Privileged classes of people and sometimes common people with difficult medical problems have always traveled to undergo treatment outside their home country. Nineteenth-century centers of medicine in Europe attracted patients from colonies in Africa and the Far and Middle East.

In the 20th century, the growing fame and prestige of specialized centers such as the Mayo Clinic, Cleveland Clinic and Johns Hopkins attracted large numbers of patients to the United States. The numbers grew along with the expansion of air travel and the development of new technologies and procedures, such as bypass surgery, which were unavailable elsewhere.

Along with the new procedures and new technologies came the growing reputations of physicians and institutions that pioneered them, or that became very good at using them. But reputation was not the only factor in referrals: Many patients preferred the privacy and anonymity that distance from home naturally afforded and that U.S. and European laws guaranteed. These patients also were assured of excellent nursing care and reduced risk of infection, compared with staying at home for treatment. These differences, however, are disappearing.

20th- versus 21st-Century Strategies

Medical tourism was and is not only a demand-pull industry: Providers long have used supply-push through a variety of interrelated market strategies. First, there were seminars, academic affiliation and the training of foreign medical graduates. A second strategy was to obtain (and then market) an excellent reputation for patient care and customer service through such vehicles as Press-Ganey and the U.S. News & World Report hospital rankings. Third, institutions with the vision, culture, budget and capability have adopted a strategy of engaging in overseas ventures and investment.

Will these strategies continue to work in the 21st century? Consider these new realities:

  • At least anecdotally, there is an increase in the number of well-trained professionals returning home because the markets there are opening up — a reverse brain drain.
  • Thanks to economic globalization, medical technologies are as readily available overseas as they are here. The advantage of being the only place with advanced technologies, and the only place having the experts to use them, is gone.
  • The political and social instability resulting from terrorism has made travel more difficult at both ends of a medical journey.
  • Growing safety and ethical regulation, from FDA oversight to restrictions on embryonic stem cell research, have slowed advances in medical technologies in the United States.

These new realities are giving other countries a chance to catch up and compete with the United States. In recent decades we have seen game-changing work on lithotripsy (Germany), laparoscopic genitourinary surgery (France), prostate ultrasound (Japan) and slightly different stem cell therapy approaches to spinal cord injury surgery (Portugal and China).

Consequences and Impediments

In practical terms, this means that:

  • most specialized procedures now are performed in the erstwhile international patient's home country;
  • improvements in the standard of nursing care overseas make patients more confident of staying at home to have procedures done locally;
  • most referrals now are for superspecialized quaternary care, or they result from the patient's preference rather than the home doctor's recommendation;
  • the contribution of new technology from the European Union and from Japan, China and other countries will grow.

Given that the cost of care in countries outside the United States is increasingly more affordable and accessible than it is here, and that the quality and technology gap has all but closed (at least with respect to prominent providers in India, Taiwan, Turkey, Brazil, Singapore and other countries that have made medical tourism a national priority), U.S. hospitals may lose not only international patients, but also their “home” patients.

Last December's issue of Medical Tourism magazine gave a sense of how fast medical tourism is growing and, if you are a health care provider, of its potential impact on your practice. It reported, for example, that:

  • a Northwestern University study suggested the United States would save $144 million by sending 7,500 patients to hospitals in Turkey;
  • an uninsured Memphis filmmaker opted for triple-bypass heart surgery in India because he could not afford to have it in the United States;
  • even insured Americans may opt to travel to be fully covered for treatment at four hospitals in Taiwan, if they are insured by the New Era Life Insurance Group, whose very name is suggestive.

Developing and Implementing a Strategy to Compete

So what should your strategy be? We don't know whether Johns Hopkins' recent deal with PepsiCo to provide orthopedic surgery for its workers, or the Cleveland Clinic's deal to provide heart surgery for Lowe's employees, were intended to counter the threat from medical tourism or were simply a search for new revenues; but the effect is a form of domestic medical tourism in which workers can receive care at top hospitals while their employers save some money and perhaps have healthier and happier workers.

Providers with a good reputation and a good care model, educational model and business model can franchise their brand to credible institutions and investors abroad. They can consider providing international education services and technical assistance. And they can offer services via telemedicine. The only impediments to such strategies are institutional goals that ignore any cultural differences with potential foreign partners and clients, legal requirements (especially related to licensure and credentialing, which are gray areas, particularly with regard to telemedicine) and, not least, economics: Business-class seats to the BRIC countries (Brazil, Russia, India, China) and the Middle East, where much of the opportunity lies, don't come cheap.

Deciding and implementing a strategy is not easy. But, for providers who can overcome those barriers, the strategy might include a combination of in-person visits with lectures, rounds and surgical demonstration, in conjunction with distance connectivity via telemedicine, for example, to provide specialist consultation, review radiology exams and pathology slides, and even perform telesurgery.

Our Televideo Network

We have established a program between Detroit and Brazil that does all of this except for telesurgery; but even that is possible with the latest da Vinci robots that can handle dual-console, long-distance tele-operation. Right now we also are preparing to expand into international tele-education services, including lectures, tumor boards and surgical demonstrations.

Finally, it's worth noting that the televideo network we've set up helps to save on some of those $9,000 tickets to India and Brazil, by enabling us to negotiate affiliation agreements, consult with clients on project development, and follow up on ongoing projects, all without leaving home.

How much of a threat is medical tourism to your institution? We would really like to hear your views.

David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. He is also a regular contributor to H&HN Daily and a member of Speakers Express. J. Edson Pontes, M.D., is a urology professor at Wayne State University School of Medicine in Detroit, and he practices at the Karmanos Cancer Institute. He is also the head of international services for the Detroit Medical Center.