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The Hilltop Review

Volume 10 Issue 2 Spring Article 6

October 2018

Medical and Its Effect on United State Healthcare in a Highly Connected Global Landscape

Katarina Haist Western Michigan

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Part of the Business Administration, , and Operations Commons, and the and Medical Administration Commons

Recommended Citation Haist, Katarina (2018) "Medical Tourism and Its Effect on United State in a Highly Connected Global Landscape," The Hilltop Review: Vol. 10 : Iss. 2 , Article 6. Available at: https://scholarworks.wmich.edu/hilltopreview/vol10/iss2/6

This Article is brought to you for free and open access by the Graduate College at ScholarWorks at WMU. It has been accepted for inclusion in The Hilltop Review by an authorized editor of ScholarWorks at WMU. For more information, please contact wmu- [email protected].

Medical Tourism and Its Effect on United State Healthcare Industry in a Highly Connected Global Landscape

Katarina Hasit

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29 Executive Summary out to customers traveling on their own or For centuries people have traveled to opting not to have the expensive procedure all together. other countries to obtain the best healthcare. History of Medical Tourism Traditionally these popular destinations were The concept of medical tourism is not highly developed countries; the trend of people a new age topic in the healthcare field. Greek traveling to less developed areas for treatment pilgrims were among the first recorded is relatively new. The average person is more occurrence of medical tourism when they connected to the world around them than ever traveled from the Mediterranean to Epidauria, before through globalization. Information a small territory in the Saronic Gulf about the best practices are more widely (Tsolakidou, 2012). The area was the sanctuary available than ever before. The importance of of the healing god Asklepios and Hygeia; the physical barriers to business such as geography healing abilities of these holy hot springs were and time are being eliminated. Due to this widely believed (Tsolakidou, 2012). People “flattening” per Friedman, the competition were drawn to these locations in large and expertise for areas in Science, , numbers, and locations that wanted to , and Mathematics (STEM) can be differentiate themselves from their shifted overseas. The availability of competition would incorporate activities such information boosts the quality of care as gambling , dancing, or other social in developing countries to a level of care activities (Weisz, 2011). Therefore, for more rivaling that of developed countries, but than 2500 years the idea of travel for health of without the excessive cost associated. the body and mind has been around. The and healthcare During the early 1900s, Europe and the infrastructure of the are not United States were known for their very ready to compete on this global scale of progressive and forward thinking medical field. healthcare. A lack of transparency of costs, Many people from developing countries high administrative costs, and little proactive traveled for treatment in developed countries planning of infrastructure to accommodate to for their aliments that were beyond the medical the trend each contribute to the United States capabilities in their home country. Due to falling behind in this competition. Increasing “rapid scientific discovery and medical transparency and decreasing administrative progress in the ensuing decades stimulated a costs can help improve the long-term proliferation of medical facilities in developed infrastructure of the healthcare system to nations, making the latest clinical techniques diminish the potential financial impact of and technological increasingly people traveling abroad for cheaper but high- available to the citizens of these countries” quality procedures. A medical facilitator could (IMTJ, 2008). These same treatments were be incorporated into the hospital infrastructure unavailable or offered at a lower quality to to help retain some of the lost earnings. The those in the developing country, so people facilitator would with foreign hospitals living in these countries were traditionally and centers of excellence to coordinate travel, forced to travel for top of the line medical care. accommodations, translators, and after-care This line of thinking illustrates the traditional back at the domestic hospital. Legal liability view of medical tourism. would then be mitigated through of Shifting Trends in Medical Tourism the patient from the medical facilitator instead Comparative to ancient times, medical of a physician recommendation. By offering tourism in recent years has changed with the these services for the patient, the hospital can global trends. In Friedman’s “World is Flat” still receive a portion of the income and paper, he stated that many events from 1989 to improve customer satisfaction rather than lose around the year 2000 lead to a flattening of the

30 world. His definition of a flat world refers to industrialized countries in North America and the ability for the anyone in the world to be Europe. Upon finishing , some able to collaborate and transfer ideas in real certified physicians stay in the developed time no matter their geography, distance, and country to practice . Others return to potentially language (Friedman, 2005). These their home country to practice medicine and traditional barriers to the transfer of improve the current trend of healthcare in their information are becoming less significant. home country (IMTJ, 2008). Through Information about healthcare procedures, increased access to education due to quality, and qualifications of doctors can now globalization, physicians in developing easily be looked up and compared using the countries can work to meet and potentially . Global competition for talent and exceed international qualifications and board resources will only increase if this trend certification while serving domestic and continues. international patients. Friedman suggests that in modern Reversal of Medical Tourism America, we have three issues that are causing Many medical patients in traditionally gaps between the United States and other parts developing countries are no longer forced to of the world. These are ambition, numbers, travel to the United States or Europe to have and education (Friedman, 2005). American more advanced procedures performed. children may feel a sense of entitlement when Instead, the medical travelers now come from compared to other people their age in different developed countries seeking out better value areas of the world. The average American child with faster treatment times and cheaper costs then lacks ambition and devotion to do as in less developed countries. (IMJT 2008). The much when compared to children in China or traditional drivers of medical travelers of high India and their drive for self-betterment, quality procedures have been diminished. creating the first gap. Compounding this issue Many hospitals around the world in multiple is the number gap. This refers to the number countries are in competition on the global of children in the United States who are not scale, raising the total quality offered to going into STEM fields. When compared to patients in their care. Today’s conscientious other countries, there are less qualified people patients are increasingly balancing “health domestically in STEM fields. We are creating a needs against many other considerations, and shortage of these jobs within the United States, medical concerns may even be subordinate to so companies are forced to look elsewhere to other issues such as allocation of personal fill these positions. Friedman suggests that resources (IMJT 2008)”. If a patient cannot companies can get better-skilled and more afford to pay for a treatment in the United productive workers, sometimes for less pay States, the patient may settle for a cheaper than American workers (Friedman, 2005). It is procedure somewhere else that may not be top theorized the education gap is due in part to in their field, but still safe. the first two issues along with less emphasis Drivers of New Age Medical Tourism placed on the content of the United States Costs may be the main reason for the STEM fields in lower education. This could reversal of the medical tourism trend. A have a major impact on the healthcare system movement toward free access to healthcare has since it falls into the STEM category. recently gained support to alleviate the Another reason for the shift toward motivation to travel to other countries for medical tourism is the increase in access to medical procedures. While the primary driver higher education for people in developing of medical tourism would be voided, another countries. Many opportunities for driver would just compound the higher efflux postgraduate for those of people that would want to travel due to living in developing nations involve travel to avoid long wait time. To quantify the

31 difference in wait times: in 2005 if a person conditions. The Center for Disease Control received a referral for a hip or knee and Prevention (CDC) warns about general replacement, they could receive treatment risks that patients traveling around the world within a couple days if at a medical tourism may face with medical tourism but specific destination. The same person in British risks are based on the area being visited. The Columbia, Canada would have to wait 21.8 and CDC identifies risks including a 28.3 weeks for a hip or knee replacement communication barrier if you don’t speak the respectively (Asian Pacific Post 2005). The native language and do not have an interpreter, promptness of a cure can help prevent long counterfeit , increase risk of blood term injury in the case of many medical issues. clots from flying after surgery, and increase risk Traveling to reduce wait times can be more of antibiotic resistant bacteria. (CDC 2016). beneficial for the patient’s health for these The CDC also recommends checking the scenarios. qualifications and credentials of the facility The motivation for medical tourism is where the procedure will take place. Travelers further extrapolated by people who are need to remember that the standard of care in underinsured or not insured at all. If the the United States may not be the same when patient’s does not cover all the traveling to other institutions around the expenses, or the patient doesn’t have world. The Joint Commission International, insurance, the patient is more likely to seek low DNV International Accreditation for cost medical treatments abroad (Horowitz and Hospitals, and the International Society for Rosensweig 2007). Options for people with Quality in Healthcare are among the few little to no medical insurance were to pay the accrediting agencies that have lists of standards excessive costs and go into debt or not getting that facilities need to meet to be accredited the procedure done promptly and gamble that (CDC 2016). When choosing a facility abroad their health condition will not deteriorate while for medical treatment, it is imperative to look they come up with the difference. Through for international high caliper accreditations to medical tourism, patients could get the attempt to reduce the risk of low quality procedure they need at a portion of total cost. operations. An additional driving force causing Centers of Excellence Example people to travel from developed countries to Many accreditation have developing countries for procedures is the given accreditation to locations around the domestic inaccessibility of certain medical world known as Centers of Excellence. One treatments. These medical treatments could be such center is Bumrungrad International elective surgeries not covered by insurance or Hospital in Bangkok, Thailand. Bumrungrad controversial operations that have legal opened its main facility in 1977 and outpatient barriers. These treatments could include stem opened in 2008 (Bumrungrad 2017). cell therapy, joint resurfacing, disc Their is easy to navigate and offers replacement, reproductive therapy, and sexual multiple services for medical tourist. Their reassignment surgery (Horowitz and special international services include “over 150 Rosensweig, 2007). Many of these procedures interpreters, international/airport concierge are not viewed as necessary by the domestic , embassy assistance, VIP airport insurance company. People who are willing to transfers, e- contact center, international travel to a certified developing country’s insurance coordination and international hospital will save money in travel costs and in medical coordinators, visa extension counter, the out of pocket cost of the procedure. and Muslim prayer room (Bumrungrad 2017)”. Medical Tourism Quality The hospital was the first Asian hospital Many people mentally associate accredited by the Joint Commission medical tourism with high risks and unsanitary International (JCI) which also accredits

32 hospitals in the United States. Bumrungrad about their international healthcare options International Hospital was accredited in 2002, and an increase in the number of medical 2005, 2008, 2011, and 2014. Furthermore, tourists. Bumrungrad International Hospital was MTA Educational Curriculum awarded “Best Website for International Collaborations Medical Travel” award during the 2008 The MTA offers education and Consumer Health World Awards, USA. certification to people and colleges who are Bumrungrad International Hospital is interested in incorporating the medical tourism also recognized as a referral center. Their industry into their curriculum. MTA medical coordination office is open 24 hours a specifically offers cross-training programs for day to assist with referrals from around the educational institutions for multiple academic world. Their team of seven doctors and 12 paths including medicine and healthcare, nurses work to coordinate schedules and tourism and hospitality, wellness and business procedures, family questions during treatment, (MTA 2017). Some programs can be on topics and follow-up care planning. (Bumrungrad detailing physician leadership, quality 2017). By having interpreters for many improvement, patient safety, cultural different languages, the communication risk is competence and patient experience. As more reduced for the medical tourist. Medical across the country see the increase tourists who travel to centers of excellence in the industry of medical tourism, the demand know they are in good hands based on the for these kinds of programs can be inferred to communication, certification, and transparency increase. of care. MTA strategic alliance Global Healthcare Tourists should research into the Accreditation country, hospital, and doctors to help mediate Global Healthcare Accreditation some of the concerns of lower quality can that (GHA) Program is an accreditation for occur abroad. Through research, tourists can hospitals, dental , ambulatory centers, or learn that the Bumrungrad International independent practitioner offices when serving Hospital is an excellent example of the capable medical tourist and medical travelers (MTA services offered overseas. Having the 2017). The GHA evaluates overall misconception that the quality of medical care performance and streamlined function for an is the same no matter where patients go within overall positive experience for patients and another country can have detrimental lasting their families. GHA suggests “the rising health effects on their medical health. Other hospitals tourism and medical travel industries provide in Thailand may try to compete for traveling opportunity for many medical institutions to medical customers but may not have the same develop strong profit centers around services qualifications. Therefore, the patient needs to offered to traveling patients and health and be cautious when making the decision to seek wellness seekers (MTA 2017)”. As people professional medical attention abroad. share their experience at facilities specializing Medical Tourism Association in international health such as at facilities like The Medical Tourism Association Bumrungrad International Hospital, more (MTA) is a nonprofit international people will follow suit. to help people interested in Recommendation for United States medical tourism. MTA works with “healthcare Hospitals providers, governments, insurance companies, Centers of excellence such as employers and other buyers of healthcare-in Bumrungrad are becoming an increasingly their medical tourism, international patient, viable option for those living in the United and healthcare initiatives. (MTA 2017)”. MTA States. Domestic hospitals may face a decrease wants to see an increase in consumer awareness in profits from elective procedures because of

33 this. A study done by Gill and Singh explored United States faces a growing loss in patient the interest in medical tourism in the United numbers as more people are traveling out of States travelers. The study identified three main country for medical treatment than those factors when deciding to receive care traveling to the United States from other domestically or abroad: competent doctors, countries. The excessive costs associated with high quality medical treatment facility, and medical care is one of the main reasons medical prompt medical treatment when needed (Gill tourists look outside the United States for and Singh 2011). The first two factors can medical treatment (George 2013). While many easily be found in the United States at facilities blame the pharmaceutical companies, around such as John Hopkins or other top medical 14% of healthcare costs in the nation were facilities. These international centers of administration costs. Of that 14%, around half excellence must compete internationally for was estimated to be wasteful, or around $180 clients in the modern era of globalization. The billion annually in 2012 (Wikler et.all 2012). competition and comparison of “competent” Completely free access to healthcare doctors and “high” quality is necessary not will not fix the drive for medical tourism, but only with other domestic hospitals, but in lowering the costs may deter some people from comparison to Bumrungrad and similar the cost savings for the inconvenience of competitors. The quest for quality and traveling. The difference of $110,000 for competitive advantage must continue to similar quality of care in heart bypass costs is innovate and push the expectation to retain an easy decision, but if the difference was only and potentially gain clients as international $5000 or so the drive would not be as strong. locations become more a more feasible option. According to patient behavior, customers of Long Term Solution for Hospitals in the the healthcare industry are savvier when United States spending their own money instead of insurance If the international standard of quality companies’ (Herrick 2003). This means that if is similar, many people may not want to pay for the patient is fully insured and not spending a heart bypass that could cost around $123,000 their own money, they are more likely to accrue in the United States when patients could go to the $110,000 extra cost compared to if they had facilities in Thailand and receive the same to pay that out of pocket. By using a third-party treatment for $13,000 (Lunt et al, 2011). In the payment method through an insurance United States, the per capita healthcare costs company, employer, or government, cost are far beyond those of any other nation in the analysis is reduced for the consumer when world. In 2002, the cost per person for seeking quality of care. healthcare in the United States averaged $5267 Transparency (Bodenheimer 2005). Thus, if the quality of the Another reason why customers also hospitals is similar, the wait time is probably may not seek the best costs is the lack of less, and the procedure is around a tenth of the transparency in medical costs. For example, cost, the international option in Thailand is a when people in the United States think of the feasible option. Furthermore, the patient can last time they had to go for a doctor visit, they usually bring their family and have a mini- usually go somewhere that has been vacation in another country while they are recommended by others and takes their healing post-operative. Domestically the insurance. Rarely do people compare what the hospitals need to do something to combat the cost difference between doctor offices are potential loss of revenue as more people start when making decisions. The MTA is working to see the viability of this option. towards a Quality of Care Project that will look Medical Reform for one methodology to quantity healthcare The medical care system of the United cost reporting. The program would allow States must be reformed to lower costs. The multiple stakeholders such as insurance

34 companies, employers, and patients to commissions for medical facilitators that they compare international hospitals’ quality of care have worked with in the past. Therefore, a with others around the world (MTA 2017). The medical facilitator may face an ethical dilemma research will also allow patients to obtain to channel patients through that third-party to information about quality, costs, patient certain programs instead of a program that may volumes and patient safety. Through an be better for them. Patients may trust the increase in transparency, the global market can facilitator to have their best interest at heart, be completely open to competition for top but the medical facilitator could be sending the quality doctors and affordable costs. patient to the place that will pay the biggest Short term solution commission instead of the best quality for the Policy reform and changing patient. infrastructure for the healthcare system will If a hospital was to incorporate a take significant time and planning. In the medical facilitator branch into the hospital meantime, the healthcare industry is potentially infrastructure, the hospital can help mediate still losing the race for healthcare quality at people coming to the United States for affordable prices in the global market. treatment. Furthermore, the facilitator branch Currently, the medical tourism threat is not can help patients who are interested in pressing enough to give many hospitals cause traveling abroad for medical care. The idea may for alarm. Instead of waiting until it is too late, seem counterintuitive to offer information for hospitals in the United States should begin to sending patients away from the institution, but implement changes to be proactive in the a partial payment is better than receiving a net global market of healthcare. One potential income of zero from the patient who travels avenue is expanding options in the hospital to for the procedure. Furthermore, the hospital include a medical facilitator office. can create a of improving care to Medical Facilitators customers that may not be able to afford the The role of a medical facilitator is to procedure at the hospital. These customers work to patients who are interested in may be the underinsured or the unemployed. being medical tourists with facilities rated for The hospital can make a contract and liability high quality and patient safety (Synder et. All waiver for the patient who will travel to 2011). Their role can include: “booking another country for the procedure and the transportation and accommodation; hospital can perform the aftercare on the arranging for medical services and tourist patient. Therefore, the hospital will net a packages; transferring medical records and portion of the administrative costs that would arranging for follow-up care in the home normally be received from the medical country (Synder et. All 2011)”. Because the role facilitator office outside the hospital of the facilitator is to work with hospitals and infrastructure and make money on the post- patients around the world, one can infer that operative care received by the patient upon medical facilitators would have the ability to their return home. screen the facilities with inadequate quality to The benefits to incorporating a medical increase the likelihood of a positive experience facilitator to domestic hospitals go beyond for the patient in comparison to the patient relationships with patients and researching the topic on their own. customers. Hospitals can build a positive There are multiple ethical dilemmas working with other hospitals that come from the role of medical facilitators. around the world. They can share best One of the main concerns is commission practices and work to continue pushing the received from sending patients to facilities paid standard of care. can flourish with by third-party sources (Synder et. All 2011). positive competition, and such a partnership Some third-parties may pay more as would allow the correspondence of ideas

35 across nations. The ethical dilemma would be procedure in his home country. He seems out reduced from the biggest commissions since of options and is looking for assurance from the medical facilitator’s job would be a part of his surgeon. the hospital infrastructure. A pay schedule with Option One a lowered focus on commission would lower If the surgeon says that medical the risk of an ethical issue of sending someone tourism is bad medicine, the logic may be in to a lower quality location for a higher pay line with the ethical principle of non- check. maleficence. Non-maleficence means that Case Study (Weiss et. all 2010) physicians should not inflict avoidable harm, or The following case study published in set a patient in harm’s way (Weiss et.all 2010). the journal Surgery in 2010 can emphasize the This ethical principle can arguably be avoided importance of having a medical facilitator by the potential location of the hospital that the within the hospital to move the decision of a man is considering. For example, if the man referral from a surgeon to the facilitator. With went to the Bumrungrad Hospital in Bangkok, the suggested new infrastructure, the patient Thailand that advertises the accreditations the will still receive the best care and the surgeon hospital has through internationally can focus on medicine instead of tourism, acknowledged organizations such as Trent advice that the surgeon may not be fully aware International Accreditation Scheme or the of all the aspects. (JCI). The idea of potential harm would be A surgeon was presented with an mediated by the standard of care offered ethical dilemma from a 45-year-old compared to another hospital in the region that underinsured man under consideration for may not have the same standards. bariatric treatment for morbid obesity. The Furthermore, if something happened surgeon recommends a gastric banding to the patient, there lacks a precedent for suing procedure that was denied multiple times by an insurance company for directing a patient to the man’s insurance company. The insurance acceptable care that has the potential to be company offers the option for the man to suboptimal care for either a domestic or travel to Bangkok for the procedure that would international case (Weiss et.all 2010). Instead also include 4-star accommodations for the there are precedents for suing a health man and his wife at a seaside rehabilitation maintenance organization for going against a center. The man asks his surgeon for his consulting surgeon’s recommendation that medical opinion for what he should do. (Weiss results in adverse effects for the patient. et.all 2010). Consequently, the patient may push to sue the The surgeon can either give a positive surgeon instead of the insurance company if or negative recommendation. The case study there were any issues with the gastric banding identifies four options that the surgeon can do. procedure because the surgeon gave his The negative recommendation can be due to recommendation. Therefore, the surgeon bad medicine from medical tourism or that could have legal liabilities of a referral if medical tourism is bad for Thailand’s something went wrong. healthcare system. The positive Option Two recommendation is to say yes and agree that The surgeon does not give his the surgeon will resume care upon return. recommendation due to medical tourism being Furthermore, the surgeon can decide if they bad for Thailand’s healthcare system. The should require a release form or not to waive ethical principle of justice is under liability of any faulty medical work done in consideration for option two. Justice related to Bangkok. The main predicament for this case how the healthcare resources be allocated in study is that the morbidly obese man has tried equitable (Weiss et.all 2010). This multiple times and simply cannot afford the argument takes into consideration the effect of

36 crowding out that can occur when too many the man upon his return from Thailand. The travelers are coming around the world to one ethical principle in option three that is under location. These travelers can inadvertently be debate is beneficence. Beneficence means that taking resources away from the domestic the surgeon should promote wellbeing and population in need of high quality health what is best for the patient (Weiss et.all 2010). services. Why should one person be favored This recommendation recognizes the patient’s for international medical tourism instead of the autonomy. This decision would support the population of the home country if healthcare American Medical Association and American resources are in high demand? For example, if Cancer Society guidelines for medical tourism the gastric banding appointment takes that clearly states that patients must be able to precedence over someone in Thailand there pursue care at a location of their choosing may be cause for concern of injustice to the (Weiss et. all 2010) domestic population. An article by Rhodes and Schiano Some argue that medical tourism spurs dealing with the ethics of transplant tourism a trickle-down effect for both economic and claims that surgeons have a fiduciary technological advances while enhancing the responsibility for their patient instead of all quality care centers in the home country by other individual opinions, political agendas, or operating at (or beyond) Western medical justice for the medical system. For a physician standards. The opposition to this idea is that to be acting ethically per this article, the the benefits to medical tourism do not physician must choose to act within the ethical outweigh the costs to the local populations. principle of beneficence for the patient instead These costs could be as simple as “brain drain”, of any personal reasons to decide differently. implying that the trained professionals time The physician then may be advocating for the and efforts are diverted from local patients to patient potentially at the cost of personal those abroad. Furthermore, that the trained beliefs for the physician. professionals could get worn out from the Advocating for the patient may include excess amount of work from medical tourist education for the patient themselves. The and then lower their quality to all visitors to patient must be educated on the requirements their clinic. (Weiss et. all 210). The main two for post-operative care and what the doctor questions then become “are the global would need from the foreign surgeon. The economic strategies put forward by prosperous foreign surgeon would have to send copies of nations also in the best interest of the rest of records, images, and potential treatment plan the world’s people” and “do the economic to the physician in the patient’s home country. benefits of medical tourism accrue to local The transferring of documentation has the populations” (Weiss et.all 2010). During an potential for communication issues from evaluation of Thailand’s medical tourism, cultural differences, language barriers, or what Ramirez de Arellano found health personnel seems like small misunderstandings, which moving from the public to the private sector is could be a determinate for the patient. The already occurring, which resulted in the patient would have to be aware of the potential reinforcement and worsening of a health-care for miscommunication when deciding where system that was two-tiered. His claim is to have the post-operative care. (Weiss et.all currently being evaluated by international 2010). organizations. Among them are the World Option Four Health Organization and the World . (de The surgeon agrees to give his Arellano 2007) recommendation for the surgery abroad and Option Three offers to continue follow up care for the The surgeon agrees to give his patient if they sign an informed consent recommendation and agrees to resume care to document. The compromise in option four

37 allows the physician to satisfy both the ethical Conclusion principles of beneficence and physician If the current trend of medical tourism autonomy. The physician would follow the continues, the system in the United same discussion about follow up care as with States needs to make changes to be able to option three, but option four limits the liability effectively compete on the global scale. The to the physician if the patient had some issues United States needs to actively be increasing with the foreign surgery. This option primarily transparency of costs while lowering differs from the previous in legal terms rather administrative costs to decrease inflation of than a difference in medical procedure. The overall costs. Customers can now travel abroad jurisdiction for issues concerning medical care for the same high quality procedures that are is the location of the hospitals and the performed in the United States, potentially physician, not the patients’ national origin leveling the playing field of competition. The (Weiss et.all 2010). The level of compensation healthcare industry must increase productivity for cases of malpractice is a lot lower in and quality after reducing costs to stay globally developing countries than in the United States. competitive. Thus, if the surgeon chooses option four, an On a short-term scale, hospitals should ethical surgeon would explain the potential for move to adding medical facilitators to the compensation for a serious case of malpractice infrastructure of the healthcare system. This abroad would be insignificant compared to will allow legal liability to shift from physicians what the patient would receive from a domestic and help advocate and educate patients who case. The ethical surgeon’s pursing beneficence are in need of a procedure that is difficult to might require support of an operation in a obtain in the United States for a variety of foreign country, then the prudent surgeon reasons. Instead of having patients go through must understand the legal implications of third-party facilitators to find information and shifting the decision to the patient (Weiss et.all resources for your competitors, maintaining 2010). them within the hospital can help retain some The informed consent document revenue and build around the should be provided for the patient before the world with centers of excellence. patient decides to have the surgery abroad The healthcare system in the United instead of within the United States. The States can continue to be successful in the document should contain an explicit list of globally competitive, modern world by likely and unlikely risks involved in foreign working on both a short-term and long-term medical care, the surgeon’s lack of control or scale toward solutions. Medical tourism will potential lack of knowledge in qualifications of only continue to increase in popularity as more the foreign doctor or hospital staff, and people hear and share positive experiences potential for the surgeon not being able to fix compared to the costs found domestically. The any issues involved from the surgery if a case United States must be productive and of severe malpractice occurs (Weiss et.all proactive in making changes in the healthcare 2010). A very detailed document would likely system before they lose revenue and customers prevent the surgeon from being liable in a U.S for elective surgery abroad. court; informed consent documentation does not offer protection from being named in the References lawsuit. In consequence, the surgeon could Asian Pacific Post (2005, May 5). Sun, Sandand have indirect costs from another surgeon’s Surgery. malpractice because he gave the Bodenheimer T. High and Rising Healthcare recommendation for the patient. (Weiss et.all Costs. Part 1: Seeking an Explanation. 2010). Ann Intern Med.2005;142:847-854.

38 Bumrungrad International Hospital the Industry As Medical Tourism or website(2017) Retrieved June 16th from International Medical Travel. Retrieved https://www.burungrad.com/thailand June 10th, 2017 from hospital https://www.imtj.com/articles/can- Center for Disease Control and Prevention we-think-industry-medical-tourism-or- (CDC) (2016, December 5) Medical international-medical-travel/ Tourism. Retrieved June 16th, 2017 Medical Tourism Association Website (2017) from Retrieved June 16th 2017 from https://www.cdc.gov/features/medic http://www.medicaltourismassociatio altouris m/index.html n.com/en/about-the-MTA.html De Arellano, R., (2007 January 1) Patients Rhodes, R., and Schiano, T., (2010)Transplant without Boarders: The Emergence of tourism in China: A tale of Medical Tourism. International Journal twoTransplants. American Journal of of Health Services. Retrieved June 25th Bioethics2(10)3-11. Retrieved June 15th from from http://journals.sagepub.com/doi/abs http://www.tandfonline.com/doi/abs /10.2190/4857-468G-2325-47UU /10.1080/15265160903558781 Friedman, T. (2005, April 3) It’s a FlatWorld, Synder J., Crooks V., Adams K., Kingsbury P., After All. New York Times Magazine. Johnston R., (2011, September) The Research Library. (p)32-37. ‘Patient’s Physician One-Step George B (2013, July) Strategies for Removed’: The Evolving Roles of Developing Domestic and Inbound Medical Tourism Facilitators. Journal Medical Tourism within the United of Medical Ethics 37(9)530-534 States. Retrieved June 1st, 2017 from Tsolakidou, S. (2012, September 17). Greece’s https://www.researchgate.net/publica Hot Springs a Lure for Millennia tion/313851450_Strategies_for_Devel Greece.GreekReporter.com Latest oping_Domestic_and_Inbond_Medic News From Greece. Retrieved June 1st, al_Tourism_within the_United_States 2017 from Gill H. and Singh N. (2011, September 29) http://greece.greekreporter.com/201 Exploring the Factors that Affects the 2/09/1/greeces-hot-springs-a-lure- Choice of Destinationfor Medical for- millennia/ Tourism. Journal of Service Science Weiss, E.M., Spataro, P.F., Kodner, I.J., and and Management. 4(3),315-324. Keune, J.D., (2011 September) Retrieved June 10th, 2017 from Banding in Bangkok, CABG in http://www.scirp.org/journal/PaperI Calcutta: The United States Physician nformation.aspx?PaperID=7490 and the Growing Field of Medical Herrick D (2003, May 7) Why are Health Cost Tourism. Rising. National Center for Policy Weisz, G. (2011). Historical reflections on Analysis. No. 437. Retrieved June 5th medical travel. Anthropology & Medicine, from 18(1), 137-144. http://www.ncpa.org/pdfs/ba437.pdf Wikler, E. Bausch P. and Culter D. (2012) Horowitz M. and Rosensweig J (2007, Paper cuts: Reducing healthcare November 13).Medical Tourism: Administrative Costs. Center for Globalization of the Healthcare American Progress. 1-39. Retrieved Marketplace. Medscape General June 5th from Medicine, 9(4):33 https://scholar.harvard.edu/cutler/pu International Medical Travel Journal (IMTJ) blications/paper-cuts-reducing-health- (2008, September 10) Can We Think of care-administrative-costs

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