Armin Schubert, M.D., M.B.A.
ASA Representative to the Workforce Studies Group of the Association of American Medical Colleges

s we contemplate a physician and anesthesiologist shortage in the United States caused by limited supply and burgeoning service demand, it might seem far-fetched to worry about surgical cases and their anesthetics flowing to other countries in search of more economical health care.

Demand for U.S. physician services is directly related to aggregate U.S. health spending, which in turn is related to the strength of the economy. The reasons for this linkage are probably because employers cut health care benefits during times of economic challenge and individuals delay elective or discretionary medical care. Demand also is linked to population age and morbidity as well as advances in technology, including the ready access to information technology. Patients over age 65 require a multiple of medical procedures compared to their younger counterparts. The obesity epidemic (>30 percent of the U.S. population) is fueling demand for surgical and anesthesia care through the comorbidities of atherosclerotic heart disease, cancer, diabetes, degenerative joint disease and chronic pain.

Demand for surgical health care has been relatively independent of cost, primarily because most citizens have health insurance and do not see the majority of charges. However, patients without insurance, those with minimal insurance and those affected by utilization controls (such as patients from Great Britain and Canada on arduous wait lists for surgical procedures) find themselves confronted with the intriguing possibility of going to another country to have their surgical procedure performed for a fraction of the cost than in their home country with minimal wait times and frequently with luxurious accommodations. These competitors to traditional health care providers in the United States and Western Europe are mostly located in Asia, accounting for a growing industry that is beginning to contribute to globalization of surgical health care. Globalization still represents only a small part (estimated at <2 percent) of the surgical U.S. market share¹ and is not yet thought of as an important competitive factor in the health care industry.²

Globalization, however, is growing rapidly. In 2002, more than 300,000 patients from abroad were treated in Thailand’s private hospitals, with 200,000 more checking into Singapore hospitals and 150,000 going to India.³ Bumrungrad hospital in Bangkok appears to have established itself as the premier facility in Southeast Asia. Among the more than 200,000 foreign patients are more than 30,000 from the United States.⁴ In India the “medical tourism industry” is expected to grow by $1.1 billion to 2.2 billion over the next five years⁵ and has spurred medical entrepreneurship such as private hospital chains Apollo Hospitals and the Escorts Heart Institute.

Growth is rapid, and opportunities abound.⁶ By 2005, Bangkok’s Bumrungrad hospital had treated 55,000 Americans, a 30-percent increase over the previous year.¹ Other countries promoting themselves as destinations for “medical tourists” are Malaysia, Korea, South Africa, France, Jamaica, Cuba, Costa Rica, Belgium, Hungary, Poland and Lithuania. Private hospitals in these countries are attracting patients who need coronary bypass, hip and knee replacement, spine surgery, plastic surgery and eye operations. Charges are one-third to one-half the price charged by U.S. hospitals. In some cases, such as that of a patient from Alberta, Canada, having spinal surgery in India, insurance even covers part of the expense. While floating hospitals (ships) have been commissioned to perform abortions and artificial insemination off the coast of countries where these procedures are outlawed, this activity has met with formidable challenges.⁷

Medical tourists are often marginalized by members of the Western health care establishment and admonished to carefully check the certification of surgeons, anesthesiologists and facilities before making a decision. Although stories of poor outcomes from overseas surgery are rare, it would be nearly impossible for patients to obtain the kind of monetary redress available within the U.S. legal system if an adverse outcome occurred.

Responding to the increasing sophistication of their overseas patients, more than 80 overseas hospitals have obtained Joint Commission (international) accreditation, preferentially employ physicians with Western credentials and provide online consultations prior to the physical health care encounter. Several well-known international hospitals have reported surgical outcomes comparable to those expected in the United States; for example, gross mortality rate of <1 percent after coronary artery bypass graft.¹ Another competitive advantage of overseas medical facilities is their ability to hone luxury and to pamper their patients. Surgical patients recover in luxury-class facilities, attended to by private nurses, and are distracted with safaris, beach vacations, private villas, room service and the like. Plastic surgery coupled with a vacation abroad has another attraction: No one needs to know it happened.⁸

Medical tourism is quite sensitive to “scares” from disease outbreaks such as SARS³ and concerns over avian flu. Other as-yet unknowns are the longer-term track records of overseas surgical facilities and the complexities introduced into the management of revision surgery. Overseas medical enterprises also have been criticized for siphoning off much-needed medical resources from the local economy, which is often medically underserved in the extreme compared to Western societies. These enterprises may therefore face political and societal obstacles to expand at the current pace.

Outsourcing of medical care also is somewhat limited by cost differential, duration of air travel and type of medical condition. Currently, seeking medical care overseas makes economic sense for uninsured or underinsured Americans only for elective-limited duration surgical treatment that costs more than $15,000 to $20,000, when the lower costs of overseas care make up for travel expenses and incidental costs. The outsourcing trend is fueled by the substantive shifting of health care costs to the patient, which has resulted from the steady growth of health care costs in the United States. As costs rise further, more patients will find U.S. health care, and surgery in particular, less affordable and will seek lower-cost alternatives abroad. Moreover some mid-size businesses (and even the West Virginia state legislature⁹) are considering incentives to employees who take advantage of lower-cost operations overseas.^10,11

As its price rises, American-style surgical health care will almost inevitably face more overseas competition driven by the greater portability of patients, technology and quality standards. While this may spell less demand for domestic anesthesia services, it also might be accompanied by repatriation of international anesthesiologists currently in U.S. practice who again may find attractive practices in their home countries. For anesthesiologists, outsourcing surgical procedures to overseas facilities is a trend to be watched for its rapid growth, although it still represents a relatively insignificant portion of the U.S. surgical market.

References:
1. Milstein A, Smith M. America’s new refugees — Seeking affordable surgery offshore. N Engl J Med. 2006; 355:1637-1640.
2. Porter M. Redesigning healthcare (electronic mail on the Internet). Message to: Armin Schubert, 2006.
3. Balfour F, Kripalani M, Capell K, Cohn L. Under the Sea, Then Under the Knife. Business Week on the Web. February 2004 (cited December 23, 2006). Available from www.businessweek.com/magazine/content/04_07/b3870074.htm?chan=search.
4. Mydans S. The Perfect Thai Vacation: Sun, Sea and Surgery. New York Times on the Web. September 2002 (cited December 23, 2006). Available from query.nytimes.com/gst/fullpage.html?sec=travel&res=9E00E0DC1F3EF93AA3575AC0A9649C8B63.
5. Maini A, Reddy P, Srivastava H. Medical Tourism to India. Academic Search Premier (Internet). October 2004 (cited December 23, 2006). Available from web.ebscohost.com (subscription required).
6. Teh I, Chu C. Supplementing growth with medical tourism. Asia Pacific Biotech News. 2005; 9:306-311.
7. English V, Mussell R, Sheather J, Somerville A. Ethics briefings. J Med Ethics. 2005; 31:743-744.
8. Andrews M. Vacation makeovers. U.S. News & World Report on the Web. January 2004 (cited December 23, 2006). Available from www.usnews.com/usnews/culture/articles/040119/19surgery.div.htm.
9. Alsever J. Basking on the beach, or maybe the operating table. New York Times on the Web. October 2006 (cited December 23, 2006). Available from travel.nytimes.com/2006/10/15/business/yourmoney/15care.html.
10. Foster M, Mason M. Businesses may move health care overseas. The Washington Post on the Web. November 2006 (cited December 23, 2006). Available from www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2006/11/02/national/a083252S07
.DTL&type=health.
11. Kher U. Outsourcing your heart. Time Magazine on the Web. May 2006 (cited December 23, 2006). Available from www.time.com/time/magazine/article/0,9171,1196429,00.html.

Armin Schubert, M.D., M.B.A., is Chair, Department of General Anesthesiology, Cleveland Clinic, and Professor of Anesthesiology, Cleveland Clinic Lermer College of Medicine of Case Western Reserve University, Cleveland, Ohio.