One Florida doctor has seen the face of medical tourism from both sides. Dr. Dror Paley, a Canadian-born orthopedic surgeon, has invented many of the treatment protocols for limb lengthening. Patients — many children with birth defects — travel from all over the globe to seek his help. He and a second surgeon perform difficult specialty procedures on more than 1,000 patients a year at their south Florida clinic.

However, 10 percent of his operations are on adults who want to be taller for cosmetic reasons. Insurance does not cover most cosmetic surgery, so they pay out-ofpocket. By Paley’s estimation, his is one of the largest, if not the largest, medical tourism practices in the world. His ought to be a model for medical tourism, but so far, it hasn’t worked out that way.

For decades, medical tourism has promised to be a potent disrupter to the continued high cost of the current U.S. delivery system. The idea is that health care would become so price-sensitive, patients would leave their community — and even country — to travel abroad to seek care, often in tourist destinations, for a lower price. Paul Keckley, a leading health care futurist, less than a decade ago famously predicted that medical tourism would reach 35 percent market penetration. In recent years, he and other experts have kept revising their estimates down as medical tourism market penetration languishes.

In the past, these market experts have attributed this lack of growth to several factors. These include reluctance by employers, who bear the insurance costs for so many, to push for it with their health insurers. And most U.S. citizens, especially seniors, don’t want to travel abroad for care. And there are concerns about non-clinical medical tourism facilitators arranging care. Beyond these challenges are the conflicts arising from different attitudes about health-record privacy around the globe, notably issues with HIPAA — the Health Insurance Portability and Accountability Act. But some countries are developing solutions to the challenges and making progress nonetheless.

Consumer reluctance was clearly found by a Deloitte 2012 survey, where Keckley was executive director of Healthcare Solutions until 2013, that revealed Americans were less likely than citizens of any other country to go for foreign care. The idea of medical tourism may be a popular concept with health care professionals, but consumers are wary and just not that interested.

“I estimate that no more than 2 percent of U.S. and Canadian inpatient hospital stays are at overseas hospitals on any given day as medical tourists,” says Dr. Maria Todd, of the Mercury Advisory Group, which consults across a wide range of health care delivery models, such as concierge medicine, accountable care organizations and managed care.

“Medical tourism could have been a disrupter — it was poised to be a disrupter,” she said in a recent interview while consulting in Greece on medical tourism. “But it hasn’t happened.” She attributes this to several factors, one of the biggest being the lack of medical or health care experience among those working in the field, which reveals itself in small details.

“For example, I just came back from the Athens airport visiting with managers and I learned that any patient traveling to Greece who needs a wheelchair must give 36 hours notice,” says Todd, who has both physician practice and hospital experience. According to Todd, the number of handicapped patients visiting Greece has increased from 7 to 12 percent in the past seven years for those who want to vacation at resorts near dialysis centers and other health services. But airport management there reports many medical tourism facilitators are not aware of the need for wheelchairs.

“I’ve seen medical facilitator certificate programs that have medical facilitators doing work that should only be performed by a registered nurse,” Todd says. “That’s not safe.”

Then there is the bigger problem of medical record privacy and the shoving match going on between the U.S. and the European Union. “The EU openly states that HIPAA does not meet their requirements for data privacy,” Todd notes. “Because of this dispute, U.S. insurance companies are reluctant to sign off on their patients going to the EU for care because they don’t want the liability related to privacy.”

To gain ground, medical tourism needs a good example. Todd said that she thinks South Korea has gone about setting up its medical tourism system well. According to Patients Beyond Borders (PBB), South Korea’s top three product lines for inbound medical tourists are cosmetic surgery, prostate cancer and cardiology treatment.

“The Koreans have set up an arbitration system for care and outcome disputes. They also require [registration by any] medical tourist facilitator who promotes them as a destination. What I like about that is they are regulating those outside the country who are marketing the country, which protects their brand.”

According to Forbes, in 2014, 1.25 million Americans traveled “outbound” to receive medical treatment. Patients Beyond Borders, which compiles an annual publication of industry and patient information, in 2013, lists the U.S. as the second largest single “inbound” destination (850,000 to 1.25 million) for medical tourists, behind Thailand (1.3 to 1.8 million). Cosmetic surgery is the most commonly listed specialty sought by medical tourists, with dental, cardiology, cancer/oncology and orthopedics topping the list of product lines. There is no doubt health care costs are significantly less outside the U.S. For example, according to PBB, heart bypass surgery in the U.S. is $88,000 compared to $20,800 in Malaysia, while a hip replacement runs $33,000 compared to $12,500 in Malaysia. Still, Todd said that most of the cross-border medical tourism occurring in the world is between countries outside of the U.S.

Because medical tourism appears to be much more of a viable option for the uninsured, the practice self-divides into two groups. Self-pay, as opposed to insured patients, are reported in the Deloitte survey as more likely to travel abroad for medical procedures.

“Medical tourism has opened up the store throughout the world,” says Joe Harkins with the U.S.-based Medical Tourism Association, speaking for Reneé-Marie Stephano, president and a founder of the association, who was traveling out of the country. “Medical tourism offers both price-point and procedures that may not be available to a patient in their community or country.”

Many medical tourism and destination locations go hand-in-hand — location is a strong part of the draw.

“South Florida is a really nice place to recover,” says Paley who cites the contribution location makes to the healing process. “The warm climate is helpful to patient attitude, which is vital to recovery. My patients can rehab outside without wearing covers on the devices I install as part of their treatment. And they can swim in a pool or the ocean —saltwater is very good for healing wounds.”

About 10 percent of Paley’s practice is for “cosmetic limb lengthening,” a treatment for people who want to be taller. He regularly sees patients who have gone to programs in other countries who “rebound” to him with complications. According to Paley, programs in other countries will charge as little as $10,000 for limb lengthening that can result in complications, compared to up to $80,000 for a procedure at his practice. He said it can cost up to 200 percent more than the original charge to correct a complication.

Concerns about the quality and safety of medical tourism are a recurring theme. The American Medical Association’s policy H-450.937 lays out the parameters that it feels constitutes acceptable care under a medical tourism delivery model. The policy covers nine points including the directives that: patients should only be referred to institutions that have been accredited by recognized international accrediting bodies (Joint Commission International or International Society for Quality in Healthcare); financial incentives should not inappropriately limit treatment options; transfer of patient records should be consistent with HIPAA guidelines; and care should be coordinated with providers in their local community.

“The risks of seeking care outside the U.S. include the possibility that patients may have little recourse for poor outcomes,” says Robert Mills, media outreach manager for the AMA. “This is why it is vital for patients to ensure their care will be coordinated upon return to the U.S. Patients must also determine whether care will be covered (by insurance) once they return to the U.S.”

While Mills said that some insurance companies and health systems have made arrangements for patients who return from abroad for medical care, the truth is that U.S. physicians and hospitals have little incentive to participate or cooperate in the medical tourism delivery model. Local community-based providers, after all, lose business under medical tourism. Referring primary care doctors have tight and often lifelong bonds with the specialists to whom they refer patients. If medical tourism were ever to reach the 35 percent level that Keckley once predicted, it would force providers to compete on price — that would be extremely stressful to the current U.S. health care system. Everyone in the system — from doctors to nurses to hospital administrators to insurance companies — would have to reinvent themselves to compete and they would have to make less money to do so.

There is an argument to be made that medical tourism penetration could grow in the current U.S. health care environment. While the ACA has expanded coverage to millions of more Americans, the insurance plans offered have high deductibles making care more price-sensitive. Also, the growing trend of concierge medicine, a very entrepreneurial practice model for primary care doctors, could help grow medical tourism. Concierge medicine currently accounts for about 5 percent of medical practices (mostly primary care) and is growing at a rate of 15 percent a year. Physicians in concierge medicine practices have a strong incentive to serve their patients’ best financial interests, rather than that of local specialists or hospitals. However, this potential is offset by the growing trend of physician employment by hospitals, which now accounts for about 40 percent of U.S. doctors.

“We have a long way to go before the system is ready to easily slingshot Americans over the “pond” to get treatment,” Todd concludes.