Can domestic medical tourism contribute to healthcare equity? A commentary.

Pupose - This essay uses service marketing concept to discuss how domestic medical tourism (DMT) can contribute to healthcare equity in developed countries. Approach - The authors take up several vital issues. First, the potential benefits of DMT are outlined from a healthcare equity perspective; second, the challenges that DMT confronts in reaching its aim are identified; and finally, a few research areas are suggested. Finding - It is suggested that increased awareness about the healthcare service and proper service delivery are required to improve healthcare equity. Practical implication - This paper raises several research issues from service marketing to deal with delivery, communication, efficiency, and insurance practices regarding healthcare. Social implication - From a societal point of view, it explores how healthcare equity can be improved by DMT.

Introduction

This paper uses service marketing concept to discuss how domestic medical tourism [DMT) can contribute to healthcare equity in developed countries. [1], define DMT as ‘traveling from an individual’s usual place of residence to another within the country for getting better medical treatment’ (p.29]. It can be compared to cross-border healthcare agreements within the European Union among member countries that facilitate patient mobility in Europe [2]. From a public health perspective, increasing possibilities to get timely help through socialized system foster healthcare equity. Healthcare equity means providing care that does not vary in quality due to personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status [3]. This means that a healthcare system that adheres towards social solidarity like the European Union shall remove obstacles in accessing and understanding the informational and procedural requirements for patients to realize its benefits [2,3]. Information is an important part of services that quite often remain insufficient in offering proper treatment to the patients. Can DMT organize a complete package of treatment to the patients from a service marketing point of view?

Some studies suggest that international medical tourism increases inequities in private, public, and mixed care services, as it denies access to healthcare for the poor segments of the population in developing countries [4]. However, there has been less discussion regarding the ‘internal/domestic’ health trade and its potential impact on healthcare equity specifically in the context of developed countries. Focusing on within-country medical travel and complexities that can emerge from such practice is likely to trigger discussions that might contribute to quality improvements in the medical services offered to the population. It is high time to explore what services DMT can offer to a nation and society. By applying service marketing notion, this paper discusses how DMT can contribute to a better healthcare system within developed countries.

Possibilities for DMT

One issue this paper particularly stresses is whether medical facilities available in a certain area can be targeted and delivered to patients who have no access to such offerings. It has been suggested that DMT can improve the effectiveness and efficiency of care [5,6]. For instance, in the USA, structured domestic medical travel is gaining pace as organizations have contracts with centers of excellence at the national level to provide specific treatments to their employees, thus helping to reduce costs and improve quality of care [7]. This DMT practice is expected to contribute to improved quality of healthcare for the workforce (as workers can access centers of excellence). Those centers of excellence might cause a spill effect to a better quality of care to all thus contributing to overall healthcare equity. DMT can reduce the concern patients have if they travel abroad, which includes language and cultural barriers that can affect the processes of pre-and post-care negatively [8]. Recent evidence has confirmed that proximity of destination, language, and cultural likeness affect the behavior of medical travelers in choosing their destination [9].

DMT can contribute to healthcare equity differently in different contexts due to diverse healthcare systems shaped by institutional conditions across countries [10]. In the USA, the drivers of DMT include the availability of specialist physicians, decreased waiting times, high quality of care, lower costs, and inclusion of facilities under the coverage of the individual insurance program (e.g., workplace-based insurance programs) [11]. However, the European directive on patients’ mobility declares that member states should ‘retain responsibility for providing safe, high quality, efficient and quantitatively adequate healthcare to citizens on their territory’ [2, p. 1]. It is reasonable to assume that financial factors drive DMT in the USA context [e.g., 5, 7] while in the European context, it is socially driven [e.g., 2]. It is worth noting that the EU directive is still in its infancy, and changes can still be expected.

Globally, DMT is practiced in a variety of ways, such as exercising one’s rights (e.g., patient mobility in the European Union) and financial motivation (e.g., workplace insurance in the USA). However, several researchers have pointed out that since the choice option has primarily been used by affluent patients, there is a segment of the population that has not used DMT. The desire to address current concerns seems to motivate the use of service marketing, which can play an important role in reaching and providing service to a large number of healthcare consumers [12]. Marketing principles and techniques to create, communicate, and deliver value to influence target audience behaviors can benefit the society as a whole. We argue that by organizing, communicating, and delivering healthcare services to the needy people in a country, DMT has a big potential to grow and contribute to healthcare equity. To explore this potential, it is important to reflect on existing inefficiency in the service being offered and what difficulties stand in disseminating and communicating high-quality information to support the needy people in the country.

Challenges for DMT

DMT is designed to offer healthcare services to patients who have difficulty obtaining timely treatment in their locality. DMT can help healthcare providers to use unutilized resources that otherwise would be lost, as this unused excess capacity, cannot be stored for future use. Services marketing suggests that the ideal solution is a match between offering treatment and applying the excess capacity at the same time.

Insufficient knowledge and ignorance about healthcare provision policy are serious problems in promoting DMT. In service marketing, it is imperative that the service provider knows what clients need, and only then can the problem be solved with total customer satisfaction. Practitioners may fail to judge the situation accurately due to having only short-term contact with the patients or due to a shortage of resources. As healthcare is highly sophisticated, it is not easy for a patient to evaluate the outcome even after going through a complicated treatment or operation [13]. Service marketing can promote healthcare, but the promoters such as government agencies and DMT officials need to know the technique of promotion and what services they promote so that the patients and the society can benefit.

It is necessary to ensure coordination between organizations involved in offering DMT for better collaboration. Whereas good medical service is an important ingredient of the package, many other aspects are required to develop the whole concept. Organizing medical services and lodging for the patient’s families is a necessary part of the solution. Even other related issues, such as traveling by the patient’s family, need to be coordinated with relevant actors. Government organizations are important players in DMT but dealing with them is not easy; the intention is there, but bureaucratic hurdles can slow both the process and the competitiveness of the medical destination.

Future research agenda

One research issue deals with the delivery of services. In service marketing, the purpose of service delivery can fail due to not knowing what the customer wants and how to fulfill that need. It is important to consider that a patient seeking DMT is like any other customer who has a need to fulfill. This requires knowledge about the patient’s situation. Due to the sophistication of DMT service, healthcare providers must make sure that everyone, regardless of their background, gets quality treatment based on their necessities. Future research should answer the questions of how aware healthcare providers are of the patients’ demands and how they can satisfactorily fulfill them with the existing communication facilities.

A second area for research is also related to service delivery but concerns the ability and quality of doctors and service providers. Service quality can solve patients’ discomfort and thereby ensure optimal use of resources. The critique of increased healthcare inequity can be substantially decreased by utilizing the efficiency of service providers and offering quality treatment to underprivileged customers [14].

DMT offers local and national politicians an important role in harmonizing regional and national needs and making efficient use of available healthcare services within the country. Research is warranted to investigate how existing DMT is linked with a country’s medical sector and investigate what role DMT plays or can play to support population health. Potential research linking national cross border healthcare provision, is likely to aid policymakers in formulation of policies that ensure healthcare equity based on need.