Canadians' use of U.S. medical services

Cross-border healthcare: A review and applicability to North America during COVID-19

Cross-border healthcare is an international agreement for the provision of out of country healthcare for citizens of partnered countries. The European Union (EU) has established itself as a world leader in cross-border healthcare. During the Coronavirus disease of 2019 (COVID-19) pandemic, the EU used this system to maximize utilization of resources. Countries with capacity accepted critically ill patients from overwhelmed nations, borders remained open to healthcare workers and those seeking medical care in an effort to share the burden of this pandemic. Significant research into the challenges and successes of cross-border healthcare was completed prior to COVID-19, which demonstrated significant benefit for patients. In North America, the response to the COVID-19 crisis has been more isolationist. The Canada-United States border has been closed and bans placed on healthcare workers crossing the border for work. Prior to COVID-19, cross-border healthcare was rare in North America despite its need. We reviewed the literature surrounding cross-border healthcare in the EU, as well as the need for a similar system in North America. We found the EU cross-border healthcare agreements are generally mutually beneficial for participating countries. The North American literature suggested a cross-border healthcare system is feasible. A number of challenges could be identified based on the EU experience. A prior agreement may have been beneficial during the COVID-19 crisis as many Canadian healthcare institutions-maintained capacity to accept critically ill patients.

Scoping the literature on patient travel abroad for cancer screening, diagnosis and treatment

The incidence of cancer is on the rise globally. Under particular circumstances, patients are willing to travel abroad for healthcare treatments. We know relatively little however about patients travelling overseas for cancer-related screening, diagnosis and treatment. Where do patients go, for what treatments, what are their motivations, decision-making processes and treatment experiences? What do we know about patient safety and risk, and outcomes? More broadly, what are the ethical and legal implications? This review presents the first published assessment of what we term 'transnational oncology treatment', defined as patients travelling overseas or across borders for cancer screening, diagnosis and treatment. The review undertakes detailed search and retrieval of the literature, using an accepted scoping review method. We present a narrative review of existing knowledge and themes, identifying coverage and gaps. There is a five-fold agenda for future investigation: trajectories and itineraries; in depth focus on treatment decisions, experiences and outcomes; locating patient travel within wider health system analysis; exploration of professional perspectives and coordination; and situating travel within the context of health trade. Such an agenda is multidisciplinary and wide-ranging, encompassing epidemiology, health economics, health policy ethics, health politics, health management, and health policy.

Factors influencing decisions of Laotian patients to use health care services in Thailand

Background: Thailand has been facing a gradual increase in use of cross-border health care. Nevertheless, no evidence regarding factors influencing cross-border use of health care by Laotian patients in public Thai hospitals among this group has been established.

Objectives: To assess the use of cross-border health care by Laotian patients, and factors that may influence health services in public Thai hospitals along the border.

Methods: This study consisted of two parts. (1) Site-visits to 53 Thai public hospitals along the Thai-Laos border during May to July 2011 and collection of data regarding the use of health care services by Laotian patients. (2) A structured questionnaire survey was conducted via face interviews by trained researchers. Findings were analyzed using descriptive statistics and multiple logistic regression.

Results: The most common conditions for which treatment was sought were common diseases and basic operative procedures. All hospitals had been facing substantial financial burden, particularly for inpatient care. The analysis of use indicated that a perception of differences in the quality of health services, ability to pay for treatment anywhere, and distance to health services were three major factors affecting the decision of Laotian patients to cross the border to obtain health care in Thailand. Interviews with hospital directors and staff revealed that more financial support and a clear policy for care of Laotian patients was needed.

Conclusions: The perception of better quality of health care in Thailand by Laotian patients was the major factor affecting cross-border use of health care services. Assistance to improve healthcare in Laos and financial support for subsidizing care for the indigent Laotian patients is needed.

Globalization and healthcare: understanding health and medical tourism

Faced with long waiting lists, the high cost of elective treatment and fewer barriers to travel, the idea of availing healthcare in another country is gaining greater appeal to many. The objective of this review is to perform a literature review of health and medical tourism, to define health and medical tourism based on the medical literature and to estimate the size of trade in healthcare. The Medline database was used for our literature review. In our initial search for 'health tourism' and 'medical tourism' we found a paucity of formal literature as well as conceptual ambiguity in the literature. Subsequently, we reviewed the literature on 'tourism' in general and in the context of healthcare. On the basis of 149 papers, we then sought to conceptualize health tourism and medical tourism. Based on our definitions, we likewise sought to estimate market capacity internationally. We defined health tourism as "the organized travel outside one's local environment for the maintenance, enhancement or restoration of an individual's wellbeing in mind and body". A subset of this is medical tourism, which is "the organized travel outside one's natural healthcare jurisdiction for the enhancement or restoration of the individual's health through medical intervention". At the international level, health tourism is an industry sustained by 617 million individuals with an annual growth of 3.9% annually and worth US$513 billion. In conclusion, this paper underscored the issue of a severely limited formal literature that is compounded by conceptual ambiguity facing health and medical tourism scholarship. In clarifying the concepts and standardizing definitions, and providing evidence with regard to the scale of trade in healthcare, we hope to assist in furthering fundamental research tasks, including the further development of reliable and comparable data, the push and pull factors for engaging in health and medical tourism, and the impact of health tourism but, more so, medical tourism on local healthcare systems.

Beyond "medical tourism": Canadian companies marketing medical travel

Background

Despite having access to medically necessary care available through publicly funded provincial health care systems, some Canadians travel for treatment provided at international medical facilities as well as for-profit clinics found in several Canadian provinces. Canadians travel abroad for orthopaedic surgery, bariatric surgery, ophthalmologic surgery, stem cell injections, “Liberation therapy” for multiple sclerosis, and additional interventions. Both responding to public interest in medical travel and playing an important part in promoting the notion of a global marketplace for health services, many Canadian companies market medical travel.

Methods

Research began with the goal of locating all medical tourism companies based in Canada. Various strategies were used to find such businesses. During the search process it became apparent that many Canadian business promoting medical travel are not medical tourism companies. To the contrary, numerous types of businesses promote medical travel. Once businesses promoting medical travel were identified, content analysis was used to extract information from company websites. Company websites were analyzed to establish: 1) where in Canada these businesses are located; 2) the destination countries and health care facilities that they market; 3) the medical procedures they promote; 4) core marketing messages; and 5) whether businesses market air travel, hotel accommodations, and holiday tours in addition to medical procedures.

Results

Searches conducted from 2006 to 2011 resulted in identification of thirty-five Canadian businesses currently marketing various kinds of medical travel. The research project began with what seemed to be the straightforward goal of establishing how many medical tourism companies are based in Canada. Refinement of categories resulted in the identification of eighteen businesses fitting the category of what most researchers would identify as medical tourism companies. Seven other businesses market regional, cross-border health services available in the United States and intranational travel to clinics in Canada. In contrast to medical tourism companies, they do not market holiday tours in addition to medical care. Two companies occupy a narrow market niche and promote testing for CCSVI and “Liberation therapy” for multiple sclerosis. Three additional companies offer bariatric surgery and cosmetic surgery at facilities in Mexico. Four businesses offer health insurance products intended to cover the cost of obtaining privately financed health care in the U.S. These businesses also help their clients arrange treatment beyond Canada’s borders. Finally, one medical travel company based in Canada markets health services primarily to U.S. citizens.

Conclusions

This article uses content analysis of websites of Canadian companies marketing medical travel to provide insight into Canada’s medical travel industry. The article reveals a complex marketplace with different types of companies taking distinct approaches to marketing medical travel.

The current state of health care reform: the physicians' burden

Congress has passed expansive legislation to "fix" health care. US health care, however, is not "broken"; rather, it functions according to purpose. The legal standard sets health care's purpose as high-quality care, not care at a pervasive quantity or low cost. Juries focus on quality irrespective of cost, and the court's concern is not cost but whether the defendant physician has met the standard of care. As the US health system does deliver high-quality (albeit high-cost) care, it is not broken; instead, the system that defines it is broken. The legal system defines the standard of care as the care that an average physician would deliver under similar circumstances. As 91% of physicians admit to practicing defensively excessive care, the legal care standard is therefore excessive care. However, the new health care legislation passed by Congress does not address tort reform. Instead, it reduces physician remuneration and increases penalty-driven cost care control regulations. Caught between a care standard that demands high quality regardless of cost and penalty-driven federal mandates demanding low-cost care regardless of the legal care standard, physicians bear the new law's ultimate burden. US health care should not continue to focus on quality over cost and quantity; more important, the law should not continue to dictate that it do so. Rather, the system must import cost-effective care, and the law must so direct. To reduce health care costs, the legal system must first recognize a standard of care that respects cost-or tort reform that protects those physicians who do.

A European Perspective on Medical Tourism: The Need for a Knowledge Base

Since the early 1990s, medical tourism, whereby individuals choose to travel across national borders or overseas to receive treatments, has been increasingly recognized in the United States and Asia. This article highlights the emergence of medical tourism in the European context. It examines the drivers for such developments and situates medical tourism within the broader context of health globalization and forms of patient mobility in the European Union. In outlining the developments of medical tourism in Europe, the authors distinguish between two types of medical tourist: the citizen and the consumer. The discussion explores the need for greater empirical research on medical tourism in Europe and argues that such research will contribute toward knowledge of patient mobility and the broader theorization of medical tourism. The authors make suggestions about the content of this research agenda, including understanding the development of medical tourist markets, the nature of choice, equity implications, the role of brokers and intermediaries, and general issues for health management.

Privatization of local public hospitals: effect on budget, medical service quality, and social welfare

We analyze a duopolistic health care market in which a rural public hospital competes against an urban public hospital on medical quality, by using a Hotelling-type spatial competition model extended into a two-region model. We show that the rural public hospital provides excess quality for each unit of medical service as compared to the first-best quality, and the profits of the rural public hospital are lower than those of the urban public hospital because the provision of excess quality requires larger expenditure. In addition, we investigate the impact of the partial (or full) privatization of local public hospitals.

Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences

OBJECTIVES

The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences.

METHODS

Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas.

RESULTS

Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference.

CONCLUSIONS

Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both.

Managing US-Mexico "border health": an organizational field approach

During World War II Mexican and US health professionals and organizations constructed a transnational organizational field to manage the border's public health problems. Despite barriers to inter-organizational cooperation, including disparate administrative structures and North-South stratification, the field's transnational approach to health on the border has continued for 60 years. Using archival data to track changes in the number and types of organizations, this article argues that the field practitioners call "border health" reconfigured during the North American Free Trade Association (NAFTA) decade from an era of loosely organized professionals to a specialized bureaucracies era. This change brought new vitality to border health, with transnational ties increasing and diversifying, but has not weakened entrenched cross-border inequalities. The organizational history of the US-Mexico border health field demonstrates how macro-politics and inter-organizational stratification shape transnational public health problems.

Phantoms in the snow: Canadians' use of health care services in the United States

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

The Canadian health care system. An analytical perspective

The Canadian health care system is a publicly funded system based on the philosophy that health is a right, not a commodity. The implementation of this perspective is hampered by the fact that the Canadian Constitution makes health care a matter of provincial jurisdiction, while most taxing powers lie in the hands of the federal government. Further problems arise because of Canada's geographic nature and a move to regionalization of provincial health care administration. The issue is compounded by recent developments in reproductive technologies, aboriginal health, changes in consent law, etc.