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COURTESY OF THINKSTOCK

AAOS Now

Published 7/1/2015
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Charles Carroll IV, MD; Daniel K. Moon, MD, MS, MBA

Ethical Issues in Domestic Medical Tourism

The evolution of medical care and the philosophy underlying physician reimbursements have brought new ideas and forces to bear on the delivery of health care in 2015. As healthcare insurers and payers search for alternatives to the traditional fee-for-service model and pursue the goal of “value” in health care, they take into consideration various models of care. They assume that a combination of efficient service delivery with lower complication rates can optimize outcomes and improve value in surgical services.

With the rise of domestic medical tourism (DMT), more patients under the auspices of their employer or insurer will travel to designated centers of excellence for high-quality care at a negotiated rate below what other providers might accept. However, as this model becomes a part of the fabric of contemporary health care, operational and ethical issues may arise.

Patient autonomy and consent
Patient autonomy is defined as the patient’s ability to make an informed decision about his or her care without undue influence. A patient should make healthcare decisions with clarity and careful thought. The decision to seek care at a distant center of excellence should require more than financial consideration.

However, the financial incentives to participate in a DMT program can be a powerful influence. Increasingly, patients must decide between undergoing surgery locally and paying hundreds to thousands of dollars in deductibles, copayments, and coinsurance or taking an all-expenses-paid trip to another city and never paying a cent for surgery with no out-of-pocket expenses. The magnitude of financial incentives can reach such a level that they may be considered coercive.

As a society, we need to carefully consider interactions between personal and financial choices when it comes to healthcare delivery. As payers and employers become increasingly involved in defining care, quality, and value, healthcare providers must actively participate to ensure that the interests of the patient are not overlooked and that patient autonomy is optimized.

For truly informed consent, patients will need to know how the pre-, peri-, and postoperative care will be provided. Arrangements for care must be clearly outlined. Economics are important, but they should not be the most important or only factor in patient choice and decision-making.

Beneficence and nonmaleficence
The issues of beneficence (whether the proposed treatment is good for the patient and the targeted population) and nonmaleficence (the care does not harm the patient) must also be considered. When care is generally standardized, as it can be with common orthopaedic surgeries, the question shifts to whether care delivery at the DMT site is better than that provided locally.

Consideration of beneficence requires definitions of adequate and optimal care. Complications—such as infection, failure of the procedure, late bleeding, venous thrombosis, pulmonary embolus, pneumonia, cardiac issues, and others—that drive postoperative care and hospital readmissions must be considered. Who will provide the care and under what circumstances? When a payer directs patients to specific providers, how will those who deliver follow-up care be reimbursed? These issues still need to be clarified.

Experience suggests that higher surgical volumes align with better outcomes. Qualified networks of physicians will be needed to provide postprocedure care and follow-up if the payer does not bring the patient back to the DMT center for such postoperative care. Responsibility for potential complications and associated medical issues will need to be defined and coordinated to minimize the risk of harm to the patient.

Follow-up care
When a local orthopaedist, who has provided the nonsurgical care, is notified that his or her patient is going elsewhere for surgery under a DMT program, the local surgeon may be both frustrated and surprised. The DMT program essentially leverages the local surgeon’s judgement about surgical indication, but denies him or her the opportunity to perform that surgery. It may also cause the patient to question the skills and capability of the local surgeon. However, that same surgeon may be called upon to provide follow-up care to the patient, particularly if acute complications arise.

DMT programs may lack local orthopaedic surgeons who have agreed to provide standard follow-up care for patients. These programs often rely on the patient’s local primary care provider to conduct follow-up visits. This may lead to potential conflicts in the provision of care for complications.

Under one DMT program, the insurer covers return visits if a serious concern or complication arises. But the type of complication (eg, septic arthritis) may impair the patient’s ability to travel or to wait for care. Patients with wound complications may turn to local surgeons for care, putting those surgeons in a difficult spot, especially if they do not feel comfortable handling complications resulting from a DMT surgery.

A double standard of follow-up care may also be an issue at the DMT site. DMT orthopaedists treat both local and DMT patients. These surgeons may prefer that local patients follow-up with them after surgery. A double standard is created when they routinely allow out-of-state DMT patients to see nonorthopaedists or primary care physicians for follow-up care. The implications of establishing a precedent of entrusting postoperative care to nonsurgeons must be considered.

When the complete episode of care is defined, and follow-up care is coordinated and reimbursed, an optimal outcome can ensue. In the absence of such coordination, harm may befall an individual patient.

Safety, access, and ‘cherry picking’
As patients travel longer distances for surgeries, safety becomes an issue. Proper hand-offs and coordination of care must be essential components of any plan that packages surgical care to create optimal pathways and avoid system and operational failures.

As society debates the importance of equal access to care for all populations, it seems compelling that members of the same patient cohort (those covered by employer- and payer-derived programs) should have equal access to care. Why should only healthier patients be offered the financial benefits of DMT travel? DMT programs may not be intended to exacerbate access problems, but their inherent design facilitates adverse selection, ie, “cherry-picking” lower risk patients.

Several DMT programs use screening criteria based on comorbidities. Patients are only allowed to participate if they meet specific weight, smoking, and diabetes criteria. However, no clear back-up plan exists for patients who fail to meet these criteria.

In addition, DMT programs are often only available through contracts with specific employers, whose employees may generally have better access to care and be healthier than the overall population. As a result, any publicized outcomes measures should be carefully scrutinized. DMT quality metrics, satisfaction scores, and other outcome measures should be adjusted prior to comparisons to metrics and the parameters reflecting the larger population. Advertising DMT outcomes as “superior” without adjusting for or acknowledging potential selection bias is concerning and potentially misleading. Adverse selection can be cheaper regardless of location; the real question of ‘value’ is whether DMT sites provide better outcomes as well as lower costs for the same patients.

Patient-centered care
The AAOS promotes safety, optimal health care, ethics, professionalism, and education. The issues raised in this article are not meant to dissuade the consideration of new healthcare delivery models in an evolving landscape and market. On the contrary, we hope to foster constructive discussion of how the new models should be designed to account for these complex issues.

As Francis W. Peabody, MD, concluded in his famous lecture, “the secret of the care of the patient is in caring for the patient.” If we, as a profession, place the patient first and work to optimize communication and safe health care, we will provide true value to our patients. They need education and choices. Neither paternalism nor the direction of care by payers should drive healthcare decisions.

Charles Carroll IV, MD, is the past chair of the AAOS Ethics Committee; Daniel K. Moon, MD, MS, MBA, is a current member of the AAOS Ethics Committee.