Medical tourism:

implications for

general practice

Assoc. Prof. Brent Lovelock

Department of Tourism

Dr Kirsten Lovelock

Department of Public Health, Wgtn

Definition

• Medical tourism is the practice whereby

individuals travel across national borders

with the intention of receiving medical care

Scope

• Cosmetic surgery (breast, face, liposuction)

• Dentistry (cosmetic and reconstruction)

• Cardiology/cardiac surgery (by-pass, valve replacement)

• Orthopaedic surgery (hip replacement, resurfacing, knee

replacement, joint surgery)

• Bariatric surgery (gastric by-pass, gastric banding)

• Fertility/reproductive system (IVF, gender reassignment)

• Organ, cell and tissue transplantation (organ

transplantation; stem cell)

• Eye surgery

• Diagnostics and check-ups.

Destinations

Costs

USA India Thailand Singapore

Heart bypass 113,000 10,000 13,000 20,000

Hip replacement 47,000 9,000 12,000 11,000

Spinal fusion 43,000 5,500 7,000 9,000

Gastric bypass 35,000 11,000 15,000 20,000

Rhinoplasty 4,500 2,000 2,500 4,375

Breast implants 6,000 2,200 2,600 8,000

US dollars; Lunt et al 2011

Scale

• Somewhere between 60,000 and 50

million medical tourists!

• US$60B industry (Deloitte 2007)

Demand side drivers

• Changes to domestic health systems

• Familiarity

• Availability

• Cost

• Quality

• Bioethical legislation (Glinos et al 2006)

• Privacy

• Tourism

Why people ‘do’ medical tourism

40

32

15

13

Most advanced technology

Better quality care

Quicker access

Lower cost

McKinsey 2008

Decision making

• Internet

• Media

• Networks- professional, friends and family

• “We need to know more about how

individuals access, process and judge

medical tourist information they retrieve

given such information may be confusing,

overwhelming, and even contradictory” (Lunt

et al 2011)

Quality of information

• Direct-to-Consumer sales model

• A study using the search term “breast

augmentation” located 130 sites and

concluded that 34% of these sites

contained information that was either false

or misleading (Jejurikar et al., 2002).

Quality of care, clinical outcomes

• lack of comparative quality and safety data

• lack of information on infection rates for

overseas institutions

• lack of reporting of adverse events

• evidence of clinical outcomes is limited

• Travel component poses additional risk

Continuity of care

• patient follow-up by providers is rare

Liability and redress

• Differences in standards and regulations

• Difference in legal liability

• Lack of knowledge of how to pursue a complaint

• Jurisdiction

• legal disclaimers

Implications for health systems

at home• Costs of emergency or remedial treatment

• Infection outbreaks

– E.g. ‘Superbug’ NDM-1 [New Delhi metallo-beta-

lactamase]

• Impact on private health sector

• exacerbating two-tier system? (Lunt et al 2011)

• Savings for public health systems- from

‘outsourcing’? (Smith et al 2011)

• Potentially drive down costs in domestic health

systems? (Herrick 2007)

Ethical issues

• Some procedures illegal in home country

• Or experimental

• E.g. rewarded kidney donation

Cases from our study

• Qualitative study of New Zealanders who had

travelled abroad for medical treatment.

‘Rob’: 40 yrs, Auckland

• Procedure: Ear pinning

• Destination: Thailand

• Chris was travelling to Thailand with his wife, who

was undergoing a breast augmentation, so decided

to get his ears done too.

• Cost: $5500 for both airfares, accommodation and

holiday expenses, plus his surgery ($2000)

• NZ quote $6500.

• “I’d definitely go overseas because you get a

holiday out of it, and you still get a cheap operation”

• Didn’t talk to his GP…

‘Jane’: 42yrs, Auckland

• Procedure: PET scans for family

member who had a malignant

neuroendocrine tumour

• Destination: Australia Family member

• Individual had surgery in NZ. Yearly PET scans

recommended

• Travel necessary as radio-nucleotide has a very

short half life, and cant be used in NZ

• Travel and scans covered through health

insurance

‘Suzanne’: 61 yrs, Auckland

• Procedure: Full face lift

• Destination: Malaysia

• Chose Malaysia because had never been to Kuala

Lumpur

• Booked procedure through ‘Beautiful You Holidays’

• Cost was $7000 c.f. $30,000 in Australia.

• Could have recovery time while away and not have

to go through the “why I’ve been away” questions

• Chose provider on basis that they had worked on

the Malaysian Royal Family

• Didn’t tell GP

‘Alan’ 28yrs Auckland

• Procedure: Blepharoplasty

• Destination: Thailand

• Alan walked in off the street to a clinic in Phuket

• Has had three rounds of revision

surgery/treatment in Australia (all failed)

• Currently having more corrective work done in

NZ

• “Complete disaster. .. Cost thousands, and not

covered by ACC”

• “Lost all confidence, emotionally devastating,..”

‘Bob’ 75yrs, Central NI

• Procedures: Cardiac ablation

• Destination: France

• Searched internet, leading expert in France

• Procedure (at the time) was not available in NZ

• Specialist (Auckland) said there is no procedure,

“you’ve got it for life, fella”

• Specialist: “Why do you want to have a froggy

poking around in your heart for?”

• GP pushed the idea and acted as liaison with

France

‘Paul’, 59yrs, Auckland

• Procedure: cardiac ablation

• Destinations: Italy, France

• At the time there was only one person in NZ, who

was just starting to do the procedure

• Paul wanted the best, and undertook an internet,

finding a provider in Milan. But the procedure didn’t

work, and his condition returned on arrival back in

NZ

• “Claimed a success rate of 80% but that turned out

to be only 12%... Xxxxx was a charlatan…No

evidence that he had actually done anything”

‘Karmel’ 44 yrs, Wellington

• Procedure: IVF

• Destination: India

• Grew up in India. Married again at 40yrs, premature

menopause

• Did not meet criteria for public funded IVF in NZ

• Couldn’t afford private $12,000 per treatment

• In India- cost $7000 incl airfares, travel around India,

treatment and medication

• Needed a donor egg- availability and strict criteria NZ

• GP “didn’t want to know anything about it”

‘Vijay’ 48yrs, Auckland

• Procedure: Polycystic kidney treatment

• Destination: Thailand, India

• Very negative experience with NZ public health

system

• Travelled to Thailand where a friend worked and

recommended some doctors

• But not happy with culture and language there

• So flew on to India (where grew up) and had

operation successfully there

• GP was supportive of travel for treatment

‘Jack’ 58 yrs Dunedin

• Procedure: mitral valve replacement

• Destination: India

• Prognosis 2 yrs to live, could get public funded

surgery in NZ, but internet search revealed that

in Dunedin they “cut you open” c.f. overseas you

can have microsurgery

• Internet search: US $100,000; Singapore

$40,000; India $10,000 (final cost was $12,000)

• Google: 5 hospitals in Delhi; 4 in Chennai; 3 in

Mumbai.

• Infection in wound- 3 days in hospital in NZ

Implications for GPs

1. Inadequate regulation within the industry

2. Lack of systematic reporting of clinical outcomes.

3. Replacement of clinical decisions with financial

ones

4. Exposure to new health and safety risks

5. Threats to informational continuity of care

6. Provision of follow-up care and monitoring happens

at home

7. Procedures might be illegal or untested

• (Crooks and Snyder 2011)

Critical questions for

GPs

• Should I support my patient’s medical tourism?

• How much should I be involved?

• Will my involvement implicate me if anything

goes wrong?

• Shouldn’t the specialist play a role rather than

me?

• If something goes wrong, how can I best support

my patient?

Where do GPs fit?

GPs’ potential roles

• decision-making stage

• strategies for minimizing health risks

• medical records

• follow-up care