8/3/2019 Leigh Turner IJHS 2010
1/25
Globalization and Medical Care
MEDICALTOURISM AND THE GLOBAL
MARKETPLACE IN HEALTH SERVICES:
U.S. PATIENTS, INTERNATIONAL HOSPITALS, AND
THE SEARCH FOR AFFORDABLEHEALTHCARE
Leigh Turner
Health services are now advertised in a global marketplace. Hip and
knee replacements, ophthalmologic procedures, cosmetic surgery, cardiac
care, organ transplants, and stem cell injections are all available for purchase
in the global health services marketplace. Medical tourism companies
market sun and surgery packages and arrange care at international
hospitals in Costa Rica, India, Mexico, Singapore, Thailand, and other
destination nations. Just as automobile manufacturing and textile production
moved outside the United States, American patients are offshoring them-
selves to facilities that use low labor costs to gain competitive advantage
in the marketplace. Proponents of medical tourism argue that a global
market in health services will promote consumer choice, foster competi-
tion among hospitals, and enable customers to purchase high-quality care
at medical facilities around the world. Skeptics raise concerns aboutquality of care and patient safety, information disclosure to patients, legal
redress when patients are harmed while receiving care at international
hospitals, and harms to public health care systems in destination nations.
The emergence of a global market in health services will have profound
consequences for health insurance, delivery of health services, patient-
physician relationships, publicly funded health care, and the spread of
medical consumerism.
Medical brokerages and international hospitals marketing medical tourism
packages first attracted customers by selling inexpensive face lifts, tummy
International Journal of Health Services, Volume 40, Number 3, Pages 443467, 2010
2010, Baywood Publishing Co., Inc.
doi: 10.2190/HS.40.3.d
http://baywood.com
443
8/3/2019 Leigh Turner IJHS 2010
2/25
tucks, breast implants, liposuction, and other forms of cosmetic surgery. They
targeted price-conscious customers wanting procedures not covered under
private health insurance or publicly funded health plans. Purchasers could
lower their out-of-pocket costs by comparison shopping and finding low-cost
medical procedures. Some companies promoted discount surgery or first
world health care at third world prices. Typical advertising pitches featured
surf and surgery holidays in Thailand and surgeon and safari trips to
South Africa. Health care was packaged together with more commonplace
tourist attractions. Marketing executives proclaimed that their goal was to put
the hospital back in hospitality. Though brokerages and destination hospitals
still advertise cosmetic surgery bargains, they now sell a wide array of services
to a much broader clientele. Medical tourism is promoted as a solution to the
high price of medical care in the United States, as well as treatment delays incountries with publicly funded health care. In Canada, the United Kingdom,
and other countries with publicly funded health care programs, medical
brokerages attract customers tired of waiting for hip and knee replacements,
cataract surgery, and other procedures. In Canada, for example, such businesses
as Speedy Surgery and Timely Medical Alternatives solicit clients able to
afford purchase of expedited care. The United States provides a different
and potentially much broader customer base for medical brokerages and
international hospitals. It offers a large population of individuals lacking
health insurance, with limited economic resources, and needing access to
treatment for medically necessary care rather than cosmetic procedures. The
rapid proliferation of medical tourism companies in the United States is pre-
sumably connected to the number of Americans unable to obtain health insurance
or affordable access to local health care facilities. Even medical tourism com-
panies based in Canada attempt to tap into the large market of uninsured and
underinsured Americans seeking access to health care at medical facilities
outside the United States.
Marketing campaigns promoting medical tourism try to link health care
to adventure, relaxation, and holiday fun (13). The reality of international
health-related travel is often quite different from the images of enticing
beaches, romantic settings, and exotic resorts posted on many medical
tourism company websites. In the United States, popularization of medical
tourism is related to social inequalities, loss of employer-provided health
insurance, rising premiums for health insurance, limited public funding
of health care, and lack of access to affordable health care. Many factors
contribute to the high cost of care in the United States, but the low salariesof local health care workers make facilities in such countries as India
and Thailand far less expensive than hospitals in the United States.
Medical tourism reveals the shape that medicine takes when it is com-
modified, subjected to international competition, and subsumed within a global
market economy.
444 / Turner
8/3/2019 Leigh Turner IJHS 2010
3/25
UNINSURED IN AMERICA
In 2006, 47 million individuals in the United States lacked health insurance (4).
In low-wage sectors of the U.S. workforce, more than 75 percent of employees
decline health insurance (5). They cannot afford health insurance premiums;
their earnings go to cover the cost of immediate needs such as food and shelter.
As employers reduce benefits and cut health plans, increasing numbers of
middle-class Americans are losing employer-provided health insurance. Tattered
social safety nets leave many Americans without access to publicly funded
care. Forced to use personal savings, tap lines of credit, or go into debt to cover
the cost of medical care, growing numbers of Americans are entering the global
marketplace and trying to find care they can afford.
The high cost of health care in the United States drives many low-incomeand middle-class Americans with serious health problems into bankruptcy (6).
Short of outright bankruptcy, medical debt is a risk factor for being unable
to gain access to treatment (7). As medical bills accumulate, sick individuals
lose access to health care providers and health care facilities. Some caregivers
refuse to provide treatment until patients pay their bills and clear their debts.
In other instances, whether out of embarrassment, a sense of stigmatization,
fear of legal action or attracting the attention of debt collectors, or other factors,
many patients avoid seeking medically necessary care because of their unpaid
medical bills.
Denial of coverage on the basis of preexisting conditions means that indi-
viduals who can afford to purchase health insurance are often unable to gain
access to coverage for the medical interventions they are most likely to need.
Inclusion of coverage for these procedures can generate premiums exceeding$2,500 per month. High deductibles and co-payments mean that even individuals
with insurance sometimes cannot afford the medical care they require. Whether
or not they have health insurance, low-income and middle-class Americans with
limited finances are often unable to afford the cost of care at local institutions.
Some Americans living in border states travel to facilities in Mexico or Canada for
medical care. Other citizens fly to India, Thailand, the Philippines, or elsewhere
for comparatively inexpensive health care.
OUTSOURCING EMPLOYMENT
The emergence of international supply chains, the Internet, global telecommuni-
cations, global transportation networks, and interconnected economies has both
pushed and pulled jobs toward regions where workers are paid low wages andhave few benefits (8). Capital flows across borders to regions where goods
and services are produced for the lowest possible costs and sold for maximum
profits. In the United States, this process first affected workers in manufacturing
industries. It then spread through many other sectors of the U.S. economy.
The United States once had a huge textile production industry. Most of those
Medical Tourism and Global Marketplace in Health Services / 445
8/3/2019 Leigh Turner IJHS 2010
4/25
jobs were offshored to China, India, Mexico, and Thailand. Back office
administrative work capable of being digitized and electronically transmitted
over the Internet is now done in India. There, lawyers, computer programmers,
accountants, information technology specialists, and call center employees earn
far less than their American counterparts. Jobs related to the health services
industry are also outsourced. Medical transcriptions, accounting, and processing
of insurance claims are all routinely outsourced by U.S. clinics and hospitals
to offshore contractors and subcontractors.
Exploring how offshoring will alter the United States social and economic
fabric, Alan Blinder (8) estimates that 30 to 40 million U.S. jobs could move
to China, India, and other countries. From a global perspective, in some countries
these jobs might improve living standards and help individuals escape from
poverty. In other nations where labor has limited bargaining power, health-related jobs will be accompanied by low wages, nonexistent benefits, and
poor working conditions. For Americans whose health insurance is connected to
their workplace, offshoring of jobs will have profound consequences. As jobs
disappear, employees lose both income and health benefits. Obtaining affordable
health care is a serious challenge for patients purchasing medical interventions
as out-of-pocket personal expenses.
EMPLOYER-PROVIDED HEALTH
INSURANCE
Health benefits constitute a significant expenditure for American employers (9).
To control costs, maximize profits or minimize losses, and make themselves
globally competitive, U.S. companies are cutting or eliminating employee
health benefits (10). Executives threaten to move additional jobs offshore if
unions do not concede reductions in employee benefits. Employees are faced
with a choice: either they agree to wage concessions and benefit reductions or
they risk suffering additional job losses. Workers lose both income and health
insurance as jobs in the United States are outsourced to other countries. A broad
social shift is occurring in which companies are reducing employee benefits
and making saving for retirement and the cost of health care the personal respon -
sibility of individual employees.
To obtain affordable health services, middle-class and low-income Americans
lacking health insurance, paying out-of-pocket, or holding minimalist mini-med
plans offshore themselves by flying to regions where inexpensive health
services are available for purchase (1113). Unable to afford access to localfacilities, they search the global marketplace for less costly treatment.
With its large and growing population of uninsured, underinsured, and people
struggling to pay rising health insurance premiums, the United States is a leading
target market for hospitals seeking international customers. Medical brokerages
are proliferating in the United States as Americans find they must travel to
446 / Turner
8/3/2019 Leigh Turner IJHS 2010
5/25
purchase affordable health care. These companies both cater to individual clients
and offer packages for employers interested in offering health plans with an
offshore component.
MEDICAL TOURISM BROKERAGES
Medical tourism companies, or medical brokerages, play a crucial role in
advertising and selling health services across a global market. They take clients
from high-cost health care settings, coordinate travel to less expensive health care
facilities, and charge fees for organizing transportation, accommodations, and
treatment. The Internet, inexpensive telecommunications, and economy air travel
all facilitate sending customers to destination hospitals offering low-budget health
care (1, 14). The packages that brokerages market have two important features.Clients must be healthy enough to travel; medical tourism companies do not
advertise emergency medical services. And customers need to see sufficient cost
savings to justify the expense, uncertainty, and inconvenience of travel (15).
Leading medical brokerages in the United States include Planet Hospital,
Global Med Network, World Med Assist, Med Journeys, and Med Retreat.
Some agencies arrange travel to various medical facilities within a single country.
For example, IndUShealth coordinates travel to several hospitals in India.
More commonly, brokerages offer multiple travel destinations and various
price bands or price points for health services. Planet Hospital, a representa-
tive U.S. medical tourism company, sells packages to hospitals and clinics in
Argentina, Belgium, Brazil, Costa Rica, El Salvador, India, Mexico, Panama,
Singapore, Thailand, the United States, and Uruguay. At the top of the price
scale sit underutilized hospitals in the United States. These facilities are willing
to lower the price of care in an attempt to increase patient volume. Customers
able to afford mid-tier rates for treatment often purchase care at private hospitals
in Belgium or Singapore. Clients with limited financial resources typically
select hospitals in India, Malaysia, Mexico, Indonesia, or the Philippines. This
tiered model of pricing is becoming increasingly common as medical tourism
companies recognize that they can grow their customer base by offering dif-
ferent purchase entry points. In contrast, although the strategy developed by
IndUShealth is appropriate for patients willing to consider traveling to India
for treatment, it does not provide options to customers who wish to travel
elsewhere for care. As noted, most companies respond to diverse customer
preferences by offering multiple travel packages.
Because the medical tourism industry is driven by international differencesin the cost of health services, most company websites include charts and graphs
comparing the costs of care at hospitals in various countries. Charts showing
prices for orthopedic procedures and cardiac surgery reveal significant price
differences across countries. Prices in Thailand are often one-third to one-fifth
the cost of treatment at U.S. hospitals. Many Indian hospitals charge one-tenth the
Medical Tourism and Global Marketplace in Health Services / 447
8/3/2019 Leigh Turner IJHS 2010
6/25
price of procedures available at U.S. medical facilities. A coronary artery bypass
graft that costs more than $55,000 (U.S. dollars) for insured patients at hospitals
in California can cost $5,000 to $10,000 at hospitals in India (16). Cardiac
procedures priced at $200,000 to uninsured Americans are available for $10,000
in hospitals in India. Marketing initiatives emphasize price differentials and
cost savings obtained by traveling to comparatively inexpensive health care
facilities. Often, charts list how much American patients can save by leaving the
United States and traveling elsewhere for care. Given significant variation in
the cost of care for procedures performed at U.S. institutions, these charts are not
altogether accurate. Although the charts often exaggerate the typical price of
receiving care in the United States, and possibly underestimate how much it will
cost to obtain care in India or elsewhere, they do accurately convey the point that
more affordable care can often be found beyond the borders of the United States.
CORPORATE INTEREST
Following an emphasis on marketing cosmetic surgery procedures, U.S.-based
medical brokerages next targeted individual clients seeking inexpensive health
care. They solicited customers needing hip and knee replacements, dental work,
spinal surgery, and coronary artery bypass grafts. Selling to individual retail
customers, however, is a time-consuming, inefficient way to market health
services. Though medical tourism companies continue to promote procedures to
individual customers, brokerages now target small businesses, corporations, and
health insurance companies (10). This strategy enables brokerages to signifi-
cantly increase customer volume. Their ultimate goal is to negotiate contracts
with major health insurers and large employers.
North Carolinas Blue Ridge Paper Products was the first American company
to contract with a medical brokerage and arrange overseas medical care for an
employee (17). Carl Garrett, a technician at Blue Ridge, agreed to fly to India for
surgery on his rotator cuff and gallbladder. In turn, Blue Ridge offered to cover
Garretts deductibles and travel expenses and give him a share of whatever
savings the company made by sending him to India for treatment. Just before
Garrett was to leave for India, the United Steelworkers Union publicly condemned
the plan and the company cancelled the trip. Leo Gerard, president of United
Steelworkers, argued that what began as the voluntary decision of one employee
would become mandatory as companies routinely offshored employees to
countries offering low-cost health care. Gerard argued that this shift would
both increase the risk that workers would be exposed to substandard medical careand leave them stripped of the legal protections available to patients treated in
the United States. In the face of union opposition and considerable media scrutiny,
Blue Ridge discontinued plans to outsource employee health care. Nonetheless,
other businesses now contract with medical brokerages and sell health insurance
packages incorporating out-of-country treatment options. Such companies as
448 / Turner
8/3/2019 Leigh Turner IJHS 2010
7/25
GlobalChoice Health Care, Global Health Administrators, and United Group
Programs all sell global health plans to corporate clients. In exchange for
low premiums, these plans require out-of-country care for elective procedures.
Employeesable to afford more expensive plans can receive treatmentin the United
States. Both medical tourism companies and companies selecting plans with
out-of-country treatment options argue that employees are free to choose which
plans they select. Of course, this emphasis on autonomous decision-making does
not acknowledge the severe economic constraints that can prohibit employees
from being able to afford access to care in the United States.
Arnold Milstein and Mark Smith (16) argue that small businesses are the
early adopters as the corporate sector considers the prospect of offshoring
employees health care. They suggest that if liability issues are resolved, large
corporations will incorporate outsourced health care within their benefit packages.Employees paying high premiums will be able to obtain elective surgical
procedures at U.S. medical facilities. Low budget plans will require travel to
international hospitals offering inexpensive health services. The cost of health
plans will vary depending on where health services are purchased. The rhetoric of
choice and medical consumerism will be used to promote offshore health care.
HEALTH INSURANCE COMPANIES
Medical brokerages and international hospital chains are now trying to convince
major U.S. health insurance companies to sell plans covering offshore health
care. For emergency care, customers selecting these plans will obtain treatment
at local health care facilities. For elective services, customers will have to travel
to international hospitals. Blue Cross and Blue Shield South CarolinatheSouthern Blues, as they are callednow market such a plan through the separate
company Companion Global Healthcare, whose customers can purchase plans
that include provision of health services at Bumrungrad International Hospital
in Bangkok. Hospitals and clinics in Costa Rica, India, Ireland, Singapore,
and Turkey are also included in Companion Global Healthcares network of
international hospitals and clinics. Executives at medical tourism companies and
marketing directors at international hospitals are presently attempting to sell
the offshore health care option to other major insurers.
GOVERNMENTS
Interest in offshoring the health care of Americans to international medical
facilities extends beyond the corporate sector to elected government officials.For example, in 2006, Ray Canterbury, a delegate to the state legislature of
West Virginia, proposed a House Bill that would give financial incentives
to West Virginia State employees willing to travel outside the United States for
medical care (18). If Canterburys bill is eventually passed, state employees
will have the option of traveling to India or Thailand for elective health care. The
Medical Tourism and Global Marketplace in Health Services / 449
8/3/2019 Leigh Turner IJHS 2010
8/25
bill proposes to cover all travel-related expenses, eliminate co-payments and
deductibles, provide free transportation and accommodations for an accompany-
ing family member or friend, include seven supplementary sick days, and offer
employees a share of whatever savings the state gains by arranging out-of-country
care. Canterbury wants to increase competition and use the outsourcing of patients
to reduce prices at U.S. hospitals. His proposal has attracted supporters in the
West Virginia Senate. Similar legislation is tabled in Colorado. These legis-
lative initiatives have two practical goals. First, they raise the prospect that
state employees might soon have the option of having health insurance plans
that enable them to receive treatment outside the United States. Second, they
apply pressure to local health care facilities by suggesting that unless prices are
reduced, international competitors will soon start treating significant numbers
of state employees.
GLOBALIZATION OF HEALTH SERVICES
How flying from Durham to Delhi or from Charleston to Chennai for medical care
came to seem like a sensible proposition is a complicated and circuitous story.
The rising cost of health insurance premiums, job cuts, and loss of employer-
provided health insurance are key features of this narrative. A detailed exploration
of the emergence of a global market in health services would have to explore
how American medicine and health care became such massive business enter-
prises, why health care in the United States is so expensive compared with other
countries, how national economies interlocked to form a global economy, and
how biomedicine or Western medicine spread across the globe. Books such
as The Social Transformation of American Medicine (19) and Sick(20) describehow medicine in the United States came to be delivered through the market
economy. Much less well-known is how international hospitals used the doctrine
of competitive advantage to create a global market in health services. The origins
of this market can be traced to the 1997 Asian financial crisis.
Thailand
In 1997, Thailands stock market fell 75 percent and the value of Thailands
currency plummeted (21). Before July 2, 1997, it cost 25 Thai baht to buy one
U.S. dollar. By January 1998, it cost 56 baht to purchase one U.S. dollar. Investor
panic and economic turmoil rippled from Thailand to Indonesia, Malaysia, and
South Korea. From there it spread to Russia and Latin America.In the years before its economy collapsed, Thailand experienced a rapid
expansion of its middle-class population. The economic crisis erased the savings
of Thailands middle class and returned many citizens to poverty. The countrys
dramatic building boom ended, foreign capital fled Thailands economy, and
many families suffered massive financial losses. With citizens unable to afford
450 / Turner
8/3/2019 Leigh Turner IJHS 2010
9/25
private health care, for-profit hospitals in Thailand lost their customer base. Just
as they had once moved from public health care facilities to private, for-profit
institutions, many doctors and nurses left Thailands private hospitals and returned
to work at public medical facilities. During the economic crisis, several Thai
hospitals revised their marketing strategies and began targeting patients in other
countries. They solicited clients who could afford treatment and would bring
foreign currency into the country. Bumrungrad Hospital in particular succeeded
in attracting customers from Japan, Europe, the Middle East, and the United
States. Even when the financial crisis ended, Bumrungrads managers continued
expanding the hospitals international clientele. They used three strategies to
pursue this aim (22).
Taking advantage of the devalued baht and the low value of salaries and
property in Thailand, Bumrungrad executives undercut the cost of proceduresoffered at hospitals in Singapore. The marketing team placed ads in in-flight
magazines, encouraged travelers on Thai Airways to apply frequent flyer miles
toward executive physicals, and offered discount packages for surgery and other
procedures. Bumrungrad grew its clientele by using a standard sales tactic: it
beat its leading regional competitors on prices.
Next, Bumrungrad executives redesigned their hospital. They gave it the
appearance and feel of a luxury hotel. They marketed spacious private executive
suites with wireless Internet access and wide-screen televisions. They promised
free limousine pick-up service at Bangkoks International Airport and compli-
mentary visits from massage therapists. Bumrungrad executives selected the
best restaurants in Bangkok and invited their chefs to bring upscale dining to
the hospital. After a redesign of its atrium, Bumrungrad sported an Au Bon
Pain, Dairy Express, McDonalds, and Starbucks. These features had a powerful
effect on lower-income and middle-income Americans visiting Bumrungrad.
They discovered that by flying to Bangkok they could afford posh VIP services
reserved for only the wealthiest clients at private U.S. hospitals. Bumrungrads
customers offered testimonials likening the hospital to a five-star hotel. After
60 Minutes aired a clip about the hospital, Bumrungrad was bombarded with
more than 3,000 emails from Americans interested in receiving treatment there.
The institution rapidly established its standing as the leading international
hospital in a global marketplace of hospitals competing for foreign patients.
Finally, Bumrungrad executives developed a corporate philosophy promoting
customer satisfaction (22). If a patient wanted surgery and hormone therapy to
change from being male to female, Bumrungrad physicians did not introduce
obstacles by making a psychiatric evaluation part of the process. Bumrungrad brought the customer-centric philosophy of the hotel industry to the hospital
sector. With this customer-service ethic, Bumrungrad transformed itself from a
small regional hospital into an international medical center.
To executives at hospitals around the world, Bumrungrad demonstrated
that given enough incentive, price-conscious patients would travel in search of
Medical Tourism and Global Marketplace in Health Services / 451
8/3/2019 Leigh Turner IJHS 2010
10/25
inexpensive health care. Surgery could be packaged with stays in ocean-front
resorts, guided tours, and evening excursions to Bangkoks street markets and
nightclub cabaret scene. Low-budget health care could be combined with the
more traditional tourist attractions of Thailand. Sun and surgery and hotels and
hospitals could be fused to create medical tourism. Bumrungrad International
now claims to provide care to more than 435,000 international patients every
year. According to Bumrungrads marketing director, 58,000 of those patients
are American. Hospital executives are building the Bumrungrad brand by con-
structing Bumrungrad Hospital Dubai in Dubai Healthcare City and establishing
Bumrungrad International Philippines.
Private equity firms and pension funds, as well as hospital executives and
senior government officials throughout Asia, noticed the increased flow of inter-
national patients traveling to Bangkok for care. They grasped that hospitalssituated in countries with low property values, low corporate taxes, low wages
for physicians, nurses, and other health care providers, advantageous currency
exchange rates, and popular tourist destinations could attract customers from
other nations. Hospital executives, government ministers, and investors in
Singapore and India were particularly influenced by Bumrungrads success in
drawing international clients.
Singapore
Before Bumrungrad and its regional competitors in Bangkok and Phuket
undercut their prices, hospitals in Singapore held the biggest share of the
international patient market in Asia. With devaluation of the baht, Singapores
hospitals could not compete for clients on the basis of price. Hospital executives
and government officials in Singapore decided they would forgo the discount
surgery market. Singapores leaders decided to boost research and development
and build on the countrys strengths as a service economy. Government ministers
and business leaders strategized to transform the city-state into a regional
biomedical hub and build a new national bioeconomy (23). They marketed
Singapores hospitals as leading destinations for well-heeled, discerning inter-
national patients interested in obtaining top-quality care rather than bargain
basement treatment.
Hospital executives and government ministers in Singapore insist that with
a population of just 4.4 million citizens, the city-state must draw international
patients to attract medical specialists, block the brain drain of health care
providers, maximize institutional efficiencies, and promote economies of scale.According to Singapores leaders, with the increased volume of international
patients traveling to Singapore, hospital revenues will climb, medical practice
will undergo more specialization, health care providers will relocate to Singapore,
costly medical equipment will become more affordable, and economic benefits
will ripple through the city-states economy (24).
452 / Turner
8/3/2019 Leigh Turner IJHS 2010
11/25
Singapore promotes medical tourism through its Singapore Medicine website.
The portal provides links to Singapores major hospital chains, particular hospitals
and clinics, international patient centers, and lists of physicians. Singapores
medical tourism strategy is working. In 2000, Singapore attracted 150,000 inter-
national patients. In 2005, 374,000 medical tourists received care in Singapore
(25, 26). By 2012, Singapore wants to attract one million international patients
every year. The Singapore Tourism Board estimates that regular tourists spend
$144 per day whereas medical tourists spend an estimated $362 (27).
Private hospital associations, government ministries, and tourism companies in
other countries learned from Bumrungrads success and Singapores coordinated
national strategy. Hospitals in Hong Kong, Indonesia, Malaysia, the Philippines,
South Korea, Taiwan, and Vietnam now promote medical tourism. Indonesia,
Malaysia, and the Philippines have national medical tourism initiatives.Building on the examples provided by Bumrungrad International and Singapores
hospital system, India is now the fastest-growing competitor in the global
health services market.
India
Private hospital chains such as Apollo, Fortis, Max Healthcare, and Wockhardt
first promoted medical tourism to India. What started as the corporate initiatives of
a few hospital chains and business entrepreneurs soon became a national economic
strategy. India now classifies care of international patients as an export product
(2830). Hospitals in India benefit from reduced tariffs on imported medical
devices such as diagnostic imaging systems, low corporate taxes, substantialgovernment investment in local transportation infrastructure and airport hubs,
and special economic zoning laws. Medical visas enable visitors from other
countries to stay in India for extended periods of treatment and recovery.
Provinces such as Goa and Kerala advertise regional medical tourism initiatives.
Hospital management teams, airline executives, private equity funds, venture
capitalists, information technology firms, and tourism agencies all support Indias
national medical tourism initiative. Extremely low wages enable private health
care facilities to provide care at prices far below rates found in other nations.
Whereas hospitals in Singapore emphasize quality of care in their marketing
campaigns, private hospitals in India compete on the basis of marketing initiatives
that emphasize both high quality care and extremely low prices.
SELLING MEDICAL TOURISM
Newspaper advertisements, call centers, hospital websites, television commer-
cials, billboards, press releases, word-of-mouth marketing, and medical broker-
ages all draw patients to private hospitals seeking international clients. The
Medical Tourism and Global Marketplace in Health Services / 453
8/3/2019 Leigh Turner IJHS 2010
12/25
Internet plays a particularly important role in making hospitals accessible to an
international client base.
Hospitals selling health services to international clients assume that many
prospective clients are concerned about quality and safety of care in such coun-
tries as India and Thailand. Reservations about the quality of health services
available at international facilities are a major impediment to the emergence
of a global market in health services. To address such fears, marketing to
international customers uses various strategies to signal quality, competence,
and international standards of care.
International Hospital Accreditation
The emergence of a global market in health care generated a need for an organi-zation capable of assessing whether hospitals provide an international standard
of care. Such a body had to have widely recognized standards. Countries such
as Thailand and India have national hospital accreditation bodies. However,
hospitals wanting to proclaim themselves as international medical centers
want to be able to claim that they meet global standards. An American company
filled the gap by offering international accreditation.
The U.S.-based Joint Commission International (JCI) is now the overwhelm-
ingly dominant organization in international accreditation of hospitals. JCI
the international offshoot of The Joint Commissionhas now accredited more
than 220 health care organizations in 33 countries. To meet growing demand
for international accreditation of hospitals in the Middle East and Asia, in 2006
JCI opened regional offices in Dubai and Singapore. JCI accreditation plays a
crucial role in hospital marketing campaigns. Setting aside the question of what
JCI accreditation means in terms of assessing quality of health care and patient
safety, the labels marketing effect is to signal that an accredited hospital offers
an internationally recognized level of treatment.
Physician Training
Just as JCI accreditation is used to market hospitals, academic credentials are
used to sell the skills of particular physicians. Degrees, fellowships at elite
institutions, and U.S. board certification are all used to promote the profes-
sionalism of physicians employed by international hospitals. Websites for
hospitals in India and Thailand feature physicians trained in Australia, the
United Kingdom, and the United States. The message for customers is that the physicians who will provide their care trained at the best institutions in the
world. Hospitals seeking international patients encourage their physicians to
obtain U.S. board certification. In the absence of global standards for medical
education, U.S. board certification signals an international standard of training.
This international training and certification of health care providers plays a
454 / Turner
8/3/2019 Leigh Turner IJHS 2010
13/25
role in helping medical facilities present an image that they offer elite-level
medical care.
Building Brands
Around the world, some universities and hospitals have an international
reputation. Universities such as Harvard and Stanford are globally recognized
academic brands, just as Nike, Coca-Cola, and BMW are international corporate
brands. Countries developing their health services industry and promoting
themselves as leading destination sites for international clients are encouraging
brand-name academic institutions to build branch campuses and award prestigious
degrees to local students. Duke University, in partnership with the NationalUniversity of Singapore, runs a medical school in Singapore. Harvard Medical
International offers postgraduate training programs for health care professionals
at Dubai Healthcare City.
The establishment of North American medical schools and satellite campuses
in Asia and the Middle East serves multiple objectives. Many U.S. universities
are developing initiatives in global health; satellite campuses enable them to
expose students and faculty at their home institutions to other parts of the world.
Construction of branch campuses also happens to be extremely lucrative for
some American universities. Senior administrators of universities and medical
centers in North America recognize that the fastest-growing markets for pro-
fessional training are now in Asian nations. Duke University will receive more
than $350 million for establishing and running a medical school in Singapore
(31). Satellite campuses generate significant revenue for brand-name universities.
In turn, the training and credentials that these programs offer will probably shape
the global market for health services. Hospitals targeting international patients
will be able to advertise that their doctors and nurses are graduates of elite
academic institutions. Staff members with degrees from such programs will
bring instant cachet to hospitals targeting international clients.
Just as schools of medicine and nursing run by elite academic institutions are
being built in Asia and the Middle East, hospitals in these regions are cultivating
partnerships with brand-name medical centers. Johns Hopkins Medicine Inter-
national is affiliated with Indias Apollo Hospitals and operates a clinic in
Singapore. Harvard Medical International is part of Dubai Healthcare City, affili-
ated with Indias Wockhardt Hospital chain, and runs several hospitals in
China. The Mayo Clinic is a participant in Dubai Healthcare City. ClevelandClinic Abu Dhabi is presently under construction.
Co-branding initiatives play major roles in international marketing campaigns.
The Harvard name is on Wockhardt hospitals throughout India. Partnerships
with elite organizations such as Harvard, Johns Hopkins, and the Mayo Clinic
confer instant status and brand-name recognition. They act as customer magnets
Medical Tourism and Global Marketplace in Health Services / 455
8/3/2019 Leigh Turner IJHS 2010
14/25
by sending signals about quality of care and selling the promise of world-class
treatment at prices well below rates in the United States.
Technology in the International Marketplace
Just as international accreditation, training at elite institutions, and partnering
with global brands are used to sell health services on the global market, symbols
of advanced biomedical technologies convey the message that hospitals offer
top-tier health care. Bangkok Hospital advertises itself as the only hospital in
Thailand with a gamma knife for neurosurgery. Apollo Hospitals promotes its
advanced diagnostic imaging suites. These icons of modern medical care enable
hospitals to provide specialized services. They permit health care providers to
perform procedures for which hospitals in the United States and other coun-
tries charge high rates. In addition, they project an image of hospitals in India,
Singapore, and Thailand as participants in a global biomedical economy of
advanced, specialized, elite, acute care hospital facilities.
Private hospitals around the world want to attract customers from the United
States and other countries. Medical brokerages profit whenever they sell their
services to clients. Many U.S. companies see outsourcing of health services
for employees as an effective way of cutting costs. Various parties have a clear
economic interest in promoting globalization of health services. Whatever the
benefits of offshoring medical care, the establishment of a global market in
health services will have profound consequences for patients, the practice of
medicine, and the delivery of health care. Advantages of international health-
related travel are widely advertised. In contrast, little consideration is given tohow globalization of health services will transformpossibly for the worsethe
practice of medicine, the experience of receiving care, and the organization
of health systems. These concerns are scarcely matters that medical tourism
companies and international hospitals want to address at trade shows, congresses,
and other promotional events.
PATIENT SAFETY
International hospitals emphasize the high quality of the care they offer. Adver-
tising copy commonly asserts that destination hospitals meet or exceed standards
for patient safety and quality of care in the United States. Some hospitals draw
attention to the many reports on medical error and adverse medical events at
U.S. health care facilities. They use these findings to argue that U.S. patientswill receive better, safer care if they leave the United States for treatment.
In turn, U.S. organizations such as the American Medical Association and
American Hospital Association express concerns about medical tourism and
quality of care at international hospitals. The lack of comparative data from
medical facilities around the world makes it impossible to assess patient safety
456 / Turner
8/3/2019 Leigh Turner IJHS 2010
15/25
and quality of care at leading destination sites for international patient travel.
The U.S. Centers for Disease Control and Prevention has published reports about
substandard care experienced by patients who underwent cosmetic surgery at
clinics in the Dominican Republic and Venezuela (32, 33). Australia issued a
travel advisory urging its citizens to avoid treatment at unlicensed cosmetic
surgery clinics in Thailand. A website, www.bumrungraddeath.com, accuses
Bumrungrad International Hospital of providing negligent care to an American
patient who died while receiving treatment there. These reports raise concerns
but do not provide sufficient evidence with which to make broad judgments
about patient safety when individuals travel in search of affordable health care.
Thus, despite grounds for concern about quality of care and patient safety in
the global health services marketplace, there is limited evidence with which to
judge the quality of medical care around the world. With cosmetic surgerysometimes performed by unlicensed practitioners in unaccredited facilities, of all
individuals traveling for health care, cosmetic surgery patients are perhaps at
greatest risk when they travel for inexpensive surgery. Quality of care might be
less of an issue at leading destination sites for medical tourism. These institutions
have a powerful long-term economic interest in providing high-quality health
services. Of course, the profit imperative could also undermine quality of care
with its pressure to minimize costs and maximize returns.
Whatever the actual risks of receiving substandard care at bargain-priced
international health care destinations, hospitals in India and elsewhere make
dramatic claims about quality of care and patient safety. Without publishing
data in peer-reviewed journals or subjecting their claims to critical scrutiny,
they purport to offer care that is both less expensive and higher quality than
that found in leading U.S. health care facilities. Though these claims might
be accurate, they have never been tested and verified by independent parties.
Journalists and health researchers attempting to investigate the development of a
global marketplace in health services need to realize that outcomes data on
quality of care and patient safety should be regarded as advertising copy rather
than as reliable, peer-reviewed claims about mortality and morbidity rates. Inter-
national health care facilities do not publish data on medical errors, hospital
infection rates, or adverse events. Very little evidence is available with which to
compare quality of care at health care facilities around the world. Claims about
patient safety and quality of care are used to promote health care facilities and
reassure potential customers that inexpensive medical care is also high-quality
care. Until these claims are subjected to serious critical scrutiny, they should
be regarded simply as components of broader marketing initiatives. Healthresearchers who uncritically reproduce these claims fail to realize how they are
advancing the economic interests of the very institutions they are supposedly
subjecting to scholarly analysis.
Serious efforts to set high standards for international accreditation could play
a valuable role in promoting access to reliable, publicly accessible information on
Medical Tourism and Global Marketplace in Health Services / 457
8/3/2019 Leigh Turner IJHS 2010
16/25
patient safety and quality of care at international health care facilities. Independent
analysis by an accreditation body able to withstand regulatory capture by the
institutions it purports to evaluate could bring greater transparency to the quality
of care at health care facilities around the world. At present, international patients
can comparison-shop on the basis of price. They have no reliable way of com-
paring the safety and quality of care they are likely to receive at international
facilities. Improving the quality of information available within the global health
care marketplace would require major changes to processes of international
hospital accreditation.
CONTINUITY OF CARE
Continuity of care is another problem with efforts by U.S. patients to findaffordable health care in the global marketplace. The medical tourism industry
uses a procedure-driven approach to delivering health care. Discrete procedures
are assigned an economic value and then marketed to international patients. The
procedure-driven approach advertises treatment as a singular event. Prospective
customers are attracted by low prices for hip procedures, cardiac procedures, and
other interventions. This narrow framing of health care delivery emphasizes
surgical interventions and promotes an understanding of health care based on
specific tasks that can be assigned economic values. Obscured in this account
is the extent to which health care occurs as a continuum over time. A less
procedure-driven account of health care would recognize the importance of
care extending from early conversations about a patients ailments to long-term
recovery from illness or injury. Characterizing health care as medical procedures
performed in discrete episodes of treatment conceals the many interactions that
should occur before provision of specific treatments. In some instances, with
better communication and preventive care, the continuum of care need not include
surgical intervention. In addition, the focus of medical tourism companies and
international health care facilities on promoting particular procedures obscures
the level of care patients require following orthopedic surgery, cardiac surgery,
and other procedures. Because of the episodic nature of interventions sold in
the global health services marketplace, continuity of care is a serious problem.
Surgical treatment dominates how treatment is promoted, and the need for care
both before and after surgery is neglected. While some patients return home
with medical records and an after care plan, others return to the United States
with no medical documentation, no follow-up treatment plan, and no ready means
of gaining access to local health care providers. Viewed across a sufficientlylarge patient population, this procedure-driven, discontinuous model of health
care is likely to have significant consequences. Having obtained care at a facility
in another country, some U.S. patients are likely to return home and have non-
existent or inadequate long-term care. Though some medical tourism companies
make arrangements for follow-up care with local health care providers, the
458 / Turner
8/3/2019 Leigh Turner IJHS 2010
17/25
procedure-driven way in which the medical tourism industry frames health care
poses a major challenge to the notion that health care delivery occurs along a
continuum and that all phases of treatment can have a significant effect on
patients health. Few medical tourism companies currently describe how they
propose to assist patients who require costly care and follow-up treatment after
their return to the United States.
Patient safety is the most publicized concern with medical tourism. However,
the most significant long-term consequences of a global market in health services
are related to the worldwide establishment of medicine as a profit-driven business
enterprise. Medical tourism represents the full integration of medicine with
global capitalism. Ability to pay determines access to care; the more customers
are prepared to pay, the more services they can purchase. Add-ons such
as stays in luxury hotels and exclusive tourist resorts are determined by howmuch customers are prepared to pay. In turn, limited economic resources buy
limited care.
FROM COVENANT TO CONTRACT
Describing his fathers preDepression era medical practice in Flushing, New
York, Lewis Thomas (34) captures a period before American medicine was
fully integrated into the market economy. In The Youngest Science: Notes of
a Medicine-Watcher, Thomas describes a time of small-town physicians, the
doctors office next to the living room in the family home, house calls, and an
unstated sense of duty that included treating patients regardless of their ability
to pay. Thomas sketches what medicine in the United States was like before
the spread of managed care organizations, hospital marketing campaigns, and
medical debt-collection agencies. Noting the often shaky financial status of his
fathers practice, Thomas writes (34):
Very few of the patients paid promptly, and a good many never paid at all.
Some sent in small checks, once every few months. . . . These were the years
everyone thinks of as the good times for the country, the ten years before the
Great Depression. The town was prosperous, but the practice of medicine was
accepted to be a chancy way to make a living, and nobody expected a doctor
to get rich, least of all the doctors themselves. In the town where I grew up,
there were two or three physicians whose families seemed rich, but the money
was old family money, not income from practice; the rest of my fathers
colleagues lived from month to month on whatever cash their patients
provided and did a lot of their work free; not that they wanted to or felt anyconscious sense of charity, but because that was the way it was.
Sixty years after the era Thomas describes, William May (35) used the phrase
the physicians covenant to describe the moral bonds connecting doctors and
patients and making medicine more than a service available for purchase in the
Medical Tourism and Global Marketplace in Health Services / 459
8/3/2019 Leigh Turner IJHS 2010
18/25
marketplace. In The Physicians Covenant: Images of the Healer in Medical
Ethics, May articulates an understanding of medicine in which ties between
physicians and patients differ from the contractual relations between buyers and
sellers of goods or services. May describes powerful, quasi-religious bonds of
trust and moral commitment connecting patients to physicians. For May, the
intimacy of medicine, the involvement of doctors in the personal lives of their
patients, the role of the physician in birth, the life course, and death, and the special
moral obligations of doctors toward patientsall infuse the practice of medicine
with moral gravitas and a sense of duty. For some contemporary doctors, the
practice of medicine retains this dimension. To them, being a doctor involves far
more than just providing a service in exchange for remuneration. For other patients
and physicians, the notion of medicine as calling, vocation, or form of community
service survives more as nostalgia for a dimly remembered past than as con-temporary experience. In contrast to the 1920s, 21st century American health
care is delivered in a market-driven bureaucratized economy.
Managed care organizations control costs and carefully monitor the corporate
bottom line. Investors in private hospital chains and clinics want managers to
maximize their return on investment by reducing costs, increasing earnings, and
providing treatment to paying customers. Hospitals boost revenues by advertising
for customers, marketing high-margin procedures, and refusing to cross-subsidize
care for patients who cannot afford treatment. Focused health care factories
specialize in doing shoulder operations or hernia repairs and maximize profits by
increasing patient volume and reducing time to complete procedures. Manage-
ment teams bring efficiency-optimizing techniques from the factory floor to the
hospital floor. Private hospitals hire hotel managers to improve customer service.
Hospital chains run much like other large corporations. Medicine, and more
broadly health care, is embedded within a larger service-oriented, bureaucratized,
profit-driven market economy.
With the shift away from covenantal relations to contracts between buyers and
sellers, standard market mechanisms come into effect. Vendors try to maximize
their economic returns and control the risk of economic loss by marketing profit-
able procedures and limiting or eliminating less lucrative forms of health care
delivery. They use commonplace advertising techniques to increase market share.
Hospitals compete for patients, avoid patients that will harm their economic
bottom lines, and attempt to build their brands and control costs while maxi-
mizing revenues (36). In turn, patients, relabeled as customers or medical
consumers, want the best possible services at the lowest possible prices. With no
special moral ties connecting patients to doctors, patients paying out-of-pocketfor care comparison-shop and go where they can get the lowest prices on services.
In a global economy in health services, the lowest prices for health care are
typically not found at U.S. hospitals. Customers with limited financial resources
are compelled to offshore themselves to get affordable treatment (11, 37).
Price-conscious consumers travel from Durham to Delhi and Boston to Bangalore
460 / Turner
8/3/2019 Leigh Turner IJHS 2010
19/25
to get the best deals for health services. Bound by moral covenants, patients and
physicians are connected by ties that are not reducible to market transactions.
Brought together through contractual relations, patients relate to doctors as buyers
to sellers. The notion of a covenant binding physicians to patients makes little
sense in an economic context in which patients select health care facilities on the
basis of price, travel to countries to which they have no ties, receive services from
physicians with whom they have no prior relationship, and then leave after
receiving the services they purchased. Buying medical interventions becomes
much like buying other services in the global marketplace.
THE CUSTOMER IS ALWAYS RIGHT
The integration of health services with the global marketplace is connected to aradical shift in the internal morality of medicine. In more traditional models of the
patient-physician relationship, the ancient maxim primum non nocere, first, do
no harm, is supposed to guide the practice of medicine. According to this norm,
physicians must exercise clinical judgment when deciding whether a treatment is
medically indicated. In service-based market transactions, the guiding principle
of business is the customer is always right. Clients rather than vendors should
decide what they will purchase. Satisfying customer preferences played an
important part in making Bumrungrad a leading destination site for international
patients. Such a philosophy, embedded as a core norm in the global delivery of
health services, is reshaping the practice of medicine. Satisfying customers
desires is different from respecting the internal morality of a profession guided by
norms of beneficence, nonmaleficence, and clinical judgments about what care
is warranted. A global health services market will enable some patients to obtainmedical care that they could not afford to purchase in their local communities.
It will probably also contribute to the spread of a consumerist ethos in which
health care providers serve the needs of customers, rather than respecting
medicine as a practice with internal normative standards. Generating earnings
rather than practicing medicine according to an internal professional morality
that emphasizes promoting health and avoiding harm plays a part in the global
marketing of procedures such as commercial organ transplants and stem cell
injections with unknown contents and no demonstrated therapeutic benefits.
CONTRACTS AND CAVEAT EMPTOR
In the United States, physicians have legal obligations to disclose risks, benefits,
alternatives to treatment, and consequences of non-treatment. The concept ofinformed consent is in part based on this moral and legal duty. In the global
marketplace, contracts tie customers to providers of health services. In
marketplace transactions governed by contracts, vendors have obligations to
purchasers, but much greater emphasis is placed on the responsibility of buyers
to exercise diligence when making purchases. Medical brokerages state that they
Medical Tourism and Global Marketplace in Health Services / 461
8/3/2019 Leigh Turner IJHS 2010
20/25
merely facilitate or coordinate health care services. They assume no legal
liability in the event of adverse events, medical error, negligence, or medical
malpractice. Visitors to medical brokerage websites are told that customers choose
where to obtain medical care, what procedures to purchase, and whom to select as
a physician. Clients are told to do their homework before purchasing health
services. Before customers sign contracts with medical brokerages, they sign
waiver-of-liability forms. These documents are designed to shield brokerages
from legal action if their clients suffer harm when obtaining treatment abroad.
Countries such as India, the Philippines, and Thailand are not known for strong
regulatory oversight mechanisms in the field of health care (38). Physicians in
these settings typically pay low rates for medical malpractice insurance. Plaintiffs
rarely receive significant settlements even if malpractice or negligence is estab-
lished. Many cases never work their way through complex, backlogged bureauc-racies. There is a global market in health care services, but no accompanying
transnational legal infrastructure governing the international sale of health
services. Buyer beware accurately captures a global economy in which
customers often find they are unable to obtain redress when they are harmed
while being treated. The global health services marketplace functions with few
transnational safety nets or protective mechanisms in place.
COMMUNICATION
The profits to be gained from selling medical services in the global marketplace
are likely to shape social interaction with customers. Medical tourism companies
are in the business of selling health care. Sales representatives at automobile
dealerships do not encourage customers to consider walking to work, riding a
bicycle, or buying a subway pass before considering purchase of a vehicle.
Medical tourism companies are the car dealerships of the global health services
industry. They exist to sell health services in volume. They are not bound by
an enforceable code of ethics, legislation governing health professionals, or
the fiduciary duties of physicians. The profit imperative is likely to shape how
they disclose information to customers. To boost sales, company representatives
will be inclined to exaggerate benefits, minimize risks, leave unmentioned any
alternatives to treatment, and accommodate customers preferences. Earnings
come from selling services rather than from serving the best interests of patients.
With this emphasis on selling procedures, some travelers will fly to international
health care facilities and receive medically unnecessary care.
In marketplace transactions where destination hospitals have made substantialinvestments to attract international clients, both medical tourism companies and
international hospitals want to boost sales. Government officials want to reap
returns from investment of tax dollars in the medical tourism industry. Bonds of
neighborliness, duty, and community will not temper these market transactions.
Business interests are likely to have a significant effect on what information is
462 / Turner
8/3/2019 Leigh Turner IJHS 2010
21/25
communicated to clients. The cumulative framing effect is to sell medical pro-
cedures rather than to carefully assess whether particular medical interventions
are truly necessary.
PUBLICLY FUNDED HEALTH CARE AND GLOBAL
PRIVATIZATION OF HEALTH SERVICES
News media coverage of medical tourism commonly addresses risks related to
obtaining treatment abroad. This orientation toward the interests of the traveling
patient overlooks how global privatization of health services risks undermining
local access to health care. Private, for-profit hospitals in India, Thailand, and
other nations sell services to foreign patients, expatriates, and local economicelites. They do not provide health care to local citizens with minimal economic
resources. Rather, they maximize profits and offer better rates than competitor
hospitals by refusing to cross-subsidize care. Maximum earnings are achieved by
selling high-margin procedures to patients able to pay out-of-pocket for treatment.
These hospitals do not profit by offering inexpensive low-technology care or by
treating patients who need care but cannot afford to pay for treatment.
Privatization of health services in countries such as India and Thailand does
not simply put access to affordable health care beyond the reach of local patients.
It also undermines publicly funded health care facilities. With higher salaries
in private hospitals catering to medical tourists, public health care facilities in
Thailand and elsewhere have difficulty retaining health care providers. Brain
drain occurs from publicly funded hospitals to private medical centers (39).
As doctors and nurses leave public institutions, the differences between public
hospitals and private institutions are magnified. Public hospitals become the
health care destination of last resort even for low-income patients who cannot
afford treatment at for-profit private hospitals. Promotion of medical tourism in
such countries as India and Thailand is likely to undermine national efforts to
improve health equity. For-profit hospitals maximize profits by ignoring the
low-income populations that surround them. Public health care facilities are
hollowed as health care professionals move to private, for-profit facilities. Paying
international patients rather than ill individuals from local communities become
the preferred clientele.
Thus, as the global spread of for-profit health centers benefits customers with
the financial resources to purchase care, it risks harming low-income patients
by undermining public access to affordable care and pulling health care providersfrom the public sector into private facilities. The rise of medical tourism is
related to the global spread of a form of capitalism that tolerates striking inequal-
ities in income and health. Hospitals that challenge this trend by providing
subsidized care to low-income patients risk becoming less competitive by
increasing the cost of treatment for wealthier customers.
Medical Tourism and Global Marketplace in Health Services / 463
8/3/2019 Leigh Turner IJHS 2010
22/25
PROMOTING THE DEVELOPMENT OF A GLOBAL
MARKETPLACE IN HEALTH SERVICES
Despite the lack of serious efforts to explore the risks and harms related to the
rise of the medical tourism industry, multiple parties are contributing to the
expansion of a global marketplace in health services. Individual institutions
such as Bumrungrad International see an opportunity to expand the number
of international patients purchasing health care in Bangkok. Medical tourism
companies and medical tourism associations use assorted marketing strategies to
promote, routinize, and normalize obtaining health care at international facilities.
Private hospitals band together to form networks and associations, and these
collectives are then marketed to international patients. National and regional
governments in such countries as India, the Philippines, Singapore, and Thailandare taking steps to build bioeconomies and transform themselves into medical
hubs for patients from around the world.
At the international level, the World Bank is an ideological and financial
proponent of helping medical facilities in low-income nations use the doctrine of
competitive advantage to increase their market share of international patients.
World Bank economists have challenged the discriminatory effect of existing
forms of health insurance and used economic analysis to argue that patients should
be able to use portable health insurance to obtain health care at destinations
around the world. The World Bank has also played an important role in bringing
together executives from international health care facilities and providing them
with venues for discussing how to move patient care into the global marketplace.
The World Trade Organization has also participated in creating architecture
for a global marketplace in health services. The general mandate of the World
Trade Organization is to eliminate barriers to trade and promote the spread
of global markets, and it has had an important role in demarcating the various
ways in which health services can be traded across borders.
Multiple social actors are deeply engaged in promoting the expansion of a
globally integrated marketplace in health services. Most of these organizations
stand to profit from further privatizing heath care and promoting mass movement
of patients into the international marketplace. In this atmosphere of enthusiasm
for pushing delivery of health care into the global marketplace, little consideration
is given to how the rise of the medical tourism industry might harm patients,
damage publicly funded health care systems and reduce local access to care in
destination nations, and alter the fabric of health care delivery in countries from
which patients are leaving in search of affordable health care. Subject to massivemarketing efforts, medical tourism and the globalization of health services
has been subjected to little serious, critical academic scrutiny. Despite a wide-
spread failure to consider dangers associated with the emergence of a global
marketplace in health services, patients are traveling the world in search of
affordable medical interventions. The consequences of this development are as
464 / Turner
8/3/2019 Leigh Turner IJHS 2010
23/25
yet unclear. Nonetheless, it is evident that the marketing of medical tourism has
leapt far ahead of the development of legal protections for international patients.
CONCLUSION
The percentage of the U.S. population lacking health insurance is growing. Denial
of claims, exclusion of preexisting conditions, high premiums and co-payments,
and accumulation of medical debt further reduce access to care. As premiums for
health insurance climb, jobs in manufacturing and service industries are moving
to countries where labor costs are lower than in the United States. Employees
who keep their jobs often must surrender health benefits in negotiation with
company management. As employees find their health benefits reduced, nonprofit
safety net hospitals are trying to reposition themselves and reduce their exposureto patients lacking health insurance and unable to pay out-of-pocket for care.
At the top of the U.S. economic pyramid, the countrys elite remain able to
purchase health care at American medical facilities. Lower-income and middle-
class individuals increasingly struggle to afford the cost of health care in the
United States. Thoroughly enmeshed in the larger market economy, U.S. health
care now takes the form of other service industries. It defers to customer prefer-
ences, is sold through standard marketing techniques, and is available for purchase
to those consumers with sufficient economic resources. Older notions of the
physicians covenant have little place in such a market-driven health service
industry. Secularized, stripped of any special meaning, diminished to just another
service available for purchase in the marketplace, and with personal ties to
patients replaced by impersonal interactions inside large bureaucracies, hospitals
must now compete for customers in the global health service economy. Wealthycustomers are still able to afford health care in the United States. Lower-income
and middle-class Americans increasingly find themselves traveling to offshore
hospitals offering health services at discount prices. With the physicians covenant
but a faint memory, and the nations social safety nets badly frayed through
years of cutbacks and cost-containment strategies, the age of global comparison
shopping for health services has arrived.
REFERENCES
1. Connell, J. Medical tourism: Sea, sun, sand and . . . surgery. Tourism Manage.
27:10931100, 2006.
2. de Arellano, A. R. Patients without borders: The emergence of medical tourism. Int.
J. Health Serv. 37(1):193198, 2007.
3. Turner, L. First world health care at third world prices: Globalization, bioethics,
and medical tourism. BioSocieties 2:303325, 2007.
4. Gould, E. The erosion of employment-based insurance: More working families left
uninsured. Int. J. Health Serv. 38(2):213251, 2008.
5. Milstein, A., and Smith, M. Americas new refugees: Seeking affordable surgery
offshore. N. Engl. J. Med. 355:16371640, 2006.
Medical Tourism and Global Marketplace in Health Services / 465
8/3/2019 Leigh Turner IJHS 2010
24/25
6. Himmelstein, D., et al. Illness and injury as contributors to bankruptcy. Health Aff.
W5:6373, 2005.
7. Seifert, R., and Rukavina, M. Bankruptcy is the tip of a medical-debt iceberg.
Health Aff. 25:w8992, 2006.
8. Blinder, A. Offshoring: The next industrial revolution? Foreign Aff ., March/April
2006, pp. 113128.
9. Blumenthal, D. Employer-sponsored health insurance in the united states: Origins
and implications. N. Engl. J. Med. 355:8288, 2006.
10. Foster, M., and Mason, M. Businesses may move health care overseas. Seattle-Post
Intelligencer, November 2, 2006.
11. Kher, U. Outsourcing your heart. Time, May 21, 2006, pp. 4447.
12. Lancaster, J. Surgeries, side trips for medical tourists. Washington Post, October
21, 2004.
13. Roth, M. Surgery abroad an option for those with minimal health coverage. PittsburghPost-Gazette, September 20, 2006.
14. Carrera, P., and Bridges, J. Globalization and healthcare: Understanding health and
medical tourism. Expert Rev. Pharmacoecon. Outcomes Res. 6:447454, 2006.
15. Mattoo, A., and Rathindran, R. How health insurance inhibits trade in health care.
Health Aff. 25:358368, 2006.
16. Milstein, A., and Smith, M. Will the surgical world become flat? Health Aff.
26:137141, 2007.
17. Rai, S. Union disrupts plan to send ailing workers to India for cheaper medical care.
New York Times, October 11, 2006.
18. Searls, T. Overseas surgery debated in house. Charleston Gazette, February 24,2006.
19. Starr, P. The Social Transformation of American Medicine. Basic Books, New
York, 1982.
20. Cohn, J. Sick: The Untold Story of Americas Health Care Crisisand the People
Who Pay the Price. HarperCollins, New York, 2007.21. Blustein, P. The Chastening: Inside theCrisis that Rocked theGlobalFinancial System
and Humbled the IMF. Public Affairs, New York, 2001.
22. Talbot, M. Nip, tuck, and frequent-flier miles. New York Times, May 6, 2001.
23. Gin, B. Singapore: A global biomedical sciences hub. Drug Discov. Today 10:
11341137, 2005.
24. Chantarapitak, P. The transformation into one of the leading destinations for health-
care. Singapore Med. Assoc. News 38:2527, 2006.
25. Yap Chin Huat, J. Medical tourism/medical travel (part one). Singapore Med. Assoc.
News 38(5):1721, 2006.
26. Yap Chin Huat, J. Medical tourism/medical travel (part two). Singapore Med. Assoc.
News 38(7):1416, 2006.
27. Travel Smart-Asia Watch. Travel and hospitality industry set to tap into Asias
US $4 billion medical tourism market. Travel Smart-Asia Watch, April-May 2006,
pp. 14.28. Mudur, G. India plans to expand private sector in healthcare review. BMJ 326:520,
2003.
29. Mudur, G. Hospitals in India woo foreign patients. BMJ328:1338, 2004.
30. Sengupta, A., and Nundy, S. The private health sector in India. BMJ331:11571158,
2005.
466 / Turner
8/3/2019 Leigh Turner IJHS 2010
25/25
31. Wagner, M. Duke on track with $100M Singapore medical school. Triangle
Business J., August 11, 2006.
32. Centers for Disease Control. Rapidly growing mycobacterial infection following
liposuction and liposculptureCaracas, Venezuela, 19961998. MMWR Morb.
Mortal. Wkly Rep. 47(49):10651067, 1998.
33. Centers for Disease Control. Brief report: Nontuberculous mycobacterial infections
after cosmetic surgerySanto Domingo, Dominican Republic, 20032004. MMWR
Morb. Mortal. Wkly Rep. 53(23):509, 2004.
34. Thomas, L. The Youngest Science: Notes of a Medicine-Watcher. Viking, New
York, 1983.
35. May, W. The Physicians Covenant: Images of the Healer in Medical Ethics.
Westminster Press, Philadelphia, 1983.
36. Petromilli, M., and Michalczyk, D. Your most valuable asset: Increasing the value
of your hospital through its brand. Marketing Health Serv. 19:49, 1999.37. Garloch, K. High costs send patients overseas for care. Charlotte Observer,
December 10, 2006.
38. Mudur, G. Inadequate regulations undermine Indiashealth care.BMJ328:124, 2004.
39. Wibulpolprasert, S., et al. International service trade and its implications for
human resources for health: A case study of Thailand. Hum. Resourc. Health 2:10,
2004.
Direct reprint requests to:
Leigh Turner
Center for Bioethics
University of MinnesotaN504 Boynton, 410 Church Street SE
Minneapolis, MN 55455
Medical Tourism and Global Marketplace in Health Services / 467