Benefits and challenges of caring for international patients

Money matters

Foreign patients typically have limited or no medical insurance coverage and thus may be paying out of pocket or through limited governmental subsidies. Many refugees and asylum-seekers have no insurance or money to pay for care. (A full discussion of refugee care is beyond the scope of this article). Thus, it is necessary to ascertain in advance who will pay for the care.

Clinicians must be sensitive to the exorbitant costs of medical care and medications in the United States, particularly from the perspective of foreign patients. We strive to provide the best cost-effective care, but what is considered cost-effective and standard care for a patient with US health insurance may be viewed differently by international patients. For some foreign patients, some tests and treatments may be just too expensive, raising personal and institutional ethical concerns regarding how best to evaluate and manage these patients. Ideally, these issues should also be addressed before the patient’s appointment is scheduled.

Clinicians must optimize diagnostic and medical management while minimizing unnecessary testing. This principle further underscores the importance of obtaining a complete medical history and physical examination within a time-sensitive and well-coordinated plan of care.^2,4

Continuity of care after the patient leaves

As the medical evaluation and care plan approach completion, ensuring some form of continued medical care can become challenging. Some foreign patients may have the financial or legal means (eg, through an extended medical visa) to remain for further care and follow-up, but most do not.

Finding an available, willing health provider in the patient’s native country for continued management may be difficult and time-consuming. Most US medical centers have no established system to identify available foreign health providers, and usually the patient and family are responsible for arranging continued healthcare back in their home country.

Opportunities for possible improvement of care are noted in Table 2.

ADVANTAGES OF CARING FOR INTERNATIONAL PATIENTS

Despite the possible challenges, there are many benefits of caring for international patients.

Gaining medical knowledge

In US medical centers caring for both regional and referred patients, providers are often exposed to medical conditions that range from common ailments to the rare conditions (or “zebras”) taught during residency training. From the medical education standpoint, international patients provide US health providers heightened opportunities to encounter diseases not commonly seen in the United States (eg, infections such as malaria, schistosomiasis, drug-resistant tuberculosis, and advanced or end-stage forms of noncommunicable diseases). Although not limited to international patients, chronically neglected diseases often give providers first-hand experience in the natural history of select disease progression.

Gaining cultural knowledge

Caring for international patients also enables health providers to learn about different cultures, societal norms, and regional beliefs affecting healthcare. In essence, international patients enable US providers to become more diversified and enlightened with communication skills and assorted managerial strategies on a global scale.

These patients remind us of the stark differences regarding access and quality of medical care globally, particularly in lesser-resourced locations. In a busy domestic medical practice with its own daily challenges, many of us forget these international healthcare disparities, and often take for granted the comparative abundance of healthcare resources available in the United States. Provider frustrations about domestic policies and concerns for a “broken” healthcare system often blind us to the available resources we are fortunate to have at our disposal.

Further, as members of the global community, we have the opportunity to learn from international patients while broadening our view of humanity, thereby enhancing our awareness and empathy toward patients and communities struggling with under-resourced healthcare systems. Healthcare providers are often touched by the gratitude of patients for the opportunity to receive treatments that may otherwise be unavailable. Such experiences may motivate many US health providers to become more engaged in coordinated strategies for global health improvement.

Reimbursement is possible

Caring for international patients should not financially deter US health care centers. Complex, multidisciplinary care evaluations may incur notable expenses; however, alternative and more lucrative payer systems, including government subsidies, can be involved to maintain revenue, reimbursements, and even possibly lead to increased donations.^3–5 Given the potential for high costs to be incurred, US providers and institutions need to continually ensure appropriate evidence-based use of resources and cost-effective care without compromising the quality of care provided. The price of certain drugs has been rising astonishingly in the United States, and some patients may therefore prefer to obtain them for long-term use upon return to their home country.

High-quality cost-effective care is satisfying to the patient, provider, and institution, and also may save money that can be reallocated.⁴ Providers also may find personal fulfillment in striving for and achieving such goals, despite the potential challenges throughout the course of care.

Opportunities for improvement

Regardless of the challenges presented by international patients, participating medical centers often enjoy the prestige and credibility of becoming an “international healthcare center.”^4,7 From the standpoint of medical education, these centers have the potential to train providers with increased clinical and cultural competencies along with expanding healthcare services to include clinical, educational and research opportunities abroad.

Research is needed to provide evidence-based guidance on best strategies for patients, clinicians, and healthcare systems to effectively care for international patients.

Suggested opportunities for maximizing advantages are noted in Table 3.