The Case

A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provider to an orthopedic surgeon who recommended a total knee replacement. The patient was eager for the surgery so he could return to his active lifestyle, but the elective procedure couldn't be scheduled for a couple of months. In addition to the delays with scheduling, the patient also became concerned about the costs associated with the surgery and his likely postoperative rehabilitation needs.

Based on a neighbor's recommendation, the patient explored alternate options and ultimately had his total knee replacement performed overseas. The surgery was scheduled within 2 weeks, at a fraction of the cost to the patient of domestic surgery, and provided a very satisfying experience overall. Approximately 2 weeks after the surgery, when the patient was back home, he developed acute pain and swelling in his surgically repaired knee. He contacted the US-based orthopedic surgeon who originally saw him, explained the circumstances, and was told he could not be seen because "we didn't perform the surgery, so you should contact your operating surgeon." The patient was ultimately seen in the emergency department and received appropriate treatment for uncomplicated postoperative swelling.

The Commentary

The case presented has two improbable reasons for the patient to travel to another country for his joint replacement. If he lives in the United States, it is unlikely that he would be subjected to a wait of several months or put on a queue to wait for surgery, although that might be a cause for medical travel in other industrialized nations. Second, his concern about the cost of postoperative rehabilitation would not be mitigated by traveling out of the country for surgery. In fact, problems with obtaining postoperative rehabilitation services are more likely to be exacerbated by medical travel. The outcome in the case also is improbable. Sadly, after a major operation involving a complex synthetic joint, it is unlikely that the difficulty is no more than postoperative swelling to be addressed in one visit with no follow-up.

These particulars aside, the overwhelming advantage of joint replacement, or any medical procedure, done overseas is that the operation is less expensive.(1) This advantage has led increasing numbers of Americans to obtain overseas surgery, which makes the issue raised by this case increasingly relevant.

This case highlights the issue of continuity of care. Without arrangements for provision of postoperative care by a surgical team familiar with the patient, the type of implant used, technical aspects of the operation, perioperative infection precautions, and early postoperative stabilization, it is difficult to provide standard postoperative care. This patient developed a postoperative problem, but even absent this, he needs a physician to arrange and write orders for physical therapy to resume weight-bearing activities and encourage mobilization of the joint.

When consulted by a patient returning to the United States with local wound problems 2 weeks after surgery, the orthopedic surgeon's response is not simply because he or she is miffed that the patient chose to obtain surgery elsewhere. Rather, that surgeon is placed in a very difficult position medically, ethically, legally, and financially. He or she has no first-hand information about the procedure, such as the quality of the tissue closed around the prosthesis or the technique for attaching the ends of the device to the femur and tibia. He or she may be unfamiliar with the specific device used (a device that may or may not be approved for use in the United States). If the situation looks problematic due to the possibility of infection or excessive swelling, the patient may be facing months of imaging studies, parenteral antibiotics, analgesics, and therapy. For a patient with health insurance, this may or may not be covered depending on whether the policy covers the costs of care related to surgery that was not approved and covered initially. For a patient who is underinsured or uninsured, these costs would have to be paid out of pocket.

This last issue raises concerns regarding liability exposure, since a patient with an adverse outcome or a disappointing result, unable to pursue a successful legal claim against an offshore provider, may associate the poor outcome with the subsequent care provided in the United States. Even if the case is uncomplicated, the US surgeon who initiates postoperative care is agreeing to provide the long-term follow-up that is needed to meet the standard of care. This means that if the patient develops pain or mechanical problems with his knee prosthesis in the future, the US surgeon would properly be responsible for ongoing care by virtue of having functioned as treating physician.

From a quality-of-care perspective, the potential argument for offshore surgery would be if the patient were unable to financially afford the operation here in the United States. In this situation, the patient hopefully would be aware of the need for adequate follow-up care and the relative risk of complications with his procedure. The US surgeon to whom he turns after his return would have an ethical obligation to treat a life-threatening problem. Few would insist that that surgeon is obliged to deliver non-emergent or long-term care for a patient returning from surgery abroad. Similarly, if the patient has health insurance, there is no consensus that US insurance companies should have to cover follow-up care or costs associated with complications in patients who elect to have surgery abroad.

The Big Picture: Medical Tourism in Context

The roots of "medical tourism" lie in the practice of a modest number of Americans who over the years have had inexpensive cosmetic procedures while on vacation in foreign countries. Today, the term is inadequate for the growing health care phenomenon of "outsourcing" or "offshore surgery."

A consequence of escalating health care costs in the United States, the global market for long-distance medical services is expanding. Several operational models are already in place. There is the outsourcing of hospital services such as transcription, insurance processing, and information technology to other countries with lower labor costs. Certain medical jobs are also moving offshore as low-wage foreign providers offer deep discounts on services like the real-time reading of radiographs.(2) Offshore surgery is seen as an opportunity for low- and middle-income Americans to have surgery for 20%-25% of the cost in the United States, often with surgeons who are US trained, may be US board-certified, and who may be working in hospitals that are JCI (Joint Commission International) accredited.(3)

Growth in the global market is being driven by the complex and costly needs of an aging population, an increasing number of uninsured, the high cost of health care for US companies, referrals by US corporations and insurance companies, and aggressive marketing by hospitals in countries like India and Malaysia. With the building pressure for outsourcing surgical care, many questions are raised. These include quality and safety, the ability to assess competence, and the question of who will bear the responsibility for postoperative follow-up care. Other fundamental issues are legal redress, medicine's relationship with big business, potential erosion of the American health industry by foreign competition, and consequences for the US surgical workforce. Another debatable element of offshore surgery is the access overseas to services, organs, devices, and technologies still in clinical trials or unavailable in the United States due to regulatory constraints.(4)

The surgical procedures that lend themselves to offshore care are non-urgent, short-duration treatments that are expensive in the United States and appropriate for patients with less severe conditions.(5) Orthopedic joint replacement surgery, some cardiac surgery, weight-loss surgery, cosmetic plastic surgery, dental surgery, and infertility treatments are those most frequently offered by the offshore hospitals seeking US patients and offering lower prices.(6) The countries able to offer these values are developing nations that do not have the drivers that make American health care so expensive: cost of labor, cost of equipment and facilities, and the cost of pharmaceuticals and devices. The financial differences can be dramatic. For a hip replacement that might cost $32,000 in an American hospital, the cost would be $9000 in India. A cardiac bypass costing $100,000 in the United States costs about $12,000 in Bangkok.(7)

With lower cost as the primary reason for medical travel, until recently most American participants have been uninsured or underinsured people trying to cope with large out-of-pocket costs.(8) A relatively limited group, the number of individuals obtaining surgery under these circumstances is thought to have been 500,000 in 2009. This may change, however, as US health care insurers and large employers look at the savings they could enjoy by providing a mechanism for their members or employees to travel for surgery.(9) Promoted and facilitated by a burgeoning industry supporting medical travel, the logistics may become more manageable and the numbers of participants could increase rapidly. At this point, there are no solid estimates, but most economists predict a many-fold increase in medical travel over the next 10 years.(10) The unknowns include the impact of health care reform in the United States in terms of the number of uninsured, limitations on covered benefits, and the regulation of the health insurance industry.

This patient's experience illustrates several key points for those considering or advising others about medical travel:

• For patients without health insurance, the need for follow-up care must be calculated in the cost of the surgery.
• For patients with health insurance, the insurer's policies about coverage of postoperative care need to be clear before proceeding.
• Even for straightforward interventions such as dental work or minimally invasive cosmetic surgery, follow-up is needed and complications can occur. For more complex procedures such as weight loss surgery, measures such as lap band adjustment are commensurately more complex and spread out over time.
• Patients who travel for advanced medical procedures available overseas but not adopted by US surgeons pending outcome studies and clinical trials should seek expert advice before going forward with these interventions.
• Any health insurer sending patients to a foreign country for surgery should guarantee that US-based follow-up care is available, require credentialing and assessment of the providers in the foreign country comparable to that in the United States, and ensure that patients have the same appeal and legal rights as they would in the United States.
• Entities accrediting offshore facilities should consider the establishment of measures to ensure continuity of care and longitudinal care as necessary components of a safe organization.

From a policy perspective, offshore surgery has been described as a market correction for runaway health care costs in the United States. Some postulate that it may force the health care industry in the United States to make the changes necessary to render health care affordable. While a popular argument, the types of procedures appropriate for medical travel (non-urgent, short-duration, costly, suitable for healthier patients capable of air travel) account for less than 2% of US spending on health care. Moreover, from an operational standpoint, implementation of organized overseas programs will skim off from a US hospital the most lucrative interventions with the best results, a practice unlikely to improve its bottom line.

The most pressing task for the American medical community is the education of patients who choose to travel abroad for medical care. Patients need to be informed that complications occur in a predictable number of interventions under any circumstances, that devices and treatments available outside the United States may not be subject to rigorous scrutiny, and, most importantly, that a surgical procedure is not an isolated event. The US health care system recognizes this with global surgical fees that include up to 4 months of postoperative care. This, of course, contributes to the costs that make US health care more expensive than offshore care.

Mary H. McGrath, MD, MPH Professor of Surgery, Division of Plastic Surgery

University of California, San Francisco

References

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