someon in exports followed by the Czech Republic and Turkeyts amounting to US$418 million and US$409 million,
[6], meanwhile, is further illustration that the direc-ement is not one-way and that wide price differentialse instrumental in the calculus for seeking care abroad,
Fig. 2. S
domesance cpublica healt medical tourism [3,4].
g the (unmet) need for health care
eart of the growth in medical tourism providing therives continued growth , is the unmet need of indi-health care [1,3]. The need for health care is neitheror binary. Decisions to engage in medical tourism atal level, may include considerations for the individualove a decision to purchase a good, service or commod-onal consumption and enjoyment, such as making an
of consequences for ones health and life. For example,cluding total hip replacement, total knee replacement,tery bypass graft, etc. are regarded as high risk as withment of antibiotic resistance [79].rated in Fig. 1, the hierarchy of health care needs goesse which are medically indicated for which funding isd not restricted [1012]. Consequently, the unmet needa medically necessary treatment which is inaccessible
being [3,13care systemnon-health
2. On the d
Identicmaking prodecisions retreatment (ties availabin the decisis determinthe extent alized. To ilas a (fertilito the numof treatmenthen fullls]. These needs are to be primarily met by the health; preventive health services may well be addressed by
care action.
ecision for medical tourism
ation of need is the rst step in a sequential decision-cess toward engaging in medical tourism: subsequentlate to the type of treatment sought and the location ofsee Fig. 2). Information about need, treatment modali-le and options for treatment abroad are core elementsion to seek treatment at home or abroad. While needed by the individual, the health care system inuencesto which a hierarchy of needs for health care is actu-lustrate, even as in vitro fertilization (IVF) is approvedty) treatment within a health care system, restrictionsber of covered treatments or the high market pricingts can lead to an unmet need, which medical tourism
in non-domestic locations [14,15]. In this regard, while
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302 V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304
need is independent of economic considerations (i.e. need existsonly where there is an effective service to improve health) to theextent that health care as a commodity is consumed to attain health,economic circumstances lead to needs not being met [11,16].
2.1. Should
The deciwho not onlmaking [17identicatioconsult a hthrough anof-mouth [decision to
Consultitreatment wfessional wof treatmenaspects of thare broughsystems thminimal, coprovision w
The procthe provisiotion takes pwithin and/the domestoutcomes fsuch, medicbut of the h
2.2. Shoppi
That thefeature of mand the conand havinging power epitomizes centered hemedical toutreatment a
Europeaauthority reing from dinsured patfor out-of-cprior to thetourism offcare system
Importinages of healThe export to turn excecare, unfortresulting frhealth care,repeat purcrepeat purc
Obtaininmedical toupose seriouof procedurreviewing t
of quality with regard to decision-making in medical tourism issomewhat beyond the scope of this paper, the matter of quality ofinformation pertaining to medical tourism decision-making will bediscussed in the remaining part of the paper.
(Exp
make cle
ed exendse theationible urgerndatian Mns toe of tereandinial th
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ited bces, a
caree sinitatioe loc.
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env I stay or should I go?
sion-making model postulated here considers a patienty wishes to be informed but also is involved in decision-,18]. The rst decision point in the process is then of a treatment option which leads the patient toealth professional locally or abroad, either directly or
intermediary, medical concierge, broker or by word-1921]. Which option is selected inuences the nalseek medical care, domestically or otherwise [22,23].ng a local health professional may likely result in localhile consulting an intermediary or foreign health pro-
ill expand the individuals options regarding locationt. The latter make manifest the latent consumeriste patient-doctor interaction as nancial considerations
t up [24,25]. For patients who come from health careat are publicly funded or where the private sector isnsideration of the direct and indirect costs of serviceill be made alongside quality.ess of engaging in medical tourism does not end withn of health care abroad considering that full recupera-lace back at home even though initial recovery happensor outside the health facility abroad. This implies thatic health care system (primarily) deals with any adverseollowing any temporary exit of patients [2628]. Asal tourism is not just an issue of the individual patientealth care system as a whole.
ng for medical care abroad. . .
patient is sovereign throughout the process is a keyedical tourism. By gathering information on the needcomitant medical treatment that will satisfy as such,
control over decision making and exercising purchas-to access a range of treatments, the medical touristthe empowered patient touted as critical to a patient-alth care system [2426]. To be sure though, not allrists end up footing the bill or paying the full price ofbroad.n legislation holds that the national purchaser or healthimburses for the treatment of the patient abroad result-elays in treatment domestically [13,27]. In Canada,ients may receive reimbursement from the public purseountry care but are generally required to seek approval
delivery of treatment abroad [28]. Be as it may, medicalers relief for the individual patient and also for healths [3,26].g medical services can be a means of overcoming short-th resources and dealing with stretched health budgets.of medical care, in the meantime, offers the opportunityss capacity into productive use. The market for medicalunately, is far from the perfect, frictionless ideal [29,30]om the search, experience and credence attributes of
that is, features that can be evaluated by the senses, byhases and that cannot be perfectly evaluated even withhase, respectively [31].g from the decision-making process of engaging inrism, medical tourism is rife with issues of quality thats threats to the safety of the patient such that the typee and choice of provider need to be considered whenhe risk of care abroad [7,32]. Whereas surveying issues
3. . . .
To requirereportand frito guidinformof credafter sommeAmericSurgeooutsid
Whin defepotentshouldthat siglish quas DISCsupporinform
3.1. Ve
QuaknownCanadadards These Qualitycare astraininprocestend torather
As oaccredResourhealthincreasaccredtals arEurope
It iwhich count ahospitArabiaing thaan inpaever, athe ne
4. Con
Medrivenforeignensive) deal? Confronting quality issues
informed decisions on medical treatment, patientsar, appropriate information, and often rely on theperiences of third parties as well as advice from family
[13,22]. Increasingly, patients carry out online researchir decisions to consume health care. Unfortunately, the
highway, that is, the Internet, is no foolproof sourceinformation (p. 64 [19]). The promise of sun and seay may put in abeyance the medical professionals rec-on prompting medical professional groups such as theedical Association and the American Society of Plastic
issue guidelines for individuals considering treatmenthe U.S. [32,33].s the guidelines as well as regulations are unequivocalg the interests of their members or constituents, thereats to patients safety and welfare are serious andbe taken lightly [34]. Even if not perfect, mechanismsf not to ensure quality, exist to guide decisions. To estab-
health information online there are rating tools such [20,29]. Quality labels such as HONcode certicationablishing the reliability of information and quality of
on treatment choices online [20,35].
providers of services abroad
of hospital care can be compared through commonly regarded accreditation systems such as Accreditationrnational, the Australian Council on Healthcare Stan-national and the Joint Commission International (JCI).es are all recognized by the International Society forHealth Care (ISQua) which accredits external healthent organizations, their standards, and their surveyor]. Given the high costs associated with accreditationospitals that place value in international accreditation
for accreditation from one of the accreditation bodies multiple accreditations.
May 2012, a total of 370 international hospitals werey JCI, the international division of the Joint Commission
US-based afliate of the Joint Commission that certies facilities in the United States, reecting a double-digitce 2010, and indicating its standing in the market forn of hospitals [37]. Two-thirds of JCI-accredited hospi-ated in Asia while a little over one-fth are located in
rth noting that while Thailand, India and Singapore,egarded as destination countries for medical tourism,g the countries with the most number of JCI-accredited
heir numbers pale in comparison to Turkey (40), Saudi and United Arab Emirates (33) (see Fig. 3). Consider-t all dental and cosmetic surgeries are carried out ont basis for which accreditation is chiey designed, how-itation through the proper national agency would be
st source of guidance on quality of medical care.
ing remarks
tourism is more than an economic issue or a price-nomenon given the nature of services sought and theironment in which treatment is delivered [5,15,29]. That
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V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304 303
Source: [35].
patients sehealth is coas such, resiveness of unmet needing to EasteUS or West
Consideengaging ina concertedpolicy-makand welfare[34,28]. Direncouraginfor making than can brsystem thaton medical
Of coursachieving dof resourceseration of toffers, advageneral anddence on thand providi
Contributo
PMC conthe initial tributed to of the nal
Competing
The auth
Provenanc
Not com
Acknowled
A prelimUniversity, of the EuroSweden, 30
acknowledge feedback from the participants to the conference andthank Dr. Neil Lunt as well for discussions and collaboration of pre-vious work on medical tourism and comments on an earlier versionof this paper.
nces
t N, Caturitaith R,
liter1;103rera Pdical t6;6(4
pkins at is 0;31(nels Vrism1;8(1anizance 2iciesalendetheticagi Krism: ctive &
arasistancical, a602
Instiportra.ibm.cessedn S, Ge servdicineds B. atmenier ARers n1;23(orn Mility hropoyer A8;24:er RBnt decitney. Zeits8;102d BJ, ntierst N, Consumond
ding mgh J, CisionsusineFig. 3. Top 10 countries with JCI accredited hospitals.
ek access to care abroad says something about hownstrued and how domestic health care is regarded and,ects to a certain extent on the performance and respon-domestic health care systems [26,28]. This, is driven by(s) of medical tourists, be they Western Europeans y-rn Europe or Southeast Asia, or Asians traveling to theern Europe for treatment.ring that the sequential decision-making process of
medical tourism is strewn with concerns of quality, effort involving professionals, regulators as well asers should be undertaken in order to protect the safety
of individuals who avail of such a temporary exit optionecting patients toward sound health information andg them to be critical of information are important stepsinformed decisions. This requires developing a systeming medical tourism to account as well as an accounting
would support the development of an evidence basedtourism [2,27].e, where patient involvement is regarded as crucial inesired health outcomes and promoting the efcient use, medical tourism should be welcome [3,25]. In consid-he challenges and opportunities that medical tourismncing scholarship on the globalization of health care in
of medical tourism in particular, calls for empirical evi-is increasingly popular and complex form of accessingng medical care.
rs
tributed to the conceptualization of the paper, writingdrafts and approval of the nal submission. VR con-the review, completion of the nal draft and approvalsubmission.
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Why do patients engage in medical tourism?1 Introduction1.1 The global market for health care1.2 Fulfilling the (unmet) need for health care
2 On the decision for medical tourism2.1 Should I stay or should I go?2.2 Shopping for medical care abroad
3 (Expensive) deal? Confronting quality issues3.1 Vetting providers of services abroad
4 Concluding remarksContributorsCompeting interestProvenance and peer reviewAcknowledgementsReferences