Slowly, slowly.... The EU Directive on Cross Border Healthcare

 

The vision was that EU citizens would be banging on the doors of hospital elsewhere in the EU.

An incredible amount of time and effort has been invested within government departments and healthcare services across the European Union in the implementation of the Directive. In the UK, the European Union (EU) Directive on patients’ rights in cross-border healthcare became law on 25 October 2013. NHS England is now responsible for administering and determining applications made under the S2 route and the EU Directive route. A central team (the ‘European team’) operates within NHS England’s Leicestershire and Lincolnshire Area Team, to manage the process on behalf of the whole of England. Local Clinical Commissioning Groups (CCGs) who commission healthcare services for their local population are often involved in supporting the decision making process. So, there's a system in place to support patients who wish to exploit their right to travel.

Other EU states are making slow progress with the implementation, and there's a variety of approaches. According to EU Health Commissioner, Vytenis Andriukaitis, “Some countries have very elaborate systems of prior authorization; others seem to use a lower level of reimbursements than they should and others have different administrative requirements.”

Informing patients

Extensive information has been provided for patients within the NHS Choices web site on seeking treatment under the Directive. At Intuition, we published " A UK patient's guide to the European Directive on Cross Border Healthcare", and distributed it online and in print to relevant organisations around the UK.

We have also featured the EU Directive heavily in our print publication - The Patients' Guide to Treatment Abroad -  that is distributed in GP practice and clinic waiting areas across the UK.

However, there has been little active communication of these new rights to the public as a while. The government and the NHS isn't inclined to say to people:

"Hey, did you know you can go and get your hip done in Brussels, and we'll pay for it!"

...because it wouldn't go down well with the politicians or the public. You can argue that sending patients abroad may reduce some of the pressure on the NHS but it will not have a significant effect on the NHS budget, and that's what counts.

The hospitals and clinics overseas and the medical travel facilitators targeting UK patients just don't have the marketing budgets (or just won't spend the money) to get the message across to the UK healthcare consumer. On the one hand, they're saying, "Why aren't people coming to us from the UK, we're much cheaper... Why isn't the NHS sending us patients, we're much cheaper." On the other hand, many are not prepared to invest in getting their message across in an effective way.

A trickle... not a flood

The reality is that few people across Europe know their rights to cross border care. And perhaps those people who are aware of them wish to access healthcare at home. Some industry proponents were hoping that the EU Directive would result in patients flooding across borders to exercise their rights. It's been more of a trickle.  Here are some of the numbers:

In the UK:

  • In 2014, S2 forms issued by the UK for healthcare in another Member State: 1,350 (Around 80% of these are for maternity/birth in another country).
  • In 2014, EU Directive reimbursements: 727 (of which 48 were subject to prior authorisation). There were 46 refusals to pay under the EU Directive refusals.

In Croatia:

  • 250 requests for reimbursement under the Directive received in the 18 months since the Directive became law.

According to a report in Politico, "Croatians are not generally using the directive because the health care provided by the older EU members, and even some newer ones, like Slovenia, is more expensive than in Croatia.... But the cheaper medical services in Croatia attract Slovenians and Italians, who go there mostly for dental treatment".

In Poland:

According to the Polish National Health Fund:

  • 2,000 applications for reimbursement received since November 2014, of which 1,200 were reimbursed

An EU report on the implementation of the Directive is due to be published in September.

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World Medical Tourism Day: Today’s the day!

 

Despite its staggering impact on the economies of small islands such as San Serriffe, medical tourism remains one of those industries that remains largely ignored, and exists in the dim and dark corners of most people’s minds when it comes to seeking a solution to a healthcare problem.

The inaugural World Medical Tourism Day (WMTD) draws special attention to the role of medical tourism in contributing to the revenues earned by hotels and conference venues who have been the main beneficiaries of the exponential growth in the industry.  A conference has been announced to bring together the multitude of medical tourism conference organisers worldwide. Medical Tourism Conference Organisers and Opportunists 2016 (MTCOO 2016) will be a unique event taking place over a period of five weeks across five continents during April 2016. The MTCOO 2016 “road show” is expected to attract over 1,000 delegates across the world. Turkey has already agreed to sponsor the event and will be sending a full delegation representing the country’s numerous health tourism associations.

World Medical Tourism Day events

World Medical Tourism Day will be marked today by a series of events taking place across the globe.

  • Thailand will be attempting to set a world record for the number of medical tourists treated in one day. Officials from the Guinness Book of World Records will be on hand to ensure that multiple counting of medical tourists does not occur.
  • Fly2Cosmetic, the medical tourism start up of 2014 that has capitalised on the growth seen in the market for cosmetic surgery abroad, will be celebrating with a special “round Europe” flight, dropping off cosmetic surgery patients at their desired destinations and picking them up post surgery that evening.
  • Following his sacking by the BBC, former Top Gear presenter, Jeremy Clarkson will be announcing his new medical programme “Top Gurney”. The programme will feature “A Doctor in a Reasonably Priced Hospital” where each week an overseas surgeon is challenged to complete a gallbladder removal in the quickest time and at the lowest cost.
  • The San Serriffe Medical Tourism Association (SSMTA) will mark the event with the creation of a new app based certification programme for those involved in the medical tourism sector. The new Mobile Medical Tourism Professional Program will be delivered via SMS messages, and an e-certificate will be issued for local printing. Program fees ($150 plus SMS charges) will be collected via PayPal or Bitcoin payment. A certificate framing service will be offered as a $50 add on.
  • In a pre-election initiative, the UK Independence Party (UKIP) will be launching its new programme to fix the NHS. All non-UK citizens working within the NHS (accounting for approximately 25% of NHS staff) will be required to relocate to their country of origin and provide services to UK patients from their home country. It is anticipated that the resulting boom in UK patients travelling abroad will overwhelm the healthcare services in some destinations, but will deliver a £5 billion cost saving to the NHS . 

How to take part and raise awareness

This year's official celebrations will take place in Berkhamsted, Hertfordshire and include a high-level, lunch time, Think Tank on the 2015 theme with the participation of anyone we can gather in the Kings Arms, a great pub across the road from the offices of International Medical Travel Journal..

To keep up-to-date with this year’s WMTD activities, and to learn more about MTCOO 2016, keep an eye on the IMTJ twitter feed.

Or wait 14 days and celebrate on April 15th

Alternatively, if you believe the above is all a load of tosh, and want to know what’s really going on in the world of medical tourism, sign up for the IMTJ Medical Travel Summit, taking place in London April 15th-16th 2015. 

And join the celebrations at the dinner for the IMTJ Medical Travel Awards on April 15th. We may even serve up a traditional English fruit fool for dessert...

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When will medical tourism reach the tipping point? (Part 1)

  • , ,
 

Is medical tourism getting there....?

The global medical tourism market is still a very long way from the tipping point. The industry is immature; the market is showing growth in some areas and declining in others. The hype, the razzmatazz just hasn't delivered.  What I wrote about the medical tourism goldrush back in 2010, still rings true today. Five years ago we were seeing headlines like:

  • “One million medical tourists flocking to India”
  • “Bumrungrad attracts more than 400,000 foreign patients each year”
  • “Philippines is set to cash in on the $3-trillion global medical tourism market”
  • “Half a million Britons travel for treatment....”

None of the above was true then, and none of it has come true in the intervening years.

Back in 2010, we had the MTA's Edelheit expounding “Medical tourism is growing exponentially every year"; the mantra was re-iterated year after year. And in 2015, we're still getting this kind of "puffery":

"Indeed, medical tourism is booming. An estimated 11 million health care consumers pumped US$438.6 billion into local and national economies overseas this year alone – that’s 14 per cent of the world’s tourism dollars, according to the Medical Tourism Association (MTA)." (Business Traveller 31/10/14)

Seriously... medical tourism accounting for 14% of the tourism market?

What's the reality?

A market that's immature, a market that's seen incredible churn, a market where a great deal of cash has been burned with little return.

We haven't seen the "exponential growth" of medical tourism. What we have seen are pockets of growth where healthcare providers have developed and marketed their services to meet an international patient's needs and where the potential customer is prepared to make that massive leap of faith.... travelling to another country for healthcare. There's no denying that some who have identified their niche and tailored their service accordingly have achieved an excellent ROI.  

Fertility treatment is one area that has seen the growth of international patient travel. The drivers have been varied, depending on the patient's source country. It’s often not about cost. It may be about availability and access to fertility treatment. It may be about the less restrictive regulation of fertility treatment that exists in some countries. It's an area where there has been some attempt to set standards by credible international or regional bodies, rather than through the "get rich quick, sell a certificate" approach. Within the Fertility Treatment Abroad site, we were able to create a Good Practice Score (GPS) for each of the participating clinics, based on the recommendations of the European Society of Human Reproduction and Embryology for the treatment of international patients. The GPS embraces twenty factors which assess the suitability of a clinic for the delivery of services to international patients. It helps patients to make that leap of faith.

The barrier of fear

We must never forget that the decision to travel abroad for surgery or treatment is often a decision of last resort. Few people want to go to another country, another culture, another healthcare system to get well. Most want access to satisfactory healthcare "on their doorstep" or just within their own country. The challenge for the industry is to overcome the barrier of fear that many potential medical tourists face. The trade off between low cost and quality in healthcare is perceived as a significant one. A patient may need an operation, but may not want to run the perceived risk of going to a country where they can get the surgery at half the price.

The perception of medical tourism in many source countries has been tarnished by the failures of the industry to date. I live in the UK. I have a wide social and business network. How many people do I know who have actually jumped on a plane or a train and gone outside of the UK for healthcare? The answer....

One.

Someone who works for me... who is an ex-nurse.... who has a reasonable understanding of the risks.... who went to Budapest for major dental work at one of Hungary's leading dental implant clinics.... and who suffered a dental tourism disaster. The Hungarian clinic didn't want to know.  The costs to correct the shortcomings of the dental work back in the UK were far more than the anticipated savings from going abroad. The individual massively regrets that decision.

Such stories are too common for an industry that wants to become credible and grow. Poland's image as a medical tourism destination for UK patients  is damaged by the reputation that their cosmetic surgeons earn in the media and on programmes such as "Botched Up Bodies". An EU/polish government funded project has spent the last three years spending money to promote Poland as a credible medical tourism destination. But I doubt that little has changed in the actual service that is delivered to international patients or the perception of the destination.   The message...don’t go out and promote a product, until you've got the product right.

First in, first out...

One of the characteristics of the medical tourism sector over the years has been the constant churn of hospitals, clinics and agencies/facilitators that are attracted to the market. Many of the early entrants came in, failed to deliver an acceptable service or realised that the market wasn't living up to the promise, and exited. The MTA's over hyping of the market and the resulting churn can be seen in their own membership data. An organisation that claims to "represent the industry" had around 150 or so hospitals, clinics and facilitators as members back in 2010. In 2014, only 2 of those 150 members from 2010 had been retained*. In 2014, the number still stood at around 150. Not what you might describe as exponential growth. Another 140 plus had stepped in to plug the gap.  If the industry had been growing at an exponential rate, if the MTA members had been seeing the promised success, we'd see a very different picture.

We see a similar pattern within the Medical Travel Directory maintained by IMTJ.  We recently undertook a data cleansing process on our directory of hospitals, clinics and agencies involved in medical tourism and delivering international patient services. It's a big database that we maintain. We identified close to 1,000 records that are now invalid. Businesses had closed down, web sites had disappeared.... many of these were start up facilitators keen to exploit the market growth.

So... where do we go from here?

You'll have to wait to the next blog article for my views on how we fix the problem.

Does the industry need a radical shake up... or should we plough on regardless,  in the hope that "if we build it, they will come"?

* Source: Analysis of MTA membership lists for 2010 and 2014

* Source: Analysis of MTA membership lists for 2010 and 2014 
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Comparing hospital performance and informing patient choice

 

Comparing hospitals - lessons from the USA

A recent article in the British Medical Journal, has highlighted the problems that have arisen in the USA with hospital ranking and hospital comparisons. There's a multitude of systems in the USA that publish comparisons and rankings of US hospitals.

But a recent study has pointed out the shortcomings of the systems. An article," National Hospital Ratings Systems Share Few Common Scores And May Generate Confusion Instead Of Clarity" published in Health Affairs, reviewed the ratings given to US hospitals by US News, Healthgrades Leapfrog and Consumer Reports. The study found that:

"No hospital was rated as a high performer by all four national rating systems. Only 10 percent of the 844 hospitals rated as a high performer by one rating system were rated as a high performer by any of the other rating systems."

So, four hospital rating systems all said "these are the best hospitals" but delivered different results. One example highlighted is the Fort Lauderdale area of Florida. In this instance, 21 out of the 24 hospitals in Fort Lauderdale were ranked very highly by at least one rating source. In Baltimore, Maryland region, 19 out of 22 hospitals earned an award for outstanding performance.

If you were a resident of Fort Lauderdale or Baltimore, which hospital, out of the 21 or the 19 respectively, would you choose for treatment?

Thus Baptist Hospital of Miami features the "US News Best Regional Hospital" award on its home page but doesn't mention the other three rating systems that may have viewed it less favourably. On Healthgrades, the scorings for Baptist Hospital of Miami put it in the average category for many procedures.

According to the BMJ article, one of the study's authors, Timothy Vogus, associate professor at Vanderbilt University’s Owen Graduate School of Management, says:

“There’s essentially no agreement about what the top hospitals are, and in some cases a hospital rated top by one is at the bottom according to another. There are huge differences in what they measure.”

The role of marketing in hospital awards

Of course, the marketing teams in the US hospitals see the benefit of these rating systems. A savvy marketing team selects the rating system that gives their hospital a great score, and highlights this in their promotion. The rating system provider benefits from payments made to them for the hospital to license the use of the award to promote their excellence. The issue of payments for licensing awards is discussed in "Should hospitals pay to promote a U.S. News & World Report award?".

"The small gold badge, emblazoned with "Best Hospitals," comes at a hefty price. If you want to put that badge on any of your marketing materials, you'll be asked to sign a yearly licensing agreement. Cleveland Clinic has a licensing agreement for digital, print, TV, and radio spots with U.S. News..... Children's Hospital Boston uses the U.S. News signage and logo in elevators, throughout buildings, in advertising campaigns, at conferences, and on its website".

What does it cost to license a US News award? According to the article, Boston Children's Hospital paid $40,000 for its licensing agreement. University of Utah Health Care was asked to pay around $30,000 and one hospital marketing department is quoted as saying its hospital paid $230,000 to use  the U.S. News award to promote five of its hospitals.

A definitive solution?

US News believes its latest approach to measuring hospital quality will provide a definitive solution. The new Best Hospitals for Common Care ratings cover nearly every hospital in the country and evaluate each one in five common surgical procedures and medical conditions that account for millions of hospitalizations a year. The UK based firm, Dr Foster was brought in by US News to help devise the new system. Dr Foster has been instrumental in developing the systems used to assess the performance of NHS hospitals in the UK.

But the day when a medical tourist will be able to make a realistic comparison of two hospitals in different countries are a long way off.

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Why would a US patient travel to Wales for sinus surgery?

 

A recent news story on CNN attracted my interest when it featured a US patient who travelled to Wales (in the United Kingdom) for sinus surgery to save money. It was headlined “'I can't afford surgery in the U.S.,' says bargain shopper”. It’s an interesting story which shows how the media can sometimes put a slant on a story to create news, but it does highlight some real opportunities for medical tourism providers.
The story (view the CNN video) tells us about Godfrey Davies, an American, who needed sinus surgery. It tells how he “set out on a mission to find an affordable surgeon”, and was appalled at the costs that he was going to incur in the USA. The story was picked up by a multitude of other web sites who took it at face value.
If you view the video, you get one impression. If you dig a little deeper, you actually get to understand the full story and where this patient fits within the medical tourism marketplace.
As a Brit, I found it a bit odd when I viewed the video. My first impression? Here’s a story about an American guy travelling all the way to Wales for surgery....... Why would he do this? And why Wales? But then I dug deeper. It was in fact a story about someone who started life as a “Welsh bloke”, became an “American guy” and went home for an operation. There’s a clue in his name (Davies...it’s a Welsh surname) and in his slightly odd accent (It’s a Welsh accent). Godfrey comes from Wales. It is where his family lives. He’s a UK and a US passport holder. He married an American and became a US citizen in 2002. He doesn't have health insurance in the US because he believes that the quoted premium of $1,000 per month is too much. He says that "with the deductible and co-pay, I would have had to pay more in over three and a half months than coming home to Wales."
So, what can medical tourism businesses learn from this story?
Firstly, don’t take news stories at face value. There’s sometimes an underlying logic to a news story which the media doesn’t always fully expose. It may make the news less newsworthy. In this case, it’s understandable why a Welshman (as opposed to an American) might choose Wales as a medical tourism destination.
Secondly, it highlights one of the key factors in why people select medical tourism destinations. Godfrey Davies chose Wales because it is an excellent cultural match, there is no language problem for him, and he feels 100% safe there. And it’s cheap!
Godfrey went to the BMI Werndale Hospital in Bancyfelin, Carmarthenshire. It is part of BMI Healthcare, Britain's leading provider of independent healthcare with nearly seventy hospitals and clinics nationwide. To give you another example, I myself had a total knee replacement at one of BMI Healthcare’s hospitals near London, The BMI Clementine Churchill Hospital. How much would it cost for a knee replacement in an American hospital? $50,000. How much did it cost me in the UK? £10,000 all in ($15,000). The UK price is cheaper than Korea ($17,800), and not far off the prices that Americans pay in countries such as Thailand ($12,000) and Singapore ($10,800). Given the cultural and language match, and the lower travel cost, if you were an American which destination would you choose?
Thirdly, it’s a great example of the kind of American medical tourists that some medical tourism businesses should be targeting..... people from their own country. Thus, the biggest and most realistic opportunity in the USA for Korea based medical tourism providers is most likely to be Korean Americans. Target the easy win, if you want to succeed.
Fourthly, it supports the argument that the UK might actually be an attractive medical tourism destination for US patients. Despite the different accent, there’s no language barrier! There’s a public healthcare system that delivers excellent outcomes. And there’s a private hospital system that already provides treatment for patients from all over the world who travel to the UK to access healthcare quality and expertise. And...... as Godfrey Davies has demonstrated, you can save an awful lot of money over UK prices.
How much does private treatment cost in the UK?
In addition to Treatment Abroad, we also run various UK health information sites. One of these is Private Healthcare UK. It will tell you all you need to know about private treatment in the UK.
If you want to know what UK private treatment costs go to Private hospital treatment - What does it cost? and select an operation.
And if you’re an American (or a Welshman) and you want to follow in Godfrey Davies' footsteps, you can get a quote for UK surgery by completing the enquiry form for UK private hospital treatment.

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How does the US healthcare system stand up against the UK's?

  • ,
 

Caroline Ratner at IMTJ has just published a summary of US reaction to the Obama healthcare reforms from the medical tourism sector, so I suppose I had better throw my comments into the mix.
First, let me stress that I am by no means the world expert on the US healthcare reforms! (Does one exist?) But I have been asked by the UK media recently to comment on the reforms and in particular to comparisons with the UK healthcare system. It’s been interesting to watch from afar how a nation is having to deal with both rising healthcare costs and demands for increased expenditure on healthcare.
It’s acknowledged that the USA is one of the most expensive healthcare systems in the world, spending 15.3% of the nation's GDP on healthcare (WHO statistics). This compares to around 8.2% of GDP for the UK and similar for other European countries. Despite the high expenditure, the USA gets atrocious value for money out of what it spends.
Take a look at these comparisons:

The UK spends less than half the amount per capita compared to the USA, but provides a similar number of doctors, more nurses and more beds per 10,000 citizens. Not bad value for the taxpayer's money.
Despite these facts......in the healthcare reform debate in the US, the UK NHS has been used as an example of “how not to do it” and at one point those campaigning against the reforms launched a series of television adverts using “tragic” stories from Britain's National Health Service to contest Barack Obama's plans. The reality of the UK NHS is rather different... it works pretty well most of the time and it costs the nation half of what the US spends (as a percentage of GDP). If .......you were a US politician and could wave a magic wand which would transform the US healthcare system overnight to an NHS system of universal healthcare, free (in most cases) at the point of delivery, AND it would cost the country half the money....what would you do. It’s a no brainer. But there are no magic wands.
The perception of the NHS overseas is very different to the experience of the NHS within the UK Here’s a couple of recent, typical quotes from US industry commentators on medical tourism and the US healthcare reforms:

  • “People from UK and Canada is (sic) not looking for treatment outside their countries because of being denied of healthcare insurance or financial constraints, it is because of high cost of care and extensive waiting times for elective surgeries”
  • “ (the reforms) will also potentially create long waiting times for medical procedures which will create situations like in Canada and the UK, where patients travel outside their country because of long queues for important surgeries.

Note the references to the long queues and extensive waiting times in the UK. This kind of uninformed and factually incorrect comment does little for the credibility of the medical tourism industry. It’s political dogma.
Here are the hard facts on UK waiting lists:

  • The average NHS waiting time from referral to treatment is around 8 weeks. It’s often much shorter.
  • Anyone suspected of having cancer has the legal right to wait no more than 2 weeks to see a specialist
  • Anyone referred for elective procedures has the legal right to start treatment within 18 weeks
  • If there is a significant waiting list in your local area, you have the right to exercise patient choice and go to another hospital anywhere else in the country to avoid the wait. (internal medical tourism). You can also compare outcome data, infection rates and many other data online through NHS Choices
  • If you have a serious and life threatening problem, there’s virtually no waiting list. That’s why I’ve only ever met one British heart surgery patient who has gone abroad for treatment. Despite this, I’m regularly amazed by overseas providers or consultancy companies who call me to discuss their plans for attracting British patients overseas for major surgery such as heart bypass.

And here’s some recent “real life” experience.

  • The Web Communications Manager at my company recently celebrated the birth of his first child. Unfortunately, the birth was at 27 weeks so it has not been easy for him or his wife. The child has been in paediatric intensive care for some weeks in a local hospital, and has recently been transferred to Great Ormond Street Hospital in London for heart surgery. Is he happy with the NHS care?....Yes. Has it cost him a penny?.... No.
  • My wife has a recurrent inflammatory problem at the back of her eye. She has regular assessments at the local NHS eye unit, and recently went for a minor procedure. It was urgent, so she didn’t have to wait. She went to the brand new eye state of the art NHS eye unit at Stoke Mandeville Hospital. How long did she wait?..... a week or so. How much did she pay?..... Nothing?

Are British patients flooding overseas for treatment because of “long queues” and “extensive waiting times”? No. The majority of UK medical tourists are not patients requiring elective surgery that they can’t get or will not wait for on the NHS. The reality of healthcare is that patients want affordable (or free) treatment close to home, or within their country. Before they even consider going abroad for treatment, they explore all the avenues for treatment within their own country.The NHS has its faults, of course, but no system is perfect. And would I swap our NHS for the current US model? No, I couldn’t afford it..... either as an individual or as an employer!
So, will the Obama healthcare reforms lead to a massive surge in medical tourism, as some have suggested? No.
Medical tourism will continue to grow as more patients become aware of the possibility of low cost treatment abroad. But we should never forget that what every patient wants is affordable healthcare on their own doorstep.....and travelling for treatment is for many a last resort.

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A new paper highlights the growth of 'infertility tourism' in Europe

 

A recent paper presented at the Annual Meeting of the European Society of Human Reproduction and Embryology in Rome highlights the growth of “infertility tourism” at a time when many medical tourism businesses are feeling the pinch of the recession.
The article, “Cross border reproductive care in six European countries” provides a review of inbound infertility tourism to six European countries receiving patients - Belgium, Czech Republic, Denmark, Slovenia, Spain and Switzerland. Data was collected from 46 centres in these countries. Patients came from 49 different countries, but almost two thirds came form only four countries - Italy (31.8%), Germany (14.4%), The Netherlands (12.1%) and France (8.7%).
Drivers of infertility tourism
Why are these infertile couples crossing borders for infertility treatment? It varies from country to country but the main driver is the law on infertility treatments within the home country. This is the predominant reason for patients coming from Italy, France, Germany, Norway and Sweden. Italian law banned sperm donation in 2004; German law bans egg donation; in France, assisted conception for single women or same sex couples is illegal and there is a ban on advertising for egg donors; regulation regarding donor anonymity affect Scandinavians and British patients; some countries have regulations that limit reimbursement of assisted conception to a maximum age.; some countries have legal limits on the amount that can be paid to donors thus reducing availability of sperm and eggs.
Difficulties in accessing treatment at home were a driver for a third of UK patients, and a wish for “anonymous” donation was expressed by around one in five patients.
There’s also some indication of specific cross border flows: Italians favour Switzerland and Spain, the Germans prefer Czech Republic, the Dutch and French opt for Belgium.
18.3% of patients were looking for semen donation, 22.8% for egg donation and 3.4% for embryo donation.
Market opportunity for medical tourism businesses?
The study estimated that “a minimum estimated number of 11 000–14 000 patients per year” visits the six countries in the study; it may well be much higher than this.
If you’re in the medical tourism business, download the paper; it’s a useful insight into the opportunities in infertility tourism and to the kind of patients that seek it..... which should be a major influence on your marketing. Understanding your market is key to the success of any medical tourism business. For example, the internet was a frequent source of information about infertility treatment abroad in Sweden (73.6%), Germany (65.0%) and the UK (58.5%).
So, it’s good news for my healthcare web publishing business that a Google UK search for “infertility treatment abroad” brings up Treatment Abroad at number 1 and our other sites in positions 2, 3, 4, 6 and 10 in the top ten Google UK results!

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Is medical tourism on the road to recovery?

 

Following my outpourings on the “Outlook for Medical Tourism in 2010”, I am pleased to say that I’ve received some positive feedback (always a good thing.... I’ll keep on blogging!). And some reassurance that I am not alone in my view of the medical tourism world.
In particular, one of the long established medical tourism facilitators told me “how it was” in 2009 and how they think it might be in 2010. It’s refreshing to hear someone be open and upfront about their business experiences in medical tourism and the challenges that are facing people in the business.
I’d like to share some of these comments with others in the medical tourism world. Here is what it was really like in 2009 for one medical tourism business, a business that is well established, well run, and isn’t a “one man and his dog” outfit. I’m going to respect their confidentiality and not name the company concerned.
The view from the marketplace
Here’s what our medical tourism facilitator had to say about 2009:
“We have dabbled in the elective surgery market and have come to the same conclusions as you.... that to continue in this sector we would need to consolidate and concentrate on niche or rather more specialist sectors. Otherwise, we are finding ourselves becoming a "Jack of all trades and Master of none".
Last year was a really bad year. We were very busy with enquiries, but our conversion rate was disappointing and for those that did convert, the average spend was down. We have put the conversion problems down to a 50/50 mix of:

  1. Recession - people not spending, or when they are travelling for treatment, they are spending less.
  2. Competition - it seems in the last 18 months that every person in Europe, with a spare room and who knows a dentist, has jumped on the medical tourism bandwagon.

Another factor that has not helped is the pound sterling rate against other currencies, especially the Euro; this has meant a 20% increase in costs and prices. This does not only apply to the treatment cost but the patient stay while they are away. (Hotel rates are more expensive, eating out is more expensive etc.) The effect has been significant. Our patient numbers fell by 30% in 2009 and the average spend per patient dropped by 25%.”
So, a difficult time for this medical tourism business. But it is not unique. Some dental clinics in Europe have been relating similar experiences. One major implant centre in Budapest has reported overseas patient numbers down by more than 20% and a similar 25% fall in average spend per patient.
Do these experiences reflect the reality of the medical tourism business in recession?
Lies, damned lies and statistics?
The UK is one country where we count stuff. We have an Office for National Statistics and they employ around 4,000 civil servants who count stuff...including medical travellers. At Treatment Abroad, we do our bit to keep the civil servants in jobs by buying the data that they produce – specifically, the International Passenger Survey (IPS), a survey of a random sample of passengers entering and leaving the UK by air, sea or the Channel Tunnel. The IPS attempts to identify the number of people both travelling into the UK and out of the UK where the prime reason for travel is medical treatment (as opposed to business or a holiday).
Now.... you need to take these statistics with a very large pinch of salt. Statistics contain statistical errors and the smaller the sample, the bigger the risk of the error.
Here is a graph of IPS data showing outbound medical travellers from the UK from 2002 to 2009 (projected from 3rd quarter statistics). The sample size in this data is small - the number of actual travellers interviewed in each quarter who stated that their prime reason for travel was medical is around 50 to 100. So, there is room for wide variations in the data!
But, it may well be a reflection of the actual trends in UK medical tourism and for 2009 may indeed reflect the experiences of many in the marketplace who have seen the number of medical tourists in decline over the last 18 months or so, since the credit crunch hit.
Light at the end of the tunnel?
Our medical tourism facilitator quoted above has a more positive outlook for the future:
"We have already seen an increase in booking numbers for dentistry in 2010. January is already 100% up on January 2009 (and nearly the same number as in 2008, so something is starting to change.”
With some good news on the economic horizon in the UK, we may be seeing an increase in consumer confidence. House prices are increasing, and we have seen a return to economic growth, albeit not as good as many would have hoped. We wait to see what the effect may be on unemployment. But, like many industries, medical tourism follows the trends in the economy as a whole. Medical tourism is not immune to recession and certainly is not flourishing in it.
The way forward.. focus and think niche
Back to our medical tourism facilitator, who is planning the strategy for 2010:
“Our progress for 2010 will be to expand the dentistry further and concentrate more on the cosmetic surgery. We had taken a step back on cosmetic surgery in 2009, due to the difficult climate and similar to your (Keith Pollard’s) points about offering too much, we have recognised that rather than be a "Jack of all trades.....", we need to have a separate department. Having the same staff switching between the two products (dentistry and cosmetic surgery) does not really work.”
And our medical tourism facilitator concludes with a message for all in the industry:
“I totally concur with the conclusions of your article, and recognise that this medical tourism industry is not as simple and as great as people have made out. Only the companies that keep adapting and recognise the importance of focusing and having the correct resources to manage a particular sector of this industry will survive or be commercially viable.”

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Was 2009 a good year for medical tourism?

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Before looking forward to 2010, let's look back and assess where medical tourism is now. So, was 2009 a good year for medical tourism? In 2009, we heard medical tourism “experts” across the world continue to talk up the potential for medical tourism without any sound basis in reality. It’s in the interests of some within the industry to boost the profile of medical tourism and frankly to exaggerate its potential. But whereas some industry pundits talk in tens or hundreds of thousands of patients, others talk in millions.
These over optimistic forecasts have in themselves created a burgeoning medical tourism industry and a flurry of market entrants who may find that the going gets tough in 2010. Much of the current medical tourism sector has been built on hype rather than solid foundations. “In the land of the blind, the one eyed man is King” said Erasmus, and this has certainly been true in medical tourism.
Reality bites.... in the UK
The medical tourism sector is (a) not immune to recession and (b) is not going to thrive in a recession. The argument that people are more likely to look for low cost treatment overseas if money is tight just doesn’t stack up. How has the recession affected self paid treatment in a mixed healthcare economy such as the UK? The number of patients paying cash for elective surgery such as hip and knee replacements and the discretionary spend on cosmetic surgery is down 20% over the last 12 months. And the missing 20% are not going abroad because it’s cheaper. They are hanging on to their money, delaying treatment or deciding to spend their money on more essential outgoings.
Reality bites.... in the USA
For many new entrants to the market, the USA is seen as the “golden goose” of medical tourism. It depends what you read and who you believe. Compare these predictions and numbers:

For 2008

  • Prediction: “it is expected in 2008 that several million Americans will travel overseas” (Medical Tourism Association).
  • Reality: - outbound US medical tourist numbers declined to 540,000 in 2008 (Deloitte Medical Tourism Update)

For the future

  • “23 million Americans could be traveling for medical tourism in 2017.” (Medical Tourism Association – Sep 2009).
  • Recession adjusted forecast: 1.62 million medical tourists in 2012. (Deloitte Medical Tourism Update – Oct 2009)

Is either of these future predictions anywhere near the mark? What might be the factors influencing an upward or downward trend:

  • Obama... the President who may change the way that the USA funds healthcare. And he’s making progress. Universal healthcare coverage in whatever final form it takes pushes medical tourism to the margins.... which is where it is in most developed countries. People do and will travel for treatment but it will always be a small minority wherever they are.
  • Insurers, employers, HMOS’s..... We’re still a very long way from seeing funders of healthcare make a significant move towards using medical travel as a way of reducing healthcare costs. Will it happen? Yes... but slowly and at the margins.
  • The recession isn’t over.... and it isn’t going away anytime soon. In both the US and Europe, unemployment levels hit 10% in December 2009. American workers have been unemployed an average of 29 weeks, the highest ever recorded since the data was tracked from 1948 onwards. Americans are visiting their physicians less, reducing the number of drugs they pay for. They are reducing their level of care. But as with the UK, large numbers are not offsetting this by pursuing lower cost options overseas.

According to a report in USA Today this month, medical tourism is number nine in the top ten travel trends for 2010 in the USA. According to USA Today, the three drivers are:

  1. More coverage of overseas medical care by major U.S. insurers.
  2. An increase in individual insurance policies that typically carry a high deductible.
  3. A marketing push by companies that combine travel and medical services.

But will these drivers drive significant growth in the USA or elsewhere in the world?

  • Some, but only a few, insurers will provide coverage....but will patients actually want to travel?
  • There may well be an increase in deductibles....but will patients be able to afford to “top up” their healthcare anywhere....in their home country or overseas.
  • Companies may well increase their marketing spend and may increase public awareness a little....but what we don’t have in medical tourism is a “big player”, a company that’s prepared to risk hundreds of thousands of dollars/pounds/euros in bring medical tourism to the masses.

So... is it medical tourism boom or bust in 2010?
Neither. Medical tourism is not the Holy Grail that will save holiday destinations around the world who are already suffering from the “let’s stay at home” effect of the credit crunch? It’s not the easy win for hospitals and clinics who have been adopting the “if we build it, they will come” approach. The reality is that we will see growth in the long term.....growth where medical tourism makes sense and not at the exponential rates that some have predicted.
The good news (for medical tourism) from the economic downturn is that every Western government is going to be under pressure to cut public expenditure and that usually means cuts in healthcare provision. Let’s take the UK as an example. The UK government knows that it cannot afford to fund the healthcare system as it has in the past. The UK national debt in 2010 is 72% of Gross Domestic Product; ten years ago, it was 33% of GDP. In Ireland, the Irish government unveiled one of the most severe budgets in the Republic's history embracing cuts in public expenditure across the board.
In many countries, the pressure on public funding of healthcare will be greater than ever before. In the long term, an ageing population demanding more healthcare and pressure on healthcare budgets will mean more patients funding their own care and looking at overseas treatment as a serious option. And that means there’s an opportunity for medical tourism.
Regional healthcare not global healthcare
In truth, there has never been a global healthcare market, and it’s unlikely that there will be one in the near future....unless, of course we:

  • Invent an aircraft that can cut flight times by several hundred percent without increasing flight costs and global warming! Unlikely.
  • Convince disparate healthcare systems worldwide to standardize the way they treat patients. It isn't going to happen.
  • Get doctors in different countries to work together in providing continuous care for an individual patient (or at least talk to each other!). Some hope here, perhaps....

Where does medical travel really work...and happen? Across borders....from one neighbouring country to enough....within rather than between continents. However in need of treatment they are, and however desperate they are to save money, the number of patients who are prepared to board a plane and fly for eight hours plus to a different country with a different language and culture is minimal. It’s medical tourism at the margins. And it’s medical tourism that puts patients at risk through combining surgical procedures with long flights.
Patient flows in medical tourism follow low cost airline routes with short flight times or cross border land routes. Americans flying or driving South for surgery, Brits traveling to Budapest for dental treatment, the Japanese heading West to Korea for cosmetic surgery, the Indonesians travelling to Malaysia and Singapore, Central Africans heading for South Africa and so on.
The competition is going to get hotter
With medical tourism numbers failing to live up to the inflated predictions, we may now be faced with too few patients for too many providers. Those who have come to the market in the last twelve months are going to wonder where all the promised patients are. The simple laws of supply and demand mean increased competition. But that doesn’t necessarily mean that prices will plummet. Only the foolish will drop prices to attract patients. Consumers don’t opt for the cheapest when it comes to making healthcare decisions. Yes, they want to save money, but cheapest implies low, quality, risk...all those things that medical tourists are trying to avoid. Added value, customer service, creating new business from existing or past customers will all become important in differentiating your business, and attracting new patients.
New models for medical tourism?
The credit crunch, increasing competition, the slow growth in patient numbers (if we see any growth at all in the near future) will encourage new approaches to medical tourism. We’ve seen the Hungarian “dental tent” come to the UK, and we hear that cruise ship medical tourism is on the agenda of the European Medical Travel Conference. And perhaps in 2010, we may see the serious adoption and exploitation of telehealth and e-medicine in the medical tourism sector.
In a recession....find a niche
So, what can those pursuing the Holy Grail of medical tourism learn from all this?
One key to success in a recession is to find a niche and ideally one that is a recession proof niche - one that people spend their hard earned cash on when money is tight. Whereas many healthcare providers try to be all things to all patients, those that succeed will select their niche and focus their efforts.
There are some niche areas of healthcare that are relatively recession proof and may prove attractive. Infertility treatment is a good example:

  • Public funding of infertility treatment is under pressure in many countries.
  • The need is high and people aren’t prepared to delay treatment too long.
  • Money may be tight, but having children is the one thing that they may spend money on rather than anything else.
  • It’s high value.

There are others...get your thinking cap on and go out and find them.
In summary
2010 may be the year in which we see some rational thinking and some rationalisation in the medical tourism world. Perhaps the recession will bring some of the “blue sky” thinkers down to earth. New market entrants are going to feel the pinch; the long established players will maintain their reputation, improve their services and continue to thrive.
Long term, the medical tourism sector is here to stay.
Stay with it.... businesses that ride out the recession will come out of it in better shape. It’s still an attractive market sector and the business is there for those who take the long term view.

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Freedom of movement is spreading doctors, not just patients, around the world.

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The internationalisation of UK healthcare…. and the challenge for medical tourism destinations 

UK Healthcare

Many countries across Europe want to attract patients from the UK seeking treatment abroad. But freedom of movement for healthcare workers and the attractions of the UK mean that the UK patient can now access “international healthcare” in their local private or NHS hospital.
My recent experience as a patient in a UK private hospital, and of the healthcare staff who provided my care, highlights the challenge faced by overseas providers in retaining the staff they need to deliver services to the international patient.

Would a UK patient travel abroad for hernia surgery?

As a keen (but ageing!) sportsman, it was only a matter of time before I became one of the 25% of males who need surgery for an inguinal hernia. The waiting time for this surgery at my local NHS hospital is 14 weeks. Not too long to wait, but I have private health insurance through AXA PPP and this enabled me to choose a consultant (Mr Abhay Chophada) and a hospital (BMI Clementine Churchill Hospital) that I felt were best for my needs.
Would a UK patient travel abroad for inguinal hernia surgery? Very few would consider this. A UK patient can opt to wait for free NHS treatment, use private health insurance (if they have it) or can seek surgery on a “fixed price” basis. Most UK private hospitals will offer a fixed price, all inclusive package for hernia surgery. Prices range from around £1,800 to £2,500 depending on the hospital and the surgeon. This price includes pre-operative assessment, post operative follow up, the surgeon and anaesthetist fees, all hospital related costs and a guarantee.

A UK care team… from India, Serbia, Portugal, Lithuania, Egypt, Romania, Turkey and Russia

What is interesting about my patient journey is how UK healthcare is being delivered by an international healthcare team.
Let’s start with the surgeon. Abhay Chophada undertook his medical training in India, gaining his MBBS and Master’s degree in Surgery from the University of Pune. He then moved to the UK gaining further qualifications and experience at the University of London, and University College London Hospital. He holds an NHS Consultant position at Ealing Hospital NHS Trust and has a thriving private practice.
When I went for my pre-operative assessment:

  • The nurse was from Serbia. She moved to the UK to gain experience and to earn four times the wage she would earn in Serbia.
  • The phlebotomist was a first generation member of an Indian family.
  • The cardiac physiologist was Portuguese. She had trained at the Coimbra University Hospital and moved to the UK to earn three times the salary.

The care team during my operation on Saturday comprised:

  • A nurse from Lithuania.
  • A nurse from Romania.
  • A nurse form Turkey
  • A physiotherapist from Egypt.

On entering theatre for the operation, I bumped into Sergei Vagonov, a Russian anaesthetist who had been a guest speaker at our “Future of Harley Street” event.

The UK healthcare system’s reliance on international staff

My patient journey highlighted the extent to which healthcare professionals overseas are attracted to the UK’s private healthcare system. But it’s not unique to the private healthcare sector. Data from the Health and Social Care Information Centre (HSCIC), show that 11% of all staff who work for the NHS and in community health services are not British. 26% of NHS doctors are non-British. India provides the highest number of doctors from overseas. The Philippines provides the highest number of overseas qualified nursing, midwifery and health visiting staff. Poland, Nigeria, Zimbabwe, Portugal, Pakistan, Spain and Germany also feature highly.
For a full analysis, see this interesting infographic from the Guardian.

The challenge for medical tourism destinations

The harsh reality for countries that seek to become medical tourism destinations is that they are losing their best staff to the countries that they see as a source of patients. For healthcare systems such as the UK where there is pressure on staff and resources, the immediate solution is not to export patients… it is to import doctors and care givers.

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