According to conventional wisdom, the global medical tourism industry is experiencing rapid expansion, with medical tourism companies proliferating and patients traveling around the world for medical care. Both health researchers and journalists assume that Canada’s medical tourism industry is experiencing dramatic growth, and that medical tourism companies are seeing a stream of clients seeking hip and knee replacements, treatments for cancer, “liberation therapy,” stem cell injections, assisted reproduction, cosmetic surgery, and other procedures.1,2 News reports describe medical tourism companies helping their customers escape lengthy queues for care in Canada, access interventions unavailable at Canadian hospitals, and obtain affordable out-of-pocket treatment.3,4 These businesses send residents of Canada to hospitals and clinics in such countries as Costa Rica, Cuba, the Dominican Republic, India, Mexico, and Thailand.5,6 However compelling it might seem, this now-standard account of globalization of health care and the expansion of the medical tourism industry overlooks something important about Canadian businesses promoting transnational medical travel. Medical tourism companies across Canada are not all experiencing a rapid growth in clients. To the contrary, approximately half of all medical tourism companies established in Canada since 2004 are no longer in business.
Defunct businesses
I began studying Canadian medical tourism companies in 2006. Drawing upon news reports, repeated Internet searches, and conversations with several medical travel facilitators and Canadians who had sought care in India, the United States, and elsewhere, by 2007 I was able to identify 15 medical tourism companies operating in Canada.7 (I also located travel agencies marketing travel to health care facilities in India and Thailand.) By 2011, approximately 18 companies with home offices or affiliate branches in Canada had attempted to enter the business of marketing medical care provided at health care facilities in Costa Rica, India, Thailand, and other international destinations. Seven additional companies organized regional, cross-border medical travel to health care facilities in the United States, as well as private clinics in Canada. Lumping together these 2 types of businesses, Canada has approximately 25 medical tourism companies advertising various medical procedures. Two additional companies restrict themselves to marketing “liberation therapy” interventions for multiple sclerosis in India, and 3 weight-loss companies market bariatric surgery and cosmetic surgery in Mexico, in addition to promoting other weight-loss strategies. These latter businesses send Canadians to international medical facilities, but they do not market themselves as full-service medical tourism companies. In addition to these operational companies, to my surprise, 25 Canadian medical tourism companies have not survived as functioning businesses.
Medical tourism companies based in different parts of Canada—operating with distinct business models, and exhibiting varying degrees of business savvy and marketing sophistication—failed despite widespread claims about the rapid growth of medical travel and the emergence of a global marketplace for health services. While proponents of medical travel were touting the arrival of the mobile medical consumer, 2 Canadian medical tourism companies specializing in “dental tourism” came and went; 1 Canadian company ceased marketing heart and liver transplants performed in Colombia; and 22 additional Canadian medical tourism companies disappeared from the medical travel marketplace—13 in Ontario, 7 in British Columbia, 4 in Quebec, and 1 in Alberta. The one business established with the purpose of both sending Canadians abroad and attracting US citizens to medical facilities in Canada ranks among the defunct medical tourism companies. It is unclear whether the company ever managed to attract international patients to Canadian health care facilities or send Canadians to hospitals and clinics beyond Canada’s borders.8 Some Canadians do travel abroad for medical care, and there is reason to suspect that the number of Canadians going abroad for treatment is increasing. Acknowledging this—although it is important to note that there are no reliable data available that establish how many Canadians go abroad for care every year or the rate at which travel abroad is increasing over time—what is not widely known is the fact that within a few years of opening for business, approximately half of all Canadian medical tourism companies have closed.
Few identifiable characteristics distinguish functioning medical tourism companies from shuttered businesses. Companies with unsophisticated web portals failed; businesses with professional-looking websites and clever marketing strategies suffered the same fate. Canada’s 2 dental tourism companies, perhaps because many dental procedures need to be performed over a period of visits rather than in 1 encounter, no longer send patients abroad for care. The most salient feature of medical tourism companies that ceased functioning is that 14 of them marketed medical procedures in just 1 destination nation. Perhaps these businesses erred in emphasizing choice and medical consumerism while offering their clients access to just 1 medical facility or to treatments within a single country.
Some medical travel facilitators do appear to have expanded their clientele. Several medical tourism companies have differentiated themselves from their competitors by consistently managing to attract news coverage and by developing social media strategies that take advantage of free marketing opportunities provided by YouTube, Facebook, and Twitter. Rather than suggesting that the entire industry is based more upon marketing bluster than actual client demand for health care at international medical facilities, perhaps what is happening is that several companies are beginning to dominate the Canadian marketplace for medical travel. Even if industry consolidation is occurring and reflects a shift from small start-up enterprises to more mature businesses, the high failure rate of Canadian medical tourism companies is noteworthy yet does not appear to have been noticed by Canadian family physicians and other doctors, health researchers, journalists, and prospective clients of medical tourism companies.
Cautionary notes
Several cautionary notes emerge from the opening and relatively swift closure of numerous medical tourism companies across Canada. First, family physicians asked by their patients for assistance in exploring options for arranging medical care outside Canada should urge those patients to exercise caution and avoid making hasty decisions based upon limited information. Family physicians should encourage their patients to conduct due diligence and learn as much as possible about the companies they are considering. Not all companies have lengthy track records of successfully arranging medical care at medical facilities based outside Canada. Likewise, if postoperative care is required after patients return to Canada, prospective clients of medical tourism companies need to understand that many of these businesses do not survive as going concerns. If postoperative care is required or legal action is considered as a result of receiving substandard care abroad, there is risk that some of these companies will have closed and will not respond to queries from their clients. Family physicians, if approached by patients exploring the possibility of going abroad for health care and willing to discuss this option, should advise their patients to investigate the following about the medical tourism companies: how long they have been in business; whether they have been the subject of consumer complaints; whether they are likely to remain operational while patients are abroad receiving care and then following treatment; whether they have sufficient capital to remain in business; and whether the companies have business models that involve arranging preoperative and postoperative care, selecting destination facilities on the basis of third-party assessment of quality of care and patient safety, and providing health-related information in an honest and thorough manner, including discussion of risks and benefits of treatment, and provision of travel insurance and medical insurance in the event that problems occur during the course of receiving treatment abroad.9,10
Most family physicians will find themselves ill-equipped to help their patients consider various medical travel options and navigate Canada’s medical tourism industry. Until Canadian medical tourism companies are better regulated and have more established, publicly verifiable track records, family physicians will likely find it difficult to provide informed advice to patients by helping them distinguish reliable, high-quality domestic medical tourism facilitators from unstable businesses likely to soon exit the marketplace.
Second, family physicians and their patients need to understand that there is considerable “churn” in the medical tourism industry. When risks of medical tourism are reviewed, health researchers typically emphasize the risks of receiving substandard medical care, acquiring infectious diseases, or receiving inadequate postoperative care. In addition to these health-related risks, the subject of financial risk to patients needs to be considered in patient-physician discussions about using medical tourism facilitators to arrange transnational health care. Medical tourism companies come and go; many of these businesses have an impressive presence on the Internet but employ few staff members and have at best a modest “bricks and mortar” presence. Just as consumer advocates recommend that customers use credit cards when buying packages from travel agencies, prospective clients of medical tourism companies should consider reducing financial risk by using credit cards rather than making cash payments when purchasing medical care. Clients of one Canadian medical tourism company reportedly paid fees to the business to have medical procedures performed at a medical facility in the United States. The medical tourism company then allegedly kept the payments and did not pay for health services provided at the destination hospital.11 The US hospital subsequently initiated debt-collection proceedings against the patients. Meanwhile, the medical tourism company closed; its office was shuttered; and calls from irate clients were not returned. The 2 company owners were subsequently charged with multiple counts of fraud. Such cases are presumably uncommon, but they reveal that patients can be exposed to financial risk when they contract with medical tourism companies. Family physicians should advise their patients to take whatever steps they can to reduce financial risk when consulting with medical tourism companies.
Third, advocates of expanding Canada’s medical tourism industry and promoting increased transnational health care options to Canadians should understand that, while barriers to establishing a medical tourism company are low, easy entry into the marketplace is not a harbinger of commercial success. Perhaps some Canadians remain concerned about the quality of care they might encounter abroad; are reluctant to receive treatment far from their communities and loved ones; are fearful of acquiring infections while receiving medical care; or worry about continuity of care and follow-up care.12,13 For whatever reason, not all medical tourism companies develop adequate client bases. Proponents of developing Canada’s medical tourism industry should be forewarned that roughly half of these companies close within a few years of opening for business. It is possible that some medical tourism companies are established in Canada because entrepreneurs underestimate the challenges associated with transforming the business concept of marketing transnational health care into a functioning, sustainable business enterprise.
Fourth, health policy makers in Canada need to understand that the Canadian medical tourism marketplace is fluid and, in many respects, surprisingly turbulent. Medical tourism companies often burst into public visibility with a flurry of press releases and news coverage and then fade from view.14 Unsuccessful businesses do not announce their disappearance. It is possible that hyperbolic accounts of both the promise and the perils of medical tourism are detached from an environment in which a proliferation of medical tourism companies either has not been accompanied by overwhelming demand for international medical travel or has occurred in a context in which a modest number of businesses are attracting most of the Canadians able and willing to pay for elective, out-of-pocket international medical care.
Exaggerated success
Some Canadians seek expedited access to treatment. Other Canadians, as news media coverage of individuals going abroad for “liberation therapy” reveals, travel to gain access to procedures that are unavailable in Canada.15,16 Another cohort of travelers goes abroad for interventions—commercial kidney transplants and commercial surrogacy are 2 obvious examples—that are outlawed in Canada.17,18 Different types of medical travelers all warrant attention from health researchers; there are many reasons to investigate the various ethical, social, clinical, economic, and public health facets of medical travel.19 However, it is also important to avoid exaggerating the success of medical tourism companies and overselling the social phenomenon of medical tourism. A comprehensive account of the medical tourism industry in Canada requires addressing commercial failures and not just businesses successfully marketing their services on company websites, blogs, and social media platforms. Health researchers are beginning to understand how, where, and why the medical tourism industry developed. Researchers interested in the medical tourism industry in Canada should also explore why, in a country with a lengthy history of public dissatisfaction with wait times for various medical procedures, approximately half of all Canada-based medical tourism companies have exited the marketplace for medical travel. Canadian family physicians approached by patients considering going abroad for medical care have a particular need for research examining all facets of Canada’s medical tourism industry.
Footnotes
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La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’avril 2012 à la page e186.
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Competing interests
None declared
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The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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