Psychological Barriers to Understanding the Market for Medical Tourism

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In recent years medical tourism has become somewhat of a buzzword in the USA – it might even be worth calling it a bubble, given both its links and likeness to the dot-com investment bubble. Although one could view this evolving industry as a manifestation of globalization and more liberal trade common in all sectors of the economy, some have attempted to classify this as a unique phenomenon – often considering it a “disruptive” technology that could revolutionize health care, both here and abroad.

Others paint a more sinister picture, claiming that healthcare tourists are “refugees” escaping the high prices of the U.S., displaced from the comfort and quality of American health care systems in order to afford care (with the natural extension that they are sacrificing both comfort and quality by doing so).

In reality, the U.S. plays a minor role in the international market for healthcare tourism. The American market is dominated by the Asian market, and both Asia and the Americas are minuscule compared to the size of the European market. This disparity is in part due to the misconceived definition of “health tourist,” which focuses on national boarders rather than state boarders.

If we focused on the E.U. and just looked at its collective exterior border, much of the internal trade amongst its member countries would be omitted. Similarly, if the focus in the U.S. were to shift to patients crossing state borders for healthcare, the numbers would be much higher. In fact, Americans cross state borders for healthcare every day in search of better quality of care, better physicians, greater convenience of scheduling and even better pricing.

What is surprising about the American market is that most of the current discussions focus on exporting patients to other nations, rather than the traditional market of attracting wealthy foreigners to our elite hospitals systems. It is clear, however, that the debate on health tourism is being manipulated for political means (e.g. healthcare reform in the USA is hard to sell if you focus on the positive elements) and such manipulation is being made possible by a lack of data on health care tourism (both coming and going).

For example, health care statistics in the USA, such as the percentage of GDP devoted to healthcare, are distorted by foreigners who seek health care – quite often at any cost – but who are just added to the statistics for the domestic market.

If we are going to truly understand healthcare tourism in America, then there are at least three barriers that we have to overcome. Unlike most trade barriers, these barriers are in many respects psychological ones or relate to historical biases or have been generated by misinformed media coverage of the issue.

Like many trade issues, there are vested interests looking at the market for medical tourism either as an opportunity, (particularly those that want a quick buck out of exploiting this market,) or a threat to the status quo. To date, there has not been a rigorous discussion concerning the potential gains from trade associated with the internationalisation of health care services.

The first barrier to understanding health tourism is realizing that it is not dominated by flows of patients from the developed to the developing world per se. Many health care tourists come from developing countries that lack specialist care or infrastructure. For example, many health care tourists in Singapore come from Indonesia.

In fact, when one assesses international trends, two assertions can be made. Generally, patients travel to countries with relative similar levels of development and patients normally seek care in their own region. Of course, many exceptions can be found to these rules, but it is important to note them as exceptions.

The second barrier to understanding the market relates to the push and pull of patients. In the U.S. we need to stop focusing on the push factors that are leading people to consider healthcare tourism and focus on mechanisms to pull patients towards our facilities. This will be difficult as the notion of push is so engrained into the American health care system.

(When has your surgeon ever said, “Lets schedule the surgery when it is best you?”) Managed care engrained the notion of push, and pay-for-performance will do little to make care more patient-centered. In reality, many Americans choose foreign providers because they are attracted by the quality of facilities, customer service and a holistic approach to care.

Finally, to understand healthcare tourism one has to realise that it is more than just travel for medical procedures, rather, it incorporates a broad range of lifestyle and wellness factors. While many hospitals in the U.S. are venturing into the realm of complementary and alternative medicine, the environment of the typical aging hospital infrastructure of the USA might negate some of the benefits of these therapies.

An example of how medical tourism enhances wellness relates to dedicated recovery time. In the U.S., it is common for a patient to return to work or return to their day to day grind before they physically are ready. By travelling abroad, patients are spending a dedicated amount of time for recovery – often my combining holiday time with their health care – in order to achieve a better state of wellness. The ability to combine holiday with health care is obviously a lure for patients to go overseas.

John FP Bridges Ph. D. ~ John is and Assistant Professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health ( and a Senior Fellow at the Center for Medicine in the Public Interest ( He is an advocate for the scientific study of patient preference in the area of Pharmacoeconomics, outcomes research and technology assessment and is the founding editor of a new journal titled The patient – Patient centered outcomes research. He is also a co-author (with Percivil Carrera) of a study titled “Globalization and Health care: Understanding health and medical tourism’ published in the Expert Revue of Pharmacoeconomics Outcomes Research (2006;6(4):447-453). He can be contacted via email on