Has the time come for "medication tourism"?

Everyone has probably heard the term medical tourism. This is not travel for peace of mind and cultural experience, instead it is travel to another country for medical care at a lower price or to gain access to medical treatments that might not be available in their home country. For decades, some individuals have been traveling to major medical centers located in lower cost areas of the world for various types of surgeries, dental procedures, ophthalmic procedures, and fertility treatments. AARP just published an article in their magazine focused on this subject.1 The article emphasized both the cost difference between having surgery in the United States and other countries (eg, Costa Rica, Hungary, India, Malaysia, Mexico, Poland, Singapore, Thailand, and United Kingdom) and the safety issues with this practice. The authors stated that a survey of employers found that 5% were currently covering these types of surgery and 25% were considering adding this type of option to their health plan benefits in the next 3 to 5 years.1 A survey of human resources personnel in 2014 found that about 17% included the option to go abroad for specific medical care in their health plans.2 The trend is increasing. The Medical Tourism Association estimates that 1.6 million Americans traveled to another country for a medical procedure in 2013, and this number is expected to increase. The estimated economic impact is $20 to $65 billion dollars per year.3–5 The cost of some of the new medications in the United States has been staggering, especially when you consider that the clinical evidence for their approval is based on surrogate markers and not long-term clinical outcomes. These perceived high price tags have stimulated discussions around health care centers, professional meetings, medical plans, and various blogs about what might be called medication tourism. This practice has been going on for years in Canada and Mexico, especially with patients who live near the borders of these countries. A patient can travel to another country and purchase the same drug at a lower cost than if they bought it in the United States. However, the patient also has to figure out how much drug they can legally bring back into the United States. Can they bring a month’s worth of drug, several months, or the entire treatment course? If patients bring back less than the entire treatment course, they will have the additional expense of making other trips to that country for more drug, but at least they will be home with family and friends for part of their treatment and will be supporting their local economy. Patients can decide to stay in the other country for their entire treatment course. This option is potentially very possible for drugs that are associated with mild and infrequent adverse effects (eg, oral hepatitis C drugs) and that have a high price differential between another country and the United States. Gilead Sciences has signed with several generic drug manufacturers to produce sofosbuvir to sell in 91 developing countries.6 The list price for sofosbuvir is $30,000 per month in the United States, and the estimated cost in India and Egypt will be $300 per month.6–8 Medication tourism may represent a new avenue of business for the timeshare or hotel industries. They could offer a package deal that includes the cost of airfare, housing, food, some entertainment, and follow-up visits with health care providers; this would still be a cost savings to the individual and their insurance company. There are already numerous Web sites (eg, PatientsBeyondBorders.com, OnlineMedicalTourism.com) and organizations (eg, Medical Tourism Association) designed to help individuals with their medical tourism, so why wouldn’t they be interested in prompting medication tourism? Medical and medication tourism are not without their unplanned complications and cost. International travel alone can be associated with an increased risk of deep vein thrombosis; exposures to tuberculosis, amoebic dysentery, traveler’s diarrhea, hepatitis A, Ebola, and malaria; reactions to the required vaccines; unstable political environments; poor communication with non-English-speaking health care providers; medical mishaps; and differences in medical malpractice laws.3,9 All of these factors need to be considered prior to a patient embarking on this type of medical care; however, a number of these locations are very safe, healthy, and have practitioners who were trained in the United States. There are a number of local economic factors that also should be considered if this practice becomes widespread. What is the impact of this type of patient transfer and shift in the provision of health care to facilities not located in the area in which the person lives? Will it have a negative impact on local and state tax revenues, charitable care at home, pooled medical coverage, health care provider employment, and financial support of the local medical clinics? Will the individual miss more work, and how will that affect their employer? What is the economic impact of these changes on other businesses in the area (eg, housing, daycare, groceries, restaurants, and retail stores)? What about the patient who cannot afford medication tourism because of lack of funds or time or due to family commitments? Should they purchase their drugs from foreign suppliers or internet pharmacies? What happens if these businesses sell fake or stolen drugs? This can harm the patients and society. The patients will not get the medications they need, and the society will have to deal with the cost of illegal drug sales. Patients who cannot afford their medications may become more dependent on publicly financed medical plans or the pharmaceutical manufacturer’s assistance programs. But maybe there is an entirely different answer to the problem. Maybe the prices of these drugs need to be lowered, especially those that are sold in other countries for a fraction of the price charged in the United States. Or maybe the United States can move from a free-market economy for drug prices to a system where the government controls the price of the drugs. Until changes are made to reduce drug costs, we need educate our patients about the benefits and risk associated with medication tourism.