There are many issues within the medical tourism industry, that can be overcome with greater communication from all parties. Senior academics from Bowling Green State University, Ohio, USA and Beijing Union University, Beijing, China present their analysis.
With the election of Donald Trump, there is an intense discussion about healthcare in United States. Most of these discussions focus entirely upon modifying or changing the current system. There is a great degree of uncertainty. (3; 24; 37) These discussions do not recognize Medical Tourism as an element to improve healthcare in the United States and globally to achieve stability. (29; 36) The focus of this article is to examine some of the barriers to medical tourism and the development of a global health system that will help improve the quality of service as well as reduction of cost.
Global tourism for medical purposes is becoming more popular as an alternative to domestic services within a country. (32; 36)There are many reasons why an individual is seeking medical services as inbound tourists in another country. (1; 15; 35)) Quality of service, cost, specialized services, etc. are just a few of the reasons individuals are seeking these services. Most Medical Tourism programs are a direct result of government efforts.(15; 18)There are some programs that are private, but are indirectly influenced by government regulations such as Visas, as well as language, hospital capacity, regulations, etc. (31) Most countries want foreigners as clients because of the increased revenue. A question of services being provided to foreigners’ and not to the residents is an issue that is being struggled with by many countries. (1; 34) Most of these programs are directly influenced by money and the ability of the client to pay at a higher rate than the residents.
The evolution of Medical Tourism programs within most countries is the purview of the government and its medical community. (13; 21; 27) The question being raised by this article is the standardization of services especially as it relates to quality of care. The primary decision for a foreigner to visit for medical services is usually based upon quality. (9; 35) The quality of services differs among different countries as it relates to their standard of education and care. There are obviously standards for medical education, but these are not consistent across all certification requirements within a particular country. (22; 24) There is obviously standardization through international Hospital certification, which is a help in answering questions of standardization of care and services. Standardization of services is a primary concern. The primary focus of this article is cooperation and it’s influence the barriers that directly influence the delivery of international services.
(36) The current status of Medical Tourism is a very competitive arena. (9; 21; 30) This competition leads to the fractionation of international services. There are obvious forces through the United Nations that are interested in a cooperative effort, but these endeavors are just a small part of a wider effort that is needed to provide a cooperative atmosphere for international Medical Tourism services.
The obvious topic for international cooperation is infectious diseases and their spreading through travel and movement of people throughout the global community. (11; 19) The primary mechanisms of these efforts have been isolation of infected individuals and the banning of these individuals from entering a country. Many times these individuals spread the diseases because they do not know their infected. The host country often has a screening process. This screening process is not effective in many cases. The international communities, both political and non-political often respond by sending assistance and medical services to where these infectious diseases are found. The response to these crises has been widely different depending upon the nature of the crisis. Different international organizations have taken the lead in these efforts. The history of infectious diseases has not been good and was often driven by fear. In today’s modern world, these diseases are better understood, but fear is still a driving force that influences many of the decisions. This essay does not deal directly with cooperation that is a result of infectious diseases but focuses upon the medical services that directly influences individuals seeking care for their medical problems. This does not discount cooperative structures that have been established through these infectious diseases. The care for individuals is a very different issue.
The need is to develop better cooperation in delivery of services through international cooperation by lessening the competitive structure. (25; 36) The primary issue here is one of duplication of services and the ability to deliver highly specialized services on a global basis to individuals. (18; 21)The obvious question is the need for medical services in Third World countries. There is no doubt that there is a need in this arena and that there is a cooperative effort to provide these services. (12) It is obvious there is a continuing need and a direct outgrowth of poverty and war.
These international efforts are usually directed toward basic services. Medical Tourism’s primary focus is upon individual services usually of a specialized need for the individual. (9; 37) The arguments here are group versus individual needs. (23) This discussion often turns to one of wealth versus poverty. (38) This is not an issue that can be resolved by this article. The primary focus of this article is upon individual services.
Better medical services can be achieved through more cooperation.
Some of the barriers to development of a system of global health are: certification, competition, standards, communication, continuing education, infectious diseases and public health, insurance, international agencies, and technology.
Certification
Certification has been discussed briefly above as an element/barrier to globalization. Certification in this context has to be the ability to recognize credentials from one country to another. (20; 35) In the United States, the credentialing process is by state. Foreign doctors immigrating into the United States have to meet the standards for the state in which they apply. (9; 13; 37) Most of the time this is directly related to additional education because the education received outside the United States is not perceived to be the same. The credentialing process of a US Doctor going to a foreign country is similar in that they have to meet the credentialing process of the country in which they are trying to provide medical services. On many accaision this is not an immigration issue, but is an issue of practicing medicine in the other country on a temporary basis.
Credentialing is a very political process under the guise of one’s education not being equivalent. (26; 30; 32) This is for the protection of territory by medical associations. There is a very real concern about equivalency and standards, but this should be able to be resolved if the credentialing is handled by an international agency that can ensure standards. This is a barrier and most medical associations, states, or countries are not going to give up their credentialing process. (27) This is a means or a method of control of medical services.There needs to be a superstructure developed that can ensure quality and development of standards. The testing process can remain the same. This testing can be by exam or it can be by a team of experts that are providing oversight.
Competition
Competition is the demand for medical services and the protection by each country to provide services. Each country wishes to increase the number of clients and there competitive position. (16; 35) They market their medical services and this is an effort to attract clients, especially from other countries. Many times the attraction is the cost of the medical services. (6; 26) These other countries are in direct competition with the United States because of the high cost of the medical services. (18; 37) Quality is the primary concern of the client. (15; 16; 23) Competition is a barrier and needs to be reduced and replaced by a cooperative system. Cooperation can help improve the quality medical services in many of the countries.
The primary focus on quality often revolves around research that is being completed and delivered to clients. This is a starting point in which cooperation could be developed in relation to a specific area of treatment to provide medical excellence. (17) There are even intercountry competitive aspects because there is a treatise that some medical professionals want to be first to discover and become famous because of their discoveries or innovative services. This competition is inbred in the medical community and it will take many years to develop a sense of cooperation. (20; 24) This does not suggest that there are not some cooperative efforts, but the primary focus is competition. Beyond research, medical services related to quality are essential. This means that the medical services provided must be on the cutting edge with the doctors and medical staff keeping up with the most innovative methods. (14; 32) Innovation, in this context, does not mean risk but conservative practices that will develop quality medical services. Some suggest that competition improves medical services. Competition, in this context, is one of cost. (6; 15; 31) This is the very basis of the competition between countries. It may be that competition reduces cost, but it also may be that competition reduces quality and services because cooperation and collaboration is the basis of improvement.
Standards
Standards in this context can refer to doctors, hospitals, etc. Certification of doctors has already been discussed in the above paragraph. (13; 37) Hospitals already have an international organization that certifies them. It must be recognized first that there are a number of different types of classifications of hospitals based upon their level of care from inpatient care to emergencies. The certifying organizations are the Joint Commission International and the International Society for Quality Health Care. These organizations implement critical standards across all types of hospitals on an international basis. Reviewing hospitals on this basis is obviously a check and balance to a minimum level of service. It is recognized that there is obviously a tremendous difference because standards only assure a minimum level of service. (36) It is very important to realize that these hospitals have different rankings based upon best performance of service. (20; 28) There are various criteria based upon performance rankings. It is important to recognize the nature of these rankings and who is developing the criteria. (10; 29) These rankings must be checked from a number of sources in order to isolate the best care provided by hospitals and doctors with the highest ranking. Many times there are rankings of doctors based upon limited reviews or websites. The criteria used must not be self-reporting only. The criteria must be scrutinized as with hospitals. (28; 33) There are really no consistent standards of ranking of performance for either doctors or hospitals.
It is recognized that industry or professional associations in some instances rank the hospitals and doctors and in these particular cases they provide a level of scrutiny that is preferable. The primary question is standards need to be developed to assess levels of performance beyond minimum standards that are achieved by the industry for doctors and hospitals. There needs to be a set of performance criteria for review on an international basis. (33; 37) This is very difficult to implement because the medical profession wishes to control the review of doctors and hospitals. The reasons primarily are for ensuring control over the medical services provided.
Communication
Communication in this context refers to medical service providers and their ability to relate to one another. (14; 17; 32) There must be more effective communication within a country as to the medical services provided to unify around certain goals and the development of centers of excellence. (20; 36) The other type of communication is between different countries. There is little or no communication among different countries and medical services provided to the client. Once a client leaves a country, many times there is no follow up care. Communication is the responsibility of the client. (24; 32) This does not suggest that when the procedures are performed in one country that the information is not transferred to the other country based upon the clients request. MedRepublic is a company that is connecting clients and doctors through an informational network. There is a desperate need not to provide only rudimentary information, but detailed information about case details, impacts and prognosis. Follow up on these kinds of cases is essential to the quality of the client’s health after a procedure. (38) This is a very simple process and should be instituted based upon an inter-cooperative effort among various medical service providers. The most difficult problem with communication is language and difference in medical procedures. (27) Even with effective communication, there has to be an improved information transfer because of these differences.
Continuing Education
Continuing education is essential to the continued improvement of skills. (20; 27; 33) Most countries medical associations require continuing education. This is an essential element for quality services. The medical profession through active research is changing almost daily. (17; 29) Many times the pharmaceutical companies help improve services, but it is up to the individual to keep up with the rapid changes that are occurring within the profession. Even though there is continuing education, much of the information presented may be outdated because of the nature of the research being conducted. The continuing education must not lag behind the research studies. (30) Those providing continuing education exercises must be up on the current methods and procedures and constantly provide information between continuing education exercises. The continuing education provided must be consistent across all countries and represent a common perspective.
Infectious Diseases and Public Health
The overriding concern in recent years has been the spread of infectious diseases. Public health is essential in all the countries that have a standard for the spreading of infectious diseases. (7; 8; 11; 19; 31) One of the positive notes has been when infectious diseases are identified, many countries provide medical services to the host country that indeed reduces the spread of these infectious diseases. With the migration of refugees, the spread of disease has been more rampant. It is very difficult to control when people are fleeing death and destruction. (11; 19) Full impact of the migrations of refugees has not been fully felt or understood.
The public health in most countries is woefully inadequate. Countries that have the resources and personnel must help underprivileged countries, if not the disease may find it’s way to their populations. The screening of immigrants is essential to limit the problems with disease. This is not possible in all cases and once the immigrants arrive at the destination their screening must be provided in order to limit or control the spread of certain diseases. Health practices must be updated and standardized for all countries, even the most poverty-stricken, and must be assisted by those who have the personnel and resources.
Insurance
Insurance can always a problem. There are various insurances, but most do not pay or realize the benefits of medical tourism, especially on bottom-line cost. Four major insurance companies that are exploring medical tourism are (3; 5; 27): Anthem Blue Cross; Go Insurance, United Groups, and Medical Travel Shield. Most of the services provided are private pay. BasicPlus, which is an insurance underwriter, also provides Medical Tourism Coverage. (2) There are a few innovative approaches like Meta-share and insurance within a country that can be purchased as a visitor that helps defray the cost of services.
There is an extensive education program needed to help insurance companies understand the financial as well as quality of service benefits to their clients. (22; 35) Many insurance companies cover travel and emergency services, but beyond that very little. Litigation may also be a real problem in the future. (2) Travel insurance can be purchased for short periods of time while individuals are away from home, but most of these coverages are not extensive and have high deductibles. Many of the insurance companies, especially in the United States, do not have the vision to understand medical tourism and its application for the development of global health. (28) Most countries that have socialized medicine have limited coverage for foreign procedures because these are dollars leaving the country that could be spent on medical services within a country. Currently medical tourism is private pay or very limited policies that have a partial assistance with medical costs. Those companies that provide medical tourism Insurance are different by locality and services.
International Agencies
There are two international agencies that deal with healthcare on a global basis: Joint Commission International and International Society for Quality Health Care. (9; 13; 37) The United Nations assists in these endeavors. There are also many non-profit agencies that provide medical services in Third World countries. (12) The focus here is not on these non-profit agencies that have provided excellent services to the poor of the world. There needs to be a global effort to recognize that medical services must have some organization to develop international standards. (20; 24) It is also recognized that the primary purpose of this organization also is to coordinate and help poorer countries to raise the quality of their medical services. This basic discussion should also focus around the difference between residents and nonresidents. (12; 32) Many times nonresidents can afford the very best quality healthcare in the country for medical services and the residents cannot. This issue must also be addressed by an international agency. A country where the residents do not receive the same quality of services as the nonresidents needs to be helped as much as Third World countries. (12) It is essential that all services be standardized so that there is a common level of delivery of services, beyond the wealthy who can afford medical services anywhere. (16; 33) There needs to be a means to develop homogeneous medical services to world populations in an effective manner. This involves new methods of delivery. With the increase in technology, doctors can consult through electronic means and provide diagnosis on a very effective basis. These new technologies must be managed and expanded to world audiences. New methods of delivering must also be found through medical education using these highly developed technologies.
Technology
Technology is one of the keys as outlined to the more effective delivery of medical services worldwide. With supercomputers like Watson that can integrate research and process it very quickly and effectively provide diagnoses, it can help solve some of the medical service deliveries in many countries. There has to be an effective information exchange with the Internet and the medical community within a country having access to the most modern and effective technologies like Watson. This sets up an interesting question regarding information flow and development and its impact upon medical services worldwide. This may be the primary mechanism to help solve many of the barriers that have been outlined. This type of network will require effective education in the host country. Integration is an essential element to the success and development of these information exchanges.
Conclusion
One of the simplest issues that will help solve many of the problems of follow-up is an exchange of information between the doctor providing services and the home country. This is the first of the steps that must be developed in the information flow cycle to improve services. The standardization of certification programs as outlined is the other element that must be implemented to improve medical tourism services. Communication among medical communities in the host countries and the standardization of certification procedures are the very first steps to overcoming the barriers.
There has to be comprehensive studies for effective development and integration of medical services but this can be effectively achieved with technology, and services can be improved significantly. It is essential that many of the barriers isolated be reduced, but the primary problem is one of attitudes among the medical professionals within each country. Once these attitudinal problems are overcome, many of the barriers will disappear and technology can be applied to increase communication and improve services worldwide. Technology has to be applied in order for these barriers to be overcome, but the attitudinal problems of the medical professionals must be the first problem overcome. The educational process is also key to overcoming these barriers. Once these barriers are overcome with the educational process, technology can be effectively applied and cost can be reduced and medical services can be improved worldwide to deliver a common level of medical service that is effective.
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