Medical Tourism: Global Competition in Health Care

Health | International | Policy Reports

No. 304
Thursday, November 01, 2007
by Devon M. Herrick

Ensuring Quality for Medical Tourists

Some American medical trade groups caution patients about the quality of treatment abroad. Speaking of foreign medical providers, Bruce Cunningham, president of the American Society of Plastic Surgeons, told the U.S. Senate Select Committee on Aging, “Without a complete understanding of the medical standards for the health institution or facility, medical providers, surgical training, credentials, and postoperative care associated with surgery, a patient can be ill-informed — and worse, at significant risk.” In fact, Cunningham's warning could easily apply to U.S. hospitals as well.  Information on quality is not readily available to patients, and what is available is often difficult to interpret or irrelevant. Cardiac Surgery Mortality

“The quality of American hospitals varies widely.”

Measuring Quality.  Despite claims of high U.S. standards, results vary widely by hospital.  Consider one of the most commonly performed procedures in the United States today — coronary artery bypass graft (CABG) surgery:

  • Hospitals in California that perform CABG surgery have an average mortality rate of nearly 3 percent (2.91).
  • The California average is nearly four times higher than the Cleveland Clinic, considered the best hospital in the nation by U.S. News & World Report .

Closer inspection of California hospitals shows wide variations in quality: [See Figure IV.]

  • The University of California Davis Medical Center experienced no deaths among the 136 patients receiving CABG surgery in 2003.
  • Fountain Valley's mortality rate of 2.14 percent was below the state average of 2.91 percent.
  • But Desert Regional Medical Center, which performed a similar volume of surgeries, had a mortality rate of more than 6 percent — twice the California average and 10 times Cleveland Clinic's average.
  • Beverly Hospital performs few CABG procedures, which may explain its high mortality rate of 13.79 percent.

“A number of foreign hospitals are accredited in the United States.”

How does the quality of facilities overseas compare to those in the United States?  Some of the more prestigious providers, such as Apollo Hospital Group and Wockhardt Hospitals (which is affiliated with Harvard Medical School) in India, and Bumrungrad International Hospital in Thailand, offer a better level of care than the average community hospital in the United States. [See the sidebar on Bumrungrad.]

As in the United States, many hospitals abroad do not disclose recognized quality indicators.  But most hospitals that compete on the international level generally do.

  • Dartmouth Hitchcock Medical Center in New Hampshire and Ohio's Cleveland Clinic have quality indicators on their Web sites. 
  • National University Hospital Singapore also discloses information demonstrating that its quality compares very favorably internationally.
  • India's Apollo Hospital Group has devised a clinical excellence model to ensure its quality meets international health care standards across all its hospitals.

Other Indian hospitals are working to create standards for reporting performance measures.

“Some American hospitals have foreign affiliates.”

Electronic Medical Records.   Because potential medical tourists must first be evaluated remotely, most large health care providers and medical intermediaries for patients use electronic medical records (EMRs) to store and access patient files. Patients can then discuss the procedures with potential physicians via conference call. Modern hospitals abroad also use information technology to identify potential drug interactions, manage patient caseloads and store radiology and laboratory test results.

By contrast, only about one out of four U.S. hospitals store medical records electronically. Third parties pay 87 percent of medical bills in the U.S. health care system, and most of the third parties do not reimburse physicians or hospitals for the use of EMRs.  Since others pay the bills, patients usually do not choose hospitals or physicians based on their use of EMRs.

“Some foreign hospitals have U.S. trained or U.S. certified physicians.”

Hospital Accreditation. More than 120 hospitals abroad are accredited by the Joint Commission International (JCI), an arm of the Joint Commission for the Accreditation of Hospitals that accredits American hospitals participating in Medicare. The International Standards Organization (ISO) also accredits hospitals that meet internationally agreed-upon standards.  Nearly 150 foreign hospitals are accredited by ISO and JCI.

In addition, some countries are adopting their own accreditation standards.  For instance, the Indian Healthcare Federation is developing accreditation standards for its members in an attempt to reassure potential patients about India's high quality health care. 

Hospital Affiliation.  Some foreign hospitals are owned, managed or affiliated with prestigious American universities or health care systems:

  • The Cleveland Clinic owns facilities in Canada and Vienna, Austria; and in Abu Dhabi, the clinic already manages an existing facility and is building a new hospital. 
  • Wockhardt (India) is affiliated with Harvard Medical School.
  • Hospital Punta Pacifica in Panama City, Panama, is an affiliate of U.S.-based Johns Hopkins International. 
  • JCI-accredited International Medical Centre in Singapore is also affiliated with Johns Hopkins International. 
  • Dallas-based International Hospital Corp. is building and operating hospitals in Mexico that meet American standards. 
  • Bumrungrad International Hospital in Thailand has an American management team to provide American-style care.

“Patients should check the credentials and quality of foreign providers.”

Physician Credentials.   Foreign health care providers and medical travel intermediaries also compete on quality by touting the credentials of the medical staff.  These physicians are often U.S. board-certified, while others have internationally respected credentials.  Many of the physicians working with medical tourists were trained in the United States, Australia, Canada or Europe.  Nearly two-thirds of the physicians who work with PlanetHospital have either fellowships with medical societies in the United States or the United Kingdom, or are certified for a particular specialty by a medical board.

Online Communities.   Potential patients can get some idea of the safety and quality of medical providers by searching online for testimonies of patients who have had surgery abroad.  These Internet communities facilitate the exchange of information about providers, including facility cleanliness, convenience, price, satisfaction with medical services and the availability of lodging while recuperating.

“Medical tourists can purchase malpractice insurance to obtain compensation for bad outcomes.” has built such a community.  Members, including both former and prospective patients, can exchange information in online discussion forums on such topics as destinations, specific physicians and types of surgery.  Members answer questions about side effects, complications and occasionally even discuss patients who have died from surgery.  A few members who had cosmetic surgery have even posted before-and-after photos.  If a facility performed low-quality work on a member, others in the community know to avoid the provider. For example, patients who were disfigured by Mexican cosmetic surgeons created a Web site ( to warn away other patients. is another Web site with a forum where members can interact. Authors of books on medical tourism also interact with readers online.  Jeff Schult, author of Beauty From Afar , has links to articles, reviews and a blog where readers can comment on topics of interest. 

When Things Go Wrong.  Even with the most skilled physicians, patients may have adverse outcomes.  When a medical tourist experiences injury or even death, it is natural to wonder whether a poorly trained physician or substandard hospital played a part.  Of course, sometimes adverse events are due to the patient's pre-existing health conditions or other factors not the fault of the physician; but, as with any service providers, doctors aren't perfect.

Little evidence exists to indicate that botched operations are a widespread problem in the medical tourism industry.  Anecdotal evidence tends to involve cosmetic surgery patients who went to facilities that were not screened by a respected intermediary or whose physicians' credentials were not checked.

Sometimes complications from cosmetic surgery are due to a patient's having too many procedures performed too soon.  Most American physicians advise against multiple or consecutive cosmetic surgeries in a short period of time.  But patients often have limited time off from work and consider travel and recuperative time as part of the cost of surgery.  Thus they are tempted to economize by having more work done than is medically recommended.

Some foreign physicians entice patients with package deals that combine multiple surgeries for one low price.  It is not uncommon for South American doctors to offer package prices that include full body liposuction, a breast lift or augmentation (with implant) and a tummy tuck. The package price can be as low as $6,500 (plus travel and lodging) in Colombia, Costa Rica or Mexico.  The comparable surgery costs $12,000 to $15,000 — and sometimes as much as $30,000 — in the United States. Women who receive that much cosmetic surgery at one time often find recuperation slow and extremely painful.  They may also need postoperative monitoring in a clinic for several days with intravenous antibiotics and blood transfusions, all of which can add several thousand dollars to their cost.

The Web-based intermediaries mentioned elsewhere in this study could help potential patients more carefully choose a destination and physician through a rating system similar to those found for travel and hotels on eBay, Orbitz, Travelocity or Expedia.  A rating system would help steer patients to facilities that have more satisfied customers. Health care providers that fail to supply the quality and level of service American patients expect would be blackballed, or at the very least learn valuable lessons about what patients want.

Foreign laws governing medical liability are not as strict as those in the United States, nor is malpractice compensation as generous.  Foreign physicians typically do not carry the same level of malpractice insurance as do American physicians. The threshold for malpractice is higher outside the United States, and there is limited recourse through the court system in some countries.  Injured patients may not even have the right to sue at all. 

Moreover, a medical tourist would have no recourse through the American court system. It is doubtful an American court would hold an intermediary liable since medical tourism “matchmakers” are not health care providers, and, thus cannot commit malpractice. 

Reputable facilities abroad will work hard to prevent and correct problems.  Although it rarely happens, patients may have to travel back for follow-up care if they do not have a U.S. physician willing to provide it.  A patient may travel overseas again because the cost of treating unexpected complications is lower abroad.  Additionally, some providers include treatment for complications in their package price.

Medical Malpractice Insurance by Contract.  Medical tourists who have little recourse in foreign courts when malpractice occurs have another option: They can purchase a medical malpractice policy that pays in the event a procedure is botched from AOS Assurance Company Limited, an insurer based in Barbados.

One of the ways AOS ensures quality (and reduces its risk) is by covering only procedures performed in accredited hospitals by credentialed physicians.  For instance, an American patient needing angioplasty can obtain $250,000 of coverage for a fee of $1,124.55.  A patient wanting $100,000 in financial protection against a botched facelift would pay $225. In the event of medical malpractice, AOS Assurance Company Limited will compensate insured patients or their beneficiaries for lost wages, repair costs, out-of-pocket expenses, rehabilitation, severe disfigurement, loss of reproductive capacity and death. Claims are administered by an independent, Canadian-based firm, Crawford & Company.

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