Medical Tourism

Introduction

Medical tourism is defined as traveling to another country for medical care. People may travel internationally to seek less expensive procedures or a procedure they cannot receive in the country where they reside. A medical tourist's pursuit of health care abroad may also be influenced by a desire to receive care from a healthcare professional who shares their culture or language. Medical tourists may base their choices on recommendations from friends, family, or social media, and some medical tourists may combine medical care with a vacation.

Medical tourism is a worldwide, multibillion-dollar market that continues to grow with the rising globalization of health care. Surveillance data indicate that millions of U.S. residents travel internationally for medical care each year. Medical tourists from the United States most commonly travel to Mexico, Canada, the Caribbean, and several countries in South America. Categories of procedures that U.S. medical tourists pursue include, but are not limited to, cosmetic surgery, dental care, cancer treatment, fertility treatment, and organ transplantation.

Medical tourists often use private companies or medical concierge services to identify healthcare professionals or clinics that can perform a procedure. Social media are common sources of information about where to go for certain procedures and which facilities and healthcare professionals serve medical tourists. Costs for procedures are usually out of pocket, although some U.S. health insurance companies and large employers have alliances with healthcare facilities outside the United States and may pay for care.

Categories of medical tourism

Cosmetic tourism

Traveling to another country for aesthetic surgery is known as cosmetic tourism. These are among the most frequently sought procedures abroad among U.S. residents. Common procedures sought by cosmetic tourists include abdominoplasty, breast augmentation, buttock augmentation (e.g., "Brazilian butt lift"), liposuction, and rhinoplasty. Popular destinations often are marketed to prospective tourists as low-cost, all-inclusive cosmetic surgery vacations for elective procedures not typically covered by insurance. Complications, including infections and surgical revisions for unsatisfactory results, can compound initial costs.

Dental tourism

Dental care is the most common form of medical tourism among U.S. residents, in part due to the rising cost of dental care in the United States; a substantial proportion of people in the United States do not have dental insurance or are underinsured. Dentists in destination countries might not be subject to the same licensure oversight as their U.S. counterparts.

Oncology tourism

Oncology, or cancer treatment, tourism often is pursued by people looking for alternative treatment options, better access to care, second opinions, or a combination of these. Oncology tourists are a vulnerable patient population because the fear caused by a cancer diagnosis can lead them to try potentially risky treatments or procedures. Treatments or procedures obtained abroad may have no established benefit, placing the oncology tourist at risk for harm due to complications (e.g., bleeding, infection) or by forgoing or delaying approved therapies in the United States. Patients receiving immunosuppressive treatment may be vulnerable to infection while traveling (see Immunocompromised Travelers chapter).

Rehab tourism for substance use disorders

Rehab tourism involves travel to another country for substance use disorder treatment and rehabilitation care. Travelers exploring this option might be seeking a greater range of treatment options at less expense than what is available domestically or might prefer a setting that provides more distance and privacy (see Substance Use and Substance Use Disorders in Travelers chapter and Box 5.3.1 for pros and cons of rehab tourism). Travelers considering rehabilitation programs in another country should understand the local laws regarding the substance for which they are seeking treatment and know that attitudes and quality of services toward treatment for substance use disorders may not be equivalent to what they would receive in the United States (see Traveling with Prohibited or Restricted Medications chapter). Depending on the substance, some countries may require registration with law enforcement registries before admission to a program.

Reproductive tourism

Reproductive services sought outside the United States include fertility treatments and abortions. Some do so to avoid associated barriers in their home country, including high costs, long waiting lists, and restrictive policies. Others believe they will receive higher quality care abroad. People traveling to other countries for fertility treatments often are in search of assisted reproductive technologies (e.g., artificial insemination by a donor, in vitro fertilization). Many women seek abortions outside of the United States due to laws that limit access to medications or procedures used to terminate pregnancies.

Those seeking fertility or abortion services abroad should be aware, however, that practices can vary in their level of clinical expertise, hygiene, and technique. In addition, those seeking abortion outside the United States should also research legality of the procedure in the destination country.

Transplant tourism

Transplant tourism refers to travel for receiving an organ, tissue, or stem cell transplant from an unrelated human donor. The practice can be motivated by reduced cost abroad or an effort to reduce waiting time. An increased prevalence of chronic conditions such as kidney disease has driven up the demand for transplant tourism.

Depending on the location, donors might not be screened as thoroughly as they are in the United States. Furthermore, organs and other tissues might be obtained using unethical means. Transplant tourists may not receive adequate follow-up, including documentation from their surgeons, increasing the risk of postsurgical complications.

The pre-travel consultation

Medical tourism is not without risks (see Risks and Complications section), which can vary depending on many factors. Standards for quality of care, including adherence to infection control practices, vary significantly outside the United States. Medical tourists should take steps before they travel to reduce risk of an adverse health outcome. At a minimum, those considering medical tourism should have a discussion with their primary healthcare professional in the United States well in advance of travel. Medical tourists could also consult a travel medicine specialist for travel advice tailored to their specific health needs and destination 4–6 weeks before travel. Medical tourists should be up to date on all routine vaccinations, especially hepatitis B virus immunization (see Vaccination and Immunoprophylaxis—General Principles chapter).

If consulted, the travel medicine specialist should discuss current medical conditions and ensure that the medical tourist will have a sufficient supply of all regular medications to last the duration of their trip. If the travel medicine specialist or medical tourist has concerns about a medical condition or medication, the tourist should be referred back to their primary care professional.

Medical tourists should discuss the plan for addressing complications related to the treatment or procedure with both their U.S. healthcare professional and the healthcare professional performing the treatment or procedure outside the United States. In addition, medical tourists should check their domestic health insurance plan carefully to understand what services, if any, are covered outside the United States (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Travelers might need to purchase supplemental medical insurance coverage, including medical evacuation insurance. This is particularly important for travelers going to remote destinations or places lacking medical facilities that meet the standards found in high-income countries. Medical tourists also should be aware that if complications develop, they might not have the same legal recourse as they would if they received their care in the United States.

Remind medical tourists to request copies of their overseas medical records in English and to provide this information to any healthcare professionals they see subsequently for follow-up. Encourage medical tourists to disclose their entire travel history, medical history, and information about all surgeries or medical treatments received during their trip.

Risks and complications

All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. Counsel medical tourists that participating in typical vacation activities (e.g., consuming alcohol, participating in strenuous activity or exercise, sunbathing, swimming, taking long tours) during the post-operative period can delay or impede healing. Advise medical tourists not to delay seeking medical care if they suspect any complication during travel or after returning home. Obtaining immediate care can lead to earlier diagnosis and treatment and a better outcome.

Infection

Among medical tourists, the most common complications are infection-related. Inadequate infection prevention and control practices place people at risk for blood-borne infections, including hepatitis B, hepatitis C, and HIV; bloodstream infections; donor-derived infections; and surgical site infections. Moreover, the risk of acquiring antimicrobial-resistant infections might be greater in certain countries or regions; some highly resistant bacterial (e.g., carbapenem-resistant Enterobacterales [CRE]) and fungal (e.g., Candida auris) pathogens appear to be more common in some countries where U.S. residents travel for medical tourism.

Several infectious disease outbreaks have been documented among medical tourists, including fungal meningitis in patients who received epidural anesthesia in Mexico, CRE infections in patients who underwent invasive medical procedures in Mexico, and surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic.

Noninfectious complications

Noninfectious complications that are common in the United States may also occur abroad, including blood clots, fat thromboembolism, contour abnormalities after cosmetic surgery, surgical wound dehiscence, and death.

Travel-associated risks

Traveling during the post-operative or post-procedure recovery period or while being treated for a medical condition could pose additional risks for patients. Air travel and surgery independently increase the risk for blood clots, including deep vein thrombosis and pulmonary emboli (see Deep Vein Thrombosis and Pulmonary Embolism chapter). Travel after surgery further increases the risk of developing blood clots because travel can require medical tourists to remain seated for long periods while in a hypercoagulable state.

Commercial aircraft cabin pressures are roughly equivalent to the outside air pressure at 6,000–8,000 ft above sea level. Medical tourists should not fly for 10 days after chest or abdominal surgery to avoid risks associated with changes in atmospheric pressure. The American Society of Plastic Surgeons (ASPS) recommends that patients undergoing laser treatments or cosmetic procedures to the face, eyelids, or nose wait 7–10 days after the procedure before flying. The Aerospace Medical Association published medical guidelines for air travel that provide useful information on the risks for travel with certain medical conditions (see Air Travel and Travelers with Chronic Illnesses chapters).

Like other international travelers, medical tourists may be targets of violent crimes such as kidnappings (see Safety and Security Overseas chapter). Those considering medical tourism should check with the U.S. Department of State's (DoS) website to learn of the current threats before making the decision to travel. Once at the destination, medical tourists should be vigilant of their surroundings and pay attention to any new alerts sent by the embassy or consulate. Travelers may sign up to receive notifications of important safety information for their destination country, including the local area where they are staying, by enrolling in the DoS's Smart Traveler Enrollment Program before or during travel.

Risk mitigation

Multiple resources are available for healthcare professionals and medical tourists assessing medical tourism–related risks (Table 5.3.1). When reviewing the risks associated with seeking health care abroad, encourage medical tourists to consider several factors besides the procedure; these include the destination, the facility, and the treating healthcare professional. Medical tourists should ensure that they understand which services are included as part of the cost for their procedures; some overseas facilities and healthcare professionals charge substantial fees for follow-up care in addition to the base cost. Medical tourists should also know whether follow-up care is scheduled to occur at the same facility as the procedure.

Make patients aware that medical tourism websites marketing directly to travelers might not include (or make available) comprehensive details on the accreditations, certifications, or qualifications of advertised facilities or healthcare professionals. Local standards for facility accreditation and healthcare professional certification vary and might not be the same as those in the United States. Some facilities and healthcare professionals abroad might lack accreditation or certification. In some locations, tracking patient outcome data and maintaining formal medical record privacy or security policies are not standard practices.

Medical tourists should be aware that pharmaceuticals, laboratory services, and medical devices used in other countries might not be subject to the same regulatory scrutiny and oversight as in the United States. In addition, some drugs could be counterfeit or otherwise ineffective because of expiration, contamination, or improper storage.

Professional organizations have developed guidance, including template questions, that medical tourists can use when discussing what to expect with the facility providing the care, the group facilitating the trip, and their own domestic healthcare professional. For instance, the American Medical Association developed guiding principles on medical tourism for employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States (Box 5.3.1). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism, with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to healthcare professionals in the United States, which can facilitate continuity of care and proper follow-up.

ACS recommends that medical tourists use internationally accredited facilities and seek care from healthcare professionals certified in their specialties through a process equivalent to that established by the member boards of the American Board of Medical Specialties. Accrediting organizations (e.g., The Joint Commission International, Accreditation Association for Ambulatory Health Care) maintain listings of accredited facilities outside of the United States. ACS, ASPS, the American Society for Aesthetic Plastic Surgery, and the International Society of Aesthetic Plastic Surgery all accredit physicians abroad. Advise medical tourists to do as much advanced research as possible on the facility and healthcare professional they are considering using, including reviewing these sources before committing to medical care abroad. Also, inform medical tourists that accreditation does not guarantee a good outcome.

Table 5.3.1: Online medical tourism resources

Box 5.3.1

Notes

*Please see American Medical Association's (AMA) 2008 resource titled New AMA Guidelines on Medical Tourism for more information.

Additional guidance for U.S. healthcare professionals

Healthcare facilities in the United States should have systems in place to assess patients at admission to determine whether they have received medical care in other countries. Healthcare professionals should obtain an explicit travel history from patients, including any medical care received abroad. Patients who have had an overnight stay in a healthcare facility outside the United States within 6 months of presentation should be screened for CRE. Admission screening is available free of charge through the Antibiotic Resistance Laboratory Network.

If possible, notify state and local public health as soon as medical tourism–associated infections are identified. Returning patients often present to hospitals close to their home, and communication with public health authorities can help facilitate outbreak recognition. Healthcare facilities should follow all disease-reporting requirements for their jurisdiction. Healthcare facilities also should report suspected or confirmed cases of unusual antimicrobial resistance (e.g., CRE infections, C. auris) to public health authorities to facilitate testing and infection control measures to prevent further transmission. In addition to notifying the state or local health department, the Centers for Disease Control and Prevention requests notification of complications related to medical tourism by emailing medicaltourism@cdc.gov.

Acknowledgements

The following authors contributed to the previous version of this chapter: Grace D. Appiah and Michael Christ.