AAOS Now explores the growing trend of traveling abroad for medical care

As U.S. healthcare costs continue to increase, many Americans are facing difficult choices. Should a 61-year-old uninsured waitress who needs bilateral knee replacement wait until she’s eligible for Medicare before having the surgery because she can’t afford the $100,000 total cost? Or what about the 46-year-old self-employed construction worker who needs disk surgery, but the $90,000 estimated cost would bankrupt his company?

In both cases, over the objections of their U.S. physicians, the patients became “medical tourists,” traveling to Bangkok, Thailand, for their surgeries. According to the National Coalition on Health Care, 500,000 Americans went overseas for medical care in 2005. They traveled to locales such as India, Singapore, Thailand, Mexico, and Costa Rica for dental procedures, heart surgery, fertility treatments, and orthopaedic surgery—and paid as little as one-tenth of the average charges in the United States.

With 44.8 million Americans currently uninsured—and millions more underinsured—it’s likely that medical tourism’s popularity will continue to grow. And, as more Americans opt to travel overseas for medical care, their physicians are raising significant patient safety concerns.

Low-end medical costs, high-end accommodations
“People come to India for a wide range of procedures,” says Rajesh Rao, co-founder and chief executive officer of IndUShealth, a Raleigh, N.C.-based company that coordinates overseas health care in Indian hospitals for American patients. “Orthopaedic procedures are quite common because people will put off the surgery until they find the right solution.”

According to Rao, his clients undergo such common orthopaedic procedures as arthroscopy and knee replacement as well as shoulder, rotator cuff, and spine surgeries. Rao uses the example of hip resurfacing, a procedure that was only recently approved by the FDA for use in the United States, to illustrate the dramatic price difference between the costs of surgery in India compared to in this country.

“Hip resurfacing typically costs upwards of $45,000 or $50,000 in the United States,” says Rao. “In India, the same procedure is done for roughly $7,000. Even with the cost of travel and the stay, the total cost is between $10,000 and $11,000.”

IndUShealth, which was founded in 2005 by Rao and Tom Keesling, a former CEO of a U.S. hospital, has seen its business grow substantially. The company started out with just a trickle of business but now provides its services to approximately 1,000 patients a year.

“It [medical travel] has gone from being esoteric to something that people can understand and get their arms around because they’ve heard of others who have gone there and been successful,” says Rao.

Some major American health insurers are considering providing coverage for their customers to receive medical care abroad. Self-insured employers are also showing interest in signing deals for their employees to travel abroad for medical care. IndUShealth, for example, has several individual and corporate clients.

“At this point, our focus is on looking at offering what we have to companies,” says Rao. “We have a pretty large network of people who are beginning to tap into what we provide.”

Along with India, Thailand is another popular destination for medical tourists. The country is home to the 554-bed Bumrungrad International Hospital, a healthcare organization that treats approximately 400,000 international patients each year. It has more than 700 nurses and 945 physicians, covering 55 subspecialties. More than 200 of its physicians are U.S.-board certified, and a large percentage of the medical staff carry board certification from the United Kingdom, Australia, Germany, or Japan.

The Orthopaedics Center, which is one of the hospital’s 25 specialty centers and clinics, advertises a complete range of diagnostic, therapeutic, and surgical orthopaedic services, including everything from general orthopaedics to joint replacement, treatment of peripheral nerve disorders, and orthopaedic oncology. Its orthopaedic-related facilities include a dedicated outpatient clinic and specialized cast rooms and treatment areas.

Along with its emphasis on providing excellent care, the hospital also creates an upscale environment for patients—so much so that its patients feel more like they’re at a fancy hotel than a medical facility. Bumrungrad’s spacious “single deluxe” room, for example, features a granite dining table for four, carpeting, and a private marble bathroom with a shower, refrigerator, and drinking water. Restaurants such as McDonald’s, Au Bon Pain, and Starbucks, which deliver to hospital rooms, are just steps away from the hospital.

More important than any of these amenities, however, is that Bumrungrad International is accredited by The Joint Commission International (JCI), the international arm of the organization that evaluates and accredits U.S. hospitals. According to Keesling, IndUShealth holds JCI accreditation in such high regard that it refers patients only to hospitals with that status. So what kinds of safeguards does JCI-accreditation put in place in international healthcare organizations?

Safety and international accreditation
Karen H. Timmons, president and CEO of JCI, says that more than 100 healthcare organizations are accredited by JCI. These hospitals must meet stringent requirements for the safety and quality of their care. JCI-accredited healthcare organizations must collect, monitor, and evaluate data on an ongoing basis to assess organization quality and patient safety. JCI-accredited hospitals must also comply with the International Patient Safety Goals, requirements that address issues such as avoiding wrong-site, wrong-patient, and wrong-procedure surgery; ensuring effective communication; and reducing the risk of healthcare facility-acquired infections.

“One of the most important parts of JCI accreditation is the credentialing and privileging of the staff,” says Timmons. “Our standards are very consistent with those of the Joint Commission (previously known as JCAHO) with respect to ensuring that credentialing and privileging are renewed every 3 years to make sure there is appropriate staffing and that staff are trained appropriately.”

Not all international organizations are JCI-accredited, however. The safety monitoring at these unaccredited healthcare organizations is left up to the discretion of the government; some countries, says Timmons, have no form of licensing at all.

Patient safety concerns
According to Joshua J. Jacobs, MD, chair of the AAOS Council on Research, Quality Assessment and Technology, safety and quality of care at international hospitals may fall short in many areas.

“Medical tourists need to be concerned about the safety of the hospital’s blood products, allograft safety, and whether the hospital has a full array of devices available,” says Dr. Jacobs. “What about the drugs the hospital is using—are they under the control of an appropriate regulatory agency? Is the organization following appropriate protocols for prophylactic antibiotics and wrong-site surgery? All of these safeguards have been put into place in U.S. hospitals. At international hospitals, you don’t always know what you’re getting yourself into.”

Dr. Jacobs also notes that the availability and adequacy of ancillary services can pose safety issues.

“The surgeon may have been trained in the United States and may use all the contemporary devices, but what about the training of the anesthesiologists, nurses, physical therapists, and medical consultants?” he wonders.

After patients have left the facility and are on their way back home, other problems can arise.

“It may not be advisable for patients to take long trans-Atlantic or trans-Pacific flights in the early postoperative period,” says Dr. Jacobs. “There’s also an issue of continuity of care. It’s valuable to continue to receive care from the physician who actually performed the surgery because there are variations of current surgery techniques. The patient’s surgeon is the most knowledgeable about what happened during the procedure and may modify the postoperative protocols accordingly. If a patient seeks care for a postoperative complication from a surgeon who didn’t perform the procedure, the patient is at a disadvantage.”

The future of medical tourism
According to Timmons, many patients use the Internet to search for other options and alternative treatments. She also points to the continued expansion of overseas healthcare organizations.

“I think globalization of health care is here to stay,” says Timmons. “We’re seeing growth of healthcare chains. Before, there might have been a concentration of one hospital chain within a country. Now, we are starting to see them grow beyond their borders. For instance, Bumrungrad International is now building other facilities around Asia.”

Dr. Jacobs believes that patients who are national and international healthcare consumers will continue to explore medical travel as an option.

“These groups of patients shop to find the care that they think is best for them based on word of mouth, information from the Internet, and recommendations from their physicians. Patients are far more mobile these days than they used to be in seeking their care, particularly in elective orthopaedic procedures,” he admits.

Although you may not be able to prevent your patients from investigating overseas medical care, you can help raise their awareness of patient safety issues to consider. See the box below for a list of the types of safety issues that medical tourists may face at some international facilities.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Safety issues patients should investigate if considering surgery overseas
I. Patient safety issues, such as

• Blood safety
• Allograft safety
• Device regulation, hospital inventory of devices
• Drug regulation
• Prophylactic antibiotic protocols, evidenced-based guidelines
• Wrong-site surgery protocols
• Sterility procedures/infection control
• Nosocomial infection history

II. Availability and adequacy of

• Ancillary services (magnetic resonance imaging, physical therapy)
• Medical consultants
• Intensive care unit services
• Blood banking services

III. Credentialing and certification

• Hospital certification
• Nursing care
• Surgeon credentials/certification
• Anesthesiologist credentials/certification

IV. Postoperative complications/postoperative follow-up issues

• Availability of subspecialists in case of complications, particularly if medical comorbidities are present
• Deep vein thrombosis/pulmonary embolism (thromboembolic disease)
• Hazards of trans-Pacific/trans-Atlantic travel
• Wound infection management
• Continuity of care
• Late onset postoperative complications

Courtesy of Joshua J. Jacobs, MD