When Canadian researchers examine the subject of medical tourism, they typically focus on ethical, social, public health and health policy issues related to Canadians seeking health services in other countries. They emphasize study of Canada as a departure point for medical tourists rather than as a potential destination for international patients. Several influential voices have recently argued that provincial healthcare systems in Canada should market health services to international patients. Proponents of marketing Canada as a destination for medical tourists argue that attracting international patients will generate revenue for provincial healthcare systems. Responding to such proposals, I argue that there are at least seven reasons why provincial health systems in Canada should not dedicate institutional, financial and health human resources to promoting themselves as destinations for medical tourists.
During his time as British Columbia's minister of health services, Kevin Falcon, currently that province's deputy premier and minister of finance, asked, "Why can't British Columbia be the Mayo Clinic of the North?" (Fowlie 2010). Falcon proposed attracting patients from the United States and elsewhere and using the money these people spent on health services as revenue for British Columbia's health system. He speculated about the possibility of charging international patients four to five times the cost of treating them (MacLeod 2010). Falcon claimed that international patients would not receive priority treatment before Canadians. Rather, he stated that medical tourists would take advantage of "unused capacity" by having surgery on evenings and weekends (Fayerman 2010). Falcon is not the first public figure to propose that Canadian healthcare facilities should position themselves as destinations for international patients. Brian Day, former president of the Canadian Medical Association and one of Canada's most outspoken advocates for an expanded for-profit, private healthcare sector, has for several years argued that Canada should profit from selling health services to foreign patients (Hall 2007). In 1993, Dennis Timbrell, at the time president of the Ontario Hospital Association, proposed attracting international patients to Ontario hospitals and using the money they paid to keep healthcare professionals employed and hospital units open (Priest 2008). More recently, the business consulting firm Deloitte (Purdy and Fam 2011) issued a report proposing that Canadian provinces promote both medical travel to healthcare facilities outside Canada and inbound medical tourism to Canadian hospitals and clinics. Deloitte's proposal attracted coverage by national news media. Canadian interest in marketing health services is part of a larger global trend in which countries as diverse as Barbados, India, Mexico, Singapore and South Korea promote medical tourism initiatives as a vehicle for promoting economic and social development and generating revenue that can be used to subsidize publicly funded healthcare (Connell 2006; Turner 2007a,b).
Thus far, researchers addressing medical tourism in a Canadian context have focused upon Canada as a point of departure for medical travel (Crooks and Snyder 2011; Turner 2007a,b). Addressing such topics as information disclosure and informed consent, quality of care and patient safety, continuity of care, roles and responsibilities of Canadian medical tourism facilitators and financial burden of treating medical tourists who return home with post-operative complications requiring costly treatment by publicly funded Canadian medical facilities, health researchers have explored ethical issues and risks facing Canadians engaging in medical tourism and going abroad to healthcare facilities situated in such countries as Costa Rica, Dominican Republic, India, Mexico, Singapore and Thailand (Penney et al. 2011; Snyder et al. 2011; Turner 2007a,b). To date, bioethicists, health policy specialists and public health researchers have not examined and addressed recent proposals to make Canadian provinces destinations for medical tourists. Positioning provincial healthcare systems and particular healthcare facilities as destinations for international patients raises numerous ethical issues and prompts concerns about health equity, optimal allocation of health human resources and the possibility that increased medical tourism to Canada might lead to significant expansion of for-profit, privatized healthcare in Canada.
Promoting Canada as a Medical Tourism Destination
Before identifying risks associated with attempting to position Canadian provinces as destinations for medical tourists, I should note that there are numerous instances when treating patients from outside Canada is both justifiable and commendable for Canadian healthcare facilities. For example, Canada has several outstanding paediatric care facilities, and there are compelling humanitarian reasons for providing care to children who come to Canada for specialized treatment that they cannot obtain in their local communities. However, providing humanitarian care or treating individuals from elsewhere who fall ill or are injured while visiting Canada is different from attempting to develop a large for-profit medical tourism industry that markets health services to international patients. Here, I present seven reasons why provincial healthcare systems in Canada should not attempt to sell health services to medical tourists.
1. Shift Toward for-Profit, Privatized Health Services
Positioning Canadian provinces as destinations for significant numbers of international patients is likely to lead to a greatly expanded role for private, for-profit healthcare in Canada. Canada's publicly funded system of universal access to healthcare, a system in which all Canadians have access to medically necessary health services regardless of personal wealth or social status, is based upon the principle that all Canadians have an equal right to medically necessary care. Personal wealth is not used to determine who obtains access to treatment or goes to the front of the line for care. Establishing a sizeable marketplace for health services risks redrawing the line between publicly funded healthcare and for-profit, privatized medicine in Canada and would constitute a major shift in how healthcare is delivered in Canada. Creating a for-profit healthcare sector that caters to international patients paying out of pocket for medical procedures and excludes Canadians who also wish to pay for whatever health services they seek seems unlikely. It is therefore important to understand the full significance of promoting Canadian healthcare facilities as destinations for international patients paying for care. If Canadian provinces try to attract large numbers of medical tourists purchasing medical care, Canadians with sufficient financial resources will likely insist that they, too, should be able to purchase what at present are publicly funded health services.
Advocates of an expanded for-profit healthcare sector within Canada understand that attracting international patients who pay for treatment in Canada can then be used to justify why Canadians with substantial financial resources should be allowed to purchase expedited access to medically necessary care. Responding to Falcon's proposal to make British Columbia a destination for medical tourists, Mark Godley, owner of one of British Columbia's private surgery centres stated, "I hope for the sake of all of us that his idea does fly" (Fayerman 2010). He added, "It will be virtually impossible to prevent a mixed private/public model in the event that Americans come here for health care." Citizens and health policy makers who are not driven by the notion that health services are best provided through market mechanisms need to understand that promoting medical tourism to Canada is a strategy that risks functioning as a "Trojan horse" within Canada's publicly funded provincial health systems.
2. Allocating "Unused Capacity" to Medical Tourists Rather Than Addressing Health Needs of Canadians
Many hospitals in Canada have "unused capacity" because of provincial resource allocation decisions that, for financial reasons, limit access to some health services. Unused operating rooms could be utilized to treat wait-listed Canadians rather than paying, international patients. While queues persist for such treatments as bariatric surgery, hip and knee replacements, and coronary artery bypass grafts, if medical tourists seeking these surgical interventions were to receive immediate treatment, there is reason to fear that they could jump to the front of the line while Canadians are left waiting for care in the very hospitals their tax dollars built. Delays that Canadians face in obtaining access to various health services constitute a major barrier to positioning Canadian healthcare facilities as destinations for international patients. At the time when Falcon first proposed taking advantage of "unused capacity" to make British Columbia a destination for medical tourists, over 72,500 British Columbians were wait-listed for treatment (BC Ministry of Health Services Wait Times Registry 2010). Countries with significant wait times for many medically necessary medical procedures are not well positioned to market health services to international patients seeking these same interventions. Providing such treatments to international patients could further increase wait times in Canada and, ironically, have the practical effect of forcing more Canadians to consider going abroad for medical treatment. Rather than determining how to market medical procedures to US residents and other international patients, politicians and provincial health planners should instead direct their attention towards ensuring that the health needs of Canadians are addressed in a timely manner. "Unused capacity" should be used to reduce wait times in Canada.
3. Marketing Medical Tourism Is a Poor Use of Public Resources
Although advocates of national and regional medical tourism initiatives portray medical tourism as a profitable revenue stream, it could easily become a financial sinkhole in which public funds are wasted on expensive marketing campaigns or, as has happened in India, are captured by corporations (Thomas and Krishnan 2010). Proponents of the economic potential of medical tourism strategies make unsubstantiated claims about the number of Americans seeking medical care outside the United States. For example, Kevin Falcon states, "We know that every year several hundred thousand Americans travel outside of America and spend billions of dollars on their health care" (Fowlie 2010). Brian Day (2009a,b) often mentions a number from a 2008 report by Deloitte claiming that an estimated 750,000 Americans went abroad for medical care in 2007, with the number of US medical tourists expected to climb to six million in 2010 (Keckley and Underwood 2008). A review of the report's sources reveals that these claims are baseless. The numbers are taken from an editorial that was posted to the website of India Daily (Baliga 2006) and not based upon any research or data concerning the actual number of Americans going abroad for medical care. Policy making and health system planning need to be based upon accurate data rather than numbers not obtained through credible research methods. Researchers using survey findings, as well as data from the US Bureau of Economic Analysis and the International Trade Administration, estimate that between 50,000 to 121,000 US residents sought healthcare outside the United States in 2007 (Johnson and Garman 2010). Some of the outbound medical travel from the United States is from southern states to Mexican cities and towns located near the US–Mexico border (Judkins 2007). There is little reason to think that Canadian healthcare facilities, because of their geographic distance from the southern United States and the price structures they would likely use, can capture this low- and middle-income market of largely uninsured Americans travelling a short distance to Mexico for inexpensive medications, dental care and other out-of-pocket services.
4. Promotion of Medical Consumerism and Commercialization of Healthcare
Proponents of making Canada a destination for medical tourists appear unfamiliar with many of the procedures routinely marketed to international patients. Web searches for medical tourism generate ads for such procedures as "mommy makeovers," "bridal surgery specials," "designer vaginas," commercial surrogacy, "lipotourism," commercial kidney transplants and stem-cell "therapies" that have no scientific basis. While travel for medical care includes journeys for mainstream, legitimate, medically justified procedures such as orthopaedic procedures and dental surgery, part of the marketplace for medical tourism involves provision of procedures that are unproven or unethical, or are driven more by medical consumerism than medical necessity. Acknowledging that many medical tourists require mainstream medical procedures, Canada does not have an oversupply of healthcare professionals available to treat patients requiring orthopaedic surgery, cardiac procedures and numerous other interventions sought by medical tourists. Promoting Canadian provincial health systems as destinations for medical tourists could have unexpected effects upon the practice of medicine, the relationship of patients to healthcare professionals and the delivery of health services.
5. Competition in the Global Health Services Marketplace
There is reason to wonder how effectively healthcare professionals and healthcare facilities in Canada can compete on the basis of price within the global marketplace for health services. Price differentials are not the only motivation for medical tourism. Insofar as the cost of treatment matters to international patients, it is unclear how effectively Canadian hospitals and clinics can compete at the least expensive end of the marketplace. India, Indonesia, Malaysia, the Philippines and Vietnam dominate the market for inexpensive, out-of-pocket medical care. In India, for example, a coronary artery bypass graft is available for less than $10,000 (Milstein and Smith 2007). Within North America, it appears that bariatric surgery and other procedures can be obtained in Mexico at lower prices than can be found at medical facilities in Canada and the US. In the United States, brand-name facilities such as the Cleveland Clinic, Johns Hopkins Hospital and the University of Pittsburgh Medical Center occupy the niche for medical care where price is not a determining factor when deciding where to receive care. Canadian provincial healthcare systems can attempt to compete for a mid-market share or perhaps attempt to compete for clients on the basis of factors other than cost of care, but they will find that hospitals and clinics located all over the world are competing for the same customers. Aside from well-known destinations in Asia, Eastern Europe and Latin America, countries in such regions as the Caribbean and the Middle East have entered the global health services marketplace. To compete for customers, any clinic, hospital, province or country now entering the global marketplace for health services will need to have a substantial marketing budget. The investment needed to position Canada as a destination for medical tourists could be better spent by helping Canadians gain improved access to health services within Canada.
6. Medical Tourism, Continuity of Care and Patient Safety
Despite marketing claims touting the benefits of medical tourism, it is reasonable to ask how well medical tourism goes with good medical care. Patients who travel long distances shortly before or after surgery appear to be at increased risk for deep-vein thrombosis and pulmonary embolisms (Handschin et al. 2007; Gajic et al. 2005). Humans are not made of Lego bricks. Surgery involves more than simply popping knees and hips from patients, inserting replacement parts and waving bon voyage. Before surgery, physicians need to meet with patients, review their records, determine whether intervention is justified, discuss risks, benefits and alternatives to treatment, organize physiotherapy and establish plans for post-operative care. Follow-up care requires additional appointments and treating complications. Some patients who travel to international medical facilities return home with serious complications and no plans for post-operative treatment (Jeevan and Armstrong 2008; Cheung and Wilson 2007). Domestic healthcare providers in home communities of medical tourists must then assume the financial burden of providing publicly funded healthcare to treat post-operative complications (J. Birch et al. 2007; D. Birch et al. 2010). In many respects, it is very difficult to transform competent, professional medical care into a globe-spanning activity. Rather, medical care is a continuum and not just a discrete episode in the operating room. Promoting medical tourism to Canada risks building health policy on a questionable model of healthcare and a highly circumscribed notion of the patient–physician relationship.
7. Health Equity Matters
Finally, in a country that uses provincial healthcare systems and various social welfare programs to promote health equity, asking why British Columbia, Alberta, Ontario and other Canadian provinces cannot become the Mayo Clinic of the North is in many respects to pose the wrong question. The Mayo Clinic has many commendable attributes, but it is not and has never been responsible for promoting equitable access to care (MacGillis 2009; MacGillis and Stein 2009). Providing equality of access to care is a key feature of the Canada Health Act and an important component in the lives of every Canadian who obtains publicly funded access to medically necessary health services and does not have to worry about choosing between treatment and medical debt or bankruptcy. The Mayo Clinic accepts Medicaid patients from just five states; Medicaid patients from other states are not treated except in emergency services (MacGillis 2009). Regarding such an institution as an unquestioned model of healthcare delivery and a beacon for what Canadian provincial healthcare systems and hospitals should become represents a departure from the understanding that all Canadians get access to care and that no one – local citizen or international customer – gets special treatment or goes to the front of the line based upon gold-plated health insurance plans or capacity to pay for treatment.
Promoting medical tourism to Canada – if current proposals gain traction and there is an effort to transform them into public policies – would constitute a significant shift towards the expansion of for-profit healthcare for both Canadians and international patients. American patients, as well as residents of other countries, are unlikely to serve as a reliable revenue stream for funding Canadian healthcare. Whatever challenges face provincial health systems in Canada, solutions are unlikely to emerge from attempting to become the Mayo Clinics of the North. Canadians should tell their elected representatives to "Hold the Mayo" and not waste public resources on efforts to attract international patients to provincial healthcare systems that already face many challenges in providing Canadians with timely access to medically necessary care.
Faire du Canada une destination pour le tourisme médical: pourquoi les provinces canadiennes ne doivent pas tenter de devenir les « cliniques Mayos du Nord»
Quand les chercheurs canadiens se penchent sur la question du tourisme médical, ils s'intéressent habituellement aux enjeux éthiques, sociaux, de santé publique et de politiques de santé liés aux Canadiens qui veulent obtenir des services de santé dans d'autres pays. Ils mettent l'accent sur le Canada comme point de départ pour le tourisme médical plutôt que comme destination potentielle pour les patients étrangers. Plusieurs voix influentes ont récemment affirmé que les systèmes de santé provinciaux canadiens devraient mettre les services de santé sur le marché des patients étrangers. Les promoteurs de la mise en marché du Canada comme destination pour le tourisme médical affirment que la présence de patients étrangers engendrera des recettes pour les systèmes de santé provinciaux. En réponse à de tels arguments, je stipule qu'il y a au moins sept raisons pour lesquelles les systèmes de santé provinciaux au Canada ne devraient pas consacrer des ressources institutionnelles, financières et humaines pour se proposer comme destination pour le tourisme médical.
About the Author
Leigh Turner, PHD, Associate Professor, Center for Bioethics, School of Public Health & College of Pharmacy, University of Minnesota, Minneapolis, MN
Correspondence may be directed to: Leigh Turner, PhD, N504 Boynton, 410 Church St. SE, Minneapolis, MN, USA 55455; tel.: 612-626-4820; fax: 612.624.9108; e-mail: firstname.lastname@example.org.
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Brian Sanderson wrote:
Posted 2013/10/17 at 03:12 PM EDT
The Royal College of Physicians and Surgeon in Canada has recently written a report relevant to this issue
Click here for the full report
It is clear that provinces (like Nova Scotia where I live) cannot afford the medical system they already have. There are many patients with unmet needs and surgeons who can't find employment or the resources they require to be effectively employed.
To put it bluntly, Healthcare is the biggest part of the Nova Scotia Provincial Budget and the Province is drowning in debt at an accelerating rate. Thus, "universal healthcare" is sliding down the path to becoming "rationed healthcare".
I am a citizen of 3 nations have experienced healthcare in 5 nations. Canada is unique in legislating that the government shall have a monopoly on the provision of healthcare. It is because of this monopoly position that I would have to reluctantly agree with Dr Turner, for now.
But the situation in Canada is not sustainable. Indeed the government monopoly would probably have been broken already, but for the fact that many Canadians have the option of going elsewhere to get treatment that they cannot get in Canada. Thus, the paradox is that medical tourism is a safety valve for our government-run healthcare rationing system.
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