Background

Medical Tourism within the United States has become a growing industry, generally associated with people from second and third world areas coming to the United States for medical treatments. However, this trend is reversing, and there currently is a growing trend for North Americans to travel to areas associated with the developing world (Thailand, India, China and Malaysia, Singapore, Taiwan, South Korea and Turkey) for medical treatments, and couple this with a restful scenario for family or loved ones to offer social support to the one convalescing. These trends are on the increase, and according to the Confederation of Indian Industry, 150,000 medical tourists visited India at the turn of the century but by 2008 the numbers rose to 200,000. Another study conducted by ASSOCHAM [1] reported that 850,000 people visited India and expected the number to reach 3,200,000 by 2015.

According to Carabello, these destinations thrive for the following reasons:

a. Government and private sector investments in the health care infrastructure.

b. Quality assurance, data transparency and commitment to accreditation.

c. Sustained reputation for clinical excellence.

d. Successful adoption of best practices and state of the art of medical technology.

e. Availability of internationally trained, experienced medical staff.

According to Medical Tourism Facts and Figures 400,000 to 700,000 outbound American medical travelers in 2014 resorted to medical procedures outside of the United States and coupled these treatments with tourism opportunities rendering them “medical tourists.

The concept of medical tourism, while growing in popularity with the medical industry within North America, is still in its infancy among the tourism and hospitality industry. The purpose of this paper was to examine the emerging terrain of medical tourism, and address educational directions and opportunities for students within tourism/hospitality training programs and social work programs. The goal in securing this information would be to help shape curricula in medical and hospitality/tourism educational preparation programs to better prepare students for this new gray tsunami within the medical care network. Higher education systems are lagging behind in the preparation of medical tourism professionals. The lack of curriculum focus on training professionals for careers in medical tourism is highly evident [2].

Why medical tourism?

A number of advantages are associated with the concept of medical tourism. These advantages include but are not limited to:

1. Reduced costs for health care procedures (Please note that reduced costs does not mean nor equate with lower health care standards);

2. Little to no waiting periods for a proposed procedure;

3. The availability of the latest medical technologies;

4. Facilities at specialty hospitals in the city;

5. The elimination of a language barrier, eg., India.

Most people outside of the medical industry ask what types of medical procedures are components of the medical tourism industry. Some of these procedures included within the medical tourism industry include:

1. Alternative medicine;

2. Bone marrow transplants;

3. Cardiac bypass surgery (angioplasty, CABG, transplants);

4. Eye surgery (cataract, glaucoma and transplants);

5. Hip and knee replacements (orthopedic surgery);

6. Hip resurfacing;

7. Orthopedic surgery (joint and spine, sports medicine);

8. Cosmetic surgery;

9. Oncologic care;

10. Dentistry [3] (General, restorative, cosmetic) and

11. Reproductive procedures, fertility, In Vitro Fertilization and Women’s health procedures.

These procedures and countries visited need to be considered when evaluating the risk of travel for medical care. Some countries may have risk factors associated with the socio-economic, crime and sanitary conditions, which will need to be contended with.

Government Intervention also takes place at the macro and tourism administration levels in various countries. These include: 1. addressing infrastructure issues that hinder the country’s growth in medical tourism; 2. the restriction on tourist visas; and 3. the hiring of language interpreters so that people can communicate at local levels, especially within more agriculturally rich areas.

There are also disadvantages to medical tourism for residents of receiving countries. Some of the disadvantages of medical tourism in some countries such as Thailand, have an impact for the local residents. For example, Doctors have become so busy with foreigners that Thai patients have difficulty securing medical care. In addition, cultural norms may be violated because tourists may not be respectful of local cultural expectations (ie Muslim countries being exposed to bikinis on a beach.

What will this mean for tourism industry?

Medical tourism includes a tourist aspect, which is the consumption of service associated with travel which will include transportation, lodging and hospitality [4]. The tourism industry will greatly benefit from individuals and their social support network who are “grounded” in a particular country as a result of supporting a loved one through medical procedures. In addition there are also multiple benefits from a globalization and economic and standpoint. From a globalization standpoint, medical tourism can decrease the costs associated with transporting people and resources exchanging information. From and economic perspective, medical tourism can provide benefits to residents, businesses and government of the destination.

Economic benefits to the tourism industry as a result of medical tourism can include more money in the economy and additional jobs both for tourism and the health care industry. Medical tourism can also have an impact through the reduction of seasonality and cyclicality diversification of the tourism consumer base leading to the potential to attract other higher revenue support industries. Ultimately, this can lead to increasing economic activity and tax revenue which can reduce boom/bust nature of economies, depended upon within a few isolated industries. Through the diversification of a tourism consumer base, tourists will visit destinations, which they may otherwise not have not visited. Thus, this will strengthen the destination brand. Lastly, medical tourism will attract other high revenue support industries such pharmaceuticals, medical equipment, biotech etc.

What does this mean for educating tourism professionals?

Educators prepare graduates who will be managing blended and wellness hospitality establishments as medical tourism and travel opportunities continue to increase. There will be a greater need to incorporate the expertise of hospitality professionals to medical tourism in efforts to build a skilled educator labor force [5,6]. Hospitality programs can offer a high level of professionalism, room accommodations and advice about specific excursions. Hospitality programs can also provide interpreters for translation. Hospitality programs will provide knowledge and skills to manage expectations of patients and their families. Feedback from students within this study will provide pilot information to help understand what myths and conceptions need to begin to be addressed within the classroom setting. Ultimately, educators will provide students with the opportunity to learn how the medical and hospitality field relate and what opportunities they have when combined. Hospitality education training programs could add medical tourism aspects to the curriculum as an initial step toward training the tourism/hospitality workforce. Such an approach would be a good investment according to Poorani [7].

Students will potentially gain hands on experience, work with the traveler and facilitator, and by going to the field medical tourism sites. Ethical legal practices, as it relates to the medical tourism industry, will also be addressed within the preparation programs. For example, the code of ethics from receiving countries will be important to consider in manpower development and training.

Based upon this rationale, there are a series of courses which will be pertinent for the development of the workforce. Such courses can be delivered as a continuing education program offering or as a Certificate program. These courses will include:

Medical wellness hospitality which will include hospitality services, social

• Support network and patient safe along with quality care.

• Global patient services: patient cultural sensitivity, excursion tours and resource exchange information.

• Global business and organizational management: international patient.

• Marketing, international insurance company relationship, expatriate patient development, internship and practicum, hands on experience and site visitation.

• Healthcare/aging policy: course content which helps the learner.

understand issues that people face as they grow older, and the policies which respond to these unique issues impacted by people growing older.

In addition to the coursework, specifically marketing departments that will respond to medical tourism needs and issues will also need to be addressed. The marketing arenas may be hosted by the hospital as well as the hotel/site of accommodations. Some specific needs related to marketing will include visa information, visa processing, hotel logistics, fact sheets related to the culture, currency, cuisine, language, weather and customs of the host country. Attention to these details will make travelers very comfortable within their new environment. Ideally there should be a bridge or collaboration between the hospital setting and the hospitality/tourism industry [5]. Pilot programs have already been established to build models of best practice in this arena, as a result of President Obama’s National Export Initiative [5]. Rush University in Chicago, Illinois is an example of this best practice site.

A number of myths and challenges for students and the preparation of students do exists as they relate to Medical Tourism. These include some of the following:

Accreditation

How do you teach students about the process of accreditation, and if in fact a resource is accredited. Some medical facilities located in the international arena may not have accreditation endorsements, while others may meet some of the rigorous standards established within a North American context (United States or Canada).

Qualifications

Some of the myths related to qualifications is that overseas professionals are not as well qualified as North American trained physicians or interdisciplinary professionals. The truth however is that many North American trained international students return to their home countries to become a well-respected and highly esteemed professional. Thus, the question then prevails: How do you teach students about physician qualifications? What would be the recourse if something goes wrong in the process? How do you teach students about the process of investigating qualifications of medical professionals working outside of North America?

Cost factor

A myth may be that the cost factor is prohibitive, or that the cost is so low that the quality of services may not be adequate. Thus the challenge becomes: How do we begin to identify the costs of promoting medical tourism.

Insurance coverage

Another myth relates to insurance coverage, and a common perception is that insurance is not recognized outside of American soil. While this is not always true, the challenge is to what extent insurance policies will cover procedures undertaken abroad.

Malpractice

Finally, a myth that Malpractice will not be covered by facilities abroad may deter people from pursuing a medical tourism approach. What recourse does the patient have if something should go wrong? It is important to keep in mind that there are risks involved upon returning home. Patients that experience complications or infections have limited contact with overseas surgeons once they return to their home base. However, one should not automatically assume that malpractice will be an issue in the case of medical procedures undertaken outside of their home communities.

While it is important to address myths and challenges related to medical tourism, one should also consider what directions need to be addressed within the arenas of medical tourism practice, future research and manpower development. The next portion of this paper addresses these issues.

Technology

How does technology offer consumers the best medical provider to offer? With increased medical technology worldwide, there are many health care options on the global market for medical tourists. Patients can choose a number of required and elective procedures, health maintenance, health prevention and screening activities.

Marketing

How does destination image, service quality and better customer service have a strong influence towards the perception of medical tourism? By offering a wide variety of medical, surgical and dental services in comfortable, modern medical facilities. Lower costs avoiding with time for elective procedures, the ability to obtain new or experimental treatments not available within the country of residence, privacy and confidentiality for patients undergoing plastic surgery, sex change procedures are also factors used for marketing. Luxurious accommodations and excellent service, exotic destination vacations and promotion of various medical success stories with quality services.

Lower costs

The labor costs within the host country may play a role and have an impact on the overall costs of medical care and intervention. The reason for lower costs between other countries as compared to the United States is that malpractice insurance for overseas physicians. The reduced pay rate for nurses and other professionals, and greater government subsidies for health care systems. According to Rough [8], in the Arizona Republic, the reasons for the low costs is due to private insurance for overseas physicians.

Manpower development

Examination of student perceptions of the medical tourism industry is another area which requires redress, since students are the future of the hospitality/tourism industry. Without adequate preparation both about the medical tourism industry and a vision for development, the needs of the industry will not be adequately met.

A lack of data currently exists related to the impact of medical tourism and use of evidence for the purpose of building and understanding the industry of medical tourism. Business entrepreneurs may go to a given country for the purpose of conducting business in an unrelated field, and then while visiting the country for their business, also pursue a medical procedure at the same time.

According to Dr. GERL of the European Joint Educational Program [9], higher education systems have been slow in offering medical tourism options, because data is hard to come by. Hospitals measure numbers differently, like whether a tourist travelled there specifically for treatment or just happened to get sick while traveling for business reasons. Both may be considered the “international patient”, while there is a clear distinction between the business traveler and the medical tourist [10-15].

Research regarding specific health care activities and medical tourism location is needed. A number of other possible avenues in relation to medical tourism. Patient outcomes, global health policy and impact on destination countries is needed for future research initiatives. In addition, the translation of these issues into the curriculum for manpower preparation in the higher education is also necessary. Perceptions of both students and professionals preparing for the workforce related to medical tourism can also be valuable in targeting the gaps in knowledge, attitude and preparedness to respond to others in the medical tourism arena. In addition, research which addresses the role of multidisciplinary professional preparation can be essential to assure that all partners in the medical arena are adequately prepared to respond to and serve the visitors from foreign soil. Such professionals may include, physicians, social workers, nurses, dental hygienists, occupational therapists, physical therapists and the hospitality/tourism professionals [16-20].

According to Coromany [2], there is a lot of preparation that goes into helping medical travelers that is not yet understood by the average hospitality professional. Consequently, there is a strong need to help prepare the workforce so that they can adequately meet the needs of consumers who are engaged in travel resulting from their medical needs. Hospitality programs should focus upon the following as it relates to medical tourism:

• Hotel decoration: The décor of a particular hotel should be considered from.

• The vantage point of an individual who may be in recovery from a medical procedure. For example, the hotel décor and environment may not be soothing to an individual who has just undergone intense medical procedures.

• Housekeeping: Housekeeping visits must considered as part of the workforce.

• Preparation and housekeeping staff must be considerate of time for napping for both the patient and family members.

• Economic and insurance side of medical tourism: There should be a strong balance with the hospitality side of tourism that will include and incorporate how profit and insurance will impact the dynamics and industry of medical tourism.

Other topics to be considered include hotel transportation, diet, concierge preparation and duties, how to market a possible medical tourism destination, local arrangements, convenience, color and flow. It is important for hospitals to understand and prepare for the cultural and linguistic obstacles they will face when dealing with people from other cultures. Hospitality education programs can be helpful to address this need through student service learning projects, and through consultation with academic professionals.

In summary, this paper has addressed the upcoming trend toward medical tourism as a captive market for the tourism/hospitality industry. It has described some approaches within the background, to help ascertain what medical tourism is and what it entails. It has also addressed what some of the myths and challenges are within the field and lastly provided some specific strategies for workforce development and curriculum design. Medical Tourism will be an emerging trend upon the horizon, and will become an opportunity for professionals within the Tourism/Hospitality industry.