MedGenMed. 2007; 9(4): 33.

PMCID: PMC2234298
Published online 2007 Nov 13. PMID: 18311383

Medical Tourism: Globalization of the Healthcare Marketplace

Michael D. Horowitz, MD, MBA, FACS, Research Associate, Jeffrey A. Rosensweig, PhD, Associate Professor of
International Business and Finance and Director, and Christopher A. Jones, DPhil, MSc, FRSM, Research Associate

Michael D. Horowitz, Global Perspectives Program, Goizueta Business School, Emory University, Atlanta, Georgia Author's email:
Michael_Horowitz@bus.emory.edu;
Contributor Information.
Disclosure: Michael D. Horowitz, MD, MBA, FACS, has disclosed that he is Principal of Medical Insights International, a firm devoted to
studying the medical tourism industry and providing objective information and analysis for parties interested or involved in medical tourism.

Disclosure: Jeffrey A. Rosensweig, PhD, has disclosed that he has no potential conflicts of interest. He is Associate Professor of International
Business and Finance at Emory University Goizueta Business School, where he is Director of the Global Perspectives Program.

Disclosure: Christopher A. Jones, DPhil, MSc, FRSM, has disclosed that he is Principal of Patients Without Borders, LLC, a consultancy
created to provide objective information and analysis for parties interested or involved in medical tourism.

Copyright ©2007 Medscape

Abstract Go to:

The citizens of many countries have long traveled to the United States and to the developed countries of
Europe to seek the expertise and advanced technology available in leading medical centers. In the recent
past, a trend known as medical tourism has emerged wherein citizens of highly developed countries choose
to bypass care offered in their own communities and travel to less developed areas of the world to receive
a wide variety of medical services. Medical tourism is becoming increasingly popular, and it is projected
that as many as 750,000 Americans will seek offshore medical care in 2007. This phenomenon is driven
by marketplace forces and occurs outside of the view and control of the organized healthcare system.
Medical tourism presents important concerns and challenges as well as potential opportunities. This trend
will have increasing impact on the healthcare landscape in industrialized and developing countries around
the world.

Introduction Go to:

Medical tourism has captured the interest of the media. Articles, guidebooks, and broadcasts on medical
tourism are being published and produced with increasing frequency.[1–12] A Google Internet search
using the term “medical tourism” performed on July 29, 2007, returned 1,100,000 results – an increase of
300,000 in the preceding 62 days. Individual practitioners and medical organizations must be able to
provide accurate information about this rapidly evolving trend. There is a compelling need for all parties
involved in healthcare to become familiar with medical tourism and to understand the economic, social,
political, and medical forces that are driving and shaping this phenomenon.

In medical tourism, citizens of highly developed nations bypass services offered in their own communities
and travel to less developed areas of the world for medical care. Medical tourism is fundamentally
different from the traditional model of international medical travel where patients generally journey from
less developed nations to major medical centers in highly developed countries for medical treatment that is
unavailable in their own communities. The term medical tourism does not accurately reflect the reality of
the patient's situation or the advanced medical care provided in these destinations. Nevertheless, this
phrase has come into general usage and it provides an unambiguous way of differentiating the recent
phenomenon of medical tourism from the traditional model of international medical travel.

The Increasing Popularity of Medical Tourism Go to:

Although there are no verifiable statistics regarding the magnitude of medical tourism, the available
information suggests that a substantial number of patients travel to developing nations for healthcare. In
2004, 1.2 million patients traveled to India for healthcare and 1.1 million medical tourists traveled to
Thailand.[13,14] One source projects that 750,000 Americans will go offshore for medical services in
2007, with this number increasing to 6 million in 2010.[15] It is estimated that medical tourism to Asia
could generate as much as $4.4 billion by 2012, with approximately half of this revenue going to India.
[1,3] It has been estimated that the global medical tourism industry currently generates annual revenues up
to $60 billion, with 20% annual growth.[4,16,17] However, another valuation suggests that the industry is
somewhat smaller, with growth to $40 billion projected by 2010.[5]

Medical Tourism Destinations Go to:

The medical tourism marketplace consists of a growing number of countries competing for patients by
offering a wide variety of medical, surgical, and dental services (Table 1). Many of these destinations
boast modern facilities with advanced technology and appealing accommodations. A substantial number of
the physicians in medical tourism destinations received postgraduate training in industrialized nations,
have board certification (or equivalent), and may have practiced in the country where they completed their
training. Medical tourists are presently traveling to faraway countries for cosmetic surgery, dental
procedures, bariatric surgery, assisted reproductive technology, ophthalmologic care, orthopaedic surgery,
cardiac surgery, organ and cellular transplantation, gender reassignment procedures, and even executive
health evaluations (Table 2). A number of countries in Central and South America have developed strong
reputations for cosmetic and plastic surgery, bariatric procedures, and dental care.[8–10] India, Malaysia,
Singapore, and Thailand are well-established medical tourism destinations that have become popular for
patients seeking cardiac surgery and orthopaedic surgery.[1–3,11,17] Medical services in India are
particularly affordable, with prices as low as 10% of those in the United States.[2] Several highly
developed nations including Belgium, Canada, Germany, Israel, and Italy are attracting foreign patients
under the banner of medical tourism, offering sophisticated modern care with careful attention to patient
preference, service, and satisfaction.

The Global Healthcare Marketplace Go to:

The international healthcare marketplace emerged in the late 19th century when patients from less
developed parts of the world with the necessary resources to do so began to travel to major medical centers
in Europe and the United States to have diagnostic evaluation and treatment that was unavailable in their
own countries. The situation is very different in the medical tourism model, where patients from highly
developed nations travel to less developed countries, bypassing medical care that is offered in their own
community but is inaccessible or undesirable to them. Medical tourists would prefer to have major surgery
in their hometown hospital or regional referral center if they felt that was a feasible or reasonable option.
However, these patients feel pressed to balance their health needs against other considerations, and
medical concerns may be subordinated to other issues. Modern technology enables potential medical
tourists to investigate and arrange healthcare anywhere in the world from their home computer directly or
with the advice and assistance of a medical tourism agency.

For patients from highly industrialized nations, the primary reason to have medical services in less
developed countries is attractively low cost. Such cost-conscious patients choose to accept the
inconvenience and uncertainties of offshore healthcare to obtain service at prices they can more
comfortably afford.[1–4,11,12] The opportunity to conserve limited financial resources and protect the
equity in their home mollifies their uncertainties. A patient from the United States is likely to be a middle
class adult requiring elective surgical care who has no health insurance or who has inadequate coverage.
Milstein and Smith[19] describe these patients as “middle-income Americans evading impoverishment by
expensive, medically necessary operations….” The other group pursuing medical tourism are people
seeking cosmetic surgery, dental reconstruction, fertility treatment, gender reassignment procedures, and
other treatments not covered by health insurance. The common feature in both groups is that their
resources are adequate to purchase healthcare in low-cost medical tourism destinations but insufficient for
them to comfortably have the same services in their local market.

For patients from countries where a governmental healthcare system controls access to services, the major
reason to choose offshore medical care is to circumvent delays associated with long waiting lists.[20]
National health programs do not typically pay for cosmetic surgery and similar type services; therefore,
patients from Canada and the United Kingdom desiring these procedures pursue medical tourism for the
same economic reasons as those from the United States.

Patients also travel to offshore medical destinations to have procedures that are not widely available in
their own countries. For example, stem cell therapy for any one of a number of problems may be
unavailable or restricted in industrialized countries but may be much more available in the medical tourism
marketplace.[7,21] Some patients, particularly those undergoing plastic surgery, sex change procedures,
and drug rehabilitation, choose to go to medical tourism destinations because they are more confident that
their privacy and confidentiality will be protected in a faraway setting. Finally, some patients have medical
care abroad for the opportunity to travel to exotic locations and vacation in affordable luxurious
surroundings. Although medical tourism agents and travel professionals may promote the “tourism” aspect
of offshore care, the recreational value of travel has decreasing importance to patients with complex,
serious medical problems.

The primary reason that medical centers in developing countries are able to provide healthcare services
inexpensively is directly related to the nation's economic status. Indeed, the prices charged for medical
care in a destination country generally correlate with that nation's per capita gross domestic product, which
is a proxy for income levels. Accordingly, the charges for healthcare services are appropriate for the level
of economic development in which the services are provided. Low administrative and medicolegal
expenses for overseas practitioners also contribute to the affordability of offshore medical care. For
example, the professional liability insurance premium for a surgeon in India is 4% of that for a surgeon in
New York.[1]

An important consideration in medical tourism is the potential impact on the residents of destination
countries. Mattoo and Rathindran[22] suggest that revenue generated by developing countries providing
medical services to foreign patients creates opportunities to improve the access and quality of care
available to the citizens of these countries. Bookman and Bookman[23] emphasize that the government of
destination countries must implement and enforce appropriate macroeconomic redistributive policies to
ensure that the local residents of these nations actually realize the potential benefits of the medical tourism
industry. Chinai and Goswami[24] have expressed concerns that medical tourism may seriously undermine
the care of local residents by adversely impacting workforce distribution.

Quality and Safety in Medical Tourism Go to:

Faced with the choice of many medical institutions in diverse countries, medical tourists may find it very
difficult to identify well-trained physicians and modern hospitals that consistently provide high-quality
care. Some medical tourism agents, particularly those with backgrounds in healthcare, may be a helpful
resource for patients in making appropriate choices. Accreditation by the Joint Commission International,
which has accredited more than 125 facilities in 24 countries, and/or the International Organization of
Standardization may provide a useful point of reference for patients selecting offshore medical facilities.
[25]

Concerns have been voiced regarding the risk of complications resulting from travel and vacation activities
in the postoperative period.[26] The management of postoperative complications that occur after a patient
returns from an offshore medical facility, and the consequent costs of this care, are difficult issues that
remain unresolved.[17,26]

The Response to Medical Tourism Go to:

The medical community in developed countries has started to recognize medical tourism as a real
phenomenon that involves the profession, practitioners, and patients. Peer-reviewed medical and health
journals began publishing papers on this topic in 2006.[16,17,19,22] Medical organizations have addressed
medical tourism in articles and other documents posted on their Web sites.[26] The United States Senate
Special Committee on Aging held hearings on the issue of medical tourism in June 2006 and called for a
task force of experts to explore the impact and safety of lower-cost healthcare abroad.[19,27]

The insurance industry has become an active participant in medical tourism. In several states, Blue Cross
Blue Shield sells insurance policies that enable or encourage patients to have expensive surgical
procedures at low-cost offshore medical facilities.[3,5,6,12] In an effort to reduce the financial burden of
employee healthcare, several fortune 500 corporations are evaluating the feasibility of outsourcing
expensive medical procedures to offshore healthcare destinations.[6] Insurance provider networks are
currently being expanded to include physicians around the globe, and it is anticipated that within a decade
a majority of large employers' health plans will include offshore medical centers.[6]

Insurance companies are able to use a portion of their substantial savings to offer incentives to
beneficiaries willing to have care in medical tourism destinations, including waiving deductible and out-
of-pocket health expenses and paying for travel for the patient and even a family member. A particularly
interesting response to the migration of patients to offshore healthcare destinations is that some US
medical facilities are now accepting referrals from medical tourism agencies and providing highly
discounted services to American patients.[6]

In nations that have long waiting lists for certain procedures, medical tourism provides a mechanism to
clear backlogs by sending patients to foreign countries without expanding local capacity.[1] Currently, the
British National Health System is sending patients to nearby countries for this purpose, and more distant
medical tourism destinations may be used in the future.[1] Although this idea has not been explored, there
may be novel opportunities to use low-cost offshore medical destinations to provide care for unfunded
low-income patients while simultaneously relieving the burden on domestic healthcare facilities and
philanthropic organizations.

The Continuing Evolution of Medical Tourism Go to:

The medical tourism industry is fueled and driven by patients who feel disenfranchised by the healthcare
system in their home country. These informed patients shop outside the organized medical system to find
services that are affordable, timely, or simply available. Millstein and Smith[19] emphasize that the flight
of American patients to foreign destinations for lifesaving operations is a symptom of an affordability
problem that is symbolically important and must be addressed by physician leaders. These leaders must
recognize that patients, like all consumers, will search for providers who offer them maximal value, and
medical tourism is an explicit declaration about what patients value most. Physicians and hospitals in
medical tourism destinations recognize that they must provide high-quality care to develop a sustainable
competitive advantage in the international marketplace. In an article on medical tourism in Time, Princeton
University healthcare economist Uwe Reinhardt stated: “This has the potential of doing to the US health-
care system what the Japanese auto industry did to American carmakers.”[2] It is increasingly apparent
that medical tourism is changing the healthcare landscape in industrialized and developing countries
around the world, and there is every reason to believe that this trend will continue to evolve.

Notes Go to:

Note Go to:

Dr. Horowitz had full access to all of the materials and information used in this study and takes
responsibility for the integrity of the analysis thereof.

Study concept and design: Horowitz

Acquisition of materials and information: Horowitz, Jones

Analysis and interpretation of information: Horowitz, Rosensweig, Jones

Drafting of the manuscript: Horowitz

Critical revision of the manuscript for important intellectual content: Horowitz, Rosensweig, Jones

Administrative, technical or material support: Horowitz

Study supervision: Horowitz

Footnotes Go to:

Reader Comments on: Medical Tourism: Globalization of the Healthcare Marketplace See reader comments on this
article and provide your own.

Readers are encouraged to respond to the author at Michael_Horowitz@bus.emory.edu or to Paul Blumenthal, MD,
Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed
via email: pblumen@stanford.edu

Contributor Information Go to:

Michael D. Horowitz, Global Perspectives Program, Goizueta Business School, Emory University,
Atlanta, Georgia Author's email: Michael_Horowitz@bus.emory.edu.

Jeffrey A. Rosensweig, Global Perspectives Program, Goizueta Business School, Emory University,
Atlanta, Georgia.

Christopher A. Jones, Department of Health Policy and Management, Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland.

References Go to:

1. Lancaster J. Surgeries, side trips for medical tourists. p. A1. Washington Post. October 21, 2004.

2. Kher U. Outsourcing your heart. Time. :44–47. May 29, 2006.

3. Appleby J, Schmidt J. Sending patients packing. USA Today. July 26, 2006. Available at
http://www.usatoday.com/money/industries/health/2006-07-26-travel-surgery-usat_x.htm Accessed June
21, 2007.

4. Arnold K. Going under the knife abroad: medical tourism industry booms as health costs rise. The
Monitor (McAllen, Texas) :A1. November 15, 2006.
5. Konrad W. Employers make a push for ‘medical tourism’ CNNMoney/Fortune Small Business Web
site. May 15, 2007. Available at
http://money.cnn.com/magazines/fsb/fsb_archive/2007/05/01/100003808/index.htm?
postversion=2007043012 Accessed June 28, 2007.

6. Van Dusen A. Outsourcing your health. Forbes Web site. May 22, 2007. Available at
http://www.forbes.com/2007/05/21/outsourcing-medical-tourism-biz-cx_avd_0522medtourism.html?
partner=email Accessed June 28, 2007.

7. Breen K. Patients heading abroad for hope. Dallas Morning News. May 29, 2007. Available at
http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/052907dnmetmedicaltourism.399346
4.html# Accessed May 29, 2007.

8. Schult J. Beauty from Afar – A Medical Tourist's Guide to Affordable and Quality Cosmetic Care
Outside the U.S. New York, NY: Stewart, Tabori & Chang; 2006.

9. Hancock D. The Complete Medical Tourist – Your Guide to Inexpensive Cosmetic, Medical and Dental
Surgery Abroad. London, UK: John Blake Publishing; 2006.

10. Woodman J. Patients Beyond Borders – Everybody's Guide to Affordable, World-Class Medical
Tourism. Chapel Hill, NC: Healthy Travel Media; 2007.

11. Vacation, adventure and surgery? [transcript and video] “60 Minutes.” CBS television. September 4,
2004. Available at http://www.cbsnews.com/stories/2005/04/21/60minutes/main689998.shtml Accessed
January 15, 2007.

12. Is traveling abroad for cheap surgery extreme? Your Health: Taking Control [video] NBC Nightly
News. May 15, 2007. Available at http://video.msn.com/v/us/fv/msnbc/fv.htm??g=e16a5618-7fb2-4773-
a267-9a9724b394bf&f=00&fg=copy Accessed May 28, 2007.

13. Great Indian hospitality can be biz too. The Economic Times (India) July 29, 2005.

14. Sen C. Thai health tourism gives India headache. The Economic Times (India) July 24, 2005.

15. Baliga H. Medical tourism is the new wave of outsourcing from India. India Daily. December 23,
2006. Available at http://www.indiadaily.com/editorial/14858.asp Accessed January 2, 2007.

16. Jones CA, Keith LG. Medical tourism and reproductive outsourcing: the dawning of a new paradigm
for healthcare. Int J Fertil Womens Med. 2006;51:251–255. [PubMed: 17566566]

17. MacReady N. Developing countries court medical tourists. Lancet. 2007;369:1849–1850.

[PubMed: 17549816]

18. Leigh S. Reproductive ‘tourism’ USA Today. :D7. May 2, 2005.

19. Milstein A, Smith M. America's new refugees – seeking affordable surgery offshore. N Engl J Med.
2006;355:1637–1640. [PubMed: 17050886]

20. Beat waiting lists with overseas op. Daily Express (UK) July 3, 2005.

21. Bangkok International Symposium on Stem Cell Therapy for the Failing Heart. Available at
http://www.stemcellbangkok.com/ Accessed May 12, 2007.

22. Mattoo A, Rathindran R. How health insurance inhibits trade in health care. Health Affairs.
2006;25:358–368. [PubMed: 16522578]

23. Bookman MZ, Bookman KR. Medical tourism in developing countries. New York, NY: Palgrave
Macmillan Ltd; 2007. pp. 169–185.
24. Chinai R, Goswami R. Medical visas mark growth of Indian medical tourism. Bull World Health
Organ. 2007;85:164–165. [PMCID: PMC2636228] [PubMed: 17486202]

25. Joint Commission International Accredited Organizations. Available at

http://www.jointcommissioninternational.org/10241/ Accessed July 29, 2007.

26. American Society of Plastic Surgeons. Briefing papers: cosmetic surgery tourism. Available at
http://www.plasticsurgery.org/media/briefing_papers/Cosmetic-Surgery-Tourism-Briefing-Paper.cfm
Accessed June 7, 2007.

27. Safety of Medical Tourism [video] C-SPAN Web site. June 27, 2006. Available at
http://www.c-spanstore.org/shop/index.php?
main_page=product_video_info&cPath=6_11&products_id=193173-1 Accessed July 25, 2007.

Figures and Tables Go to:

Table 1
Medical Tourism Destinations*

Asia/Middle East The Americas Europe Africa Other

China Argentina Belgium South Africa Australia

India Brazil Czech Republic Tunisia Barbados

Israel Canada Germany Cuba

Jordan Colombia Hungary Jamaica

Malaysia Costa Rica Italy

Singapore Ecuador Latvia

South Korea Mexico Lithuania

Philippines United States[18] Poland

Taiwan† Portugal

Turkey Romania

United Arab Emirates Russia

Spain

Open in a separate window

*
Most frequently identified countries in literature and Internet search.
†Taiwan seeks to become a destination for Chinese-speaking patients.
Table 2
Procedures for Which Patients Pursue Medical Tourism*


Cosmetic Surgery Breast augmentation/mastopexy/breast reduction

Facelift/blepharoplasty

Liposuction/body contouring

Dentistry Cosmetic dentistry

Dental reconstruction/prosthodontics

Cardiology and Cardiac Surgery Coronary artery bypass

Cardiac valve replacement/reconstruction

Percutaneous coronary angioplasty/stenting

Stem cell therapy for heart failure

Orthopaedic Surgery and Spine Hip replacement/resurfacing

Surgery Knee replacement

Arthroscopy/joint reconstruction

Laminectomy/spinal decompression

Disk space reconstruction/disk replacement

Bariatric Surgery Gastric bypass

Laparoscopic adjustable gastric banding (Lap-Band; Inamed/Allergan, Inc.;

Irvine, California)

Body contouring subsequent to massive weight loss

Reproductive System In vitro fertilization

Hysterectomy

Prostatectomy/transurethral resection

Gender reassignment procedures

Organ and Tissue Solid organ transplantation

Transplantation
- Renal
- Hepatic

Bone marrow transplantation

Stem cell therapy

- Heart failure
- Neurologic diseases

Other Services LASIK eye surgery



Open in a separate window

*Most frequently identified procedures in literature and Internet search.

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