Medical tourism, or preplanned international travel for medical care, has increased in recent years. Reference Benowitz, Gaines and Brunette1,Reference Chen and Wilson2 Growing inequalities in healthcare access, affordability, and quality of care; an increase in available medical and dental procedures at lower costs; and tailored marketing strategies have contributed to a rapidly growing international market. Reference Foley, Haglin, Tanzer and Eltorai3–Reference Lunt and Carrera5 In 2018, the estimated annual international market value for medical tourism was $16.7–36.9 billion. 6,7 US residents may travel internationally for any type of care, such as dental care, cosmetic surgery, orthopedic surgery, or organ and tissue transplantation. Reference Benowitz, Gaines and Brunette1,Reference Chen and Wilson2,8
Complete and accurate data on medical tourism volume, destinations, procedures, and outcomes are unavailable. Reference Chen and Wilson2 Most literature describes medical tourism as an industry 6,7,Reference Ehrbeck, Guevara and Mango9 and does not focus on its unique health risks. Complications attributed to medical tourism include wound infections, bloodstream infections, donor-derived infections, and bloodborne pathogens including hepatitis B, hepatitis C, and HIV. Reference Benowitz, Gaines and Brunette1 Air travel after recent surgery increases the risk for blood clots, including deep venous thrombosis and pulmonary emboli. Reference Benowitz, Gaines and Brunette1 The risk of antibiotic-resistant infections may be increased in certain regions, and appear to be more common in some countries where US residents go for medical tourism. Reference Chen and Wilson2 The United States has experienced several outbreaks of highly resistant pathogens in medical tourists returning with complications from care they received abroad Reference Benowitz, Gaines and Brunette1,Reference Schnabel, Esposito and Gaines10–Reference Kracalik, Ham and Smith12 including the introduction of pathogens not previously seen in the United States. 13 Previous assessments have described the scope of medical tourism, though interpretation is difficult due to differences in definitions and methodologies. Reference Foley, Haglin, Tanzer and Eltorai3,Reference Lunt and Carrera5,Reference Ruggeri, Záliš and Meurice14 Currently, no reliable population-based surveillance data are available that describe US medical tourists seeking care internationally including numbers, destinations, types of care received, their reasons for seeking care abroad, and/or associated negative health outcomes.
The Travelers’ Health Branch at the US Centers for Disease Control and Prevention (CDC) collaborated with 10 states and Puerto Rico to add medical tourism questions to the 2016 Behavioral Risk Factor Surveillance Survey (BRFSS). We sought to describe medical tourism among a subset of US residents and identify possible indicators for medical tourism. Identifying medical tourists and factors influencing their decision to engage in medical tourism can inform evidence-based health recommendations for medical tourists and their providers and identify potential targets for public health interventions to support this population.
Methods
Data source
The BRFSS is a CDC-sponsored, state-based, random-digit–dialed telephone survey that collects information on health-related behaviors, chronic health conditions, and the use of preventive services by noninstitutionalized US resident adults ≥18 years old. 15
In 2015, 11 US states and territories (Arizona, California, Connecticut, Florida, Georgia, Maryland, Massachusetts, Minnesota, Oregon, Puerto Rico, and Texas) added 6 questions about medical tourism on their 2016 BRFSS surveys (Appendix 1 online). States and territories were chosen on the basis of their interest in medical tourism and their agreement to include the medical tourism questions on their 2016 BRFSS survey. The first question asked: “During the past 12 months, did you travel outside the United States to receive preplanned medical, dental, or surgical procedures or treatments?” If the respondent answered “yes” they were asked 5 additional questions: destination, type of care received, reasons for traveling for care, if they experienced any undesirable health outcomes as a result of this care, and for those who did experience a problem, if they saw a provider after returning to the United States. Respondents who answered “don’t know” or “refused” were excluded from analysis of that question. Respondents could report >1 type of care, give >1 reason for traveling for medical tourism, and list up to 3 countries that they visited for medical tourism in the previous 12 months. Interviewers wrote in answers if the respondent reported a procedure or reason not listed on the form.
Inclusion and exclusion criteria
Respondents who answered “yes” or “no” to the question, “During the past 12 months, did you travel outside the United States to receive preplanned medical, dental, or surgical procedures or treatments?” were included in the analysis. Those who answered “yes” were classified as medical tourists. Those who answered “yes” but only reported travel within the United States or did not receive preplanned care were excluded.
Data analysis
We conducted a descriptive analysis of the following core variables from the BRFSS for medical tourists: demographics, socioeconomic status, and health and health access. We used a regression model with a log-link function and a Poisson distribution to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for medical tourism for each variable. We weighted data to account for survey design and population characteristics; we used an iterative proportional fitting method to account for selection probability, nonresponse bias, and noncoverage errors. 16 We defined statistical significance as an α of .05. We calculated the prevalence of medical tourism in the study population with 95% CI. We used SAS Enterprise Guide version 7.1 software (SAS Institute, Cary, NC) for these analyses.
Results
Of 93,965 respondents asked if they had traveled outside the United States to receive preplanned health care in the previous 12 months, 93,492 (99.4%) answered “yes” (n = 535) or “no.” Those from Puerto Rico who reported the United States as their destination for medical tourism (n = 9), and those from US states who indicated Puerto Rico as their destination (n = 5) were excluded. Those who did not receive preplanned care were excluded (n = 4). Demographics and health characteristics of respondents can be found in Table 1.
Table 1. Demographic and Health Characteristics of Medical Tourists and Those Who Did Not Travel for Medical Tourism (n = 93,492) a
a Medical tourists with missing information: Race/Ethnicity 8 (1% of medicaltourists), Employment 6 (1%), Education 2 (<1%), Income 77 (15%), Maritalstatus 2 (<1%), Children living in household 5 (1%), Current health plan 4(1%), Needed to see doctor in last 12 months but could not due to cost 3 (<1%),perceived health status 1 (<1%).
The 517 medical tourists made 705 trips outside the United States and received 540 treatments, procedures, or surgeries in the 12 months preceding the interview. Dental work accounted for 299 (55%) of the procedures reported, followed by unspecified procedures (108, 20%) (Table 2). Mexico was the most frequently reported destination (291 trips, 41% of all trips) followed by Colombia (45, 6%) and Canada (28, 4%) (Table 3). Medical tourists traveled to all world regions except Antarctica (Appendix 2 online).
Table 2. Procedures and Treatments Received by Medical Tourists, by Type of Procedure, BRFSS 2016 (n = 540 procedures) a
a Respondents could list more than one procedure or treatment. Don’t Know (n = 21, 4%); Refused (n = 21, 4%).
b Includes any reported dental surgery, treatment, or procedure.
c 13 respondents specified the treatment or the medical condition they received treatment for: cancer (n = 2), infertility (n = 2), asthma (n = 1), depression (n = 1), diabetes (n = 1), eye allergy (n = 1), influenza (n = 1), hormonal (n = 1), homeopathic (n = 1), physical therapy (n = 1), hand therapy (n = 1).
d Ear, nose, throat (ENT) specialist (n = 1), leg exam (n = 1), mammogram (n = 1), cancer screening (n = 1), pap test (n = 1), clinical analysis (n = 1).
Table 3. Top 10 Most Frequently Reported Countries for Medical Tourism (n = 705 trips) a
a Refused to name country (n = 30, 4%), Other unspecified destination outside the United States (n = 22, 3%); Don’t Know (n = 19, 3%).
In total, 506 medical tourists provided 582 reasons for traveling for care. The most frequently reported reason was “too expensive in the United States” (51%), followed by “not covered by insurance” (14%), “more familiar or comfortable receiving the procedure or treatment in another country” (7%), “felt quality of care or success better in another country” (6%), and “not available in United States” (3%). Of the 297 who reported the procedure was too expensive in the United States, 208 (70%) reported receiving dental work. Of the 89 who received nondental procedures and reported their procedure was too expensive in the United States, 68 (76%) reported having health insurance.
Of the 517 medical tourists, 24 (5%) reported an unexpected or undesirable outcome as a result of the care they received abroad. Unspecified procedures (n = 9), dental work (n = 6), and kidney transplants (n = 4) were reported most frequently; facial cosmetic surgery, heart transplant, “tummy tuck,” and an unspecified medical treatment for an illness were each reported once among procedures of those experiencing unexpected problems. Also, 12 (50%) who reported an unexpected problem went to one country only on a single occasion; 5 (21%) went to the same country more than once. Furthermore, 9 (38%) went to >1 country for care for a single reported category of procedure. Reasons for pursuing care abroad among the 24 medical tourists who reported unexpected problems included that the procedure was too expensive in the United States (n = 5), it was not available in the United States (n = 5), it was not covered by insurance (n = 4), they perceived that quality of care or success was better outside the United States (n = 3), and they felt more familiar or comfortable outside United States (n = 1). Of the 5 who stated that their reason for traveling was because the procedure was not available in the United States, 4 were kidney transplant recipients, and 1 did not specify. Of the 24 medical tourists who reported an unexpected or undesirable outcome, 18 (67%) saw a healthcare provider after returning to the United States and 15 reported having health insurance.
The prevalence of medical tourism in 11 states and territories was 1.32% (95% CI, 1.00–1.64) representing ∼1,130,000 individuals (95% CI, 900,000–1,410,000). We found no statistically significant gender or age differences between medical tourists and nonmedical tourists (Table 1). The prevalence of medical tourism was higher among Hispanics and nonwhites (PR, 3.97; 95% CI, 2.48–6.32) and higher among those with <4 years of college (PR, 1.72; 95% CI, 1.14–2.59). The prevalence of medical tourism was higher among those currently working compared to those who were retired (PR, 2.46; 95% CI, 1.40–4.29). Medical tourism was more prevalent among those without current health insurance (PR, 2.70; 95% CI, 1.69–4.34) although medical tourism was still prevalent among those with health insurance. Medical tourism was more prevalent among those who indicated that cost prevented them from seeing a doctor for any purpose in the last 12 months compared to those who did not consider cost a barrier (PR, 2.39; 95% CI, 1.48–3.87).
Discussion
Our analysis of population-based surveillance data demonstrates that the actual annual volume of US outbound medical tourists is likely larger than previous estimates. Reference Chambers17,Reference Keckley and Underwood18 Medical tourists represent a large and diverse population that can be at risk for complications that require follow-up or emergency care after their return home. Reference Österle, Johnson and Delgado4,Reference Schnabel, Esposito and Gaines10 Medical tourists presenting with complications from procedures abroad may experience prolonged and expensive clinical courses due to delays in diagnosis and treatment. Reference Schnabel, Esposito and Gaines10
Our data are consistent with previous studies describing issues relating to cost as significant motivators for medical tourism. Some US health insurance providers and employers have formed alliances with facilities outside the United States to control costs, but specific plan requirements, deductibles, copays, and noncovered travel-related expenses may still pose challenges. Reference Benowitz, Gaines and Brunette1,Reference Österle, Johnson and Delgado4 We found medical tourism prevalent among those without insurance, however, medical tourists with insurance also traveled for care. Among medical tourists who sought nondental care and who reported that the procedure they received abroad was too expensive in the United States, 3 of 4 had current health insurance. This finding suggests that the care was either not covered or was inadequately covered by insurance. Medical tourists who are uninsured or underinsured may be hesitant to present to US healthcare facilities because of the costs of treatment, Reference Lozano, Ogbu, Amin, Chakravarthy, Anderson and Lotfipour19 or to provide details of their care for fear that follow-up care will not be covered by their insurance.
Medical tourists in our sample traveled to Mexico and Canada frequently, but more than half of all visits were to other destinations. While the appeal of less expensive or more convenient care motivates millions to travel internationally, techniques, protocols, training, and standards of care vary across countries, and healthcare quality can vary across facilities and providers within countries. Reference Benowitz, Gaines and Brunette1,Reference Bies and Zacharia20 Facilities may not maintain provider licensure, track patient outcome data, have rigorous infection control, provide adequate follow-up care, or maintain medical record privacy or security policies. Reference Benowitz, Gaines and Brunette1,Reference Chen and Wilson2 Some organizations have developed quality-of-care standards and established accreditation procedures through procedural assessments on quality and safety with medical tourism, but they do not provide data on patient outcomes. Reference Chen and Wilson2,Reference Helble21,Reference Reed22 Medical tourists should be aware that all surgeries (even those done in their home countries) have some level of risk regardless of the destination where they are performed, and accreditation does not ensure a desirable outcome. Reference Benowitz, Gaines and Brunette1
US residents may travel for medical care because they feel more comfortable having the procedure performed elsewhere. International travel to visit friends and relatives is common among the foreign-born population of the United States. Reference Keystone and Brunette23 Those traveling to visit friends and relatives (VFRs) may be more inclined to engage in medical tourism, and additional research is needed to understand this group and any unique risks regarding medical tourism. Although VFRs may choose medical tourism because they feel more comfortable with or trusting of care provided outside the United States, they may be targeted by advertising tailored toward them, often in their native language, emphasizing the convenience of combining a family visit with medical care, while downplaying the risks. Reference Foley, Haglin, Tanzer and Eltorai3 Clinicians advising those VFR travlers should ask about any plans to receive care outside the United States before they travel. Healthcare providers who work in acute-care facilities in the United States, especially in communities with a high foreign-born population, should be aware that VFRs may present for emergency care with complications from care received abroad. Reference Schnabel, Esposito and Gaines10
Medical tourists also travel for treatments that are unavailable or illegal in the United States. “Transplant tourism” is travel for the purpose of receiving an organ or stem cells purchased from an unrelated human donor for transplantation. Reference Benowitz, Gaines and Brunette1 Several studies have identified medical issues with transplant tourism, including high rates of serious postoperative infections including hepatitis B, hepatitis C, HIV and tuberculosis. Reference Akoh24,Reference Canales, Kasiske and Rosenberg25 Clinicians advising medical tourists, including those planning any kind of transplant surgery, should be sure travelers are up-to-date on all routine vaccinations including hepatitis B. Reference Benowitz, Gaines and Brunette1
Most reported procedures received abroad were dental. Access to dental services is a challenge in the United States. Reference Murthy26,Reference Mertz27 Dental insurance is often not included in US health insurance packages or may cover a limited number of procedures. A lack of insurance or high deductibles and copayments result in dental care being a service people frequently skip because of cost. Reference Österle, Johnson and Delgado4,Reference Mertz27 Barriers to care and the growing international market for dental services has driven US residents abroad, particularly to Mexico as our data support. Border towns in northern Mexico that specialize in dental services draw from a broad catchment area of US-resident clientele. Reference Ramírez de Arellano28 VFRs may be more inclined to travel for dental tourism. In a recent study of medical and dental tourism among immigrants in the United States, nearly half of Latinos and one-quarter of Asians surveyed had seen a dentist in a foreign country in the previous 12 months. Reference Jang29 Although dental care was the top procedure received among US residents in our sample, there is a lack of reliable data in the literature on volume, destinations, procedures (eg, routine care vs major surgery), and outcomes among dental tourists.
Our analysis has several limitations. The BRFSS information is self-reported, which can result in recall bias and interviewer or recording errors leading to misclassification bias. Data may not be representative of all medical tourists in the United States, and the locations that participated in the study may have a different proportion of medical tourists than other areas. Although we collected data regarding specific categories of procedures received, they were not comprehensive of all procedures one could receive abroad and did not include specific options for dental or routine care. We were limited by the demographic variables available in the BRFSS and could not collect data on birth country, immigration status, dental insurance, or compare rates of complications from care received inside versus outside the United States. We could not collect data on whether a medical tourist had family in another country, already knew the clinician to perform the procedure, how long the resident had been living in the United States, or whether the medical tourist had insurance at the destination. In the 9 instances in which medical tourists went to >1 country and reported an unexpected problem, we were unable to identify the country where the unexpected problem occurred.
This report summarizes the largest collection of population-based data describing medical tourism among US residents from multiple states and territories. Medical tourism was prevalent among US residents in the areas we surveyed, especially among those who experience barriers to care in the United States (eg, ethnic minorities and those without insurance coverage). Countries around the world offer quality medical care. US residents considering medical tourism should consider the procedure, destination, treating provider, and facilities where the procedure and recovery will take place. They should be aware that advertisers marketing directly to travelers may not include comprehensive details on the qualifications of a facility or provider. Medical tourists should discuss their plans with their existing primary care provider, if they have one. They should consult a travel medicine specialist for advice tailored to their specific health needs, preferably 4–6 weeks before travel. Reference Benowitz, Gaines and Brunette1 US clinicians should explicitly ascertain travel history including any medical care received abroad. Additional guidelines and recommendations for prospective medical tourists and clinicians advising them before and after travel are available on the CDC’s Travelers’ Health website and in the latest version of CDC Health Information for International Travel. Reference Benowitz, Gaines and Brunette1
Data describing the volume, destinations, procedures, and outcomes among those who do not travel specifically for medical or dental care but decide while at their destination to get a procedure locally would help inform recommendations designed to avoid adverse events among these international travelers. Future studies should also examine the potential risks between medical tourists who combine vacation packages with medical or dental care, those who organize their travel and surgery through a third party (eg, a medical concierge or a medical tourism travel agency), and those who plan their trip independently. Dental tourism among US residents in general and dental and medical tourism among VFRs should also be an area of focus for future studies.
As more US residents travel internationally for care, population-based surveillance information describing medical tourists including their travel patterns, motivations, procedures received, and their outcomes will be increasingly valuable. These can inform evidence-based recommendations for best practices for pretravel guidance and posttravel care for medical tourists, and identify risks associated with medical tourism by location and by treatment or procedure.
Acknowledgments
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors acknowledge the BRFSS coordinators and interviewers from participating states and Puerto Rico, and the CDC BRFSS program. The authors acknowledge Jason Hsia, PhD and George M. Khalil, DrPH for their technical assistance and expertise.
Financial support
This report was supported in part by the Department of Health and Human Services Office of Global Affairs.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2021.245
