1. Nelson, Roxanne


What nurses need to know about the risks and benefits for patients.


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Cosmetic procedures like liposuction and abdominoplasty, which typically aren't covered by health insurance, can be pricey. In 2014, 28-year-old Beverly Brignoni of New York City sought a cheaper way to have those procedures done-and decided to travel to the Dominican Republic to a clinic recommended by friends. But while undergoing surgery there, Brignoni died of a pulmonary embolism. An inspection of the clinic shortly after her death revealed the presence of bacteria and violations of biosanitary regulations, and the operating room was ordered temporarily closed.

Figure. The 10 most ... - Click to enlarge in new window The 10 most popular worldwide destinations for medical tourism are (from left to right) India, Malaysia, Thailand, Turkey, Costa Rica, Mexico, Taiwan, South Korea, Singapore, and Brazil. The percentage ranges above each bar indicate the average cost savings of receiving medical treatment in each country compared with the cost in the United States. Image courtesy of

Around the same time as Brignoni's death, the Centers for Disease Control and Prevention traced a multistate outbreak of mycobacterial infections, including some that are antibiotic resistant, to 21 women who had undergone cosmetic surgery at clinics in the Dominican Republic. These and other serious adverse events prompted the U.S. State Department to issue a warning to travelers considering undergoing cosmetic procedures in that country.


Cosmetic surgery is one of many types of services sought via "medical tourism"-the practice of traveling to another country for medical care. According to Patients Beyond Borders, a provider of medical travel information, about 1,400,000 Americans are estimated to have traveled overseas for medical reasons-including cancer care, dentistry, and cardiovascular care-in 2016. And Americans aren't the only ones crossing borders to find affordable health care. Patients Beyond Borders estimates that the worldwide medical tourism market is growing at a rate of 15% to 25% per year, with the highest numbers of patients heading to Mexico and Southeast and South Asia.


Not all medical tourism stories become cautionary tales: given the rising medical costs and inadequate health insurance that drive patients to seek care elsewhere, many end up pleased with the services they obtain and the lower prices they find. But the potential pitfalls of receiving medical care in a foreign country underscore the need for caution.



"Medical tourism poses many risks as well as benefits," says Franklin Shaffer, EdD, RN, FFNMRCSI, FAAN, president and chief executive officer of CGFNS International (also known as the Commission on Graduates of Foreign Nursing Schools) in Philadelphia. "Affordability is most likely the largest determinant of medical tourism, particularly regarding patients traveling from developed to developing countries." Cost savings can be substantial depending on the country in which treatment is delivered. For example, using U.S. costs as a benchmark, patients can expect to see a "discount" of 20% to 30% in Brazil, 45% to 65% in Costa Rica, and 65% to 90% in India, according to Patients Beyond Borders.


"Another benefit [of medical tourism] could be obtaining medical treatment that is not available in [a patient's] home country," says Shaffer. "Patients may find better technology, specialists, or services abroad. Often, health care providers who focus on medical tourism offer more personalized care."


Conversely, patients may face serious risks when receiving medical care abroad. These include infectious disease, complications with pre- and postsurgical care, and low quality of care. "Often, medical tourism health systems do not have standardized credentials evaluation in place," says Shaffer.


Legal risks are another caveat. "Typically, when dealing with medical tourism, there is no government or legal watchdog, which can lead to jurisdiction issues or cross-border disputes," Shaffer adds.


Katrina Bramstedt, PhD, a clinical ethicist at the Bond University School of Medicine in Robina, Queensland, Australia, points out some of the ethical concerns that surround medical tourism. Regarding informed consent, for example, patients in unrelenting pain or with chronic, debilitating, or life-threatening illnesses are vulnerable to exploitation. "If patients are also financially troubled, they become an even larger target for victimization," she says. "The combination of their illness burden, its quality of life impact, and a lack of finances can result in circumstances that impair objectivity during medical decision making."


Language barriers can create an additional problem when patients have difficulty understanding the medical information that is presented to them. And, Bramstedt says, "If the hospital or [medical] tourism broker is unscrupulous, there may be a lack of transparency about important matters such as hospital or facility accreditation, outcomes, safety profiles, physician training and certification, follow-up care, and recourse in situations of medical error."


Patients seeking organ transplants abroad are particularly at risk, Bramstedt adds. They may unknowingly receive organs bought on the black market, infected with disease, or both. And any complications from a transplant performed outside a patient's home country will not be covered by insurance.



The current political climate in the United States may affect medical tourism for both incoming and outgoing patients. Stricter U.S. entry and immigration policies could make it more difficult for overseas medical tourists to enter the country. And possible changes in U.S. health care policy could drive more Americans to seek care elsewhere. Should the Affordable Care Act (ACA) be repealed, for example, "it is expected that many Americans will lose health coverage, potentially resulting in increased cases of U.S. patients traveling abroad for medical tourism," Shaffer says. "Further, as health insurers have withdrawn from the ACA, medical tourism poses an additional opportunity for insurers to expand into an emerging market space."



Nurses can play an important role in educating patients on the risks and benefits of traveling abroad for medical care. Shaffer points out that nurses should also understand the importance of their role when these patients return. "One aspect of the care continuum that is often missing in medical tourism is posttreatment and follow-up care," he says, noting that nurses can help promote a continuous care process and ensure that care gaps are closed. When working with medical tourists, cultural competence and an understanding of the barriers that often exist between patients and providers is also critical.


"First and foremost, we need to understand the dynamics of medical tourism, and to ensure that it is being performed for the right reasons, with a competent staff, and with knowledgeable patient[s]," says Shaffer. "More nurses need to be involved in this industry to ensure that patients are safeguarded across the care spectrum."-Roxanne Nelson