Headlines vs. Reality
Over the past several months we’ve seen headlines like:  Trump’s travel ban causing angst for America’s health system (CBS News), How Trump’s travel ban could hit medical tourism hard (Modern Healthcare), and Travel ban hits hospitals hard (CNN).  Sounds pretty dire, doesn’t it?  But let’s look a little deeper. 

First, as you read further, these articles do not predict a lessening of patient travel for the serious illnesses – cancer treatments, pediatric conditions, cardiac surgery – but possibly for less complex and optional procedures that can be carried out elsewhere in the world. Additionally, there is the possibility of a negative effect on welcoming foreign medical students and researchers coming to the U.S.  These are not good consequences but they are, first of all, conjecture, and second, limited in impact.  What remains a constant is, if the condition is serious, and patients have the means, they will go anywhere in the world to get the best treatment.  

Second, the travel ban, which has not gone into effect as yet and still faces challenges, is slated to affect people from six countries:  Iran, Yemen, Syria, Libya, Somalia, Sudan. (Iraq had been included but was not allowed by a recent court decision.)  Importantly, the majority of international patients do not come from these countries.

In the most recent data, while patients visiting leading AMCs – Academic Medical Centers – come from all over the world, large numbers emanate from the Gulf Cooperation Council, Mexico, China, Bermuda, Latin America and the Caribbean.  What these countries and regions have in common are the following:  when good care is available locally but many patients still want the peace of mind of a respected second opinion; when local medical is care not perceived, at least by many local residents, to be up to the foremost standards, or is not providing the latest breakthroughs; when substantial numbers of the population have the financial wherewithal; and they have freedom/access to information and travel to the U.S. or Europe or wherever the care resides…the patients will pursue what they believe is superior care.

And, historically international medical travel to the United States follows what can be described as regular cycles.  It tends to rise over five year periods and then level off, or even decline, when several factors coincide: 1) Leading U.S. medical institutions get busy, seeing a steady flow of global patients and backing off on pro-active efforts to attract more patients and 2) Other countries achieve improvements in local healthcare that can compete, even temporarily, with U.S. and other foreign alternatives, and 3) Other competing regions not only make medical progress but step up marketing efforts to increase share. 

Typically, a few years later, two more factors come into play:  1) U.S. medicine achieves advances in treatments unavailable as yet in those countries and 2) U.S. medical centers again get aggressive in marketing to, and attracting, global clientele.  Then, the U.S. centers appointment books get filled once more, followed by local countries catching up to some extent medically, international visits leveling off, and so on…  And it seems to happen every five years.  The exception would be following 9/11, when total international travel – leisure, business, medical, educational – all declined.  When life began to return to relative normalcy, all types of international travel picked up.

Up or Down?  What’s likely to happen?
Since we are now at a high point for global medical travel, we can expect a flattening and decline based on the predictable five-year cycles.  If it occurs again, it will not be the result of a travel ban.  Or politics.  Or panic.  It will be because of patterns of human behavior in science, economics, investment, marketing, and culture.

The priority of health
Let’s look at why people come to the U.S.   AMCs are not your average, or even better than average, community hospital.  They are the leading institutions in the country and the world. They are affiliated with medical schools and have tripartite mission: patient care, teaching and research.  They exist to recruit and train the best practitioners; they are focused on the discovery of knowledge to improve health; they provide the most advanced and cutting-edge care, including new treatments considered experimental, tested in clinical trials, as well as aiming to improve the value of care for the cost.  Nowhere else in the world is the focus on excellence and advancement concentrated as it is at leading AMCs. 

As a result, people in the U.S. and from around the world come, not for routine medical issues, but for the most complex conditions, those that may require sophisticated diagnostics, high-risk surgeries, drug protocols, and new technology.  Often people from other countries simply cannot receive the treatment options in their home countries and/or face long waiting lists to be eligible for care, or lack trust in their local medical care.

Patients have come to leading U.S. medical centers for advanced diagnostic work-ups such as molecular testing for cancer and other tests for detection and/or confirmation of the need for sophisticated interventions.  They come for oncology, cardio-vascular issues, neurosurgery, pediatric care, and complex orthopedics.  Either the best treatment is not available in their home countries or the delivery is not perfected or trusted as yet.  By way of example, today bone marrow transplants are not provided in the many parts of the world yet they are carried out routinely at leading AMCs.   The U.S. continues to lead the world in the treatment of the most challenging illnesses and conditions. 

Many global citizens cannot get the best care at home but can afford to seek it out.  While some countries remain relatively unsophisticated medically, often many residents are affluent, educated, and worldly and can pay out-of-pocket, or can purchase expensive health insurance.  Or they may be employees of multinational corporations, members of the diplomatic corps and other government-sponsored individuals.  And the information on what medical advancements are occurring, and where, is readily attainable thanks to ubiquitous Internet access.  

And importantly, many international patients simply prefer the way medicine is practiced in the U.S. – private, patient-centric and patient-inclusive, transparent, and holistic.

The fact is, if the condition is serious, and patients can afford it, they will go anywhere in the world to get the best treatment.  

Perception or reality – what is occurring?
While this is not a statistical sample, here are some paraphrased highlights from responses to 2 basic questions from some colleagues at leading AMCs – small and large, in different parts of the country:

1) In the past year, in light of proposed or actual U.S. travel protocols, have you seen any meaningful change in number, origins, or other factors in patients come from anywhere abroad to your medical center…particularly GCC countries?

• No, the recent (political) changes didn’t affect the flow of patients.  Some delays in getting visas but not significant.
• We are at our peak season and seeing an increase in Saudi self-pay referrals. 
• We have seen an increase in UAE referrals.
• Most patients are from the GCC, not much from the other MENA countries.
• We have not heard concern from patients about the U.S. attitude toward travel.
• We have not heard from patients that they are having difficulty obtaining a VISA.
• No, though it may depend on the patient’s country of origin.
• No, we haven’t noticed any substantial change.

2) Overall, this year, are you seeing any flattening or decrease in number of
international patients?

• No, post 9/11, we did lose most of our patients from GCC due to anxiety, not so much visa issues. The GCC medical visits returned several months after.
• Colleagues around the country have seen some decrease in referrals from the GCC but none think that it’s due to the travel ban (although some express concern about political rhetoric.)
• For us, only one patient cancelled a visit.
• Our volume, along with just about everyone, from the Middle East is down sharply but we don’t believe the primary reason is administration policies…
• We (and others) have seen a decrease in Saudi referrals; however, we think this is due to Saudi Vision 2030 reform plan (building internal economic, medical, social stability.)
• We assure our patients that traveling to the U.S. for medical reasons is possible and that they shouldn’t worry.
• California has made it clear that we are a sanctuary for travelers.

What can/should we do?
Since the cyclical nature of international travel seems inevitable, and since the travel ban is not yet a reality, can we or should we do anything to change or affect the outcomes?  Yes.

There is no absolute assurance that five-year cycles will repeat themselves; they are historical but predictive data is not guaranteed, just probable.  So we should be ready for it to occur…or not.  And, even if they do occur, there’s no reason to live with the ups and downs when perhaps we can impact them positively.

Leading AMCs should not let themselves get complacent when patient visits are high and only react when the numbers falls.  Now, more than ever, it is important to pro-actively send the message to international communities that they are welcome at our institutions.  We, AMCs, are not anti-anyone, only pro-medical excellence.  That is why we exist. 

We should continue to enhance our outreach, assure patients we literally speak their language, understand their customs, provide appropriate accommodations, respect cultures. 

We should not be shy about letting international patient populations know about our advancements – what tests, medications, and procedures they can get here that may not be available where they live.

And we should consider the global situation an opportunity to spread our “brands” around the world, not only in perception, but in fact.  This may be the spur we need to accelerate cooperation with international communities to build first-rate medical facilities in their countries.  If there is any reluctance for the patients to come to us, this is the incentive to take our AMCs to them.

People who need the best medical care will do almost anything to get it.  The leading AMCs deliver it.  The travel ban, if it comes to fruition, may not impact that human drive. Or it may have only a temporary affect.  But it is the mission of leading medical institutions to assure it is available.  Here.  There.  Wherever it is called for.  The need for the best medical care outweighs all other factors.  It is our job to provide it.