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Globalization and Medical Care MEDICAL TOURISM AND THE GLOBAL MARKETPLACE IN HEALTH SERVICES: U.S.

PATIENTS, INTERNATIONAL HOSPITALS, AND THE SEARCH FOR AFFORDABLE HEALTH CARE
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 themselves 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 competition among hospitals, and enable customers to purchase high-quality care at medical facilities around the world. Skeptics raise concerns about quality 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, patientphysician 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

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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 in countries 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 presumably connected to the number of Americans unable to obtain health insurance or affordable access to local health care facilities. Even medical tourism companies 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 salaries of 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 commodified, subjected to international competition, and subsumed within a global market economy.

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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-income and 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 individuals 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 telecommunications, global transportation networks, and interconnected economies has both pushed and pulled jobs toward regions where workers are paid low wages and have 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

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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, healthrelated 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 responsibility 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 local facilities, 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

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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 representative 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 different 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 differences in 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

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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 significantly 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 care and 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

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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. Employees able to afford more expensive plans can receive treatment in 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 Carolinathe Southern 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

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bill proposes to cover all travel-related expenses, eliminate co-payments and deductibles, provide free transportation and accommodations for an accompanying 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 legislative 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 employerprovided 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 enterprises, 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) describe how 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

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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 procedures offered 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 complimentary 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

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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 constructing 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 international patients traveling to Bangkok for care. They grasped that hospitals situated 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 international 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).

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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 international 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, substantial government 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 commercials, billboards, press releases, word-of-mouth marketing, and medical brokerages all draw patients to private hospitals seeking international clients. The

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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 countries 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 organization 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 overwhelmingly 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 professionalism 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

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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 National University 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 professional 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 International is affiliated with Indias Apollo Hospitals and operates a clinic in Singapore. Harvard Medical International is part of Dubai Healthcare City, affiliated with Indias Wockhardt Hospital chain, and runs several hospitals in China. The Mayo Clinic is a participant in Dubai Healthcare City. Cleveland Clinic 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

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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 countries 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 healthrelated travel are widely advertised. In contrast, little consideration is given to how 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. Advertising 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. patients will 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

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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 surgery sometimes 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. International 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. Health researchers 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

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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 comparing 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 find affordable 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 sufficiently large 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 nonexistent or inadequate long-term care. Though some medical tourism companies make arrangements for follow-up care with local health care providers, the

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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 how much 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 any conscious 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

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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 contemporary 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. Management 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 profitable 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 maximizing 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-pocket for 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

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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 a radical 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 obtain medical 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 of informed 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

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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 established. Many cases never work their way through complex, backlogged bureaucracies. 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 substantial investments 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

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communicated to clients. The cumulative framing effect is to sell medical procedures 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 economic elites. 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 providers from 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 inequalities 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.

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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 Thailand are 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 massive marketing efforts, medical tourism and the globalization of health services has been subjected to little serious, critical academic scrutiny. Despite a widespread 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

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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 exposure to 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 middleclass 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 preferences, 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. Wealthy customers 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
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