Trouble in paradise?

By Emily Margosian, Assistant Editor, August 1, 2023

Earlier this year, medical tourism grabbed headlines — for the wrong reasons. Four American tourists traveling to Mexico in pursuit of cosmetic surgery were kidnapped, and two were ultimately killed. While the tragic outcome was an outlier, their original purpose for travel was not. Currently, millions of Americans travel every year to other countries for health care as part of a growing trend.

As pandemic-related restrictions around travel have eased, the medical tourism industry has rebounded, experts say, fueled by a growing global demand for cosmetic procedures and consumers with an increasing eye for value. This month, DermWorld explores the underlying factors driving the medical tourism boom — and potential considerations for dermatologists and their patients.

Popular destinations

When it comes to medical tourism destinations, among Americans, Mexico is the top spot, according to David Vequist, PhD, director of the Center for Medical Tourism Research, and professor at the University of the Incarnate Word. “In terms of countries, Mexico is number one. Colombia is number two, followed by Costa Rica,” he said. “Other well-known medical tourism locations around the world include places like Panama, the Dominican Republic, South Korea, India, Germany, Malaysia, and Turkey.”

In many cases, these locations have become medical tourism hubs due to a concentrated marketing effort from the countries themselves. “Many of these places are spending a great deal of money on digital marketing. They put content out there, and social media algorithms are going to push it out,” said Vequist. “I hate to say it, but we’ve almost gotten fat, dumb, and happy in American health care. We just expect that people will show up at our offices to get the care they need without much by way of marketing. Most doctors don’t have a lot of marketing expertise; they didn’t learn any of that in medical school. Even the people who work for them can be very naive when it comes to marketing — particularly digital marketing, and digital marketing is where the return on investment is. Most of these international locations, if they’re successful, are engaging in some form of digital marketing.”

“With declining ratios of physicians and non-physician clinicians, higher utilization, and a sicker populace, it’s created a perfect storm for medical tourism to grow.”

Increasingly, popular sites for medical tourism can also fall outside the bounds of traditional borders. “People may not be aware of this, but cruise ships are now offering a lot of cosmetic dermatologic procedures in their spa services. If you talk to some of the laser and injectable companies, cruise ships are some of their biggest customers,” said Anne Chapas, MD, FAAD, founder and medical director of a private practice in New York. “They’re offering things like fillers, botulinum toxin, and even laser procedures like radiofrequency and skin tightening. It’s inappropriate, because there’s no opportunity for follow-up if something goes wrong, and you don’t know the training and skill level of the person administering the treatment.”

Cruise ship cosmetic offerings, combined with the presence of alcohol and a “vacation mindset,” may lead patients to make decisions about their health that they wouldn’t otherwise. “When you’re on vacation, you’re in your happy place. You’re not thinking about what could go wrong,” said Dr. Chapas. “I had a patient who went on a cruise and thought it would be a good idea to get filler. They came to see me a month later with lumps and bumps all over the place. Fortunately, it was just misplaced filler, which I was able to dissolve. However, this certainly could have been a lingering infection or some other problem that could have required a much more serious intervention.”

COVID’s impact on medical tourism

While COVID-related travel restrictions temporarily stalled medical tourism, the industry has resurged, in part fueled by the pandemic itself, according to Vequist. “COVID actually exacerbated circumstances that have led to medical tourism increasing,” he explained. “People put off things or were unable to see their doctors as often as they should have because of practice closures or discomfort about going out. This is particularly evident in things like oncology, where we’re seeing people present with higher acuity. Research from the American Hospital Association showed that in 2022, the overall hospital bill was approximately 10% higher because of higher acuity levels and people presenting with more difficult issues due to delayed care.”

Additionally, the toll of the pandemic on the medical profession and resulting burnout among physicians and non-physician clinicians has also potentially contributed to a rising rate of medical tourism. “During COVID, we saw many people leaving the health care profession and going into other careers. The whole ‘quiet quitting’ phenomenon combined with the fact that we’re not graduating enough health professionals in a variety of fields around the country, and our ratios are going down,” explained Vequist. “So, with declining ratios of physicians and non-physician clinicians, higher utilization, and a sicker populace, it’s created a perfect storm for medical tourism to grow.”

As the pandemic moved much of our personal and professional interactions behind a digital screen, the resulting preoccupation in how we look has also fueled demand for affordable aesthetic enhancement. “I think patients are increasingly interested in cosmetic procedures. Certainly, during COVID, more people were hypercritical of their own appearance because they were seeing themselves on Zoom every day,” said Avery LaChance, MD, MPH, FAAD, assistant professor of dermatology at Harvard Medical School. “We saw a resulting uptick of cosmetic procedures globally, and now that people are starting to return to an office setting after COVID, they’re just as interested in cosmetic procedures.”

Identifying the medical tourist

Who seeks medical tourism? The answer might be surprising to some.

“Medical tourists come from all walks of life. It’s not necessarily someone who’s looking for a bargain,” said Dr. Chapas. “That terrible incident in Mexico was an example of someone who was seeking out a less expensive procedure. However, we also see medical tourism among people of means. I have a patient base that’s very affluent and travels frequently. So, it’s not unusual for a Brazilian patient to have treatment in Brazil, or a wealthy New York-based patient to have a face lift in California.”

This also bears out in available demographic data on medical tourism activity, according to Vequist. “In statistics, we have something called bimodal distribution, which is something we see in terms of medical tourism. On one end, we have people of lower socioeconomic means who tend to travel because they’re looking for a better value. However, interestingly, data indicate wealthy people — Instagram influencers, celebrities, athletes, politicians — also tend to travel more frequently for health care.” he explained. “While both groups are more likely to participate in medical tourism, the people who are least likely to travel are people of average means. They’re typically the ones who are going to stick with a local person in the region that perhaps had been suggested by their physician.”

The cost-value equation

While the typical medical tourist may vary in terms of socioeconomic class, cost is still a primary driver of medical tourism activity, particularly against a post-pandemic backdrop in which 5.4 million American workers were stripped of their health insurance due to COVID-related job loss.

“Health care costs have risen over time, and I think patients have become more cost-conscious when they are thinking about how they’re going to have a procedure done,” said Dr. LaChance. “They’re looking for a more affordable option, whether that’s having a procedure done with a physician extender locally, or by going overseas.”

According to Vequist, this behavior is part of a broader trend of patient consumerism in which Americans have begun to diverge from more traditional health-seeking behaviors. “Before, patients may have gone through their primary care physician for a recommendation to a specialist in their local region. Now, they’re getting on the internet and finding there are a variety of specialists, some of which are perhaps outside the country,” he explained. “They’re looking for the health care they want, at the quality level they prefer, at a certain price. People are looking for value, which is a combination of quality and price. If it were just about cost alone, I don’t think medical tourism would be as attractive to people. However, these medical tourism hubs are being transparent about their quality and being very transparent about pricing — that’s a big deal, and not always the case in our U.S. health care system.”

An additional driver for patients is package deals offered by popular medical tourism destinations, including flights, transfers, and even sight-seeing tours after surgery. “Many of these locations have more of a concierge approach. We see bundles that include airfare, a nice hotel to stay at, or a car service. When you factor all those things together, it becomes a very powerful combination,” said Vequist.

Growing demand for cosmetics

Also driving medical tourism is a growing global demand for cosmetic medical procedures. “I just got back from Asia and there’s a huge interest in cosmetic dermatology worldwide. It’s not just people in New York, Los Angeles, or Miami who are interested in these procedures,” said Dr. Chapas. “People in every country are interested in doing something to improve the appearance of their skin. I think the global rise of interest in aesthetics is also partly driving this.”

Amy Spizuoco, DO, FAOCD, FAAD, clinical instructor in dermatology at the Icahn School of Medicine at Mount Sinai, has seen an uptick in interest among her patients regarding cosmetic surgery — and the potential for reduced cost abroad. “Many of my patients come from other countries such as the Dominican Republic, Colombia, and countries in eastern Europe — or have friends that do — and have heard that cosmetic surgery is significantly cheaper in these countries as opposed to the United States. I’ve had a lot of recent questions from patients about breast augmentation, tummy tucks, facelifts, rhinoplasty, and hair transplantation,” she noted.

This craving for cosmetics can prey on patients’ judgment, particularly in the face of sophisticated marketing efforts. “When framed in lovely marketing materials that make aesthetic medical procedures look and feel like luxury commodities, people get the sense they should ‘treat’ themselves,” explained Jennifer MacGregor, MD, FAAD, a dermatologist in private practice in New York. “Unfortunately, this doesn’t always facilitate proper research and healthy skepticism about someone’s qualifications, what complications are possible, and if that person is capable of treating you if an urgent complication should occur.”

Risks of medical tourism

While millions pursue medical tourism each year, the practice is not without risk. Language barriers, different standards of care, and potential lack of regulatory oversight can lead to instances of botched care. Dr. LaChance recalls two patients who traveled to the Dominican Republic for cosmetic procedures and suffered complications from treatment they had not consented to. “One was told they were going to have autologous fat transfer for what’s called a Brazilian butt lift. However, in the months after, she ended up developing a painful, firm eruption on her buttocks overlying the site where the procedure was done.” After a referral to dermatology for suspected cellulitis, it was ultimately determined that the patient was suffering from the injection of silicone, requiring lifelong management. “We first tried to treat her with hydroxychloroquine, and she had no response to that. We eventually put her on a TNF alpha inhibitor. She showed improvement with that but will likely have to stay on it in perpetuity because the silicone is not ever going to go away,” said Dr. LaChance.

The other received what was described as a “facial” in which needles were used. “She denied having ever asked for filler and came in with these really pronounced erythematous plaques along her periorbital skin, nasolabial folds, forehead, and on the ear lobes,” said Dr. LaChance. “We ended up doing a punch biopsy that again showed these atypical vacuoles consistent with what looked like a silicone granuloma, and the appearance of silicone injected diffusely throughout her face. So, two really sad stories of patients who had procedures in which they received an agent that they were not consented for.”

Dr. Spizuoco has also had experience treating patients who developed complications from medical tourism. “I’ve had several patients present with hematomas, non-healing wounds, infections, and severe rashes. One patient of mine had silicone breast implants placed in Colombia 10 years prior and had chronic skin inflammation that was only relieved when she had the implants removed. Upon removal, the implants were discovered to be severely encapsulated and calcified. Some patients have asked me to dissolve filler that they received in other countries.”

“Anyone claiming to be better, cheaper, or more miraculous with a quick and easy fix is likely trying to sell you something. Ask questions as to why that is.”

In addition to the potential for botched care, long-distance air travel post-surgery may also heighten risk for adverse events. “Aftercare and recovery are just as important as the procedure itself, and sometimes requires several months of care,” said Dr. Spizuoco, “Many don’t realize this. Not receiving appropriate aftercare can lead to deformity, infection, and possibly death.”

Medical tourists should also be wary of the fact that medication prescribed or administered may be counterfeit or of poor quality in some countries. “There is always a risk that the products that they’re using don’t meet U.S. safety standards,” said Dr. Chapas. “You don’t know if the device that they’re using would be FDA-cleared. Every country has their own process for how they approve devices, injectables, and medications, which doesn’t necessarily meet the standard of what we do in the United States.”

As medical tourism continues to gain traction, dermatologists should consider including questions about travel as part of the history-taking process when confronted with challenging cases. “I think it’s important for us to be aware of this phenomenon because patients who do end up with adverse cutaneous reactions may come into our clinic with atypical eruptions or presentations that aren’t quite fitting with what they’re billed as,” advised Dr. LaChance. “For instance, my first patient was sent to me for cellulitis, and I knew it wasn’t. So, if you’re trying to marry an atypical clinical presentation with a patient’s history, really dig into whether they’ve had a procedure done overseas and whether it could be a complication.”

Talking to patients about medical tourism

When discussing potential risks of medical tourism with patients, emphasizing the distinction of care offered by a board-certified physician should be first and foremost. “I think as dermatologists are counseling patients around cosmetic procedures, it’s important to convey to them that they really are in the best hands with a physician who is board-certified,” said Dr. LaChance. “Within the United States, we have parameters around what materials can be used in hospital settings, and that people are getting the procedures they consented for.”

Dr. Chapas agrees that patients should be encouraged to pursue qualified care — something that isn’t always as easy to discern in other health care systems. “The rest of the world doesn’t train a lot of dermatologists, and as a result, there are very few residency-trained dermatologists outside the United States. So, if you travel outside the country, you could be dealing with an ‘aesthetic’ physician who really could be of any background. I don’t necessarily think medical tourism is a bad thing. I work in New York City and see patients from all over the world because they really value my expertise.”

Patients considering traveling for medical care should be prepared to do significant research into who will be delivering care, and what follow-up looks like in the event of complications. “I encourage my patients to seek multiple opinions, ask what can go wrong, and ask how that will be managed. For example, how they can get in touch with the doctor afterward and whether they are experienced and capable of managing rare complications,” said Dr. MacGregor. “While complications can happen, I know that I, as a board-certified dermatologist, have the best training available to mitigate that risk. If something sounds too good to be true, it probably is. Anyone claiming to be better, cheaper, or more miraculous with a quick and easy fix is likely trying to sell you something. Ask questions as to why that is.”

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