Medical Tourism and Quality Measures

Medical Tourism or the exportation of health care services and procedures is in full swing in the United States consumer driven health care movement. Since deregulation of the airlines with the Reagan administration Americans have increasingly become global travelers and consumers, so why not health care services as well? This article explores the private sector health care population that is seeking health care outside of the United States and examines some quality issues.
Previously Americans seeking health care overseas were expatriates working offshore, residents with family ties in other countries with westernized medical services, or the wealthy. Since 2000, there has been a tremendous increase in middle class Americans seeking medical services abroad. Approximately twenty billion dollars annually are spent by U.S. residents who obtain medical care off shore. The primary medical services accessed outside of the U.S.A. purview are cosmetic surgery, orthopedic repairs, cardiac procedures, organ transplants, and fertility treatments. These are also high profit services for medical facilities in the United States. Insurance companies, largely at the behest of privately insured employers, are including coverage for medical procedures provided off shore at an increasing rate in their contracts. Even the nonprofit hospital group, Christus Health in the Southwest purchased a hospital in Mexico, in order to offer lower cost procedures within their network. This triad of insurance companies, employer groups, and USA health care providers has created a tsunami of change in the provision of health care.
In 2003, I conducted research on medical tourism for Seattle Cancer Care Alliance and Fred Hutchison Cancer Research Center, for a marketing project to encourage transplant patients to obtain care in Seattle. At that time, no thought was given to patients seeking transplant procedures outside the United States for the exportation of medical care. My survey included facilities on the east and west coasts. Though I was very enthusiastic about the potential for business development for world class transplant centers, this was not shared by my direct reports. I recall how a Miami Florida facility had a very advanced patient support system, including housing, interpretation, and other assimilation services. How things have changed in a mere seven years, now United States transplant facilities must compete with international facilities who are obtaining Joint Commission International accreditation, and can offer the same services as U.S. health centers for less than half of what the same services would cost in the states, inclusive of travel expenses!
The next step to assuring a safe process for adventurous or maybe even frugal patients, who seek medical care outside U.S. oversight, is to identify quality indicators on a global scale, and incorporate quality measures into certification, and contracting of services throughout the globe. India and Thailand both have international centers that cater to western patients and other countries are rapidly developing their ability to serve global patients.
For any medical procedure involving surgery, infection is one of the risks, and is a frequent complication post-op. Infection rates by procedure and facility should be tracked and reported in a transparent manner for a primary quality indicator. A second indicator would of course be mortality, incidence of death, again, by procedure and facility. A third quality indicator would be the re-admission rate for complications from a procedure, which could include complications from co morbidities and device or surgical failure rates. Another quality indicator would be certification of facilities and clinical staffers. A part of this certification should include the frequency with which they perform the contracted procedures and their patient success and failure rates. Meaning, surgeries that go as planned as well as those with unintended consequences, including death. Cost or value should also be included in the scorecard for determining an international medical center’s performance. Administrative functioning and efficiency should also be considered in contracting for quality with an international facility. Finally, the patient’s experience should also be included in a facility’s quality assessment. These seven criteria provide a good basis to create a quality benchmark from which to gauge an off shore healthcare facility’s excellence prior to contracting for services.
Though all of these criteria are important in attempting to pre-qualify an international medical facility’s ability to perform as contracted, the patient’s health status and mobility are also essential elements of any surgical intervention. Insurance companies, who incorporate medical tourism into their contracts, should require a U.S. physician to examine each patient’s ability to seek services at a non-local facility. If the patient may be certified as healthy enough to seek services off shore, then the insurer would approve the procedure. Also, U.S. physicians are reluctant to release patients to clinicians they do not know and facilities for which they are unfamiliar. Insurance companies and health care providers should find ways to build confidence between professionals as needed. I won’t address the legal implications of off shore medical services, but I am sure it is just a question of time before a malpractice or wrongful death suit is filed under medical tourism.
This article was written by Roberta Winter, MHA, MPA, President of Praevalere Inc., a Seattle based health care consulting firm, and may be reprinted with her permission.