Medical tourism raises questions that highlight the need for care and caution

Medical tourism: future boon or future bane for Australia's consumers and health care system?

Medical tourism is being actively promoted in Australia in a way we have not seen previously. Health care is now a commodity that consumers can obtain locally and, increasingly, in foreign countries. Seeking medical treatment in other countries has been termed “medical tourism”, where treatment is combined with recreational experiences in resorts and hotels. Treatments may be for cosmetic procedures, chronic illnesses and assisted reproduction, including dental, cardiac, orthopaedic and bariatric surgery, organ and tissue transplantation, and in-vitro fertilisation.1 There are few reliable statistics on the size and scope of the medical tourism market, but reports value it in the hundreds of millions to billions of dollars for individual countries, and globally as an industry it is valued at over US$20 billion.2 In Australia, medical tourism is believed to be a growing dimension of health care, with both inward-bound and outward-bound consumers. However, there is a lack of hard evidence on medical tourism in countries within the Organisation for Economic Co-operation and Development,1 including Australia.

At face value, medical tourism presents as a positive avenue for sufficiently wealthy consumers to obtain health care without being limited by what is available to them locally. However, medical tourism cannot be judged without considering ethics, safety, costs to the community and continuity of care.

Whether it is ethical for consumers from developed countries to access health care in developing countries has been debated.1 Further, developing countries targeting medical care to wealthy consumers at the expense of treating local residents is both ethically and morally concerning.3

We do not know how consumers make their decisions to seek health care overseas. It is believed that they pursue medical tourism because of high health care costs, lengthy waiting periods or lack of access to treatments in their home countries.2 Current empirical evidence to support this is based on a small number of participants from a few countries, and needs to be verified. Furthermore, there is a dearth of Australian research in this area. Just what information consumers obtain about medical tourism, its credibility, and the decision-making processes and rationales that they use are all unknown. What level of health literacy is necessary to make an “informed decision” about the various treatments available? What does “informed decision” mean in the field of medical tourism? There is a lack of standardisation and providers make a range of unsubstantiated claims.4

These questions raise concerns about the safety and quality of the care being accessed by Australian consumers overseas. What care planning is done before, during and after an episode of medical tourism? Do consumers discuss their idea to seek medical care overseas with their local general practitioner and other primary health care professionals? Do they ask about the care by the organisation, an individual physician or the health care team? We know that care is shaped by the clinical governance of all three.5 The very limited research that exists reveals confusion and strained relationships between consumers and their health care practitioners when having such conversations.6 Evidence-based decision-making frameworks or tools for medical tourism are lacking. Models that have been proposed have not been empirically tested, so their usefulness remains speculative.

We know that continuity of care is disrupted when consumers travel overseas for medical treatment.3 We know neither what local health records are available to overseas health professionals before they treat a patient, nor what overseas health records are available to Australian professionals for follow-up care. We do not know whether or how safety, quality and continuity of care are achieved when consumers seek treatment overseas.

Medical tourism raises the prospect of serious infection concerns for individuals and biosecurity issues for the Australian health system.7 Medical tourism consumers visit medical institutions and are exposed to microbial pathogens that are different from those in their country of origin. Rates of health care-associated infections in developing countries are recognised to be higher than those in developed countries and, within adult intensive care units, infection rates are at least three times higher.8 Risks of nosocomial infection are real, having been reported in Australia and overseas.7,9 A tangential problem is the potential for political and trade conflict between countries when such nosocomial infections are reported.10

Individual harm becomes organisational harm when infected medical tourists return to Australia for further treatment. This transfers the responsibility, costs and risks of care to the Australian health care system. What is the consumer's responsibility to disclose information about overseas treatment and possible infection risks before attending an Australian health care facility? How many consumers return to Australia with nosocomial infections? What types of infections are being introduced into primary care and hospitals? What are the risks for health professionals? What infection control strategies need to be introduced? What are the costs associated with managing and removing introduced pathogens in different settings? Health professionals and hospital environments could be exposed to significant infection risks and costs of treating infections with foreign drug-resistant organisms.

These questions lead directly into considering what regulation is needed for medical tourism to maintain the safety and quality of the Australian health system. At present, limited and untested regulatory frameworks exist for any country.3 How are stakeholders, including governments, insurance companies, health professional bodies, individual health professionals and consumers, to assess the quality and safety claims of overseas health care organisations? What legal protection is there for consumers who receive poor medical care? How are consumers protected from or compensated for malpractice? What care or services will be available to solve any ongoing medical or cosmetic problems? What will be the responsibility of insurance agencies, and how will they be held accountable if they support or facilitate medical tourism? While medical tourism facilities are promoted as being accredited by writers in this field,4 the impact of these accreditation systems remain untested. An Australia health insurance provider now actively supports medical tourism, reinforcing the need for a surveillance mechanism to collect information on care outcomes, how local health care providers manage adverse outcomes, and the associated costs.

The main problem with medical tourism is that it currently has no robust empirical evidence base.1,2,10 Hence, we do not know if medical tourism will be a future boon or bane for Australia's consumers and health care system. Care and caution are needed, because the potential negative consequences for individuals and the community remain profound.