Tuesday, April 26, 2016
The dark side of medical tourism: How quick and cheap treatment abroad can prove costly to health — and B.C.'s health-care system
When Mike Watson chose to go under the knife on the other side of the world, he made the decision “out of necessity.”
After doctors in B.C. told the Okanagan father-of-three that, for medical reasons, he would have to wait six months to have a liver transplant done here, Watson looked elsewhere for options.
Doctors in Hong Kong told him his odds of survival would be better if he had the operation done immediately. Watson, 39, travelled across the Pacific with his wife, Lisa, last month so that surgeons at Hong Kong’s Queen Mary Hospital could perform the surgery, with Lisa donating two-thirds of her liver to her high-school sweetheart.
“The medical care received was world class,” Watson said last week from Hong Kong, where he’s receiving followup care and monitoring.
“After being through the process I have absolutely no regrets,” he said. “I received a second chance at life through their system.”
After facing a six-month wait for a liver transplant in B.C., Mike Watson has ‘absolutely no regrets’ about going to Hong Kong for the operation, in which his wife Lisa donated two-thirds of her liver. The Watsons are pictured In Hong Kong three weeks after the operation.
However, other Canadians have deeply regretted their decision to go abroad for medical care.
Among them is Emily Reed, 46, who travelled to Tijuana, Mexico, for weight-loss surgery last year. Reed, who lives in Hythe, Alta., near the B.C. border, said she has lost more than half her body weight in the last 14 months and now fears for her health as her weight continues to decline. She blames the botched surgery for her health issues.
“I’m just devastated,” Reed, who now weighs 124 pounds, said last week. “I’m just about out of my mind ... I don’t have a lot of strength.”
She wants to share her story to warn other Canadians about the complications that can arise from a botched surgery abroad, she said.
“I want to tell people: ‘Please be very careful when you’re doing this. You don’t want to end up like me.’”
Medical tourism growing
“I often say medical tourism is really good for some people and, unfortunately, really bad for others,” said Valorie Crooks, a Vancouver-based expert on the growing trend of international travel for medical care. “And there’s often no way to predict from the outset if someone’s going to have a wholly positive or wholly negative experience.”
More than 50,000 Canadian medical tourists make such trips every year, according to a report last year from the Fraser Institute. The same report suggested British Columbians are more likely than anyone else in the country to be medical tourists. Common reasons for going outside Canada for medical treatment include long waiting lists at home and high costs for treatments not covered by MSP.
It’s big business, too. Market analysts have estimated the value of the global medical tourism industry will grow to more than $32 billion a year by 2019, and the Conference Board of Canada reported last year that Canadians spent more than $440 million in 2013 travelling abroad for medical treatment.
Medical tourism entrepreneurs say Canada, despite its socialized health care system, is a market that’s ripe for major growth.
Valorie Crooks is an associate professor in SFU’s geography department who studies the effects of medical tourism. She says a growing number of people travelling abroad for procedures are heading for the Caribbean and Central America.
When Crooks, an associate professor in SFU’s department of geography, and her colleague Jeremy Snyder, an associate professor in SFU’s faculty of health sciences, co-founded the Medical Tourism Research Group in 2009, it was the first group of its kind in Canada. Since then, the amount of research on the topic has grown significantly, said Snyder.
But despite increased awareness, experts say there’s still a lack of data.
“If you think about the last time you went through customs, you’re not asked, ‘Did you access surgery?’” said Crooks.
“So what that tells us is that there’s actually no reliable way to know how many Canadians are engaging in this practice. (But) there are some clues we can look to.”
Those clues include hospital admissions for patients returning from abroad with complications, and surveys of Canadian doctors and dentists.
A study published last month in the Canadian Journal of Surgery examined costs borne by the public health care system of Alberta because of patients returning with complications after having bariatric surgery outside of Canada. The report concluded that “the financial cost of treating complications related to medical tourism in Alberta is substantial and impacts existing limited resources.”
The study said the estimated extra cost of $560,000 a year to the Alberta health system was an “extremely conservative estimate,” and doesn’t account for long-term care or hospital stays.
“If some of these anecdotes actually are indicative of a wider pattern, it could be incredibly expensive,” said Snyder. “But we can’t act on that without having better data.
“The argument goes, if you have somebody who is getting some kind of surgery abroad and they’re paying out of pocket, then that’s actually saving the Canadian system money.
“But on the other hand, it’s well documented that when things go bad, they can go bad pretty catastrophically and be incredibly expensive — millions of dollars in some cases. I can’t say with confidence what side of the balance that lands on ... but it’s certainly something worth knowing.
“There’s the potential there for something that’s actually draining a lot of money out of the medical system.”
Patients return home with complications
Source: Glenn Cohen, a Harvard Law School professor and a leading expert on medical ethics and the law. Cohen says Canadian medical tourists often travel to the country of their birth or ethnic origin. In other cases, says Cohen, certain countries have become known for specific kinds of medical tourism.
When Crooks and Snyder started the Medical Tourism Research Group in 2009, the top international destinations Canadians reported visiting for treatment included India, Thailand and China.
Crooks calls those the “Medical Tourism 1.0” destinations: Asian countries with large hospitals and investments in medical infrastructure looking for ways to use excess capacity while generating revenue.
In the last five or six years, Crooks said, more Canadian medical tourists have reported trips to “Medical Tourism 2.0” destinations, which are often in the Caribbean or Central America, with smaller, purpose-built medical facilities tailored to foreign clientele.
“In that ’Medical Tourism 2.0’ sector, there’s a lot more of a view that this is a tourism diversification project, often being led by Ministries of Tourism or Trade, and not by the health sector, which creates a lot of challenges,” she said.
B.C.’s Ministry of Health advises against travelling out of Canada for medical treatment.
“We recommend patients have surgeries locally so they can benefit from the support provided by our health care system before and after the procedure,” ministry spokeswoman Kristy Anderson said in an email.
“All surgeries come with some risk, and people who go abroad could have potentially life-threatening complications, particularly in countries that may not have the regulations or standards that we have in B.C.”
Some physicians say that while they discourage out-of-country surgery, they understand what drives patients to make that choice.
Dr. Ali Zentner, a specialist in internal medicine and obesity, always advises her patients against leaving Canada for bariatric surgery. But when Canadians such as Emily Reed decide to travel abroad to have bariatric surgery, Zentner understands the “need and the desperation.”
“With the scarcity of bariatric options available to British Columbians and to Canadians as a whole, it’s no surprise that these patients are going elsewhere for care,” said Zentner, director of the Vancouver Island Bariatric Program.
“Patients are forced to perhaps put themselves at risk of substandard care. You can get a botched surgery, absolutely, let’s be frank, because who knows what the standard of care is?
“We’re seeing a lot of patients who went elsewhere and had complications, and now we’re definitely faced with the added burden, the added concern associated with that.”
Dr. Ali Zentner says more Canadians are returning from foreign treatment with complications, which burdens local health care.
It’s a symptom of the Canadian health system’s inadequate treatment of obesity, said Zentner.
In Canada — where one in four adults is clinically obese — providing better care is not only “good medicine, it’s also good finances,” said Zentner.
More Canadians seem to be returning from overseas procedures with complications — and not only in her field, said Zentner.
“More and more, we’re seeing it for hip replacements and knee replacements,” she said. “Medical tourism is happening. It’s a definite reality, especially when a need is greater than a supply.”
Many 'transplant tourists' have complications
Dr. Jagbir Gill, a transplant nephrologist at St. Paul’s Hospital, said stories like that of Mike Watson — a Canadian who travelled abroad with a live donor to get an organ transplant — are fairly rare.
More common, Gill said, is a practice called “transplant tourism,” where patients travel overseas to pay for an organ on the black market. This practice is illegal, unethical and dangerous, said Gill.
“Buying and selling of organs is illegal in Canada and in the vast majority of countries,” he said.
Those countries include the most common destinations for Canadian transplant tourists: China, Pakistan and India.
“The hospitals and doctors that facilitate the purchase of organs are breaking the law in their country, so we can’t realistically expect that they will ensure the safety and standards required to safely deliver transplantation,” said Gill.
A “large percentage” of transplant tourists experience complications, including severe infections and higher rates of rejection, Gill said. And the risks are not limited to those patients.
“What’s most worrisome is that the types of infections we are seeing in patients who return after obtaining a transplant abroad are often more severe and may not be the typical infections we see after transplantation here.
“For example, we have certainly seen more multi-drug-resistant infections in these patients and this, in my opinion, is a major problem from a public health point of view. It’s a serious concern for all Canadians when we are importing complex infections through illicit organ transplantation.
“In my view, we need to seriously consider the implications of this on the public health of all Canadians and what measures we can put in place to prevent this.”
Gill’s team at St. Paul’s still sees three to five cases a year of returning transplant tourists, he said.
“If we have a patient to whom we have expressly advised against this option, it is disconcerting when they still go this route. There’s no question that this tarnishes the relationship between the doctor and the patient,” Gill said.
“We may feel that it is best to transfer the chronic care of this patient to a different transplant program within the city. This is not meant to punish patients who have purchased a kidney, but is to provide the most objective care possible for all patients.”
Canadian companies coordinating treatment abroad
A growing number of Canadian companies are entering the multi-billion-dollar medical tourism industry.
Last year, the inaugural edition of Canada’s medical tourism trade show attracted participants from 20 countries to Montreal.
This year, Destination Health is expected to draw thousands of attendees to Ottawa in September, said founder Pablo Castillo. He’s considering holding the 2017 event in B.C.
The show, Castillo said, “is about empowering people so they can easily find reliable health care services in other countries.”
Medical tourism “is still a taboo in Canada” but “without a doubt a rapidly growing sector,” he added.
Guillaume Debaene, general manager of West Vancouver-based MediTravel International, said medical travel “is becoming more and more popular for Canadians.”
“However, millions of them still don’t know what it is exactly and that it is available as a possible solution for them.”
Meanwhile, in Armenia, Raffi Elliott has founded a company that he is aiming to turn into the “expedia.com of health or medical tourism.”
The Canadian is based in the Caucasus republic’s capital, Yerevan, which he described as “the Silicon Valley of the (former) Soviet Union,” and a perfect place for a “marriage of tech and health.”
His company, gettreated.ca, targets Canadians seeking medical care abroad, helping them access dental work and plastic surgery in Armenia. His Canadian customers have been happy so far, Elliott said, even though some of them may have never heard of Armenia before.
Gettreated.ca will soon increase the range of medical services it offers, Elliott said. “It could be anything from open-heart surgery to invitro fertilization.”
Along with a wider range of services, Elliott said he plans to expand from Armenia to serve Canadian medical tourists in Israel, Ukraine, the United Arab Emirates and Poland.
The goal is to serve 35 to 50 clients a month through gettreated.ca by the end of this year, Elliott said. They are targeting 100 patients a month next year.
“Public health care in Canada is seen as a bit of a religion. It’s something you can’t really criticize or discuss openly,” Elliott said. “But it has its shortfalls and a lot people end up falling through the cracks.
“I think a lot of Canadians would actually be surprised by the number of Canadians who, despite public health care, actually go to the United States and pay tens of thousands of dollars to get something done,” he said.
Plan to make B.C. a health-care destination fell flat
When Kevin Falcon raised the idea of promoting B.C. as a destination for medical tourism, it did not meet a healthy reception.
Then B.C.’s health minister, Falcon told the legislature in May 2010 that he had been in touch with a number of B.C. surgeons and “the message that I’ve received is that government should not just look at health care as a cost, that there is a potential for revenue to be generated in the health care system.”
With hundreds of thousands of Americans flying out of the U.S. every year for medical care, Falcon said, “You could charge these individuals enough that you could not only cover the costs of the operation or whatever the elective surgical procedure may be, but you could also have enough ... to plow back into the system to provide quicker and better access for British Columbians that may be on elective waiting lists.”
Earlier that year, Falcon had asked: “Why can’t British Columbia be the Mayo Clinic of the North?”
Several voices piped up in opposition.
The idea Falcon floated was described as “a non-starter for health care” in an op-ed from Alice Edge, co-chair of the B.C. Health Coalition.
“We need to build on the proven public innovations that make this system stronger, and not be distracted by marketing schemes dressed up as public policy,” Edge wrote.
In a 2012 article in the academic journal Healthcare Policy, Leigh Turner, an associate professor from the University of Minnesota’s Center for Bioethics & School of Public Health, concluded: “Canadians should tell their elected representatives to ‘Hold the Mayo’ and not waste public resources on efforts to attract international patients to provincial health care systems that already face many challenges in providing Canadians with timely access to medically necessary care.”
The idea seems to have died on the table.
Last week, a Ministry of Health spokeswoman said: “At this time the ministry is not considering a plan to market health care services to individuals outside our province. Our priority at this time is to improve access to care for British Columbians and to ensure that British Columbians are able access the care they need as close as possible to home.”