Medical Tourism

Earlier this month, the insurance company WellPoint announced a program that will allow employees of a Wisconsin printing company to get coverage for non-emergency surgeries in India. It's a first for WellPoint, but puts the insurer in good company. Over the past few years, some U.S. insurance companies — dismayed at losing income from uninsured Americans who get cheap surergies abroad or clients who choose to pay out of pocket for discount foreign surgeries rather than expensive in-network co-pays — have announced plans to include foreign medical procedures among those covered by health plans.

It's no wonder. The medical tourism industry has experienced massive growth over the past decade. Experts in the field say as many as 150,000 U.S. citizens underwent medical treatment abroad in 2006 — the majority in Asia and Latin America. That number grew to an estimated 750,000 in 2007 and could reach as high as 6 million by 2010. Patients are packing suitcases and boarding planes for everything from face lifts to heart bypasses to fertility treatments. (See The Year in Health, from A to Z.)

People have been traveling for centuries in the name of health, from ancient Greeks and Egyptians who flocked to hot springs and baths, to 18th and 19th century Europeans and Americans who journeyed to spas and remote retreats hoping to cure ailments like tuberculosis. But surgery abroad is a fairly modern phenomenon. As health costs rose in the 1980s and 1990s, patients looking for affordable options started considering their options offshore. So-called "tooth tourism" grew quickly, with Americans traveling to Central American countries like Costa Rica for dental bridges and caps not covered by their insurance. (A large percentage of today's medical tourism is for dental work, as much as 40% by some estimates.)

Many U.S. doctors and dentists were appalled at the idea of their patients turning to foreign hospitals for care that they considered dangerously cheap. But where many U.S. medical professionals saw great peril, countries like Cuba saw opportunities. Beginning in the late 1980s, the island country started programs to lure foreigners from India, Latin America and Europe for eye surgeries, heart procedures and cosmetic procedures. The Cuban government said it welcomed 2,000 medical tourists in 1990. (See pictures from an X-Ray studio.)

After Thailand's currency collapsed in 1997, the government directed its tourism officials to market the country as a hot destination for plastic surgery, hoping to boost revenues. Thailand quickly became the go-to country for comparatively inexpensive sex-change operations, where patients faced fees as low as $5,000, as well as looser requirements for pre-surgery psychological counseling. Thailand is now a destination spot for all types of plastic surgery as well as a host of routine medical procedures. Bumrungrad International Hospital in Bangkok is probably Thailand's best-known mecca for medical tourists, boasting patients from "over 190 countries" and an "International Patient Center" with interpreters and an airline ticket counter.

In recent years, companies all over the U.S. have sprung up to guide Americans through the insurance and logistical hurdles of surgery abroad, including many in U.S. border states affiliated with medical facilities in Mexico. The physician-managed MedToGo in Tempe, Arizona, founded in 2000, says its clients save "up to 75% on medical care" by getting it in Mexico. The Christua Muguerza hospital system — located in Mexico, but run by U.S.-based Christian hospital group since 2001 — includes a scrolling text box on its web site informing visitors how "very close to you" its Mexican facilities are. ("from Houston 1 hr 37 mins!" "from Chicago 3hrs 15 mins!") Meanwhile, New Zealand is trumpeting its expertise in hip and knee replacements and South Korea is enticing medical travelers with high-end non-medical amenities like golf.

For those who wrinkle their noses at the thought of going under the knife in a foreign, let alone still-developing, country, the American Medical Association introduced a set of guidelines in June for medical tourism. The AMA advocates that insurance companies, employers and others involved in the medical tourism field provide proper follow-up care, tell patients of their rights and legal recourse, use only accredited facilities, and inform patients of "the potential risks of combining surgical procedures with long flights and vacation activities," among other recommendations. Joint Commission International, a non-profit that certifies the safety and record of hospitals, has accredited some 200 foreign medical facilities, many in Spain, Brazil, Saudi Arabia, Turkey and the United Arab Emirates.


By Kate Pickert Tuesday, Nov. 25, 2008

Europeans Announce Pioneering Surgery

PARIS — Physicians at four European universities have successfully transplanted a human windpipe, using stem cells from the recipient’s own bone marrow to reline a donor trachea and prevent its rejection by her immune system, according to an article in the British medical journal The Lancet.

The operation, performed in June, was the first to use stem cells in transplanting an airway, and is considered an important advance because it allowed the surgeons to replace a larger segment than had generally been possible in the past. The hope is that the stem cells will transform themselves into the kind of cells that normally line the windpipe and carry out important functions such as clearing mucus out of the airway.

Similar techniques using other types of cells from patients have been used to fashion bladders and also to grow skin for grafting.

In this case, surgeons used stem cells from the patient’s bone marrow because they have the ability to transform themselves into different types of tissue. In that sense, the marrow cells are similar to embryonic stem cells, but they are free of the ethical issues raised by the use of embryonic cells. It is not certain whether the transplanted stem cells have continued to function in the patient or whether other cells from her body have become part of the new airway.

A surgeon not associated with the case, Dr. Eric M. Genden, chairman of otolaryngology at Mount Sinai Hospital in Manhattan, said the report seemed promising, but added: “I would take the results cautiously. Time will tell.”

Dr. Genden predicted that the work would not turn out to be a panacea for people with diseased or damaged tracheas, or windpipes. He said that other teams had tried partial tracheal transplants, with mixed success, and that he had done a dozen from 2005 to 2007, using the patients’ own skin cells, not stem cells, to line the trachea. All are still in place, but so far it has not been possible to replace an entire trachea, he said.

“I have one of the largest populations of patients with these problems in the U.S., and unfortunately, they’re all going to be calling about this,” Dr. Genden said.

The transplant operation described in The Lancet was performed on a 30-year-old woman, Claudia Castillo, in June in Barcelona to relieve severe shortness of breath and damage to her airway caused by tuberculosis. The surgery followed weeks of preparation carried out at the universities of Barcelona, Spain; Bristol, England; and Padua and Milan in Italy.

Ms. Castillo was hospitalized in March because her left bronchus — the tube connecting the windpipe to the left lung — was so badly damaged by tuberculosis that she was unable to walk more than a few steps at a time, according to a statement from Bristol University.

“The only conventional option remaining was a major operation to remove her left lung which carries a risk of complications and a high mortality rate,” the statement said.

“We are terribly excited by these results,” said Prof. Paolo Macchiarini of the University of Barcelona, who performed the operation. “Just four days after transplantation the graft was almost indistinguishable from adjacent normal bronchi.”

Moreover, two months after the surgery, lung function tests on Ms. Castillo “were all at the better end of the normal range for a young woman,” the Bristol University statement said.

Martin Birchall, a professor at the university, said the transplant showed “the very real potential for adult stem cells and tissue engineering to radically improve their ability to treat patients with serious diseases. We believe this success has proved that we are on the verge of a new age in surgical care.”

The Bristol University statement said a segment of trachea, roughly three inches long, was taken from a 51-year-old donor who had died of a cerebral hemorrhage. Using a new technique developed in Padua University, the trachea was stripped of its donor’s cells over a six-week period “so that no donor cells remained,” the statement said.

At the same time, at Bristol University, stem cells removed from Ms. Castillo’s bone marrow, and cells taken from one of her lungs, were grown into “a large population” and used to “seed” the donated windpipe using a new technique developed in Milan to incubate cells. Her cells embedded themselves in the cartilage of the donor’s trachea.

Four days after the seeding, the graft was used to replace Ms. Castillo’s damaged bronchus.

Normally after transplants there is a high risk of rejection because the recipient’s immune system attacks the foreign organ. Most transplant patients, thus, need immunosuppressant drugs to prevent rejection.

“The patient has not developed antibodies to her graft, despite not taking any immunosuppressive drugs,” the statement from Bristol University said.

Alan Cowell reported from Paris, and Denise Grady from New York.


By ALAN COWELL and DENISE GRADY