PERIOPERATIVE LEADERSHIP Medical Tourism: A Nurse Executive’s Need to Know CYNTHIA PLONIEN, DNP, RN, CENP; KATHLEEN M. BALDWIN, PhD, RN, FAAN, ACNS-BC, ANP-BC, GNP-BC, CEN, FAACM
M
edical tourism is evolving as a rapidly growing market that spans the globe. As insurance premiums rise and co-payments for surgical procedures increase, US citizens are seeking affordable medical care that is not available in the United States. For people in countries outside the United States, wait lists limit and prohibit access to surgical procedures, so these prospective patients search for opportunities that provide additional options for surgical care outside their home countries. Nurse executives in perioperative settings might ask, “Why do I need to know about medical tourism?” The answer lies in their desire to be effective leaders and the accountability inherent in being competent at their leadership role. Competencies are considered the single biggest contributor to the difference between effective and ineffective managers.1 A number of major health care organizations have identified key competencies for clinical and organizational leadership roles. In particular, the American Organization of Nurse Executives (AONE) has outlined competencies expected of managers at all levels and in all settings.2 The AONE listing has become the standard in expectations of nurse leaders and managers. The AONE competencies include communication, knowledge of the health care environment, leadership, professionalism, and business skills.2 To be knowledgeable about the health care environment,
perioperative nurse leaders must understand the factors that have led to the phenomenon known as medical tourism. Currently, a global trend exists in which patients cross borders of their homeland seeking medical care. The movement is inbound as well as outbound, depending on the needs of the patient and the medical offerings in various countries. Knowledge of the medical tourist environment includes an awareness of concerns (eg, quality of care, costs, wait times) related to medical tourism that apply to US hospitals as well as US citizens. Perioperative nurse leaders have the opportunity to share knowledge and research information that may not be readily available to patient populations and other health care professionals. Nurse leaders also are in a position to influence public policy that guides regulations supporting safe care from medical tourism providers. This article describes the evolution and status of outbound medical tourism (ie, the flow of elective surgeries from the United States to outside countries). MEDICAL TOURISM TODAY Today, Americans travel abroad and people from foreign nations travel to the United States seeking to undergo surgical procedures. An estimated seven million people travel around the world as medical tourists.3 Between 850,000 and 1.2 million citizens
The AORN Journal is seeking contributors for the Perioperative Leadership column. Interested authors can contact Cynthia Plonien, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.08.007
Ó AORN, Inc, 2014
October 2014
Vol 100
No 4
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easily share the market. According to the Executive traveled out of the United States in 2013 in a quest 3 Nursing Committee at Sidra, the facility will be set to find quality care at a lower cost. The countries apart from similar organizations by incorporating with the greatest number of medical tourists in orhigh-end technology and being affiliated with a der of volume are Thailand, United States, Malaysia, major research center. Currently, Sidra is hiring Singapore, India, Mexico, Korea, Brazil, Taiwan, 3 nurses from North America and seeking the Turkey, and Costa Rica. Procedures sought by highest accreditation medical travelers for nursing via JCI include coronary artery bypass graft It is evident that affordability and quality of care accreditation, and (CABG); full faceare evolving as improvements in technology to will be monitoring lift; gastric bypass; facilitate world-class patient care and close the and measuring key hip replacement; gap that previously existed between the United performance indicators States and other countries. (Carol Drummond, implant-supported MS, CNM, RN, exdentures (ie, upper ecutive director of and lower); in vitro nursing, Sidra Medical and Research Center, fertilization cycle, excluding medication; knee Qatar, e-mail communication, May 2014). Currently, replacement; porcelain bridge (ie, four-implant); the hospital rhinoplasty; spinal fusion; and valve replacement 4 with bypass. n is hiring English-speaking nurses, Quality of Care Quality medical treatment is a primary consideration for medical tourists, and there are organizations that contribute to safe international practices. The Joint Commission International (JCI) has accredited more than 600 international organizations with a Gold Seal of Approval.5 As an accrediting organization, the JCI works as a partner with international facilities to support their pursuit of excellence. The American Nurses Credentialing Center (ANCC) MagnetÒ Recognition Program is an international organizational credential that recognizes nursing excellence in health care organizations.6 The ANCC offers ongoing support and resources for organizations seeking Magnet status. It is evident that new values are emerging that facilitate world-class patient care and close the gap in quality that has previously existed between the care provided in the United States and that available in other countries. For instance, Sidra Medical and Research Center is a new facility being built in Qatar. This facility is designated for care of women and children. Although not targeting medical tourism as a strategic plan, the organization could 430 j AORN Journal
n
is applying for Magnet status, is seeking JCI accreditation, and n plans to monitor and measure key performance indicators. n
Although not targeting medical tourism as a strategic plan, the organization could easily share the market. Similarly, the Cleveland Clinic, based in the United States, will open a 364-bed, multispecialty hospital in Abu Dhabi in 2015. Included will be five centers of excellence: heart and valvular disorders, neurological conditions, digestive diseases, eye and respiratory diseases, and critical care.7 Another reason the gap is closing in the quality of care with medical tourism is that physicians are crossing borders. Many international hospitals recruit US physicians. For example, Bumrungrad International in Thailand has 225 US board-certified physicians and surgeons on staff. 3 Several US medical schools (eg, Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Centre, and Duke-National University of Singapore) are working with overseas providers to develop joint initiatives to elevate the quality of care provided internationally.8
PERIOPERATIVE LEADERSHIP
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TABLE 1. Comparative Costs of Major Surgical Procedures
Procedure Average savings (%) Coronary artery bypass graft Valve replacement with bypass Hip replacement Knee replacement Spinal fusion In vitro fertilization cycle, excluding medication Gastric bypass Four-implant porcelain bridge Implant-supported dentures (ie, upper and lower) Full face-lift Rhinoplasty
a
South United Costa Statesb Rica India Malaysia Mexico Singapore Korea Taiwan Thailand NA 45-65 65-90 $88,000 $31,500 $14,400 $85,000 $29,000 $11,900
60-80 $20,800 $18,500
40-60 $37,800 $34,000
25-40 $54,500 $49,000
30-45 40-65 $29,000 $21,000 $33,000 $18,000
50-75 $23,000 $22,000
$33,000 $14,500 $8,000 $34,000 $9,500 $7,500 $41,000 $17,000 $9,500 $15,000 NA $3,300
$12,500 $12,500 $17,900 $7,200
$11,500 $12,800 $22,500 $7,800
$21,400 $19,200 $27,800 $9,450
$15,500 $10,500 $15,000 $12,000 $18,000 $18,000 $7,500 $4,800
$16,500 $11,500 $16,000 $6,500
$18,000 $11,200 $6,800 $23,000 $9,500 $7,200 $10,500 $4,400 $3,500
$8,200 $7,800 $3,800
$13,800 $8,500 $4,200
$13,500 $12,000 $6,400
$12,500 $13,000 $10,500 $9,500 $5,800 $4,600
$12,000 $10,500 $3,900
$12,500 $6,200
$5,500 $3,600
$5,250 $2,800
$8,750 $4,750
$4,500 $3,500 $3,400 $2,800
$5,900 $4,700
$5,600 $3,500
$5,300 $4,300
NA ¼ not applicable. a
b
Data as of April 2014. International estimates include all treatment-related costs but exclude travel and accommodations. Figures are averages and reflect more common incidence of cost. All figures are in US dollars. US costs vary based on location, materials, equipment used, and individual patient requirements. Figures are averages and reflect more common incidence of cost.
Data printed with permission from Patients Beyond Borders, Chapel Hill, NC, http://www.patientsbeyondborders.com.
Cost of Procedures Cost is a primary driver in the choice of destination for the medical tourist. India is known as the world’s medical travel “thrift” destination, offering a savings of 60% to 90% on a variety of procedures. The Harvard-affiliated Wockhardt Hospital in India has performed more than 20,000 heart procedures with a 98% success rate. The average cost of a CABG in the United States is $88,000; in India, the average cost is $14,400.4 Monterrey, Mexico, has four firstrate JCI-accredited hospitals offering bariatric and weight management programs at a savings to its patients. The cost of gastric bypass surgery in the United States is $18,000; in Mexico, it is $13,800 (Table 1). Susan Athey, a real estate broker in Texas, explained in e-mail correspondence that she made the choice to have gastric sleeve surgery in Monterrey, Mexico (June 2014). Athey’s surgeon was board certified with specialty endoscopic training at the Texas Endosurgery Institute, San Antonio, Texas, and the European Institute of Telesurgery
in France. According to Athey, undergoing the procedure was an incredible experience in terms of quality and costs. She was impressed with the professionalism and the caring attitude of the physicians and nursing personnel as well as the billing and admissions personnel. She also appreciated the comfort and service of the four-star hotel where she stayed before and after the procedure. The procedure and the recovery occurred without incident. Athey explained that the only issue was that some care providers had a language barrier. Citizens like Athey are leaving their home countries for what they can clearly identify as improved quality, reduced costs, and often decreased wait time for elective procedures. Consequently, US health care practitioners and facilities are experiencing the financial effect of outbound medical tourism on the US economy. According to the Deloitte Center for Health Solutions, health care costs continue to rise at a rate of 6% each year.9 Medical tourism offers a savings of up to 70% after travel expenses and
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may demonstrate a 35% annual growth in coming addition to the cost of the surgical procedure for 9 years. The effect of the growth holds huge implisignificantly less than the cost of the surgery alone in the United States. For example, Blue Cross Blue cations for US health care providers as well as Shield of South Carolina is covering procedures in consumers. Thailand, authorized through Companion Global. Of particular concern is the migration of patients The program is inclusive of follow-up visits in the who need outpatient surgery. Technological adUnited States with physicians at Doctors Care.12 vances have allowed surgeries that previously were performed in an inpatient setting to be performed on an outpatient basis. Patients who previously spent Risks and Ongoing Concerns days in a hospital after surgery are now released a Medical tourism is not without challenges. As the few hours after the procedure is completed. Although world market for health care develops, genuine the reduced time for recovery is appreciated by concerns about travel and treatment are being patients, the financial cost covered by the patient identified.13 Several professional organizations has significantly increased. Outpatient surgeries have developed guidelines and checklists for require higher co-payments and deductibles than patients who are considering international travel procedures performed in inpatient facilities. The for medical care. The Centers for Disease out-of-pocket expense makes medical tourism an Control and Prevention (CDC),14 the American attractive option. AcSociety of Plastic cording to a report Surgeons (ASPS),15 published by the the Organization In response to the increased number of US patients choosing the international market for Deloitte Center for for Safety, Asepsis gastric banding procedures, some US surgeons Health Solutions in and Prevention 2009, 75% of medical and associated ambulatory surgery centers are (OSAP),16 the offering to perform the procedure for as low tourists’ procedures American College as $8,900. are scheduled as outof Surgeons (ACS),17 10 patient services. and the Aerospace In some situations, Medical Association18 the expansion of domestic medical tourism has have each published guidelines. These organizations driven costs down in the United States. A few years have identified a number of risks associated with ago, gastric banding procedures cost $20,000, while medical tourism. Some of the risks include surgeons in Mexico charged $10,000. In response to n variability in training, the increased number of US patients choosing the n differences in standards, international market for this treatment, some US n accuracy of medical records, surgeons and associated ambulatory surgery centers n absence of support networks, are offering to perform the procedure for as low as n lack of opportunity for follow-up care with $8,900. Cosmetic surgeons also are responding to surgeons, market-driven competitive pricing by decreasing n exposure to endemic diseases, their fees for procedures that are paid for in adn language barriers, and vance with cash.11 15 n compensation for liability associated with injury. Third-party payers have developed a new approach to lowering costs as well. Several insurers From a practical point of view, patients also should in the United States are launching medical tourism consider the physical effects of travel. Continent pilot programs with their benefit plans. Insurers will hopping can be exhausting for a healthy person; for cover the cost of travel and accommodations in the very ill, it can be hazardous.19 For instance, air 432 j AORN Journal
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travel after surgery increases the incidence of blood clots and pulmonary emboli in medical tourists.18 Continuity of care is a widespread concern. Often, patients find that little, if any, communication occurs between health care professionals abroad and those at home.20 Patients should consult a travel health provider at least four weeks before travel for advice tailored to addressing their preoperative and postoperative needs.8
medical colleagues, the public, and patients about the health care environment, inclusive of medical tourism, is a service. It is a service that leaders perform with a potential to change and improve the health and wellness of patients desiring to improve and maximize their health status.
ROLE OF NURSE LEADERS Medical tourism is embedded in our culture and will continue to grow and expand as intercontinental travel becomes affordable for citizens with average incomes. The quality gap between medical treatment received in the East and West has narrowed, with common standards evolving through facility accreditations and certifications that are now accepted throughout the world. Patients are looking at the global market for health care solutions. From a patient perspective, the conceptual framework of health-seeking behavior has been applied to those searching for health care through international tourism.20 The term health-seeking behavior includes health promotion in protecting and maintaining health through the patient’s response to illness and wellness.20 Professional nurses can positively influence patients’ health-seeking behaviors by advocating for patient choice and educating, counseling, and offering support to the patient and his or her family members.21 Knowledgeable nurses play a dual role in patient education by providing information on appropriate sites as well as related risks and ethical and legal dilemmas.21 According to the World Health Organization, research about medical treatment abroad is in its infancy and there are an array of questions that need to be answered.19 Future research is needed to address public health implications, legal and regulatory issues, ethical concerns, and transnational infections as well as to identify best practices.19 As nurse leaders, it is our duty to take steps to be knowledgeable about health care in the world marketplace. Increasing the knowledge of nurses,
References
Editor’s note: ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD.
1. McCarthy G, Fitzpatrick J. Development of a competency framework for nurse managers in Ireland. J Contin Educ Nurs. 2009;40(8):346-350. 2. The American Organization of Nurse Executives. AONE Nurse Executive Competencies. Chicago, IL: The American Organization of Nurse Executives; 2005. 3. Patients Beyond Borders. Estimated number of medical travelers by country: 2013. Chapel Hill, NC: Patients Beyond Borders; 2014. 4. Patients Beyond Borders. Major procedures: comparative costs. Chapel Hill, NC: Patients Beyond Borders; 2014. 5. JCI accredited organizations. Joint Commission International. http://www.jointcommissioninternational.org/about -jci/jci-accredited-organizations. Accessed June 26, 2014. 6. Magnet Recognition ProgramÒ overview. American Nurse Credentialing Center. http://www.nursecredentialing.org/ Magnet/ProgramOverview. Accessed June 26, 2014. 7. Respaut R. Cleveland clinic exports marquee Ohio brand to Abu Dhabi. Reuters. April 2014. http://www.reuters .com/article/2014/04/11/us-healthcare-cleveland-abudhabi -idUSBREA3A0CI20140411. Accessed June 26, 2014. 8. Lee CV, Balaban V. Chapter 2. The pre-travel consultation: counseling & advice for travelers: medical tourism. Centers for Disease Control and Prevention. http://wwwnc.cdc .gov/travel/yellowbook/2014/chapter-2-the-pre-travel -consultation/medical-tourism. Accessed July 31, 2014. 9. Forward. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 2009:2. http://www.deloitte.com/view/ en_US/us/Insights/centers/center-for-health-solutions/ 55d9f278c9184210VgnVCM200000bb42f00aRCRD.htm. Accessed July 31, 2014. 10. Growth drivers. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 2009:11. http://www.deloitte.com/ view/en_US/us/Insights/centers/center-for-health-solutions/ 55d9f278c9184210VgnVCM200000bb42f00aRCRD.htm. Accessed July 31, 2014. 11. Huffman K. Is it time to “medicalize” medical tourism? Int Med Travel J. http://www.imtj.com/articles/2013/ medicalizing-medical-tourism-60164. Access June 26, 2014. 12. Role of health plans to incentivize medical travel. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 5. http://www.deloitte.com/assets/Dcom-UnitedStates/ Local%20Assets/Documents/us_chs_MedicalTourism_ 102609.pdf. Accessed June 26, 2014.
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13. Ozan-Rafferty M. Engaging patients in a global market. Gallup Business J. December 17, 2009. http://business journal.gallup.com/content/124586/Engaging-Patients -Global-Market.aspx. Accessed June 26, 2014. 14. Magill AJ, Shlim DR. Chapter 1. Introduction: perspectives: why guidelines differ. Centers for Disease Control and Prevention. http://wwwnc.cdc.gov/travel/yellowbook/ 2014/chapter-1-introduction/perspectives-why-guidelines -differ. Accessed July 31, 2014. 15. The dangers of plastic surgery tourism. The American Society of Plastic Surgeons. http://www.plasticsurgery .org/articles-and-galleries/dangers-of-plastic-surgery -tourism.html. Accessed July 31, 2014. 16. Travelers guide to safe dental care. Checklist for obtaining safe dental care abroad. The Organization for Safety, Asepsis and Prevention (OSAP). http://www.osap.org/? page¼TravelersGuide#Checklist. Accessed July 31, 2014. 17. American College of Surgeons (ACS) (ST-65). Statement on medical and surgical tourism. Bull Am Coll Surg. 2009; 94(4):26-27. http://facs.org/fellows_info/bulletin/2009/ 2009-april-bulletin.pdf#page¼25. Accessed June 26, 2014. 18. Medical guidelines for airline passengers. Aerospace Medical Association. May 2002. http://www.asma.org/asma/ media/asma/Travel-Publications/paxguidelines.pdf. July 31, 2014. 19. Helble M. The movement of patients across boarders: challenges and opportunities for public health. Bull World Health Organ. 2011;89(1):68-72. http://www.who.int/bulletin/ volumes/89/1/10-076612/en/. Accessed June 26, 2014. 20. Eissler LA, Casken J. Seeking healthcare through international medical tourism. J Nurs Scholarsh. 2013;45(2):177-184.
434 j AORN Journal
PERIOPERATIVE LEADERSHIP 21. Ben-Natan M, Ben-Sefer E, Ehrenfeld M. Medical tourism: a new role for nursing? Online J Issues Nurs. 2009;14(3). http://www.nursingworld.org/MainMenu Categories/ANAMarketplace/ANAPeriodicals/OJIN/Table ofContents/Vol142009/No3Sept09/Articles-Previous -Topics/Medical-Tourism.html. Accessed July 31, 2014.
Cynthia Plonien, DNP, RN, CENP, is the director of the Graduate Program of Nursing Administration and a clinical assistant professor at the University of Texas at Arlington College of Nursing, TX. Dr Plonien has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Kathleen M. Baldwin, PhD, RN, FAAN, ACNS-BC, ANP-BC, GNP-BC, CEN, FAACM, is a nurse scientist and an acute care nurse specialist at Harris Methodist Hospitals Southwest and Cleburne Texas Health Resources, Arlington, TX. Dr Baldwin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
M
edical tourism is evolving as a rapidly growing market that spans the globe. As insurance premiums rise and co-payments for surgical procedures increase, US citizens are seeking affordable medical care that is not available in the United States. For people in countries outside the United States, wait lists limit and prohibit access to surgical procedures, so these prospective patients search for opportunities that provide additional options for surgical care outside their home countries. Nurse executives in perioperative settings might ask, “Why do I need to know about medical tourism?” The answer lies in their desire to be effective leaders and the accountability inherent in being competent at their leadership role. Competencies are considered the single biggest contributor to the difference between effective and ineffective managers.1 A number of major health care organizations have identified key competencies for clinical and organizational leadership roles. In particular, the American Organization of Nurse Executives (AONE) has outlined competencies expected of managers at all levels and in all settings.2 The AONE listing has become the standard in expectations of nurse leaders and managers. The AONE competencies include communication, knowledge of the health care environment, leadership, professionalism, and business skills.2 To be knowledgeable about the health care environment,
perioperative nurse leaders must understand the factors that have led to the phenomenon known as medical tourism. Currently, a global trend exists in which patients cross borders of their homeland seeking medical care. The movement is inbound as well as outbound, depending on the needs of the patient and the medical offerings in various countries. Knowledge of the medical tourist environment includes an awareness of concerns (eg, quality of care, costs, wait times) related to medical tourism that apply to US hospitals as well as US citizens. Perioperative nurse leaders have the opportunity to share knowledge and research information that may not be readily available to patient populations and other health care professionals. Nurse leaders also are in a position to influence public policy that guides regulations supporting safe care from medical tourism providers. This article describes the evolution and status of outbound medical tourism (ie, the flow of elective surgeries from the United States to outside countries). MEDICAL TOURISM TODAY Today, Americans travel abroad and people from foreign nations travel to the United States seeking to undergo surgical procedures. An estimated seven million people travel around the world as medical tourists.3 Between 850,000 and 1.2 million citizens
The AORN Journal is seeking contributors for the Perioperative Leadership column. Interested authors can contact Cynthia Plonien, column coordinator, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.08.007
Ó AORN, Inc, 2014
October 2014
Vol 100
No 4
AORN Journal j 429
October 2014 Vol 100
PERIOPERATIVE LEADERSHIP
No 4
easily share the market. According to the Executive traveled out of the United States in 2013 in a quest 3 Nursing Committee at Sidra, the facility will be set to find quality care at a lower cost. The countries apart from similar organizations by incorporating with the greatest number of medical tourists in orhigh-end technology and being affiliated with a der of volume are Thailand, United States, Malaysia, major research center. Currently, Sidra is hiring Singapore, India, Mexico, Korea, Brazil, Taiwan, 3 nurses from North America and seeking the Turkey, and Costa Rica. Procedures sought by highest accreditation medical travelers for nursing via JCI include coronary artery bypass graft It is evident that affordability and quality of care accreditation, and (CABG); full faceare evolving as improvements in technology to will be monitoring lift; gastric bypass; facilitate world-class patient care and close the and measuring key hip replacement; gap that previously existed between the United performance indicators States and other countries. (Carol Drummond, implant-supported MS, CNM, RN, exdentures (ie, upper ecutive director of and lower); in vitro nursing, Sidra Medical and Research Center, fertilization cycle, excluding medication; knee Qatar, e-mail communication, May 2014). Currently, replacement; porcelain bridge (ie, four-implant); the hospital rhinoplasty; spinal fusion; and valve replacement 4 with bypass. n is hiring English-speaking nurses, Quality of Care Quality medical treatment is a primary consideration for medical tourists, and there are organizations that contribute to safe international practices. The Joint Commission International (JCI) has accredited more than 600 international organizations with a Gold Seal of Approval.5 As an accrediting organization, the JCI works as a partner with international facilities to support their pursuit of excellence. The American Nurses Credentialing Center (ANCC) MagnetÒ Recognition Program is an international organizational credential that recognizes nursing excellence in health care organizations.6 The ANCC offers ongoing support and resources for organizations seeking Magnet status. It is evident that new values are emerging that facilitate world-class patient care and close the gap in quality that has previously existed between the care provided in the United States and that available in other countries. For instance, Sidra Medical and Research Center is a new facility being built in Qatar. This facility is designated for care of women and children. Although not targeting medical tourism as a strategic plan, the organization could 430 j AORN Journal
n
is applying for Magnet status, is seeking JCI accreditation, and n plans to monitor and measure key performance indicators. n
Although not targeting medical tourism as a strategic plan, the organization could easily share the market. Similarly, the Cleveland Clinic, based in the United States, will open a 364-bed, multispecialty hospital in Abu Dhabi in 2015. Included will be five centers of excellence: heart and valvular disorders, neurological conditions, digestive diseases, eye and respiratory diseases, and critical care.7 Another reason the gap is closing in the quality of care with medical tourism is that physicians are crossing borders. Many international hospitals recruit US physicians. For example, Bumrungrad International in Thailand has 225 US board-certified physicians and surgeons on staff. 3 Several US medical schools (eg, Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Centre, and Duke-National University of Singapore) are working with overseas providers to develop joint initiatives to elevate the quality of care provided internationally.8
PERIOPERATIVE LEADERSHIP
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TABLE 1. Comparative Costs of Major Surgical Procedures
Procedure Average savings (%) Coronary artery bypass graft Valve replacement with bypass Hip replacement Knee replacement Spinal fusion In vitro fertilization cycle, excluding medication Gastric bypass Four-implant porcelain bridge Implant-supported dentures (ie, upper and lower) Full face-lift Rhinoplasty
a
South United Costa Statesb Rica India Malaysia Mexico Singapore Korea Taiwan Thailand NA 45-65 65-90 $88,000 $31,500 $14,400 $85,000 $29,000 $11,900
60-80 $20,800 $18,500
40-60 $37,800 $34,000
25-40 $54,500 $49,000
30-45 40-65 $29,000 $21,000 $33,000 $18,000
50-75 $23,000 $22,000
$33,000 $14,500 $8,000 $34,000 $9,500 $7,500 $41,000 $17,000 $9,500 $15,000 NA $3,300
$12,500 $12,500 $17,900 $7,200
$11,500 $12,800 $22,500 $7,800
$21,400 $19,200 $27,800 $9,450
$15,500 $10,500 $15,000 $12,000 $18,000 $18,000 $7,500 $4,800
$16,500 $11,500 $16,000 $6,500
$18,000 $11,200 $6,800 $23,000 $9,500 $7,200 $10,500 $4,400 $3,500
$8,200 $7,800 $3,800
$13,800 $8,500 $4,200
$13,500 $12,000 $6,400
$12,500 $13,000 $10,500 $9,500 $5,800 $4,600
$12,000 $10,500 $3,900
$12,500 $6,200
$5,500 $3,600
$5,250 $2,800
$8,750 $4,750
$4,500 $3,500 $3,400 $2,800
$5,900 $4,700
$5,600 $3,500
$5,300 $4,300
NA ¼ not applicable. a
b
Data as of April 2014. International estimates include all treatment-related costs but exclude travel and accommodations. Figures are averages and reflect more common incidence of cost. All figures are in US dollars. US costs vary based on location, materials, equipment used, and individual patient requirements. Figures are averages and reflect more common incidence of cost.
Data printed with permission from Patients Beyond Borders, Chapel Hill, NC, http://www.patientsbeyondborders.com.
Cost of Procedures Cost is a primary driver in the choice of destination for the medical tourist. India is known as the world’s medical travel “thrift” destination, offering a savings of 60% to 90% on a variety of procedures. The Harvard-affiliated Wockhardt Hospital in India has performed more than 20,000 heart procedures with a 98% success rate. The average cost of a CABG in the United States is $88,000; in India, the average cost is $14,400.4 Monterrey, Mexico, has four firstrate JCI-accredited hospitals offering bariatric and weight management programs at a savings to its patients. The cost of gastric bypass surgery in the United States is $18,000; in Mexico, it is $13,800 (Table 1). Susan Athey, a real estate broker in Texas, explained in e-mail correspondence that she made the choice to have gastric sleeve surgery in Monterrey, Mexico (June 2014). Athey’s surgeon was board certified with specialty endoscopic training at the Texas Endosurgery Institute, San Antonio, Texas, and the European Institute of Telesurgery
in France. According to Athey, undergoing the procedure was an incredible experience in terms of quality and costs. She was impressed with the professionalism and the caring attitude of the physicians and nursing personnel as well as the billing and admissions personnel. She also appreciated the comfort and service of the four-star hotel where she stayed before and after the procedure. The procedure and the recovery occurred without incident. Athey explained that the only issue was that some care providers had a language barrier. Citizens like Athey are leaving their home countries for what they can clearly identify as improved quality, reduced costs, and often decreased wait time for elective procedures. Consequently, US health care practitioners and facilities are experiencing the financial effect of outbound medical tourism on the US economy. According to the Deloitte Center for Health Solutions, health care costs continue to rise at a rate of 6% each year.9 Medical tourism offers a savings of up to 70% after travel expenses and
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may demonstrate a 35% annual growth in coming addition to the cost of the surgical procedure for 9 years. The effect of the growth holds huge implisignificantly less than the cost of the surgery alone in the United States. For example, Blue Cross Blue cations for US health care providers as well as Shield of South Carolina is covering procedures in consumers. Thailand, authorized through Companion Global. Of particular concern is the migration of patients The program is inclusive of follow-up visits in the who need outpatient surgery. Technological adUnited States with physicians at Doctors Care.12 vances have allowed surgeries that previously were performed in an inpatient setting to be performed on an outpatient basis. Patients who previously spent Risks and Ongoing Concerns days in a hospital after surgery are now released a Medical tourism is not without challenges. As the few hours after the procedure is completed. Although world market for health care develops, genuine the reduced time for recovery is appreciated by concerns about travel and treatment are being patients, the financial cost covered by the patient identified.13 Several professional organizations has significantly increased. Outpatient surgeries have developed guidelines and checklists for require higher co-payments and deductibles than patients who are considering international travel procedures performed in inpatient facilities. The for medical care. The Centers for Disease out-of-pocket expense makes medical tourism an Control and Prevention (CDC),14 the American attractive option. AcSociety of Plastic cording to a report Surgeons (ASPS),15 published by the the Organization In response to the increased number of US patients choosing the international market for Deloitte Center for for Safety, Asepsis gastric banding procedures, some US surgeons Health Solutions in and Prevention 2009, 75% of medical and associated ambulatory surgery centers are (OSAP),16 the offering to perform the procedure for as low tourists’ procedures American College as $8,900. are scheduled as outof Surgeons (ACS),17 10 patient services. and the Aerospace In some situations, Medical Association18 the expansion of domestic medical tourism has have each published guidelines. These organizations driven costs down in the United States. A few years have identified a number of risks associated with ago, gastric banding procedures cost $20,000, while medical tourism. Some of the risks include surgeons in Mexico charged $10,000. In response to n variability in training, the increased number of US patients choosing the n differences in standards, international market for this treatment, some US n accuracy of medical records, surgeons and associated ambulatory surgery centers n absence of support networks, are offering to perform the procedure for as low as n lack of opportunity for follow-up care with $8,900. Cosmetic surgeons also are responding to surgeons, market-driven competitive pricing by decreasing n exposure to endemic diseases, their fees for procedures that are paid for in adn language barriers, and vance with cash.11 15 n compensation for liability associated with injury. Third-party payers have developed a new approach to lowering costs as well. Several insurers From a practical point of view, patients also should in the United States are launching medical tourism consider the physical effects of travel. Continent pilot programs with their benefit plans. Insurers will hopping can be exhausting for a healthy person; for cover the cost of travel and accommodations in the very ill, it can be hazardous.19 For instance, air 432 j AORN Journal
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travel after surgery increases the incidence of blood clots and pulmonary emboli in medical tourists.18 Continuity of care is a widespread concern. Often, patients find that little, if any, communication occurs between health care professionals abroad and those at home.20 Patients should consult a travel health provider at least four weeks before travel for advice tailored to addressing their preoperative and postoperative needs.8
medical colleagues, the public, and patients about the health care environment, inclusive of medical tourism, is a service. It is a service that leaders perform with a potential to change and improve the health and wellness of patients desiring to improve and maximize their health status.
ROLE OF NURSE LEADERS Medical tourism is embedded in our culture and will continue to grow and expand as intercontinental travel becomes affordable for citizens with average incomes. The quality gap between medical treatment received in the East and West has narrowed, with common standards evolving through facility accreditations and certifications that are now accepted throughout the world. Patients are looking at the global market for health care solutions. From a patient perspective, the conceptual framework of health-seeking behavior has been applied to those searching for health care through international tourism.20 The term health-seeking behavior includes health promotion in protecting and maintaining health through the patient’s response to illness and wellness.20 Professional nurses can positively influence patients’ health-seeking behaviors by advocating for patient choice and educating, counseling, and offering support to the patient and his or her family members.21 Knowledgeable nurses play a dual role in patient education by providing information on appropriate sites as well as related risks and ethical and legal dilemmas.21 According to the World Health Organization, research about medical treatment abroad is in its infancy and there are an array of questions that need to be answered.19 Future research is needed to address public health implications, legal and regulatory issues, ethical concerns, and transnational infections as well as to identify best practices.19 As nurse leaders, it is our duty to take steps to be knowledgeable about health care in the world marketplace. Increasing the knowledge of nurses,
References
Editor’s note: ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD.
1. McCarthy G, Fitzpatrick J. Development of a competency framework for nurse managers in Ireland. J Contin Educ Nurs. 2009;40(8):346-350. 2. The American Organization of Nurse Executives. AONE Nurse Executive Competencies. Chicago, IL: The American Organization of Nurse Executives; 2005. 3. Patients Beyond Borders. Estimated number of medical travelers by country: 2013. Chapel Hill, NC: Patients Beyond Borders; 2014. 4. Patients Beyond Borders. Major procedures: comparative costs. Chapel Hill, NC: Patients Beyond Borders; 2014. 5. JCI accredited organizations. Joint Commission International. http://www.jointcommissioninternational.org/about -jci/jci-accredited-organizations. Accessed June 26, 2014. 6. Magnet Recognition ProgramÒ overview. American Nurse Credentialing Center. http://www.nursecredentialing.org/ Magnet/ProgramOverview. Accessed June 26, 2014. 7. Respaut R. Cleveland clinic exports marquee Ohio brand to Abu Dhabi. Reuters. April 2014. http://www.reuters .com/article/2014/04/11/us-healthcare-cleveland-abudhabi -idUSBREA3A0CI20140411. Accessed June 26, 2014. 8. Lee CV, Balaban V. Chapter 2. The pre-travel consultation: counseling & advice for travelers: medical tourism. Centers for Disease Control and Prevention. http://wwwnc.cdc .gov/travel/yellowbook/2014/chapter-2-the-pre-travel -consultation/medical-tourism. Accessed July 31, 2014. 9. Forward. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 2009:2. http://www.deloitte.com/view/ en_US/us/Insights/centers/center-for-health-solutions/ 55d9f278c9184210VgnVCM200000bb42f00aRCRD.htm. Accessed July 31, 2014. 10. Growth drivers. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 2009:11. http://www.deloitte.com/ view/en_US/us/Insights/centers/center-for-health-solutions/ 55d9f278c9184210VgnVCM200000bb42f00aRCRD.htm. Accessed July 31, 2014. 11. Huffman K. Is it time to “medicalize” medical tourism? Int Med Travel J. http://www.imtj.com/articles/2013/ medicalizing-medical-tourism-60164. Access June 26, 2014. 12. Role of health plans to incentivize medical travel. In: Medical Tourism: Update and Implications e 2009 Report. Charlotte, NC: Deloitte Center for Health Solutions; 5. http://www.deloitte.com/assets/Dcom-UnitedStates/ Local%20Assets/Documents/us_chs_MedicalTourism_ 102609.pdf. Accessed June 26, 2014.
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13. Ozan-Rafferty M. Engaging patients in a global market. Gallup Business J. December 17, 2009. http://business journal.gallup.com/content/124586/Engaging-Patients -Global-Market.aspx. Accessed June 26, 2014. 14. Magill AJ, Shlim DR. Chapter 1. Introduction: perspectives: why guidelines differ. Centers for Disease Control and Prevention. http://wwwnc.cdc.gov/travel/yellowbook/ 2014/chapter-1-introduction/perspectives-why-guidelines -differ. Accessed July 31, 2014. 15. The dangers of plastic surgery tourism. The American Society of Plastic Surgeons. http://www.plasticsurgery .org/articles-and-galleries/dangers-of-plastic-surgery -tourism.html. Accessed July 31, 2014. 16. Travelers guide to safe dental care. Checklist for obtaining safe dental care abroad. The Organization for Safety, Asepsis and Prevention (OSAP). http://www.osap.org/? page¼TravelersGuide#Checklist. Accessed July 31, 2014. 17. American College of Surgeons (ACS) (ST-65). Statement on medical and surgical tourism. Bull Am Coll Surg. 2009; 94(4):26-27. http://facs.org/fellows_info/bulletin/2009/ 2009-april-bulletin.pdf#page¼25. Accessed June 26, 2014. 18. Medical guidelines for airline passengers. Aerospace Medical Association. May 2002. http://www.asma.org/asma/ media/asma/Travel-Publications/paxguidelines.pdf. July 31, 2014. 19. Helble M. The movement of patients across boarders: challenges and opportunities for public health. Bull World Health Organ. 2011;89(1):68-72. http://www.who.int/bulletin/ volumes/89/1/10-076612/en/. Accessed June 26, 2014. 20. Eissler LA, Casken J. Seeking healthcare through international medical tourism. J Nurs Scholarsh. 2013;45(2):177-184.
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PERIOPERATIVE LEADERSHIP 21. Ben-Natan M, Ben-Sefer E, Ehrenfeld M. Medical tourism: a new role for nursing? Online J Issues Nurs. 2009;14(3). http://www.nursingworld.org/MainMenu Categories/ANAMarketplace/ANAPeriodicals/OJIN/Table ofContents/Vol142009/No3Sept09/Articles-Previous -Topics/Medical-Tourism.html. Accessed July 31, 2014.
Cynthia Plonien, DNP, RN, CENP, is the director of the Graduate Program of Nursing Administration and a clinical assistant professor at the University of Texas at Arlington College of Nursing, TX. Dr Plonien has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Kathleen M. Baldwin, PhD, RN, FAAN, ACNS-BC, ANP-BC, GNP-BC, CEN, FAACM, is a nurse scientist and an acute care nurse specialist at Harris Methodist Hospitals Southwest and Cleburne Texas Health Resources, Arlington, TX. Dr Baldwin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
