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The ‘patient's physician one-step removed’: the evolving roles of medical tourism facilitators
  1. Jeremy Snyder1,
  2. Valorie A Crooks2,
  3. Krystyna Adams1,
  4. Paul Kingsbury2,
  5. Rory Johnston2
  1. 1Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
  2. 2Department of Geography, Simon Fraser University, Burnaby, Canada
  1. Correspondence to Dr Jeremy Snyder, Blusson Hall 10516. Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada; jcs12{at}sfu.ca

Abstract

Background Medical tourism involves patients travelling internationally to receive medical services. This practice raises a range of ethical issues, including potential harms to the patient's home and destination country and risks to the patient's own health. Medical tourists often engage the services of a facilitator who may book travel and accommodation and link the patient with a hospital abroad. Facilitators have the potential to exacerbate or mitigate the ethical concerns associated with medical tourism, but their roles are poorly understood.

Methods 12 facilitators were interviewed from 10 Canadian medical tourism companies.

Results Three themes were identified: facilitators' roles towards the patient, health system and medical tourism industry. Facilitators' roles towards the patient were typically described in terms of advocacy and the provision of information, but limited by facilitators' legal liability. Facilitators felt they played a positive role in the lives of their patients and the Canadian health system and served as catalysts for reform, although they noted an adversarial relationship with some Canadian physicians. Many facilitators described personally visiting medical tourism sites and forming personal relationships with surgeons abroad, but noted the need for greater regulation of their industry.

Conclusion Facilitators play a substantial and evolving role in the practice of medical tourism and may be entering a period of professionalisation. Because of the key role of facilitators in determining the effects of medical tourism on patients and public health, this paper recommends a planned conversation between medical tourism stakeholders to define and shape facilitators' roles.

  • Informed consent
  • legal aspects
  • philosophy of the health professions
  • truth disclosure
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Medical tourism is a growing industry that involves patients intentionally travelling abroad for non-emergency medical services. This practice entails risks for patients, including exposure to infectious diseases,1 complications from treatments,2 3 difficulties due to the rigours of travel and problems obtaining follow-up care at home.4 For example, a Canadian patient who had travelled to Costa Rica for an experimental multiple sclerosis treatment recently died following complications. This patient was forced to return to Costa Rica following the development of complications because he had difficulty obtaining aftercare in Canada.5

Individual medical tourists are sometimes aided in arranging for their care abroad by medical tourism facilitators or brokers.i These facilitators play a key role in advertising the availability of medical tourism, providing prospective patients with information and overseeing follow-up care.6 7 As such, these individuals play a crucial role in shaping medical tourism as a practice and in exacerbating or mitigating both its positive and negative effects.

Other players in the provision of medical services have developed established roles through professionalisation, including clear governing norms designed to protect patient safety.8 Whereas the roles of some health professionals involved in medical tourism have been explored,9 little is known about facilitators‘ roles in the industry or how they conceive of them. In public statements, some have expressed a clear role akin to that of a medical professional.10 11 Others have declined to play a role in regulating patients’ behaviour, with one facilitator stating that ‘our ethics are agnostic’.12 In this paper, we present findings from interviews with 12 Canadian medical tourism facilitators. Our goal is to obtain a better understanding of their perceived roles and identify steps towards a planned conversation with other industry stakeholders to shape these roles in the interests of medical tourists, countries hosting these patients and members of their home countries.

Background

Patients typically choose to look for alternative medical options via medical tourism when services in their home country are unavailable, unaffordable, or waiting lists are too long.13 Patients may thus avoid high out-of-pocket payments or lengthy periods of compromised quality of life due to the pain incurred while on a surgical waiting list by choosing to go abroad for medical care.14 15 With more and more patients turning to the internet to research healthcare options and long-distance travel becoming easier, medical tourism is increasingly being viewed as a viable way to access medical care.16

It is thought that facilitators play a large role in disseminating information about medical tourism, promoting the practice to a wide audience.13 Facilitators often use popular media outlets and the internet to advertise potential medical destinations and procedures.17 18 Once potential medical tourists are identified, facilitators' roles can vary greatly to include all or some of the following: booking transportation and hotel accommodation; arranging for medical services and tourist packages; transferring medical records and arranging for follow-up care in the home country.4 6

Medical tourism facilitation is an evolving profession that sits at the nexus of many complex ethical issues. These issues include the (in)equitable use of healthcare resources, cultivation of a two-tier healthcare system in patients' home and destination countries and the migration of public funds to private businesses.18 Facilitators' roles may expose them to other types of ethical challenges. For example, they may direct patients to services that are against the medical advice of their home physicians, are illegal or unapproved in their home country,5 or for which there is no capacity for follow-up care in their home system.3

A number of concerns have been raised regarding some of the business dimensions of medical tourism facilitation.19 Facilitators may neglect to inform patients of how their services are paid for, which could lead medical tourists to misunderstand their roles. Patients may travel abroad lacking proper informed consent for medical procedures or an understanding of how their facilitator chose the destination and providers being used.7 17 It has been posited that lack of regulation within the industry may further muddy patients' understanding of facilitators' roles along with other complex dimensions of medical tourism.14

Methods

This analysis is part of a study that is seeking to understand Canadian patients' involvement in medical tourism. The study involved interviewing both Canadian medical tourism facilitators and Canadian medical tourists. This analysis examines the former dataset.

Before recruitment, ethical approval was obtained from Simon Fraser University. To recruit facilitators, we employed an exhaustive strategy.20 This involved identifying companies through published media accounts, reviewing membership in the Medical Tourism Association (MTA) and running online searches. Twenty-two facilitation companies were identified. A representative from each was contacted, requesting that one or more employees participate in a phone interview. Twelve facilitators from 10 companies agreed to participate.

Interviews were conducted using a semistructured guide. Semistructured interviews allow participants to add comments beyond the specific questions being posed that they believe are relevant to the study.20 Questions in the guide probed: business dimensions; information exchange with medical tourists; medical tourists' decision-making and facilitators' roles in medical tourism. Interviews lasted on average 45 min. All but one took place by phone (in this case a face-to-face interview was requested).

Interviews were digitally recorded. Upon completion they were transcribed verbatim. Transcripts were then entered into N7 qualitative data management software in preparation for coding. The coding process started with each investigator conducting an independent transcript review. Following this, we collectively identified dominant issues emerging from the dataset for in-depth analysis. Three meta-themes were identified, one of which pertained to the nature of facilitators' roles. We examine this particular meta-theme in this paper. Thematic analysis followed meta-theme identification.21 This involved collaboratively developing a coding scheme that was applied to the dataset in N7. The data were coded by one investigator and confirmed by another in order to enhance the credibility of the findings.22 Coding extracts were then reviewed by four investigators who worked together to develop an interpretive matrix23—a grid that pairs discrete findings with specific sub-themes—for the meta-theme. The matrix was then used to guide the thematic analysis.

Findings

As table 1, drawn from interviewees' oral responses, indicates, facilitators see themselves as playing a role in patient care. They identify with being an advocate for the patient and play an active role in facilitating doctor–patient contact. These facilitators do tend to check with their patients after returning home and facilitate communication with patients and their Canadian doctors, although they are less active in physician communication before travel. Many facilitators also play a role in guiding patients towards specific destinations, with most working with favoured destinations and approximately half willing to endorse specific physicians, advise against specific destinations and advise against specific physicians.

Table 1

Facilitator responses to role-related questions

Three groupings of roles played by Canadian medical tourism facilitators were identified through the thematic analysis. In this section we discuss these role groupings separately. We have included verbatim quotations from the interviews whenever possible in order to let the participants ‘speak’ to the issues at hand.

Roles towards the patient

Most facilitators framed their relationship with patients as one of advocacy: ‘from an ethical standpoint, my responsibility to the patient is basically the same as if …I were that patient's physician… I really am that patient's physician one-step removed’. However, they frequently recognised the potential tension between their business interests and their role in serving as a patient advocate. ‘The first and foremost is, is advocating for the, for the clients… You know, you can't wring every penny out of every client.’ Given that most facilitators are paid directly by the facilities abroad rather than their patients,17 the need to ‘disclose to the patient how I’m paid' was stressed by one facilitator, in order to enhance transparency and maintain their integrity as a patient advocate. Interestingly, several facilitators differentiated between limited and extensive roles towards patients by labelling those preferring the former ‘brokers’ and the latter ‘facilitators’. It was thought that: ‘…it's so much easier… just to be a broker’, thus underscoring the more involved nature of facilitation. One's positioning as an advocate was seen as central to this division, with most participants being dismissive of limited, non-advocate roles.

Facilitators saw their role as providing an array of information to patients. This ranged from providing details regarding specific physicians abroad to informing patients of ‘how to navigate the city, where the airport is, how much to expect to um, be charged from the cabs’. In cases in which patients were travelling to non-English or non-French-speaking countries, this role extended to translating travel details and even medical files. Their roles as facilitators also included overseeing travel logistics, including arranging for visas and advising on which airports to use. Facilitators' personal knowledge of the facilities abroad made this information transmission role possible: ‘I know what works best because I’ve tried different options for patients and I see what is difficult for them, what is easy for them.' Most facilitators de-emphasised the tourism aspect of patients' travel in favour of the medical aspect because a focus on tourism ‘takes away from what we do’. The facilitators for the most part expressed a willingness to arrange for tourist activities and to give advice or ‘filter’ information on which activities are appropriate given the patient's medical condition as medical treatment is ‘priority one’.

Facilitators commented on the limits of their roles, particularly with regard to arranging follow-up care and personal liability. The amount of responsibility they take on for overseeing follow-up care upon patients' return to Canada depends on the procedure and varied by facilitator. For one, ‘our responsibility finishes when [the patients] step off the plane back home’. Another saw this element of care as being well within their responsibilities, as they should support the patient from ‘the time of the planning through the procedure itself and back to the patient's home and… back connecting with the hometown doctor if [needed]’. In many instances the level of actual follow-up contact between facilitator and patient was unclear as the facilitator would simply ‘recommend’ follow-up plans. When discussing liability for negative outcomes, the facilitator's lack of role in providing medical care was often stressed: ‘we are not doctors, we are a referral agency, we do everything we can but we sign an agreement with the patient to the effect that we are not responsible for the medical services per se’. Discussion of liability emphasised facilitators' roles in information transfer versus actual medical care: ‘my liability's very limited in the sense that I’m providing you with information that you requested. I didn't push it on you.'

Roles towards the health system

Facilitators commonly viewed themselves as having a positive role in patients' lives and on the Canadian healthcare system. By allowing patients to opt out of surgical waiting lists by travelling abroad, they play a role in offering ‘a kind of a safety valve’ because medical tourism ‘helps our system because there's less people involved’. One facilitator, however, noted that patient flows abroad are low, thereby limiting this positive effect. Patients are aided in that medical tourism ‘helps people solve their medical problems, which for one reason or another are not being resolved here’. On the other hand, it was recognised that if a patient faces complications when back home, ‘they’re back in the waitlist and actually push somebody else out of the way because it's now an emergency'. The potential for this negative effect was seen as limited, however, as medical tourists are viewed by facilitators as being healthier than most patients and ‘we’re taking the easy procedures and doing them… abroad and leaving the Canadian hospitals with the more complicated, higher risk cases'.

Some facilitators felt that medical tourism, and their own roles within the industry, might serve as a catalyst for addressing waiting list problems that are seen as a push factor for their patients. This pressure for change can take form through the ‘embarrassment… it causes the… powers that be in Canadian healthcare’, damage to ‘Canadian doctors’ ego' and by bringing ‘to light that there is a problem’. This situation may ‘put political pressure on the government to make things better’. By exposing Canadians to other medical systems, medical tourism may help Canadians learn ‘how some international hospitals operate to improve our hospital models’.

Many facilitators noted that they have an antagonistic relationship with Canadian physicians despite their shared roles in assisting patients with going abroad for medical care and a general desire to work cooperatively with healthcare providers. One noted that ‘most physicians… are dead set against what we do’. This antagonism may complicate continuity of care because ‘there's a major liability in terms of the doctors here, if they talk to me or talk to the doctor [abroad], because that means that they’re approving the process'. Physicians interested in cooperating with facilitators may not do so because ‘it's a kind of a professional suicide’. Of particular interest, several facilitators gave examples of physicians moving patients to the front of waiting lists in order to dissuade them from travelling abroad.

Roles towards the medical tourism industry

Facilitators stressed the importance of personally investigating the facilities abroad to which they send patients, viewing themselves as playing a role in quality control. A personal role ensures quality of care as ‘everything can look wonderful on the internet’. One facilitator noted that these site visits differentiated his services from those of others: ‘a lot of… facilitators [and] brokers will say, “yeah, we’ll send you wherever you want to go, we'll just phone them and send you” but again, that's not my comfort level'. A facilitator stressed the importance of site visits in terms of liability: ‘I don't want to assume that liability to send to somewhere that I haven't been’. Another explained that: ‘if I’ve seen it, walked through it, know where it is, that to me is part and parcel of matching my service to what your needs are to make it successful'. This need to have a connection with the facility can limit the range of facilities to which facilitators will arrange travel, with one facilitator using only one hospital with which he was personally familiar.

Facilitators thought it was important to establish personal, and sometimes exclusive, relationships with physicians and patient coordinators abroad in favoured destinations. This interest was typically voiced as being a means of ensuring quality of care for patients, and thus is a facet of their larger role in quality control. One facilitator put it in terms of having personal knowledge of the physician and being able to recommend with ‘confidence’. A personal connection can assist with personalising recommendations: ‘If I know that one surgeon is… really good with kids then I might say… “you know what, I know he does a lot of kids”… and [another] has a great rapport with seniors’. A personally known physician can also serve as a reference for other physicians, so that if the known physician says ‘“he's a good guy” then I’ll say okay'. Personal relationships are found with non-physicians as well, including workers who facilitate travel and treatment for patients once abroad. One facilitator mentioned using a family member for this purpose in order to maintain ‘personal contact’ with the patient throughout the process.

Facilitators expressed a need for more professionalisation and regulation of the medical tourism industry, but were unsure of who or what body should take on this role. This lack of professionalisation was seen to endanger both the industry and patients: ‘people try to do it [facilitation] and mess it up and that spoils… the business for everybody and not only the business, it puts the patient… at huge risk’. One noted that the inclusion of ‘tourism’ within the descriptor ‘medical tourism’ lowered the perceived barrier to entry into the profession: ‘anybody that's a travel agent or an insurance agent with no healthcare background whatsoever assumes that it's simple enough for them to add the word medical to their business and start offering this’. While the MTA serves as a professional body for the industry, a facilitator noted that it ‘lists hospitals but there's no real criteria to join, so it's… not necessarily a tool for a patient to choose one hospital over another’. Another noted that there is no association looking after the interests of patients: ‘I think that's something that's lacking in the industry… that's something that is needed’.

Discussion

The findings shared above show that there is no clear consensus on the role of medical tourism facilitators. On the one hand, a facilitator can be seen as playing a limited role, simply serving as a middleman who puts the patient in contact with medical professionals abroad and makes travel arrangements. On the other hand, a facilitator might have more personal involvement with the patient and serve as an advocate. While participants acknowledged the existence of a limited facilitation role within the industry, framing this as the work of medical tourism brokers, they viewed themselves as having a more expansive role towards patients, the Canadian healthcare system and the larger medical tourism industry. The interviews demonstrate that the facilitators we spoke with play a substantial but undefined role in medical tourism. This role is evolving and needs clarification in three distinct areas.

First, facilitators have evolving roles towards patients. While this role can be limited to serving simply as a source of information, facilitators may instead play an active role in filtering information as a way of ensuring care quality—for example, by limiting their recommendations to trusted physicians and facilities. In order to clarify their role towards patients, facilitators should develop norms around legal liability, which can be limited by embracing a narrower role in the provision of information or expanded by taking on a more active role in patient care. Increased professionalisation could also lead to an evolution of their roles, including developing norms around participation in other, non-medical activities such as tourism and transparency of sources of income, especially if commissions are received from third-party sources. Greater clarity could be achieved by standardising terminology and contracts.24

Second, facilitators have an evolving role towards their local healthcare systems. Many facilitators spoke of an adversarial relationship with the Canadian medical system. These conflicts took the form of a belief that the Canadian system is not serving its users well enough, forcing them to travel abroad for care, and an adversarial relationship with patients' family doctors. Development of a professional body representing facilitators within Canada and other countries could help to transform these individual complaints into well-developed policy positions, and possibly lead to health system reform. While the concerns of medical tourists and facilitators should not be accepted uncritically, professionalisation would help to ensure that these stakeholders' concerns are part of the continuing debate over health system reform taking place in many high-income countries with ageing populations and thus significant surgical demand. Moreover, such a body could help to mediate tensions with domestic physicians and create and enforce norms around informational continuity of care for patients travelling abroad. Procedures around information sharing could also aid in the surveillance of medical tourism, an essential public health function. Given concerns surrounding the spread of infectious disease via medical tourism,1 better information sharing could help mitigate some of the negative effects associated with medical tourism.

Finally, the evolving role of facilitators is tied closely to choices over the professionalisation of the medical tourism industry. Greater professionalisation may allow for the development of formalised codes of conduct for facilitators, including transparency around payments, site visits of facilities abroad, exclusivity of contact with foreign physicians and patient coordinators and other more concrete norms. These norms can be better developed, transmitted, and enforced through enhanced certification and training of facilitators, accreditation of facilitators' businesses and the continued development of research on the scope and effects of medical tourism.ii 25 Professionalisation of facilitators may also enable the development of links with other, professionalised industry partners, including health professionals, foreign patient coordinators and affiliated industries such as airlines. Better coordination among these professions will allow for a better understanding of medical tourism, and the development of steps to mitigate negative impacts that can be generated by medical tourism in its current, unregulated form.

At present, medical tourism facilitation is a ‘cottage industry’, with many participants operating with limited infrastructure and investment. An expanded role for facilitators along the lines of what was envisioned by the participants in this study will entail increased costs, meaning that many smaller players will be forced out of business or consolidate with larger operators. Expansion or even professionalisation of facilitators' roles is not certain, however, especially given that cost sensitivity motivates many medical tourists.13 The role of Canadian medical tourism facilitators towards patients, the Canadian healthcare system and the medical tourism industry can continue to evolve in a piecemeal fashion, as it has done up to this point, or it can take shape as part of a planned conversation with relevant stakeholders (eg, health professional organisations, public health agencies and other medical tourism industry members). Because of the key role of facilitators in determining the effects of medical tourism on patient and public health,7 17 we strongly believe that it should be the latter. A better understanding of the perspective of facilitators, as provided through this paper, is an important step in that direction.

References

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Footnotes

  • Funding This study received funding from the Canadian Institutes of Health Research.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Simon Fraser University.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i The choice of label is important, with ‘broker’ implying a limited, middleman role and ‘facilitator’ a more extensive role. While ‘broker’ is the preferred term in the literature on medical tourism, we use ‘facilitator’ here in keeping with the preferred label of the large majority of individuals with whom we spoke.

  • ii A dominant professional organisation, the MTA has been a source of controversy within the industry. The MTA offers a facilitator certification programme (http://www.reuters.com/article/idUSTRE59R23V20091028) as does the Medical Travel and Health Tourism Quality Alliance (http://community.mtqua.org/page/medical-travel-quality), although norms governing certification have not emerged.

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