The opportunities for Korea in medical tourism

South Korea is a country that has come late to the medical tourism game, but it may in the long term become one of the winners. Perhaps initially attracted by the inflated forecasts that are touted around the medical tourism industry by “industry experts” and commentators, Korea has however taken a more realistic view of where its success may lie.

The recent Busan Medical Tourism Convention provided an insight into how Korea is thinking about the opportunities presented by medical tourism. In 2010, Korea is expecting to attract around 60,000 medical tourists and the target is to attract 140,000 in 2015. This is not an unreasonable target and is far more realistic than some of the numbers that we see appearing from government and tourism organisations in other countries. The “highest quality, lowest cost” strategy is not one that Korea wants to pursue or indeed should be pursuing. Korea’s research into existing medical travellers shows that quality, convenience and trust factors far outweigh cost related drivers. In terms of relative costs of healthcare services, Korea is significantly less expensive than the USA (but then every country is) but is not as price competitive as countries such as India, Singapore or Thailand. Indeed, something like a knee or hip replacement would cost a similar amount in Korea to the cost of private treatment in the UK.

So, Korea is not going to win on cost. Nor is it going to attract vast numbers of medical tourists from Europe. Its prices aren’t competitive enough and long flight times will deter potential European patients. The same may apply to patients from the USA if the much hyped US medical tourism boom begins to happen. For a US patient, the perception of quality of care in medical destinations such as Korea, Singapore and Thailand may be very similar. So, if it comes down to the cost factor, Korea will lose out.

So, from where is Korea looking to attract its patients? The drivers of accessibility and cultural match provide the answer:

• Although the USA is a twelve hour flight away, cultural connections mean that the Korean community within the USA has to be a prime target. Around 1.2 million Korean Americans, many of whom are on the West coast should provide a source of patients.


• Within a one hour flight from Korea is Japan, already a source of many cosmetic surgery tourists, and where healthcare costs are rising fast.


• And not much farther away is China which may provide a plentiful supply of medical tourists in the longer term.


• The interesting market that Korea and many countries are turning their attention to is Russia. With the movement towards a market economy in Russia, there’s a wealthy upper class that is investing abroad, taking holidays abroad....and seeking healthcare abroad.

How can Korea create a competitive advantage in the overcrowded world of medical tourism? It may not be in Western medicine; Kang Dong Hospital in Busan is a Korean hospital that combines Western medicine with “traditional” oriental medicine and provides a model of healthcare that is attractive to many in the Far East.

Another opportunity is for Korea to build on its existing strengths and the image it has created in world markets. Through the success of companies such as Samsung and LG, Korea has created a hi-tech modern image for itself. Applying its technological knowhow and skills to the medical tourism sector may prove advantageous in creating an edge over the competition. The only technology company that I have encountered at a medical tourism conference so far is Samsung.

It has been said that Korea’s success in technology and in manufacturings industries such automotive lies in its ability to copy what others are doing, learn from their mistakes, do it better and work harder at it. If Korea applies the same philosophy to medical tourism, then some of the more established destinations will be looking over their shoulders.

Budapest: the “dental capital of Europe”

A recent visit to Budapest, the “dental capital of Europe” made me consider the perception of medical travel. Many people think that if you’re travelling abroad for treatment because it is far cheaper, then the standard of services can in no way match what you would expect in your home market. Hungary’s dental treatment providers provide a strong contradiction to this perception. I was speaking at the Business Travel Show in Budapest at a dedicated session on dental tourism, organised by the Association of Leading Hungarian Dental Clinics.

Aware of the number of new entrants into the dental tourism market, Hungarian dentists are keen to maintain their position as market leaders. They are also keen that the Hungarian government and tourism board take note of their success and provide support for the dental tourism sector.

Hungary was one of the first countries to exploit the healthcare needs of neighbouring countries and encourage patients to cross borders for treatment. It became common for German and Austrian patients to travel to Hungary for dental treatment in particular, and Hungarian dental clinics prospered in border villages and towns. When we launched Treatment Abroad five years ago, it was to some extent a response to requests from Hungarian dental clinics to increase their profile in the UK healthcare market. Having succeeded in attracting large numbers of German and Austrian patients, Hungarian clinics were spreading their wings and seeking to promote their expertise in other markets. Now, Hungarian dental clinics and services represent the largest segment of services on Treatment Abroad.

The Hungarian dental tourism market is one of the notable successes in the medical tourism market worldwide. In Budapest, the Association of Leading Hungarian Dental Clinics has been formed. The Association represents the interests of seven significant players in the dental tourism business:

• VitalCenter


• VitalEurope


• Bátorfi Dental Implant Clinic


• ImplantCenter


• Kreativ Dental


• Madenta


• Solydent

The Association has some clearly defined criteria for joining. For example:

• The practice must employ a minimum of ten dentists / oral surgeons.


• The practice must be equipped with a minimum of 5 modern dental medical operating units.


• The practice must place a minimum of 1,000 dental implants a year.


• The practice must provide digital intra-oral and panoramic X-ray.


• The practice must ensure that all practitioners work within industry recognized protocols, including clinical governance and undergo regular internal clinical audits and assessments.

See the full list of Association criteria at ALHDC Code of Practice.

The number of patients from overseas that are going through these seven clinics is staggering. Association members carry out around 75,000 treatment sessions per year. Around 60% of these are for dental tourists. The Implant Center alone inserts around 1,800 dental implants each year. Each clinic has multilingual staff and dedicated cars and drivers for transporting international patients.

Although established markets such as the UK, Ireland and Scandinavia provide the bulk of patients, new opportunities are developing in France, Italy and Russia. I visited three of the facilities - ImplantCenter, Kreativ Dental and Vital Europe. Each has a different approach to marketing its services. Whereas Vital Europe focuses on UK patients and provides both consultation and treatment facilities in London and Manchester, Kreativ relies on its overseas agents to convince patients of their quality of service and flies patients straight to Budapest without prior consultation. ImplantCenter has also dental office in Dublin and London.

The expertise and extent of dental services in each individual clinic is quite something. Each clinic has around eight to ten dentists employed by the clinic, some general dentists and some with areas of specialty such as implantology or orthodontics. All three clinics have extensive dental laboratories on site, owned and operated by the clinics themselves.

There are few private dental clinics in the UK that can match the set up of thes dental facilities in Budapest. The challenge for Hungary is how it maintains its lead in dental tourism. New competitors are entering the market, such as Croatia, Czech Republic and Slovakia, some at even lower prices than those in Hungary. The challenge for these new dental tourism competitors is how they match the standards of the "dental capital of the world".

Practice makes perfect...a message for medical tourism providers and patients

In the largest ever study of hospital mortality rates published in the UK,"death rates for emergency patients jump 6 per cent when newly qualified doctors start work. The Health Services Journal reports that "the traditional first day for NHS doctors is the first Wednesday in August. Researchers found that patients brought into hospital the week before were more likely to survive.....Researchers could not find a definite reason for the higher mortality rate, but said early August was known as an “unsafe period” in hospitals due to the influx of new doctors"

Now, what can we conclude from this?

Might I suggest that doctors with more experience are better than those with less experience? It goes without saying, really.

So, how does this help the medical tourist who is trying to make a decision about which doctor or specialist overseas to choose for their operation? The problem of patient choice in healthcare whether it is a choice of an overseas surgeon or a domestic surgeon is the "how do I know that he's any good?"issue. In the UK, we're probably ahead of the game in enabling patients to make informed choices about treatment. The NHS web site is has been renamed "NHS Choices" and in recent years there's been a drive to expose data on clinical outcomes and surgeon and hospital performance, and make this freely available to patients.

One of the strengths of the UK healthcare system (and one of its shortcomings!) is that the vast proportion of healthcare is delivered by one healthcare provider - the NHS. This means that data on processes, outcomes, performance and patient satisfaction is fairly standardised, thus enabling valid comparisons to be made between one hospital and another, between one specialist and another.

Let's imagine that I need a knee replacement. Under the NHS, I can choose to go to any hospital in the UK, not just my local hospital. But let's assume that I want to stay fairly local. Here's some of the data I can access about my local hospitals through NHS Choices. For each "quality factor", I have highlighted the best result.

Impressed? Which hospital would you choose? Or which hospital would you rule out of consideration? The above table only scratches the surface of the data that is now being made available to patients. I could also compare the quality of the food, levels of service and so on. And I can also begin to make comparisons between individual surgeons.

Where does this leave the medical tourist? The reality is that there are few countries where this kind of comparative information would be made available to the patient. And the reality is that different healthcare systems often measure things in different ways, so that comparing outcome data from a hospital in Thailand with outcome data from a hospital in India might be very difficult.

So, the medical tourist probably needs to ask some very basic questions about the hospital and specialist. One of which is a fundamental measure of "how do I know that he's any good?” It's "how many times have you done this operation before?" "Practice makes perfect" as the recent study demonstrates. Choose a surgeon with experience in exactly what you require. If you're looking for a knee replacement, choose an orthopaedic surgeon who does knee replacements and virtually nothing else. Don't choose a "general" orthopaedic surgeon who does “everything under the sun" - knees, shoulders, feet, hips etc.

And ask the guy "how many have you done this year?"

Transparency and fraud in health tourism

One of the criticisms of buying services via the web is that you cannot always be sure with whom you are actually dealing. This is especially true in the field of health and medical tourism. When you visit a site about medical tourism:

• How do you know who is behind the site?


• How can you tell what they actually know about health tourism and healthcare in general?


• How do you know if you can trust them?


• How do you know where the patient's money is going?

Next month, I'm speaking at the Annual Conference of the European Healthcare Fraud & Corruption Network (EHFCN) in Edinburgh. The Conference theme is "Cross-Border Healthcare in Europe: A Gateway to Fraud and Corruption?".

The European Healthcare Fraud & Corruption Network (EHFCN) is the only European organisation dedicated to combating fraud and corruption in the healthcare sector across Europe. The network represents 23 member associations in 10 countries, which provide healthcare services to millions of people in Europe.

According to EHFCN, "the healthcare sector appears to be particularly vulnerable to corruption. The large amounts of money involved and the complexities of many healthcare systems play a role as well as the fact that there are many processes with high risks of bribery"

And now it is turning its attention to health tourism.

As a web publishing company in the healthcare sector, it's important that Treatment Abroad is transparent, and that when we're publishing health advice on our various web sites, we ensure that the information is written by qualified medical professionals. We make sure that all of our sites go through the Health On the Net Foundation's certification process. (I recommend that all healthcare sites go through this process.) And our company has a Medical Director to oversee what we do - Dr Nick Plowman from St Bartholomew's Hospital in London.

But in the world of medical tourism, is there a problem with lack of transparency and is there significant potential for fraud?

In researching my presentation for the EHFCN conference, I've taken a look at transparency in medical tourism. I did the usual Google searches and I came across Health-tourism.com for the first time: It states that is "a guide for medical tourism, bringing you reliable, objective and useful information that will help you plan your medical travel".

While I was browsing the site, I came across this:

• Medical Tourism Transparency Award - "we have created the Medical Tourism Transparency Award. This is a badge awarded to websites of medical tourism providers whose website information meet the criteria below."

Now, let's be clear, the guys at Health-tourism.com may be decent and honest people, with the best interests of medical travelers at heart. But it was their "Medical Tourism Transparency Award" that caught my attention. Health-tourism.com says that "The purpose of this award is to encourage providers to supply necessary information on their web sites - making it easier for you to make an informed decision.

So, I put Health-tourism.com through a "Transparency Test".

I looked all over the site....

• It says that it's run by Find Global Care.I can't tell who they are or what their qualifications are.


• In the lengthy disclaimer it says "the content on this website has not been reviewed or prepared by medical professionals.


• And it says that the "relationship between the visitor/user and FGC shall be governed by the laws of Cyprus". Why Cyprus?


• I can't find any names at all.


• I can't find out who owns the site or the company.


• I can find an address - 1B, Pinetree Boulevard, Old Bridge, New Jersey.

I'm an inquisitive person.....

I did some digging for information on Find Global Care. But all I could find... was another web site - half built at www.findglobalcare.com and an entry on WikiCompany with no information on the company ownership.

So I thought I'd pay a visit to 1 Pine Tree Blvd, Old Bridge, NJ 08857, USA using Google Maps Streetview. (Isn't the web a wonderful thing?). I'm not an expert on US arrchitecture but judging by the Real Estate sigh outside and the building, this looks like an apartment building. But who lives there? And who's behind the business? And what does he or she know about health tourism?

Next, I checked out the domain name. It's registered to Udi Shomer from Illinois. Perhaps he's behind the business? Who is he? I don't know. But it's not a common name, and the web may have some info on him?

There's only ten results for a search for "Udi Shomer" on Google. (Hey, that's close to being a Googlewhack!). Let's take a look at the Udi Shomers on the web:

• There's an Udi Shomer who has an entry in the Lonely Planet guide to Thailand.


• There's a listing page for Tai Chi in Thailand.


• And there's a few references in Israeli job sites (I think).


• And that's it.

There's a clear message here for medical tourists who use the web to research healthcare services.

• Look (very carefully) before you leap.!

And if anyone knows who runs Health-tourism.com, ask them to get in touch, so that I can fill in the gaps.

Dental tourism...Let's work together

The Irish Dental Association is the most recent medical professionals body to publish a "survey" raising doubts about medical tourism.
In a recent press release from the Irish Dental Association, they state that "3 out of every 4 Irish dentists are treating patients for problems arising from treatment abroad. Let's take a look at the background to the survey, and examine some of the real concerns that are raised.
The Consumers’ Association of Ireland has published research about the high costs of dental treatment in Ireland. The Irish Dental Association accepts that Irish dentists are not immune from the wider economy and the bottom line is that Ireland is a high-cost economy. As a result, significant numbers of Irish dental patients travel for treatment to minimise treatment costs. Some of these are cross border dental tourists. Many services carried out in Northern Ireland are between 25% and 45% cheaper than the same services in the Republic, according to the study published in the Consumers’ Association of Ireland’s magazine Consumer Choice. And of course, many Irish patients take advantage of low cost treatment in countries such as Hungary and Poland. Several Budapest dental treatment providers have offices or representatives in the Republic of Ireland.
According to the Irish Dental Association survey, 76% of Irish dentists in private practice [more than 3 out of 4] have had to treat patients for problems linked to the dental treatment they received abroad.
First, we need to examine the basis of this claim.

• There are approximately 1,700 dentists in private practice in Ireland at present.
• 440 Irish dentists responded to the survey.
• 334 said that they are treating problems arising from treatment overseas.
• So.... in fact 334 out of 1,700 said that they were seeing problems which is 20%. Obviously, this assumes that those who didn't bother are not seeing problems.

When reviewing such surveys conducted by on or on behalf of professional associations, we have to bear the following in mind:

• Inbuilt sample bias: People who see a problem are more likely to respond to a survey on that issue, than those who don't. We've seen similar bias built into surveys conducted by a PR agency in behalf of the British Association of Plastic Surgeons.
• Motivation: We always need to remember that professional associations represent the interests of their members. Losing patients to Belfast or Budapest hits the pockets of private dentists.

Nevertheless..... the Irish Dental Association has made some valid points. Are there concerns for dental patients who travel for treatment? Yes. Are the problems as big as the Irish Dental Association suggests. No.

At the end of the day, the Irish Dental Association also has the best interests of Irish dental patients at heart. Dr Donal Blackwell of the Irish Dental Association says that that one of the problems is that when considering travelling abroad for dental treatment, patients tended to focus on short term, aesthetic results rather than the long term quality of the care they receive and suggests that people travelling abroad for dental treatment actually don't know what they need when they enquire about costs. He's certainly right in some cases.

So, what's the solution and what's in the best interests of dentists and patients?

I'd like to see the following:

1. The Irish Dental Association issuing guidance for dentists and patients when considering dental tourism. See the UK General Dental Council's Dental Tourism Checklist on Treatment Abroad.
2. Irish dentists providing assessment and follow up of patients who travel abroad for treatment.
3. Irish dentists visiting some overseas dentists to get an understanding of how they work and their clinical skills and quality.
4. Irish dentists forming partnerships with overseas dentists, so that patients who need extensive treatment but can't afford Irish treatment have access to the treatment they need under the supervision of their own dentist.
5. Overseas dentists communicating with the patient's Irish dentist when a patient turns up in Budapest or Krakow - informing the patient's Irish dentist what work is to be undertaken, and providing post treatment reports on the work that has been carried out.

Common sense really. So, let's work together!

Increase in IVF tourism in Europe

At Treatment Abroad, we've seen increasing interest from IVF clinics abroad that are experiencing significant growth in patient numbers from the UK and other European countries.

The latest report from the European Society for Human Reproduction and Embryology confirms an increase in IVF treatment abroad, The report surveys infertility clinics in Belgium, the Czech Republic, Denmark, Slovenia, Spain and Switzerland and is based on a sample of 1,230 patients visiting these infertlity clinics. See details of the report in the Guardian.

Lack of access to IVF services in the home country for the over 40's and legal restrictions on infertility treatment are the prime drivers. Italy was the biggest source of IVF "medical tourists" accounting for 32% of the patients in the survey. Next was Germany (14%), followed by the Netherlands (12%), France (9%) and the UK (5%). The average age was over 37 but 63.5% of the British patients were over 40.

According to study coordinator, Dr Francoise Shenfield from University College Hospital in London, "Spain and the Czech Republic are popular destinations for oocyte donation; Swedes travel to Denmark for insemination, and the French to Belgium." She also highlighted the significant numbers of Italians who travel abroad to receive treatment that was rendered illegal in their home country under recent legislation or because they believe they will receive better quality care.Extrapolating the data, EHSRE estimates that 20,000 to 25,000 cross-border fertility treatments are carried out each year.IVF related medical tourism is a relatively new but growing trend in the UK, as couples delay having children into their 40's and then discover that they have a problem.

IVF treatment is available within the National Health Service in the UK, but access to treatment can be a problem.

• Age and waiting lists can be a barrier to treatment.


• Overweight women are excluded from NHS treatment.


• Demand for egg donation exceeds supply. ( The right of anononymity for egg donors was removed in 2005)

Obviously, private IVF treatment is available in the UK but this may be expensive and the same legal restrictions will apply.

Whereas some areas of medical tourism may be feeling the effects of the recession and the resulting impact on people’s pockets, IVF treatment abroad is an opportunity worth pursuing for those IVF clinics abroad that can demonstrate impressive results and cater for the needs of the “fertility tourist”.

Medical tourism and a medical city ...a lesson from history

Back in the mid 1990's, before someone, somewhere coined the term medical tourism, I was a UK Marketing Director with an American owned hospital company. We were big in medical tourism.... but in those days, it was known as the international patient business. One day, I got a call from a head-hunter, promising big money for an opportunity that surely I wouldn't want to miss....

This is roughly how the conversation went:

Head-hunter: "We've got these American investors who are planning to spend $500 million on a brand new 260 bed state of the art private hospital in the UK. They plan to attract international patients from all over the world. It's going to be called "Health Care International."
KP: "Sounds interesting. Where are they going to build it?"
Head-hunter: "On Clydebank. It's going to be massive."
KP: "Clydebank..... You mean Clydebank.... in Scotland....near Glasgow."
Head-hunter: "Yes, that's right. It'll be close to the airport so people will be able to fly in from all over the world. Labour costs for hospital workers in Scotland are much lower than they are in America"
KP: "Are you serious?" "Or is this a bad joke?"
Head-hunter: "I'm serious. It's backed by some American guys who are ex-Harvard Medical School and a US medical ventures company. They're going to create a medical city. They know what they're doing. They want someone to run it who knows the business inside out. You come highly recommended. Are you interested?"

I think my response was something along the lines of, "Not in your wildest dreams".

So...what happened?
Health Care International was one of the biggest disasters of all time in terms of a hospital development. They built the Clydebank hospital....... patients didn't come. Surprise, surprise, they failed to fill its 240 beds, 21 operating theatres and neighbouring five-star hotel. By 1995, it was going bust.

Unperturbed by this unmitigated failure, in walked a group of Middle Eastern investors from Abu Dhabi with a plan to "develop the hospital as a centre of international medical excellence". It grew to 540 beds. And in 2002, it went bust again. In walked the National Health Service who picked up a state of the art hospital and all the equipment for around $50 million!

It's still there. It's now part of the NHS National Waiting Times Centre and is known as the Golden Jubilee National Hospital.

And there's not a medical tourist in sight!

History repeats itself...
It was the poet and philosopher, George Santayana, who said, "Those who do not study history are doomed to repeat it."
At the core of the Health Care International debacle was a failure to understand marketing and a failure to understand the market.

• The Americans involved had little real grasp of the international patient business.
• The Abu Dhabi investors who bought it out had even less.

But they both had a vision of a booming medical tourism market and it cost them millions and millions of dollars.

Around the medical tourism world today, I see history repeating itself. Investors getting involved who may have little real grasp of the international patient business, being guided by others who may have even less.

So, my suggestion to the investors and medical tourism pundits is "Get your history books out".

Or buy a decent marketing text book. It might save you a few million!

NHS Patient Choice - Lessons for medical tourism

In the UK, "patient choice" is one of the driving forces in healthcare. Since April 2008, patient choice has been extended in the UK. Patients can choose which hospital they are treated in....anywhere in the country. Patients can choose the time of their hospital appointment. In some cases, patients can choose the individual consultant they see. The NHS Choices website lists information about all NHS hospitals, such as their MRSA rates, facilities and ratings and reviews by patients which means that patients can make an informed choice.
The NHS Choose and Book web site enables people to make their choices.
In reality, the patient choice initiative has been a bit of a disappointment. One problem is that not enough patients are actually aware that they have a choice. The Report of the National Patient Choice Survey, England - December 2008 has analysed uptake of patient choice so far.
The key findings:

• The percentage of patients recalling being offered a choice of hospital for their first outpatient appointment was 46% in December 2008, the same as in September but up from 30% in the first survey (May/June 2006)
• 50% of patients were aware before they visited their GP that they had a choice of hospitals for their first appointment, up from 48% in September and 29% in the May/June 2006 survey.

The factors influencing choice

• Hospital cleanliness and low infection rates were given most often (by 74% of patients) as an important factor when choosing a hospital.
• The other five are quality of care (given by 64% of patients), waiting times (63%), the friendliness of staff (57%), the reputation of the hospital (55%) and location or transport considerations (54%).

So what can medical tourism businesses learn from this?

If UK patients can compare NHS hospitals on MRSA rates, post operative infection rates and outcomes, why can't they do this for overseas hospitals? Or perhaps, why is it difficult if not impossible to find a hospital treating medical tourists that publishs such data or makes it freely available on their web site?

Many people in the UK have the right under EU law to travel abroad for treatment. The EU Directive sets up a framework around this. but the basic right of free movement already exists. So, why aren't people taking advantage of this?

• They don't know they have the right.
• They don't "trust" overseas hospitals.
• They would rather wait for treatment on the NHS in their local area.

Awareness of overseas treatment options can be generated by the providers themselves. One of the best tools to consider is the use of patient stories to create local press coverage and thus raise awareness. See this story in the Scotsman. Let's see more of them!

A word of warning for medical tourism companies

A woman from Wales who underwent cosmetic surgery in Belgium is bringing a test case against the Belgian clinic in the UK courts.The patient is suing the clinic after undergoing a face-lift and upper and lower eye surgery in 2005. She claims that she has been left with scarring around the eyes and the ears and has experienced numbness of the face.

It is a significant case because it could set a precedent for other patients who wish to sue a clinic or medical tourism company after going abroad for treatment. Rather than sue in Belgium, the legal firm involved have decided to sue the clinic in the UK courts where they might expect higher payouts if they win the case. Laurence Vick, the solicitor who is representing the patient, is a medico-legal expert and specialises in clinical negligence claims. (Coincidentally, he and I were undergraduate students at the same college, many years ago!)

• See the Independent news story: Woman sues in UK over Belgian face-lift

The question of who to sue in medical tourism cases is one that faces any patient where surgery abroad doesn't work out as it should. Is surgery abroad any riskier than surgery in the UK? No one knows.... because there is no comparative data. But the answer is probably not. Nevertheless, any surgery carries a risk. Cosmetic surgery is not risk free, so there are going to be cases of alleged clinical negligence where the patient will pursue a legal action. Medical tourism companies need to be aware of this test case, particularly those that have a UK presence. Rather than sue the surgeon or the hospital in the destination country, the patient may opt to sue the medical tourism company in the UK.

The war of words....Is it medical tourism or medical travel?

I just read Constantine Constantinides informative and latest missive on medical tourism. Constantine runs Healthcare Cybernetics and is one of the "wise heads" of medical tourism.
Constantine says:

"I am getting fed up with industry newcomers (the “Johnny-come-latelys”), industry outsiders and the self-important upstarts who take issue with the word Tourism – claiming it is not “grand” enough for them to be associated with.They propose replacing it with the word “Travel”. Some even suggest we dump everything and start talking of Global Health (as if healthcare has not been global for ages).......I do not like the “tourism” word – but neither do I like the several suggested alternatives"

He makes some interesting points:

"The word Tourism is derived from Tour - from Anglo-French tur, tourn turning, circuit – a there and back journey.Travel may not include a “back”.

So, here's my two pennyworth (English idiom!).

Let's start with Google's view. Why? Because Google reflects the way that people use words.

I did a search on Google UK for various terms:

• A search for medical tourism generated 19,700,000 results. (Our Treatment Abroad and related web sites secure three of the top ten positions. A pat on the back for our search engine optimisation team!)


• A search for medical travel generated 73,300,000 results.


• A search for health tourism generated 36,600,000 results.(Treatment Abroad is no 2 for this search. Another pat on the back for SEO.)


• A search for health travel generated 250,000,000 results. A search for global health generated 133,000,000 results.

But we probably need to be a bit more specific. By putting the phrase in quotes e.g. "medical tourism", Google only returns results for the exact phrase:

• "medical tourism" generated 5,290,000 results.


• "medical travel" generated 443,000 results.


• "health tourism" generated 798,000 results.


• "health travel" generated 505,000 results.


• "global health" generated 3,220,000 results

The previous analysis tells you what words and phrases are most frequently used on web sites indexed by Google. But what terms do people use when searching? Here's another analysis. This time we look at the average monthly search volumes on Google worldwide:

• medical tourism - 90,500 searches per month
• health tourism - 14,800 searches per month
• health travel - 165,000 searches per month
• global health - 135,000 searches per month

And the winner is?

It's probably medical tourism....

Why? Because it's the phrase that's in common usage, whether we like it or not. It's what the media use when they write about the industry. It's what the man on the Clapham omnibus would probably say. Is it the best phrase to use? Probably not.

I prefer medical travel!

The challenge facing the medical tourism industry

The recent European Congress on Health Tourism in Budapest reflected some of the current issues and challenges facing the medical tourism industry, particularly those presented by a world recession. Budapest is Europe's dental tourism hub, attracting patients from countries such as the UK, Ireland, Germany, Austria, Switzerland and Scandinavia. If the recession is hitting medical tourism, then Budapest is going to feel it more than most.

There were workshops and presentations from various providers and industry players at the Budapest Congress. One of the more down to earth of these presentations was made by Dr Bela Batorfi of The Batorfi Dental Implant Clinic in Budapest. This impressive clinic usually carries out around 1,800 dental implants per year. But with the onset of the global financial crisis they have seen some worrying trends:

• The number of patients from abroad has fallen by around 30%. Medical tourists are harder to find!
• The average spend per patient has decreased from around £5,000 to £2,600. Medical tourists are spending less per visit.
• The average age of patients has increased. Medical tourists are delaying treatment.

The experience of the The Batorfi Dental Implant Clinic is reflected among many of the other dental treatment providers in Budapest. It's not the case that Budapest is losing patients and market share to other destinations. Understandably, many clinics are concerned about the fall off in business and how long it will continue.

Against the backdrop of the financial crisis, Hungary is one of the many countries planning a "medical city" aiming to attract patients from across the world to a centre of medical excellence. According to Balázs Stumpf-Biró, Executive Director of the European Medical Tourism Alliance (EuMTA), Hungary is planning to establish 100 hectares of land near Budapest’s international airport as a health complex, similar to Dubai Healthcare City.

Whether this development suffers the same fate as Dubai Healthcare City remains to be seen. The initial building boom in Dubai has come to a grinding halt. Building anything in the current financial environment is a risky business, and with the medical travel market to Hungary down around 20% to 30%, it's going to be a brave investor who lays the first brick.

Various estimates of medical travel numbers for Hungary put the number of incoming medical tourists at around 300,000 to 350,000 per annum. The vast majority of these are for dental treatment, and many may be "short trip/low cost" cross border visitors from Germany and Austria. But that's still a valuable market.

So what's the long term outlook for medical tourism destinations such as Hungary? Better than most, I would suggest. The medical travel market is here to stay and is here for the long term. Hungary has been at the forefront of medical travel in Europe for the last decade and it can retain that position.

But like most countries being encouraged down the medical tourism route it needs to tread carefully. We hear the usual overblown claims by industry proponents such as the Medical Tourism Association that "the biggest potential market for Hungary is the USA". I can just see hundreds of thousands of Americans getting out their maps of Europe, locating Budapest and booking their long distance flight via New York/London/Amsterdam for their dental implants. It isn't going to happen.

So where should Hungary be focusing its efforts?

Well... :

• There's a population of 550 million in the "United States of Europe" who may begin to exploit the opportunities within the EU Directive on patient mobility.
• Not so far away from Hungary, there are 140 million Russians who are beginning to spend their money on holidays all over Europe. Medical travel will follow this trend.
• And the UK dental problem is here to stay. See this recent article in the Independent: This may hurt a little: Rise in hospital admissions for last-ditch tooth extractions

My advice to Hungary... The same as you would get from business guru, Tom Peters (In Search of Excellence).

Stick to the knitting - stay with the business that you know!

NHS staff numbers reach an all-time high

The UK Department of Health today released it's latest update on NHS staff numbers. It reflects the investment that the UK has been putting into the NHS in recent years, and also has an impact on outbound medical tourism from the UK. NHS shortcomings and waiting times are a significant driver of people seeking elective surgery abroad. In the last couple of years NHS waiting times have come down and there is now an 18 week target which most NHS trusts are meeting.

The number of people working for the NHS has reached an all-time high. After a dip in overall numbers in the previous two years, the annual NHS census showed staffing levels recovered to reach a peak of 1,368,200 in September 2008. This is a 2.8 per cent increase on the previous year and a 27.7 per cent increase compared to 1998.

In September 2008, the NHS employed:

• 408,200 qualified nurses – up 2.1 per cent or 8,600 on 2007 and up 26.2 per cent or 84,700 on 1998.
• 25,700 midwives – up 2.3 per cent or 570 on 2007 and up 12.4 per cent or 2,800 on 1998.
• 34,900 consultants – up 3.7 per cent or 1,200 on 2007 and up 56.4 per cent or 12,600 on 1998.
• 49,200 hospital doctors in training – an increase of 5.1 per cent or 2,400 on 2007 and up 59.4 per cent or 18,300 on 1998.

The number of people in employment in the UK was 31.32 million in December 2008 which means that 4.4% of the UK workforce is employed in the NHS.

The UK unemployment rate has now reached 6.5 per cent. So, the NHS is quite a good place to have a job!

Will Obama end the American medical tourism dream?

As reported in International Medical Travel Journal this week, President Obama has pledged to cure Americans from "the crushing cost of health costs." His proposed reforms include lower prices from hospitals, salary cuts for doctors, and payment to hospitals by government insurance schemes linked to quality of care not quantity of care. He also wants to give Americans the option of a public health insurance plan. His plans follow a social insurance model which is found in some European countries.


Simplifying the funding structure within US hospitals could also lead to significant cost savings. At present an individual US healthcare provider may have to administer payments through upwards of 700 different providers.

Past research (1) has shown that while the United States spends significantly more on health care per capita than Europeans nations, Europe actually delivers more real resources per capita. For example, Europe employs a larger health workforce per capita and delivers more physician visits, hospital days, and prescription drugs than the United States. Higher prices and administrative inefficiencies account for most of this differential.

Obama's grand plan could end the American medical tourism dream. Introducing what is in effect a publicly funded healthcare system and forcing down prices could remove a key driver for outbound medical tourism from the USA.

The IMTJ's conclusion:

"If Americans are a target market, you need to keep a very close eye on US healthcare reform as it could quickly impact your business. You may even have to change from marketing on price to marketing on quality alone."

...and I tend to agree.

Recent years have seen a bandwagon effect in the medical tourism sector. And it's been a "get it cheap" bandwagon. But for decades medical tourism has been driven by patients seeking better treatment, specialist expertise, and higher quality. Some new market entrants may need to rethink their strategy.

1 Mark V. Pauly, “US health care costs: The untold true story,” Health Affairs, 1993, pp. 152–9.

EU votes on medical tourism directive

Members of the European Union's various committees vote this week on whether to make changes to the EU Directive on cross border healthcare. The Directive aims to provide a framework for patient mobility, whereby patients in one member state will have the right to treatment in another state.

The UK's General Medical Council (GMC), which regulates the country's 230,000 doctors, is running a lobbying campaign to protect Britons seeking healthcare in Europe from what it describes as "dangerous" doctors. the GMC wants the new EU laws to give patients access to the disciplinary history of incompetent clinicians.

Quoted in the Guardian, Paul Philip, the GMC's deputy chief executive says:"The vast majority of doctors do a very good job under very difficult circumstances. However, when UK patients travel to mainland Europe, there is a risk they could be treated by a doctor who is not fit to practise or not fully qualified to give the required treatment."

UK patients have full access to GMC records and are able to check whether a doctor has been disciplined, or is the subject of a disciplinary hearing. The GMC wants doctor organisations in other countries to provide similar patient access to information about their doctors.

In the first 9 months of 2008, the UK NHS paid for over 500 British patients to have treatment elsewhere in Europe. Some patients were also funded by their primary care trusts. It is estimated that another 80,000 Britons funded their own treatment overseas.

European Union medical travel Directive gets the nod from the Lords

The EU Directive on Cross Border Healthcare is making it's way through the labyrinth of British government. Slow progress, but it's progress towards a European market in healthcare.

The House of Lords EU Committee have welcomed the proposal from the European Commission for a Directive on patients' rights to cross-border healthcare. The Committee has called for improvements and has warned that, due to the unpredictable impact of the provisions in the Directive, it must be carefully monitored upon implementation.

• Download the House of Lords Committe report.

The Committee has agreed with the Commission that, as the right of EU citizens to travel to another Member State to receive healthcare has been confirmed by the European Court of Justice over the last ten years, it is essential to put in place a legal framework to replace the current ad hoc arrangements.

The Committee also considered whether patients seeking healthcare in other European Member States should pay the costs themselves in advance of treatment and then claim reimbursement later. They have raised concerns that this would prevent those without adequate financial means from taking advantage of their right to cross-border healthcare. The Committee's report recommends that a patient's own healthcare provider should pay the fees directly to the provider in the other Member State, and suggests that this could be linked with the process of securing authorisation prior to travel, which the Committee considers necessary both in order to protect the financial resources of health systems and to enable patients to make informed decisions about their treatment.

The report also calls on Member States to ensure that patients are aware of their rights under the Directive and are informed about the quality of care that they can expect, any potential language barriers, and how to make a complaint should that be necessary. Member States should finance information for its own citizens about healthcare abroad and should draw up a description of its own health system to guide other Member States. Acknowledging that it may fall to medical practitioners, such as GPs and dentists, to actually provide the information to patients, the Committee argue that the Directive should avoid the imposition of any administrative burden on healthcare professionals.

The Committee have also called for greater clarity on systems of redress when patients are dissatisfied with, or harmed by, healthcare provided in another Member State.
The Committee welcome the Directive's provision that a Member State would be able to refuse to accept a patient from another Member State if, for example, this would increase waiting times for treatment. Nevertheless, they recommend that this part of the Directive would benefit from some strengthening.

Finally, the Committee emphasise that the impact of the Directive will only be clear once it has been implemented, and so recommend that it be reviewed within three years, rather than five as proposed by the Commission.

The Committee's 57 page report can be downloaded from: http://www.publications.parliament.uk/pa/ld200809/ldselect/ldeucom/30/9780104014356.pdf

The smoke and mirrors of medical tourism

When is a medical tourism facilitator a medical travel agent?

According to our Medical Tourism Survey in 2008, around a third of UK medical tourists make their arrangements through a medical tourism facilitator. In some countries, such facilitators account for an even greater share of the market, and their influence is growing. The concern of many is the uncontrolled growth of the sector and the lack of regulation within it.

Let's say that I want to start a medical tourism facilitation business. How easy is it?

What do I need?

• I need a name. I'll call my business "Magical Medical Travels".


• I need a telephone. I've got one of those.


• I need an internet connection. I've got one of those.


• I need a web site to generate some patients. I can create something that will do the job, using a cheap package such as 1&1 web hosting.


• I need some hospitals and clinics overseas that are prepared to pay me a commission, if I send patients to them. I'm sure that I can find a few of those.


• I suppose I need to find someone in the destination country who can look after the patients while they are there.


• ....and maybe some documents that I can get the patient to sign.


• Oh, and it might be a good idea to invent a few patient testimonials...


• Do I need to be medically qualified? Well, I'm known as Dr Pollard on several internet forums, and I have some drpollard@ email addresses, so that should be fine.


• Cash flow. Well, if I take money up front from patients, and then pay the treatment providers late, that's not a problem. I'll buy some online advertising, and leave it a few months before paying the bill.


• I'll pay a few hundred pounds to join one of the medical travel associations; that will give me some credibility.

It's pretty easy really? And that's how some (not all!) medical tourism facilitators have come about. Medical tourism is a very fragmented market and there's a pretty wide range of facilitators in the business.

Which brings me back to the title of this blog: "When is a medical tourism facilitator a medical travel agent?"

In the UK and Europe, that's actually quite an important question. Let's expand the question...

"What's the difference between a medical tourism facilitator who sells a consumer a package of accommodation, travel and treatment and a regular travel agent who sells a consumer a package of accommodation, travel and related holiday activities?".

In the UK, the activities of travel agents are highly regulated. For example, the "Package Travel, Package Holidays and Package Tours Regulations" were introduced to protect consumers from unscrupulous travel agents. A package is defined as the "pre-arranged combination of at least two of the following components - transport, accommodation, other tourist services".

So, is a medical tourism facilitator a travel agent? Some would say...yes!

And if that's the case, the Package Travel Regulations come into force and my new facilitation company, Magical Medical Travels might have some problems. It means my company will be subject to controls over:

• What I can say in my brochure or web site.


• The nature of any contracts I make.


• The information I provide to the consumer.


• Changes in price.


• Security in the event of insolvency. ie. I will need to be bonded.

With regard to the latter, when someone books a holiday in the UK, many will look to see if the travel company is ABTA (Association of British Travel Agents) bonded. Which means that the company has placed a bond with an authorised institution, based on their turnover. The minimum bond is £20,000.

Even if you pay the bond, you can't join ABTA, unless you comply with their Code of Conduct, and submit to random inspection.

Let's compare this to the medical travel business, a sector that was once described last year by Avery Comarow, as the "The Wild West of Medical Care Abroad".

• Anyone can set up as a medical travel agent/facilitator.


• There's no regulation.


• There's no compulsory code of conduct.


• Anyone can join one of the associations such as MTA or IMTA.


• There's no bond required.

So what's the industry been doing to fix the problem?

• IMTA launched a Patients' Bill of Rights some while back.


• Treatment Abroad has encouraged better business practices into the market, by introducing the Treatment Abroad Code of Practice for Medical Tourism. We now have eight providers who have signed up to the Code and have been externally assessed


• MTA launched an accreditation programme in July 2008 , then hastily renamed it a certification programme, but still hasn't certified anyone (according to their web site).


• The Council on the Global Integration of Healthcare shows promise with its current development of a Medical Travel Facilitator Certification programme and its work on the Medical Tourism Facilitation Standards in the area of oncology.

In the perfect world, we need an ABTA of the medical travel world - properly funded, run by a truly representative Board of Directors, that is answerable to its membership, that publishes an annual report and financial statements, that only accepts members who meet clearly defined criteria, that inspects member premises at random, and that requires all members to place a significant bond for the protection of medical travellers.

Likely?

I doubt it.

What is more likely....

As medical travel grows, especially in a background of government driven initiatives such as the European Directive on Cross Border Healthcare, governments will begin to regulate medical travel facilitators and agents. Bodies such as ABTA in the UK and similar organisations in other countries would probably favour and support this.

"What makes a medical travel agent any different and exempt from regulation?", they would say.

What can medical tourism learn from previous recessions?

How will the medical tourism sector fare in a global recession that's affecting everything from house prices to car sales to polar bears and dog ownership!

If unemployment in the Western world climbs to record levels in the coming year, is this good news or bad news for the healthcare sector?

Some good news comes in a recent McKinsey analysis. According to McKinsey, in previous recessions, US consumers changed their their spending priorities rather than cutting all expenditure across the board. In discretionary areas of expenditure such as dining out, personal care products, and charitable donations fell. But expenditure on groceries, books, insurance, education and healthcare actually rose.

See the McKinsey analysis - Industry trends in recessions.

However.... compared to the 1990/91 and 2000/01 downturns what we are facing now could be much much worse. In the UK, there are early indications that discretionary expenditure on private education and, of more relevance, private self paid surgery is being affected.

It remains to be seen whether those with less money in their pockets will be attracted by low cost treatment abroad , and whether the credit crunch stimulates new demand for medical tourism.

How well written are medical tourism web sites?

For many medical travellers, the first point of contact with a hospital or clinic is usually a web site (see the Treatment Abroad Medical Tourism Survey 2008). And since many patients are seeking healthcare providers where communication in the English language is important, the web site is an important factor in patient choice. A site written in poor English reflects badly on the service offered and discourages potential patients.

So... how well written are medical travel web sites.

Sadly, many are written in a way that actually discourages patients from using the hospital, clinic or medical tourism service. Most would benefit from being re-written by a native English speaker .

To help solve this problem, Treatment Abroad has launched a low cost “Perfect English” service for healthcare providers who want to improve web sites targeted at US and UK medical tourists, and other English language speakers. The “Perfect English” team provides a review of the English version of a site and gives you a version re-written in “perfect English”. The team has extensive experience of producing “perfect English”; they are based in Brussels, Belgium and support many European Union politicians and officials with translation and improving the English versions of EU materials.

If you want to know more about the Treatment Abroad Perfect English service, you can complete the enquiry form on Treatment Abroad.

Marketing in the medical tourism downturn

There are conflicting views on how the global financial crisis is affecting medical tourism. The view expressed by organisations such as the Medical Tourism Association is that the "...with the economy and the credit crisis, more people are waking up and paying attention (to medical tourism)."

The harsh reality may be somewhat different. BusinessWeek reports that "...in some medical tourism hotspots, formerly booming hospitals are seeing empty beds." The MD of Parkway Hospitals in Singapore, "expects the foreign patient numbers to stabilise after dropping 10 per cent".

Whether the credit crunch encourages more people to consider travelling abroad for treatment remains to be seen. People are short of cash, unable to borrow and are delaying expenditure on house purchases, cars and other major expenditures. Healthcare is not immune to this. Although in the last global recession, healthcare was less affected, the likelihood is that people who might have considered medical tourism may decide to postpone their expenditure.

Areas likely to be affected most are those “non-urgent”, discretionary treatments such as cosmetic surgery. In countries where medical tourism is influenced by waiting lists, patients may decide to hold out for free treatment in their own country rather than go for the paid for, immediate treatment available elsewhere. In the USA, the story may be different, as the financial crisis puts pressure on health insurers and employers to find ways to cut rising healthcare costs.

The simple answer is that no one knows yet how the financial crisis will affect medical tourism. But it’s best to be prepared.

So, here are our recommendations for marketing in a medical tourism downturn (....follow these and they will also pay off, if there’s an upturn).

And no apologies for giving the services of Treatment Abroad a plug!

1. Target your activities
There are many hospitals, clinics and medical tourism operators out there who don’t have a clearly defined service strategy. What service am I selling, into what markets and to what demographics? Now is the time to think this through, and identify very clearly your market niche.

2. Maximise your return on marketing investment
Measure your return on investment on all marketing activities. And invest in those that deliver results:

• Invest in the web, because it’s the one area of marketing expenditure where you can measure your return and control your budget easily.


• Use PR. It’s a low cost and effective way of promoting your services to patients in other countries. (Become a Treatment Abroad client and we’ll give you our free guide to generating PR coverage!)


• Take advantage of free web promotion. Send your news articles to Treatment Abroad (it’s a Google approved news feed for medical tourism – your news story will get indexed by Google within the hour, if published).

3. Improve your conversion rate
Turn more web enquiries and leads into paying patients and customers. If someone has bothered to complete an enquiry form for your service, then they have probably done the same for some of your competitors. Respond faster, and respond better with an informative, personalised and high quality response. (Become a Treatment Abroad client and we’ll give you our free guide to enquiry management!)

4. Generate referral business
Past patients are the one of the best sources of future patients. 20% of medical tourists who travel for treatment have been recommended by a friend or relative.

• Give a “Recommend a friend” discount voucher that your past patients can give to a friend or relative.


• Generate word of mouth recommendations by encouraging patients to contribute to reviews sites such as Medical Tourism Ratings and Reviews.
  

5. Be brave!
Don’t cut back your marketing budget. In a recession, the strong survive. Use the opportunity to take market share from competitors who are less well equipped, and ill prepared to deal with a downturn.

Don’t cut your prices because you think it will bring you more business. Think about where you can add value to your service offering to give yourself a competitive edge and concentrate on customer service and service quality.

Put the above into practice. Then, whether we see an upturn or a downturn.... you'll be on the winning side!