Cross-border utilization of cancer care by patients in the US and Mexico – a survey of Mexican oncologists | Globalization and Health

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This study represents a comprehensive record of cancer care utilization across the US-Mexico border, with information obtained from cancer care providers working in Mexican border states. Our results show that the scope of cancer care utilization outside of patients’ home countries is considerable, and mostly driven by financial issues, availability of tests and medications, and a perception of superior care abroad [4, 7, 8, 17]. Our findings are consistent with prior studies of bidirectional healthcare utilization in the US and Mexico, particularly concerning the limited accessibility of certain therapies and recently developed diagnostic tests, such as CAR-T or NGS.

Although efforts have been made to provide universal access for cancer care in Mexico, many patients are still required to pay for medications and other healthcare expenses, which may sometimes be unaffordable. In an analysis of National Health and Nutrition Survey data, over 17% of beneficiaries of public healthcare systems could not obtain prescribed medications [18]. Since 2020, the National Fund for Wellbeing (FONSABI) has overseen financing catastrophic health expenses, such as cancer care, although the supply of medications and access to many interventions has been inconsistent since its inception [19, 20]. The limited availability of cancer drugs in Mexico is highlighted by the fact that the average availability of essential cancer medicines (as defined by the World Health Organization) covered by Mexican public health insurance is of approximately 60% [21, 22].

US-based patients who traveled to Mexico were more likely to be seeking chemotherapy, surgery, and radiation, which may be due to the lower cost of these treatments in Mexico. In contrast, Mexico-based patients traveled to the US to obtain therapies which are either unavailable or not covered in Mexico such as immunotherapy, stem cell transplantation, and cellular therapy [23, 24]. Interestingly, US-based patients traveled to Mexico often to undergo imaging and other diagnostic tests, which may be due to their affordability and accessibility, particularly for patients with limited health insurance. Mexico-based patients traveled to the US to receive more novel tests, such as NGS or nuclear medicine, which may be due to limited availability/coverage of such testing in Mexico [25].

The most common reason reported for US-based patients traveling to Mexico was inadequate health insurance coverage. Disruptions in health insurance coverage are common among patients undergoing cancer treatment in the US and are associated with worse survival [26]. Delays and denial of medical care due to health insurance review, also known as prior authorization, have also resulted in a significant adverse impact on treatment initiation, receipt of diagnostic imaging, and out-of-pocket expenses in patients with cancer [27]. These issues likely lead some patients in the US to seek care in Mexico. Other reasons why US-based patients traveled to Mexico included access to alternative therapies, language barriers in the US, and availability of a more robust social support system in Mexico. These findings correspond to previous reports highlighting the use of alternative medicine as a major driver for individuals in the US seeking care in Mexico [28]. Conversely, Mexico-based patients traveled to the US primarily due to patients’ perception that cancer care was of higher quality in the US and that medications, imaging studies, and other diagnostic tests were unavailable in Mexico. Overall, fewer respondents reported interacting with Mexico-based patients who traveled to the US to buy medications, undergo imaging, and receive diagnostic tests than the number of respondents who reported interacting with US-based patients who traveled to Mexico for these services, which most likely is due to financial issues.

Lack of financial resources was the most common limiting factor among patients who wanted to go across the border to receive care but could not. The cost associated with traveling, lodging, and reduced income related to loss of employment from taking days off from work have been shown to impose significant financial hardship on patients with cancer in both the US and Mexico [29, 30]. A significant proportion of Mexico-based patients were unable to travel to the US to receive cancer care because of passport/visa issues and language barriers, while many US-based patients were unable to travel to Mexico to receive cancer care because of the absence of a support system in Mexico.

Our results may have implications for binational and cross-border policy. In Mexico, patients with cancer can receive care from institutions in the private or public sector. Patients who receive care at private pharmacies and health facilities typically contribute financially to private insurance companies and pay out-of-pocket expenses [31, 32]. Patients treated at institutions in the public sector usually have social health insurance, which unfortunately may be limited due to medication shortages or access issues [31, 33]. In the US, patients with cancer typically receive care from National Cancer Institute (NCI) comprehensive cancer centers, NCI-designated cancer centers, or community cancer practices. Patients with cancer who lack health insurance in the US are more likely to be diagnosed with advanced-stage cancer at diagnosis and have worse survival after diagnosis [34,35,36]. People living in the US along the US-Mexico border have lower health insurance rates [37], with some reports estimating the percentage of uninsured individuals in border counties at nearly 50% [38, 39]. One proposed solution to providing care to undocumented immigrants, as well as to address the liberal utilization of healthcare in both the US and Mexico by people who lack health insurance, is a binational health insurance plan. Two such programs were “Salud Migrante” for uninsured Mexican immigrants and “Medicare in Mexico” for older Americans [40]. Theoretically, these programs would allow undocumented immigrants to travel to Mexico to receive care while their legal status is in flux and enable Americans eligible for Medicare to travel to Mexico for components of their healthcare, respectively. Ultimately, these programs were hampered by legal and regulatory challenges and had to be discontinued.

The impact of bidirectional healthcare utilization by patients in the US and Mexico is clear in Mexican border cities, where more private (compared to public) primary care providers exist to serve patients from the US seeking care in Mexico [41]. At a patient level, bidirectional healthcare utilization may also have a significant impact. Patients who travel outside their home country to receive care often receive concurrent treatment by providers in two sites, leading to duplication of diagnostic tests and treatments [42]. This phenomenon could theoretically result in increased healthcare costs and raises a multitude of patient safety concerns. Further, the quality of healthcare provided along the Mexican border, particularly concerning elective procedures, wellness services, and fertility expertise, has been called into question [2, 43]. Risks such as lack of appropriate longitudinal care, the acquisition of multi-drug resistant organisms during surgical procedures, and lack of standardized quality control measures have led to instances of significant morbidity and mortality in patients traveling to Mexico for these services [2].

A highly complex issue affecting cross-border care is the existence of legal barriers related to immigration, as highlighted by our study findings showing a significant proportion of patients saw passport/visa issues as a barrier for getting care. Over 20 million noncitizens are currently living in the US, of which almost half are uninsured [44]. In the US, undocumented immigrants are ineligible to obtain federal health insurance offered by the Federal Health Insurance Market Place as a provision of the Affordable Care Act [45, 46]. Those seeking asylum in the US are eligible for Medicaid or other forms of US-based public insurance, while qualified noncitizens can buy insurance coverage in the marketplace during their first five years in the country, becoming eligible for Medicaid after living in the US for five years. Undocumented immigrants do not qualify for these insurance plans and may be unlikely to travel to Mexico to receive healthcare while their legal status is uncertain [1, 44, 46]. The Emergency Medical Treatment and Labor Act requires the provision of healthcare to patients in the emergency department regardless of a patient’s ability to pay. However, these services are only funded for Medicaid-eligible patients through the federally funded Emergency Medicaid program, and some border states, such as Texas, have policies restricting Medicaid eligibility [47]. On the other hand, California plans to expand Medicaid coverage to all residents older than 26 with a certain income by 2024. Notably, costs associated with providing care to US-based noncitizens are lower than those associated with providing care to citizens [48].

Tracking cancer incidence and mortality in the US-Mexico border region is challenging, partly because patients travel across the border to receive care. Some have proposed that lower cancer-related mortality rates among the Hispanic population in the US are due to the so-called “salmon-bias” effect, which purports patients return to their country of origin when they receive a terminal diagnosis [49,50,51,52]. As a result, these patients’ deaths may not be captured in national registries, resulting in an inaccurate registered mortality rate.

Our study has limitations. Firstly, the information collected from respondents was based on recall rather than prospectively collected data, which highlights the potential for recall bias on the part of respondents. This highlights a potential opportunity to gather pertinent information on patients with cancer who travel internationally to receive care. Secondly, oncologists’ perspectives on why patients traveled outside their home country to receive cancer care may have been assumed. It is plausible that asking patients themselves may have yielded different results. Further, the relatively small sample size of respondents may not accurately capture the entirety of perspectives of practicing oncologists in Mexican border states. Lastly, the descriptive nature of our study make drawing statistically significant differences between the reasons US-based and Mexico-based patients traveled to receive care and the type of therapies and studies they received and underwent difficult. However, since SMEO is the largest organization in Mexico, we believe we were able to target most oncology professionals in the border area, and the proportion of responses is standard for an online survey.

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