Health Care Abroad

Traveler Summary

Key Points

• Carry a medical summary and list of medications used regularly. If possible, have records translated and carry note cards with diagnoses, medications, and allergies.
• Have contact numbers and emails for home-town physicians available on personal cell phones in order to transmit self-images or lab results and x-rays.
• Understand what the payment arrangements are for care (e.g., cash only or credit cards). Major health insurance is increasingly accepted, but in underserved areas, cash upfront is expected. Carry enough cash to initiate treatment in more austere destinations.
• Understand that many common, major illnesses (e.g., myocardial infarction, stroke, and acute abdominal illness) can be well managed locally in private hospitals in major cities.
• Have travel medical insurance and medical evacuation coverage for serious illness or injury that cannot be managed locally (such as in remote areas).
• Medical evacuation, which can disrupt care, should be considered in complicated cases once the person has stabilized or appropriate next-level care is unavailable.
• Go first to a "trusted local agent" in cities with few private hospitals or one that is large enough to have all services all the time. Such a local agent will be an internationally owned (sometimes locally owned) small to mid-size outpatient practice that can handle the appropriate referrals (even for very ill patients).
• Consult Joint Commission International (www.worldhospitalsearch.org), travel-health insurers (such as GeoBlue and Travel Guard), or an embassy or consulate for referral lists. (US embassies will not provide payment but can assist with funds transfers.) Professional and trade organizations are other resources for local routine care or referral.

Introduction

Persons traveling abroad are at greater risk for illness and injury than are non-travelers. About 30-60% of travelers experience some type of health issue while traveling abroad, and approximately 15% seek medical care.

Any medical event can be frightening, but when one occurs in an unfamiliar country, the fear and uncertainty can be greatly amplified, particularly if the traveler does not speak the local language and is not aware of local health customs.

Consequently, the first reaction to anything other than a minor illness is often to try to "get home." However, even in developing countries, travelers and long-term expatriates need not assume they must return home to receive adequate medical care. Well-equipped (often private), "cash-up-front" medical facilities with well-trained staff are often available, even in developing nations.

Assessing available care resources, however, can prove a daunting task. The challenges include understanding the capabilities and limitations of available medical resources, making timely and informed decisions about their use, and knowing when it is best to return home or an intermediate destination for a higher level of care. Proper planning prior to travel can help travelers and their providers address these challenges successfully.

Pretravel Preparation

Travelers anticipate the need for medical care. A basic concept about the need for care is that "common things happen commonly." Knowledge of these most common problems allows the traveler and his or her travel health provider to take appropriate actions to prevent these issues, prepare for their possibility, and, if they do occur, obtain care at the appropriate level on the care spectrum.

Three of the four most common issues are gastroenteritis, upper respiratory disease, and skin conditions. These issues usually lend themselves well to self-care or remote consultation, at least initially.

The fourth common issue is illness with fever; depending on the location, this may require entering the destination health care system earlier.

Items to Carry

• Basic medical kit (see Packing Personal Medications and Supplies).
• Summary of any chronic or preexisting medical conditions, contact information for the key health care provider at home, and information on recent lab tests, ongoing medications, and electrocardiogram (ECG) tracing.
• Supply of all routine medications adequate for the length of the trip plus a buffer to cover unforeseen changes in plans or situations. Long-term travelers should carry enough medications to cover until they have a means to obtain a resupply at the destination (see "Medication Issues," below).

Plan for Accessing Medical Care

Available sources of care can include self-care, local care, and evacuation. In addition, many issues can be addressed with phone calls to or video chats with a provider at home. Before departure, travelers should check with local providers to see if they are willing to communicate via phone or video chats.

For travelers with significant ongoing medical problems, if available medical care is inadequate, the trip should be reconsidered.

Travelers should develop a list of medical facilities, health care providers, and reliable pharmacies, with location and contact information.

• Consult a travel health care provider for information.
• Many US Embassy websites abroad provide non-prioritized lists of medical facilities and services. They cannot recommend specific providers but typically delete providers from the list if there has been a history of issues.
• Long-term travelers may wish to speak with others who have lived in the destination; the best recommendations for medical care often are by word of mouth.
• Travelers who are working with an overseas assistance company can ask about local doctors who may be recommended.
• Some credit card companies will provide referrals to medical facilities overseas.
• Most major cities have quick-dial emergency assistance numbers (such as 911 in the US). Ensure access to these numbers at all travel sites.
• Persons traveling with a tour group can ask about policies and procedures for accessing care during the trip.

Individuals associated with a company or organization who are being moved overseas should learn about the policies and procedures for medical evacuation.

If a pregnancy is planned or possible during overseas travel or assignment, travelers should research options for obstetrical care. For long-term travelers or expatriates, if local facilities are inadequate, some organizations send employees (or family members) home for delivery and others send patients to nearby countries with adequate facilities.

Planning for Payment

Travelers should have an understanding of payment practices of medical facilities and health care providers at the destination and have a plan for paying for medical care. Doctors' offices and hospitals in other countries expect to be paid in full, usually up front. With some exceptions (mostly in a few developed countries), personal health insurance or travel health insurance is not an accepted up-front payment option in other countries.

• Preexisting private health insurance

  • Consult the health insurance company prior to departure to learn what is covered overseas. Large insurance carriers may have lists of facilities at certain destinations for which advance arrangements are in place.

  • In most cases, medical expenses are not paid by insurers at the time of treatment, thus requiring the patient to pay and then request reimbursement.

    • Insurers may reimburse upon return if there is proper documentation (an itemized bill, in English, with procedures and diagnosis).

  • If there is a need for hospitalization, surgery, or major procedures, find out if preauthorization is necessary and how that is done, including any restrictions that may apply.

• Travel-specific insurance. There are 2 types of insurance related to travel:

  • Travel health insurance. Many variations are available. Travel health insurance is typically oriented towards providing assistance and monetary support during health situations abroad. Travelers should understand how their regular health insurance and travel health insurance would interact in the event of an issue abroad. Check for exclusions (e.g., pregnancy complications, age, preexisting conditions, injury due to activities such as scuba diving or mountain climbing). Ask if pretravel physicals are required. Some travel health insurers reimburse medical expenses only upon return, while others will pay for services at the time of need if preselected providers are used. Many travel health plans include additional services such as:

    • 24-hour call center/e-mail for referral to local hospitals physicians and dentists
    • Guaranteed payment to the medical facility delivering care or advancing money for on-site payment
    • Access to prescription replacement for lost, stolen, or forgotten medications
    • Arranging transportation home after treatment and stabilization
    • Arranging second medical opinions in hospital cases
    • Transfer of medical records
    • Access to translators
    • Coordinating with the policy holder's health insurance company at home

  • Evacuation-only insurance. This is primarily oriented to medical evacuation (including air-ambulance).

    • Even travelers with good international coverage and support from their preexisting private health insurance still need additional coverage for evacuation, which is almost never covered by individual health insurance. Arranging medical evacuation by air ambulance to a qualified medical facility, including on-board medical staff and equipment, is complex and expensive (cost without insurance typically begins at more than USD25,000 and can go over USD100,000 depending on needs).
    • Many commercial evacuation-only policies are available and are often sold through travel agents, travel clinics, and online. As with specific travel health insurance, travelers should pay close attention to any exclusions and limitations.

• Medicare and Medicaid do not pay for care or medications outside of the US

• Be prepared to pay cash "up-front" for any needed care. Travelers should create a plan for accessing cash in an emergency, which may include extending credit card limits. Have the access code and phone number of the credit card company in case a card is lost or stolen. Speak with family members or friends and review with them how to wire money if necessary.

After Arrival

Prepare for Medical Care and Emergencies

• Confirm the location and status of the facilities selected during pretravel preparation. In developing nations, the status of facilities can change frequently.
• Hotels often have commission arrangements with physicians or hospitals, so front-desk advice should be scrutinized carefully.
• Confirm locally whether it is best to call an ambulance or a taxi (or private vehicle) in an emergency. In some countries, ambulances are little more than empty vans and may be required to transport to a public facility, which may not be the best choice for medical care.
• Private hospitals often have their own ambulances, accessed by contacting the hospital directly. In that case, the relevant phone number should be kept at hand.
• Keep the emergency number close and learn how to use the telephones and dial sequences necessary to access local and long-distance circuits from any phone. Long-stay travelers should program their local mobile telephones accordingly. Keep in mind that telephone numbers, access codes, and area codes change depending on location and type of phone.

Accessing Medical Care

• If an emergency medical problem occurs (e.g., chest pain, stroke, excessive bleeding, severe abdominal pain, difficulty breathing), take quick action:
• Have a trusted companion come along to the hospital (traveling companion, friend, relative, or hotel employee if no one else is available).
• Use the emergency call number or other means to call for an ambulance or taxi and proceed to the appropriate medical facility.
• Once emergency help has been accessed, if more extensive treatment is required and travel health insurance was purchased, call the insurer for assistance. The embassy or consulate may be able to provide limited assistance, including contacting family members.

If a non-urgent medical problem occurs, the following actions can be taken:

• Check the medical kit for appropriate remedies (e.g., antibiotic for travelers' diarrhea or urinary tract infection, cold medication, antihistamines, etc.).
• Travelers with travel insurance can contact the insurer for guidance.
• If unable to rectify the problem using self-care or via phone or e-mail to a health care provider or at home, consult a local physician from the prepared list, or contact the embassy/consulate for a list of local providers.
• If other sources of help are not available, ask for a hotel physician. There is no guarantee as to the qualifications of a hotel doctor, but they may be helpful. Be sure to get the physician's name and office number in the event of follow-up problems or questions.
• Ask other travelers for recommendations for local medical care.

Considerations for Long-term Travelers and Expatriates

A high priority for new arrivals should be establishing a medical plan. Some questions to consider include:

• Where can key services be obtained (e.g., primary care, cardiology, pediatrics, OB/GYN, etc.)?
• How are appointments made?
• What is the cost of visits and method of payment?
• How is off-hours care handled, including urgent care/emergencies?
• How are prescriptions renewed?
• How to access 24-hour pharmacies?
• Once a provider is found, what hospitals do they work with?

Confirm facility information in order to decide on the best available facility should an urgent situation develop.

• Is the Emergency Room (often called "Accident and Emergency" or "A and E") open 24 hours a day?
• What X-ray and imaging services are available: plain X-rays, CT, MRI, ultrasonography?
• Are there critical care units (intensive care, cardiac care)?
• Is blood screened for HIV and hepatitis?
• Are only disposable needles and syringes used?
• Are vaccines such as tetanus, rabies immune globulin, and hepatitis immune globulin available?
• Is there an orthopedist on staff? A neurosurgeon on staff? Are there other specialists on staff?
• Do staff members speak English? Are there translators available at all times?
• Can the hospital arrange for emergency transportation to a more advanced facility?

Medication Issues

• Check for any medication restrictions

  • In some countries certain products are banned; for example, in Japan, products that contain stimulants (e.g., pseudoephedrine, an ingredient in medications such as Actifed, Sudafed, and Vicks inhalers) or codeine (an ingredient in medications such as Tylenol 3) are prohibited.

  • Some common medications (including insulin) cannot be imported into many countries without lengthy procedures to obtain a specialized permit, even for personal use.

    • Follow these guidelines for personal medications:

      • Bring quantities (only personal use) suitable for the duration of the trip plus a reasonable buffer for changes in plans.
      • Carry medications in their original prescription bottles.
      • Carry a copy of the prescription.
      • Having a valid prescription lessens the risk of confiscation at border crossings and will facilitate obtaining a prescription from a provider at the destination, should that become necessary.

• In many countries, no prescription is required for medications other than narcotics. In this case, possession of a prescription from home will still assist the pharmacist in determining the closest locally available match to the required medication.

• Travelers should be aware of the prevalence of counterfeit medications and poor quality control of medications in many countries around the world.

  • Whenever possible, use trusted pharmacies identified by sources such as an international clinic or an international medical assistance provider.
  • Attempt to ensure that medications are from international providers rather than local manufacturers, when possible.
  • Examine packaging carefully for signs of tampering or poorly executed "safety seals" designed to approximate the real product (manufacturers' websites often have detailed descriptions and pictures of their packaging and tamper-control seals to aid users in confirming that the medication is not counterfeit).
  • Finally, as with any product, if the price appears to be too good to be true, it is a red flag, although developing world prices for legitimate medications are often lower than in developed nations.

What to Expect from the Embassy or Consulate

Travelers should have the phone number and address of the embassies or consulates in the foreign countries to be visited. Especially in developing nations or anywhere where there is any instability, travelers should register with consular authorities of their own country before or immediately upon arrival. This is an online process for citizens of the US, Canada, Australia, and the EU. Locally, the embassy or consulate can be of help if a medical problem occurs.

Most embassies or consulates can assist by:

• Providing a non-prioritized list of medical facilities/services. They cannot recommend specific providers, but they typically delete providers from the list if there has been a history of issues. Due to local sensitivities, such lists are not always publicly posted on an embassy's website.
• Organizing the transfer of funds from the home country
• Informing family or friends at home in the case of an emergency or injury
• Helping organize medical evacuation
• Informing the family in the event of a death and assisting in arrangements to return the body to the home country

The embassy or consulate cannot:

• Offer medical services or drugs
• Supply cash to pay for medical expenses
• Pay for medical evacuation or guarantee payment
• Pay the expense of returning a body to the home country