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Home , Medical tourism

Medical (MT): A to our Patients Didn’t Bargain for

Linda MacConnell, PA-C, MPAS, MAEd Many thanks to Stephanie Fortuna, PA-C  Well…..  I love love love medicine  Honored to be a PA for 35 years (counting the 2 years as a PA-S) AND  I love to ! AND  The world fascinates me  ENT and  Introduced to medical tourism by Stephani Fortuna, PA-C

Why Medical Tourism? Why do WE need to know this?

 Medical tourism has been increasing worldwide  Expected to grow in the next 5-10 years, especially cosmetic procedures  Additionally for necessary medical procedures, meds & elective  The global health marketplace is booming and we need to be able to educate, inform “consent” and  be advocates for our patients who choose this path We always start with the HX:

 MT not a new concept; not initially financial This Photo by Unknown Author is licensed under CC BY-NC-ND  Medieval ages in Greece; sacred healing baths  Tourists would travel to Greek temples  Early 1700’s Bath in England  Covered sewers allowed for Spa services  Then up into the 20th century, US became the MT magnet  Technology and therapeutics  Then ; initially for interest in Ayurvedic medicine This Photo by Unknown Author is licensed under CC BY-SA  Late 20th C. travel to save $  First and Central America  Then Asian countries marketed themselves

This Photo by Unknown Author is licensed under CC BY-SA WHAT and WHO?  What: Medical tourism = pts travel to obtain medical services; typically procedures; World Health Organization (WHO) likes the term medical “travel/er”  Doesn’t count expats and emergency care obtained by tourists  Outbound*  Inbound!  Intrabound  Who?  *Travel all over the world, usually from developed to developing countries  ! More traditionally low income to high income  We’ve asked for Years about travel in the hx and here is another reason to ask WHY, WHERE and WHO

 Why: Reasons include seeking quality care; to US, Switz Costs of care, long waiting times (esp Europe and ) Limited availability of desired procedure (insurance authorization, regulations, legality) all-inclusive packages  Where: , Dominican Republic, , India, , , , ,  Some MT pts obtaining services legal both at home and their destination Hip replacements, cardiac bypass, cosmetic More Who and Why?

 Some seek services illegal @ home & destination, other country “looks the other way” Terminally ill pts: experimental tx not approved in the US  Transplant tourism—travel to a country where organ purchase or sale is illegal, but it happens—is one of the best examples of this  Travel to obtain procedures legal from a place where they are illegal or strictly regulated = “circumvention tourism”.  Examples = travel to obtain , , reproductive technology  Stem cell tourism also circumvention travel, not illegal but represents a technology restricted at home via control of biomedical therapies  Terminally ill pts: experimental tx not approved in the US U.S. vs. the world: costs of major procedures in major medical tourism locations*:

Procedure U.S Costa India Malaysia Mexico South Taiwan Thailand Rica Korea Average 45%-65% 65-90% 60-80% 40-60% 25-45% 40-65% 50-75% savings Coronary artery 92,000 31,500 9,800 20,800 34,000 29,000 27,000 33,000 bypass Valve replace- 87,000 28,000 11,900 15,000 26,500 38,000 22,000 19,000 ment & bypass Total hip 31,000 15,300 9,400 12,500 14,200 21,600 14,000 16,500 Total knee 28,000 14,200 7,200 7,800 12,300 16,200 13,400 13,200 Gastric bypass 23,000 10,500 6,800 9,250 11,500 14,500 12,700 12,600 4 implant por- 21,500 9,350 6,850 7,700 9,300 9,900 8,700 9,300 celain bridge Full Facelift 11,500 4,900 2,800 3,300 4,750 5,900 5,250 3,700 Rhinoplasty 4,800 2,600 1,400 2,800 3,100 3,800 3,200 1,600

*February 2017. All values in US dollars. U.S. costs vary due to location, materials/equipment used, and pts’ requirements and are averages based on most common costs. International travel and lodging not included. Source: Patients Beyond Borders  In Malaysia  In Costa Rica  In India  Many medical tourists spend recovery vacationing

Who wouldn’t want to recover: What’s out there?  Cosmetic and dental surgery*  Cardiovascular (angioplasty, CABG, transplants  Orthopedic (joint and spine; sports medicine)  (lap band; bypass)  Organ and tissue transplantation  Cancer (esp last )  Reproductive health  IVF treatment  Abortion  Assisted suicide  * Most Common Infections: Commensals: “Nl Flora” carried on skin, One’s commensal mouth, digestive tracts, etc. bacteria may = Pathogens: harmful disease another's pathogen causing bacteria

Why is it NOT MT pts take commensals and pathogens to the the best foreign hospitals where they travel AND: thing in the WORLD Exposure to commensals Dx and tx difficult for and pathogens of foreign Locals and travelers providers, hospitals, and who are exposed to general folks foreign “nl flora” Health Care Associated and other Infections

MT countries like Thailand & India = places where infections like TB and Malaria are endemic World Health Organization (WHO) data from many countries estimates hundreds of millions of patients around the world are affected by Health Care Associated Infections (HCAI) Low-middle-income countries > high-income ones Nosocomial infections: ~10–15% of pts in hosp in low-income countries vs 7–8% in higher income countries Case presentation

American patient with hx of obesity underwent gastric bypass surgery Approved and paid for by insurance Successful & pt lost a large amount of weight resulting in large amount of redundant tissue  Insurance would not cover abdominoplasty Pt traveled to Mexico; underwent abdominoplasty These photos are not our patient:

 Abdominoplasty = one of the MC aesthetic surgical procedures worldwide. Estimated > 800,000 people undergo each year; 6th MC cosmetic procedure  See why abdominoplasty is desired  Redundant tissue  Infection after abdominoplasty Post procedure, could Drains were removed too soon and allowed a large 18 only afford to stay 3 cm x 10 cm hematoma to days in Mexico form.

46 year old female presents w/ fever, chills, nausea and abdominal pain Case Erythema, edema and ecchymosis of the surgical site Presentation Examination CT showed large hematoma Temperature >100.4

Wound exploration, evacuation and packing or primary closure with sutures or staples Literature Review

 Post op infections not uncommon  Hygiene procedures  Commensals and pathogens  Recent study1 reported 42 infections in MTs  39/42 in Dominican Republic  MC procedures abdominoplasty, mastoplexy and lipo  Referred to as “lipotourists”  Rapidly growing mycobacteriua: Mycobacterium abscessus, Mycobacterium fortuitum, Mycobacterium chelonae  M. abscessus in 74%  Clinical take home: Think of this is a pt who traveled w/ Postop infection resistant to Rx  Multiple acid fast bacilli cultures  Clarithromycin, amikacin, moxifloxicin • 44-year-old woman went to the DR for mastopexy/ abdominoplasty April 2015 4 weeks post-op presents w/ M. abscessus infection Resolution of the infection after surgical drainage and appropriate antibiotic treatment 14 weeks after diagnosis with RGM wound infection. What’s the cause?

 WHO says: Medical procedures often occur in multiple steps; may need tx over a longer period of time  W/ foreign travel steps may be squeezed into a shorter period of time  F/U care might be needed after pt returns  Breaks the link in continuing care:  Problematic for the individual and local health system  Health care providers may hesitate to fix a problem caused by malpractice abroad; patients then turn to $$ emergency services  Consider the travel involved: e.g. a long flight from Asia to US after ortho surgery Therefore: MT may undergo less expensive procedures of questionable quality: complications post-op can cost the pt’s health and pocketbook Transparency: Difficult in the US; more so in other countries Credible outcomes information on foreign procedures is difficult Common methodology for data collection is lacking;  Statistics ltd. on MT available & not comparable country to country Can OFFER“High Quality” Care

 But says who? Unmonitored  Generally, international hospitals/facilities don’t release This Photo by Unknown Author is licensed under CC BY-SA outcomes data, adverse events, errors, nosocomial infection rates  Hard to make “data-based judgment” and substanciate safety claims  Difficult to research and find data

This Photo by Unknown Author is licensed under CC BY-NC-ND Disclaimer:

 At one point it was thought that medical tourism would SKYROCKET  Predicted by 2017: 25 million Americans would travel for care  2016: 12-15 million traveled WORLDWIDE Affordable Care Act (ACA) made foreign travel less necessary particularly for needed but elective procedures Still many travel for cosmetic procedures and from other countries Ethical considerations MT raises many ethical issues. May cause division in health care policies: ensuring the access of health care for every citizen vs promoting cutting-edge technologies for foreign pts Assets move toward offering care to foreigner w/$$$$ Concerns re: changes in pt-provider relationship: healthcare moves from patient care activity toward health care as a commodity: MT involving human body resources e.g. organs Ethical concerns raise debate Scarcity of human body resources = concerns about obtaining and using MT Ethical Concerns

 Many countries w/ restrictive/prohibitive legislation re: policies governing donation & access (organ procurement)  Big international variation in legislation and enforcement trigger international flows of pts attempting to take advantage of legal differences  Estimates in 2005 total # of recipients who underwent commercial organ transplants overseas ~5% of all recipients.  MT for transplantation is MC way of receiving transplants in some places  Human body resources typically more available where poor and vulnerable population groups will jeopardize their health for a small financial reward  Often, standards of health care for donors = poor and w/o f/u care On the plus side

 The Joint Commission (The US' main hospital accrediting agency) opened an international accrediting office in 1994 w/ growth of medical tourism from the US  Involved International accrediting groups to raise standard of care due to lack of regulation  Joint Commission routinely accredits foreign hospitals using the same standards as the US.  Joint Commission International increased # of approved foreign sites from 76 (2005) to 985 (2017) Refer pts to: https://www.jointcommissioninternational.org/about-jci/jci- accredited-organizations/  Malaysia, Dubai, Mumbai, and China  Possibly, could become the single largest purchaser of tourism medicine?  https://medicaltourismassociation.com/en/about- us.html Countries with JCI-Accredited Organizations Insurance and Medical Tourism  Insurance companies in several countries have started offering plans covering international medical care Offered at a lower price than domestic plans, expected that tx and rx are less expensive in a foreign country In the US, several plans, such as Access Baja, have developed in CA Offer options w/ lower premium and co-pays for employees of American companies wanting to obtain health services in Mexico Regulators have also become aware of the challenges of the availability of insurance coverage for medical treatment abroad EU travelers seeking acute or ambulatory care another EU country are covered directly by their home insurance arrangements MT & Insurance

 US pts w/ private insurance may participate in MT paid for by insurer  For private insurers & pts; cost = major motivator  US health insurers pay less for a than a pt. pays out of pocket; insurer pays 2.5 X less if the procedure done in Thailand MT and Insurance

 Cost savings add up  Insurers w/ large numbers of covered pts & = dramatic cost savings  Pt traveling to Costa Rica from North Carolina for gastric sleeve surgery could save $3,000 out of pocket in the US AND  Get a bonus check for $2500 from her employer; which is only a %age of the corporate savings in insurance costs  The employer could afford to do this as medical care has saved the employer nearly $10 million in health care costs over the past five years Conclusions: Take homes and talking points

 Pts desire cosmetic procedures (CP) and foreign travel for CP will  As clinicians in a border state, our pts may be more likely to engage in MT  The global health marketplace is booming and we need to be able to educate, inform “consent,” and be advocates for our patients who choose this path  Patients must be made aware of risks and benefits  Patients must understand that f/u care will be necessary  US clinicians may be reluctant to provide care for those who received foreign care  Patients must know that negative outcomes are not well documented in other countries  There is a risk for infection  There is JCI accreditation  https://medicaltourismassociation.com/en/about-us.html  https://www.jointcommissioninternational.org/about-jci/jci-accredited-organizations/ References

1. Padilla P, Ly P, Dillard R, et al. Medical tourism and postoperative infections: A systematic literature review of causative organisms and empiric treatment. American Society of Plastic Surgeons. January 24, 2018. Published online: www.PRSJournal.com  Cohen I. Medical tourism, medical migration, and global justice: Implications for biosecurity in a globalized world. Medical Law Review. Vol. 25, No. 2, pp. 200– 222 http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=6&sid=06bcca7b- 066f-4d47-8c7c-56e42844b9f2%40pdc-v-sessmgr01.