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!

What can Google tell us about medical tourism?

Who knows what's going on in healthcare? Who knows what conditions and disorders are causing people problems? Who knows what's happening in medical tourism?

Google!

Google is a treasure chest of information about how people are behaving and what issues are concerning them. Google logs the online activity and search behaviour of hundreds of millions of users. It knows what you and I do on the web everyday. It knows where we are, most of the time. And from the data that Google collects, it can draw conclusions. And so can you.

A recent example of this in the healthcare sector is Google Flu Trends . Google has realised that certain search terms are good indicators of flu activity. Google Flu Trends uses aggregated Google search data to estimate flu activity in a US state up to two weeks faster than the federal centres for disease control and prevention.

Outside of healthcare, a UK web intelligence company was able to predict the winner of a TV talent show, based on the online activities of people who were watching the show and researching the contestants online.

So what does Google know about medical tourism....? Probably quite a lot more than most people in the business.

Let's take a simple example. Suppose I want to know which are the most popular countries for cosmetic surgery for UK patients who travel for treatment.

I can analyse the search activity of UK internet users by looking at the relative number of searches for cosmetic surgery and plastic surgery which also incorporate location or country names.

I then combine all of this data to create a search volume of country related cosmetic surgery related phrases. For each country, I can then calculate a share of the total volume of searches. And we get the table on the right.

Interesting stuff.... Now, it doesn't tell me which countries people are actually going to (in the same way that Google Flu Trends doesn't actually tell you that people have flu), but I'm willing to bet that it's not a bad indicator. And it's probably a far better indicator than the top of the head data that many "experts" toss around.

So, if your job is about marketing medical tourism, you need to consult the new medical tourism guru - Google Inc.

Medical tourism: Survival of the fittest?

No industry is immune from global recession, and that has to be the case for the growing medical tourism industry. In past recessions, businesses in the healthcare sector have perhaps suffered less than others; in a recession, people still get ill, and it's often difficult to delay expenditure on healthcare. But there are some indicators that medical tourism is begining to feel the pinch.

According to a recent article in BusinessWeek, "Medical Tourism: Surviving the Global Recession", the Bumrungrad Hospital in Bangkok, one of the world's leading centres of medical tourism is seeing a fall in overseas patient revenues. Similarly, the Association of Private Hospitals of Malaysia is reducing its forecast of overseas patient revenues, and some Indian medical tourism providers are reporting that "medical tourism is on the wane". The situation is further complicated in India and Thailand by the recent terrorist incidents and political protests.

If we think back to 9/ll and the subsequent Iraq involvement, these events had a major impact on travel related businesses and medical tourism flows from the Arab States to the Western World. Countries such as the UK saw a significant drop in inbound medical tourism, and Arabic patients transferred their loyalty to countries such as Germany.

The counter argument is that in times of economic hardship, people are going to be more inclined to go overseas to avoid high costs in their own country. i.e. they look to buy cheaper, so this is good news for the medical tourism industry.

What's going to happen? Here are my thoughts:

• The speed and size of this global recession is such that it must have a negative impact on medical tourism; people are going to hang on to their cash, and delay treatment whether that is treatment within their own country or overseas.
• It doesn't necessarily mean that less people are going to travel for treatment.It probably means that the growth in number of medical travellers which has been widely predicted is going to be much less than anticipated.
• Many of the "new-born" medical tourism facilitation companies that have appeared in recent months are going to find it tough going.
• Those businesses in the sector that have their marketing act together will do best. They'll focus on those marketing activities that deliver results, they'll have a clear idea of what their marketing and service strategy is, and they'll look to generate business and referrals from existing and past patients. See "Five Tips for Marketing in a Recession"

So....it's going to be survival of the fittest in the medical tourism sector. There's plenty of opportunities out there, but there will be fewer to go around. Which means that some businesses are going to find the going tough.

How to run a medical tourism conference...

Autumn is conference season, and it seems that medical tourism is becoming the most talked about subject on the conference platform. Three years ago, there was little interest in this area, but in 2008 it seems that every events company and association has jumped on the conference bandwagon.

In recent weeks, I've attended the World Health Tourism Congress in San Francisco, the Health Tourism Development Conference in Vienna, the Health Tourism Show in London, the Global Healthcare Conference in Dubai and spoken on medical tourism to a meeting of UK NHS management, and to a Cerner Healthcare Convention in Kansas. My colleague, Philip Archbold has spoken at the Indian Medical Tourism Congress in Chennai. Coming up...I'm off to address the International Medical Travel Conference in Korea, and speak at a meeting of the Cyprus Health Promotion Board.

So, I've become a bit of a medical tourism conference "groupie.....

But it prompts the question: Do we need all these events, and are they actually worthwhile?

In my previous company, one of the core activities was event planning and management; many of these events were within the healthcare sector. So, I do have some knowledge of what makes a good event and what can go wrong. Being an attendee/speaker/delegate at these medical tourism events has been an eye opener. Frankly, compared to other industries most of them aren't delivering the goods.

Where's it going wrong?

Here are my top ten recommendations for medical tourism event organisers:

1. Set some objectives....

Most of the medical tourism events that I have attended seem to have some kind of vague objective of "let's get a bunch of people together to "address some of the issues", and facilitate some networking (and we'll make a bunch of money while we do it.....).

2. ....and measure your success!

If you don't have SMART objectives, you can't measure your success. Sending out a post event "What did you think of the conference?" survey is the usual cop out in this respect..but what is it actually measuring? Most medical tourism conferences don't even bother with this most basic of measurement tools.

3. Plan the agenda

The current approach appears to be mainly along the lines of "who can we get to speak". Why not plan an agenda, and then identify those people who would be best to cover specific topics? Let's have some speakers from outside of the medical tourism fraternity who can give a different perspective!

4. Buy professional expertise

If events aren't your core expertise, buy some expert help. Get a professional event organiser in to plan, market and run the conference, The Medical Tourism Association did a great job of getting numbers to the San Francisco Congress, but in terms of structure, content and organisation ........

5. Abolish the all day plenary session

Different people have different information needs. The medical tourism industry is a melting pot of providers, purchasers, facilitators, insurers, etc etc. Run specific, smaller workshops or sessions that cover key issues for targeted groups of delegates. Start the day with a lively, thought provoking keynote presentation then break the audience into smaller sessions. The Cerner Healthcare Convention has cracked this one. A stimulating keynote address each day followed by 300 plus targeted workshops for the 5,000 plus attendees.

6. Fire some of the speakers

I've seen good, bad and just plain awful this year. My greatest gripe? Speakers who have been given a clear and very specific brief...and then ignore it completely, often making a "This is what we do in XXXX, aren't we wonderful" presentation. All speakers are guilty of promoting their own interest/business. That's part of why they are there, and it's to be expected. But, it shouldn't make up 100% of their presentation. If you want me to name names, I'll email
them to you....

7. Ban the "destination presentation"

The conference platform is not the place to run a 30 minute "advertisement" ..... "my country/destination/hospital/company has the "highest quality healthcare", "state of the art technology" etc etc

8. Organise

If you're going to attempt to run some structured networking or "buyer meets seller" sessions, plan it properly, match up the right people and run it like clockwork. Take a look at other industries and see how well they do this.

9. Keep to time

If there's one thing a conference must do, especially when it's based on parallel sessions is run to time. If speakers over run, turn off the mike. Dubai could learn a thing or two here.

10. Make it fun!

Liven it up! We're human beings. We're out of our regular job for a few days. We want to enjoy ourselves. Will someone please do something different.....!

Finally, one medical tourism conference not to miss in 2009; the 2nd European Congress on Health Tourism in Budapest. Why? Under the guidance of a medical tourism expert, Dr Uwe Klein, perhaps this one will hit the mark?

Medical tourism: The answer to the global healthcare problem?

A recent article from McKinsey International highlights the magnitude of the challenge that leaders of governments in the developed countries are going to have to deal with sooner rather than later. The article looks at the increasing proportion of a country's wealth that is going to be dedicated to the health of its citizens in future years.

In Europe currently around 9% of GDP is spent on healthcare; in the USA, it's higher, nearer 16% of GDP. For the last fifty years, the increase in health care spending in OECD countries has been 2% above the GDP...... which means that healthcare is taking an increasing proportion of the national wealth. But what happens if this continues? McKinsey says that "if current trends persist to 2050, most OECD countries will spend a fifth of GDP on healthcare. By 2080, Switzerland and the United States will devote more than half of GDP to it, and by 2100 most other OECD countries will reach this level of spending."

Those are pretty astonishing statistics! There's a decent analysis in the article, outlining the supply and demand factors that drive this growth, and offering some arguments as to why this trend will not or cannot continue at this rate. However, the harsh reality is that whatever governments do, they and their citizens will be faced by the burden of ever increasing healthcare costs.

And that's the reason why healthcare is becoming global, and medical tourism is being talked about as one of the solutions. More and more, governments will not be able to provide and consumers will not be able to afford the healthcare that they need. The global market in healthcare provision will expand to meet the growing demand from both consumers and governments for low cost treatment overseas. And that's where medical tourism comes in.

Reference: Healthcare costs: A market based view: McKinsey International

Medical tourism ratings and reviews

It's been a couple of months since we launched medical tourism ratings and reviews. It's met with a variable response from the medical tourism industry, and from the patients themselves.

Medical tourism ratings and reviews at Treatment Abroad enables patients to provide feedback on their experience of travelling for treatment abroad. The Ratings and Reviews system is integral to our business philosophy of “helping patients to make the right choice”. It's run through Bazaarvoice, the US based world leader in reviews systems who operate similar systems for companies such as Dell, Sears, Argos and many others.

When a patient submits a review of a medical tourism agency, a hospital or a clinic, the review is checked by the Reviews Team to ensure that:

• The review is valid, honest and fair comment.


• It is not a spurious review that has been “invented” by a healthcare provider to promote their facility or to damage a competitor’s reputation.


• The review does not contain profanity or inappropriate content.


• The review does not raise issues of legal liability.

Healthcare providers and agencies are given the opportunity to respond to any negative reviews.

So...what do the healthcare providers think of ratings and reviews?
It's interesting.... those medical tourism agencies and healthcare providers that are "marketing oriented" have adopted the approach with enthusiasm. They see it as a highly attractive way of generating "word of mouth" recommendation of their services and it doesn't cost them a penny.

Companies such as Gorgeous Getaways in South Africa and Vital Europe in Hungary are actively encouraging their patients to review their services:

• View medical tourism reviews for Gorgeous Getaways
• View medical tourism reviews for Vital Europe

Others are less enthusastic....and I'm not sure why! Is it because they are fearful of patients posting negative comments about their experience? Is it because they are just not switched on to the power of "word of mouth" and the way in whiuch consumers are using the web to influence product and service purchase?

Experience from other industries shows that:

• 63% of consumers are more likely to purchase from a supplier, if it has ratings and reviews.
• 77% of online shoppers use reviews and ratings when purchasing.
• 82% of those who read reviews said that their purchasing decisions have been directly influenced by those reviews.

Asking people to record their experience of medical tourism should encourage more patients to travel for treatment abroad. And, Medical Tourism Ratings and Reviews should help healthcare providers to tune into the “patient’s voice”.

So...what do the patients think of it?
They love it! The feedback on their medical tourism experience is overwhelmingly positive, and it's helping to reassure other patients who are considering medical travel. Patients are healthcare consumers; and typical consumer behaviour is beginning to influence the way that they buy healthcare. If they can rate and review their hotel or holiday experience on TripAdvisor.... why not do the same for medical travel?

medicaltourism.com ......going, going gone?

What's a domain name worth? Especially in the growth business of medical tourism.

The Medical Tourism Association (of which my Company is a member) has recently announced that it is handling the sale of the domain name medicaltourism.com, on a commission basis. A reserve price of around $100,000 has been put on the sale.

Which raises the question of how you value a domain name and what is one actually worth?

The domain medicaltourism.com was originally owned by Sparrow Mahoney, who ventured into medical tourism after experiencing low cost surgery in Croatia after a car accident. Sparrow has now flown the medical tourism roost.The domain has been bought by a third party looking to make a fast buck.

Here’s a few recent domain sale prices in the health sector:

• healthstore.com $27,500
• healthcaresolutions.com $10,700
• healthinsurer.com $4,595
• healthglobal.com $2,700

So, would you pay $100,000 for medicaltourism.com?

There is certainly some value in the domain name.The words within a domain name can influence Google rankings, but it's certainly not a major factor. There's value in a domain name if it's associated with a strong brand or an existing web presence.

With regard to medicaltourism.com:

• The site has only 24 pages indexed on Google. Do a Google search for site:medicaltourism.com.
• It has only six inbound links logged on Google Do a Google search for link:medicaltourism.com.
• It has a negligible amount of traffic.

Bidding will take place at the World Medical Tourism and Global Health Congress in San Francisco in September.

Any offers?

EU Directive on cross border healthcare boosts health tourism

After a six month delay, the EU Proposal for a Directive on patient’s rights in cross border healthcare has finally been released. It provides an added stimulus to the already growing number of medical tourists who seek hospital treatment elsewhere in the European Union. Its aim is to create a formal framework for cross border healthcare and remove the obstacles that patients face if they wish to travel for treatment in other EU countries.


I'll attempt to answer some of the questions that people are asking about this new Directive and its impact.

Why do we need a Directive on cross border healthcare?
The Directive has come about from a desire to create a European market in healthcare, and to some extent as a result of European Court judgements which have upheld the rights of patients to gain reimbursement for treatment in other countries where they have been subject to "undue delay" in their own country.

What does it cover?
The Directive proposes a number of developments in cross border healthcare, including reimbursement of medical tourists, patient safety and quality issues, European cooperation on healthcare, assessment of new medical technology and standards for e-health and transfer of patient information between member states.

How will it affect UK NHS patients?
In April this year, NHS patient choice in the UK was extended, giving patients the right to opt for treatment anywhere in the UK. The Directive, in effect, extends this patient choice to anywhere in the EU, provided that the treatment is available at a cost which is the same or lower than the NHS cost.

Under the Directive, the NHS will be requested to establish a direct payment or reimbursement system. This means that patients will not have to fund the treatment and then claim the cost back from the NHS. They will have to fund their travel and accommodation costs. No prior approval is required from the NHS or the patient's primary care trust.

It doesn't mean that patients in the UK or elsewhere in the EU can opt for treatments overseas that are not covered by the NHS. So, if a new drug or a new procedure is available in another country, the patient cannot obtain payment for this.

How many patients will opt for treatment abroad?
Who knows? Patients may decide to travel abroad because:

• Surgeons and hospitals with better results for their treatment may be available elsewhere in Europe.
• Hospital infection rates may be lower in other European countries.
• Faster treatment may be available elsewhere.

It is worth noting that:

• There is no requirement for the patient to be suffering "undue delay" in treatment.
• The patient will need a referal from a GP.
• Patients cannot jump the waiting list in other countries..... which is one reason why why we will not see large numbers of patients travelling to the UK for treatment. They will join the end of the queue of existing UK patients.
• And since the UK is one of the most expensive healthcare providers in Europe, this will also discourage an inflow of patients from lower cost countries.

How will it affect the NHS?
It depends on how many UK patients opt for treatment abroad. If the NHS can prove that the number could be so large that it would affect the planning and funding of healthcare facilities in the UK, then it can make an application to set up a "Prior Approval" system which means that a patient would have to apply for treatment abroad. This is unlikely, I believe. It would be an admission of failure by the Government that the NHS cannot compete in a competitive European marketplace.

Overall the Directive has to be a good thing for both the NHS and UK patients. It could reduce the burden on NHS waiting lists, and offer cost savings where cheaper treatment is available elsewhere in the EU. It would also mean that NHS hospitals would face increased competition and would have to improve their performance relative to other European healthcare providers.

What else is covered by the Directive?
In addition to clarifying the position regarding medical tourism within the EU, the Directive also embraces:

• The establishment of common principles in terms of guaranteeing patient safety and ensuring quality and continuity of care.
• Stimulating greater European cooperation on healthcare including the establishment of “European Reference Networks” which would create a concentration of expertise, training and resources for specific diseases and health issues.
• Establishment of a European network for the assessment of new medical technology.
• Establishment of standards for e-health, in particular the transfer of patient information and treatment records between member states.

When will it take effect?
It's a draft directive, so it has to go through the EU mechanisms to be officially adopted as policy. But it's a part of a consultation process that's been going on for three years, so it's likely to become reality.

Good news or bad news for the medical tourism industry?
Undoubtedly, good news! It will add to the credibility of medical tourism, and will mean that people become more familiar with and confident about travelling for treatment. It will also reinforce the need for an improvement in standards and business practices in the industry. (See the Treatment Abroad Code of Practice for Medical Tourism).

Ultimately, it will result in greater patient choice and more people will choose to travel for treatment abroad.

For patients seeking treatment now who can't wait until the Directive comes into force, they can download Treatment Abroad's Guide to Medical Tourism or visit Treatment Abroad.