A effective medical tourism telehealth strategy offered by branded, world-renowned specialists can attract patient referrals to their clinic.

Medical tourism telehealth consultations seem easy enough. One simply logs into a video conferencing system or voice-over-internet-protocol (VOIP) communications platform such as Skype (and many others) and sells their knowledge. Right? The patient pays via credit card or PayPal, electronic check, or in some cases even cryptocoin such as Bitcoin or its rivals. They ask the specialist what they want to know, get their answers, and then set an appointment to come to the consulting physician’s destination for treatment. And as if by magic, another medical tourism transaction is booked.

If only it could be as easy as it seems to do this legally, ethically and technologically!

A medical tourism telehealth strategy gives rise to several challenges. Among them the primary considerations include, but are not limited to: scope, reliable technology applications and platforms, communications laws, medical examiner credentialing, privilege and licensing issues, the actually workflow process, the transfer of personal health information (PHI) data (medical records, photographs, tissue/pathology samples, lab results and radiographic images), financial compensation, and capacity issues.

In the United States, about 10 million patients receive telemedicine services each year. Internationally, the number climbs much higher, especially when one takes into account telehealth relationships between workers in remote locations such as mines, oil rigs in the ocean, Arctic and Antarctic field stations, and in remote rural areas far from fully-equipped healthcare facilities.

Telehealth also exists in the form of “nighthawking”, the practice where cardiologists, radiologists and even gastroenterologists interpret diagnostic test results and render their professional opinions and diagnoses for procedures that occurred  around the corner, in a nearby metropolis, or thousands of miles away with several international boundaries and oceans between them. These outsourcing providers supply a wide range of professional medical services in multiple locations throughout the world. The way it works is that suppliers provide primary interpretations (“reads”) and secondary over-read services to hospitals, hospital networks and independent clinics. Additionally, they provide expert opinions and over-read services to third-party administrators and insurance companies. Some have medical/legal divisions where physicians offer expert opinions, testimony and expert witness services. In most cases, in order to be legal, the nighthawking physician deliverable must be countersigned by a locally-licensed physician and the liability for the accuracy of the deliverable is assigned to the licensed physician signing off on the diagnosis and interpretation of the nighthawker.

Often, patients are unaware that telemedicine is being used. This is a sign of progress, but it is also an indication of how telehealth has been adopted by many health care suppliers. In real practice, “seven deadly barriers” exist for telehealth. These include money, regulations, hype, adoption, technology, evidence, and success. And some are actually new barriers that come with the transformation of health care by telehealth and its relationship with medical tourism. An effective medical tourism telehealth strategy must be designed and deployed that addresses and overcomes each of these barriers.

Reimbursement concerns

Provider reimbursement for telehealth is often a major barrier to adoption and market expansion.

photo of Maria K Todd, MHA PhD (right) on tour with Geoffrey Kent (left) of A&K Global Health-Kenya in Singapore, on a field research mission to Asia with Fortress Investment Group and Kamaljeet Singh Gill (center) Chief Marketing Officer at Gleneagles Singapore
Maria K Todd, MHA PhD (right) on a 19-day, 4-country field research mission to Asia for Fortress Investment Group pictured with Geoffrey Kent (left) of A&K Global Health-Kenya, and Kamaljeet Singh Gill (center) Chief Marketing Officer for Gleneagles Singapore.




Many managed care plans in the USA, Nigeria, Colombia, Mexico, Thailand, South Africa, and Malaysia have no system to implement telehealth to effectively contain costs.


Maria K Todd, MHA PhD

“Telehealth Adoption and Feasibility for Medical Tourism”

Report to Fortress Investment Group (NYSE: FIG), (2012)

Some payers,reimburse very little in the fee-for-service system, and that reimbursement is largely limited to rural outreach, or to certain institutions and academic medical centers. When the plans were designed, they didn’t include telehealth utilization and claims costs into their actuarial projections, so there was no component premium built in to the rate plans to cover these services. These innovations and the required expanded coverage to pay claims for telehealth or medical tourism services take years to weave into the approval process by underwriters, actuaries and regulators.

Health insurers are slow to add telehealth services as medically-necessary covered services because they fear that subscribers and providers will abuse the health care system or that the inclusion of teleheatlh visits, absent clearly-defined use case scenarios will lead to overutilization and drive up claims costs.

Technology companies view telemedicine as an expansion area because they see large financial opportunities. As a result, many technologies are being produced by people who are attracted to the potential market of health care without really understanding the applicability of telemedicine and all the other concerns, constraints, legalities, and consumer quality and safety issues that arise when their systems are deployed.


Today, within the USA, there are multistate systems with multistate medical practices. Providers are licensed on a state-by-state basis. Therefore, a physician at the Cleveland Clinic in Ohio, with an Ohio license cannot make a diagnosis of a patient in Colorado, unless the Ohio physician is dual-licensed in Colorado. Otherwise, the physician is considered to be practicing medicine (a regulated occupation) without a proper, in-force medical examiner’s license. Practice regulations may be an even larger barrier than licensure, as many state medical boards require an in-person consultation before initiation of any telehealth services. This presents a significant challenge to medical tourism hopefuls not licensed in the place where the patient resides or works.

Physicians and healthcare facilities considering the use of telehealth as a way to generate revenues in a lawful manner may realize their medical tourism telehealth strategy is simply not feasible. Even if the patient wants to pay for the consultation as an independent consumer, the provision of the consultation by an unlicensed provider rendering the service could be deemed against the law. If the consumer does it anyway and ends up with a misdiagnosis, what recourse is available to protect the consumer? In which jurisdiction? Much of this depends on the contractual agreement between the parties and where venue, jurisdiction and governing law is declared and how dispute resolution and quality of deliverable are addressed in the agreement.  In medical tourism, often for telehealth, there is no negotiated contract, only a PayPal payment and a Skype consultation.

How popular would it be for a world-renowned specialist physician with hopes of using telehealth to generate medical tourism referrals to ask a prospective patient to sign a Waiver and Consent that says, “The client understand and agrees that the physician is breaking the laws and regulations of the jurisdiction where the patient resides/works by engaging in professional consultation as an unlicensed Medical Examiner, and the client agrees to pay for such services. The patient further agrees to indemnify and hold harmless the physician in the event of an erroneous diagnosis or incorrect treatment advice and planning.” So instead, most don’t bring up disclaimers and contracts and simply and quietly arrange payment via PayPal or some other electronic means and carry out the consultation via Skype or one of its rivals, and seal the transaction with payment for “services”.

Another wrinkle in medical tourism telehealth strategy: dispute resolution

When a dispute arises between a medical tourism telehealth physician and a consumer, the consumer can attempt to resolve the dispute, but the complex interstate or international landscape can be fraught with frustration. There are actually the six parties to a dispute when a credit card payment is made. These include:

  • The consumer
  • The consumer’s card issuer
  • The merchant
  • The merchant’s bank
  • The law, or laws of each jurisdiction (neither may be declared preemptive of the other)
  • The transaction processor

The rules of engagement between all six players will sometimes determine whether you can cancel payment after the service is rendered, but there are no guarantees. It is for this reason that PayPal expressly forbids transactions in its Acceptable Use policy to pay for medical tourism services, and has frozen and closed medical tourism facilitator and provider accounts if it discovers the breach. What is curious is to google “using PayPal for medical tourism” and notice how many medical tourism facilitator companies and providers are in violation.

Depending on your specific situation, there may be many other challenges and constraints involved in developing and executing a medical tourism telehealth strategy as a precursor to building prospective patient relationships that might result in future medical tourism business. Your strategy must be considered within the context of these specifics to be effective and sustainable.