Discovering Medical Tourism

Medical tourism is often depicted as an outsourcing process: you go elsewhere to get cheaper prices, as a shoe manufacturer can transfer its manufacturing activities from Italy to Bangladesh.

Still, this outsourcing process is extremely different as, conversely to a classical industry, you don t keep the same machine, namely the doctor. And beyond the differences there can be in terms of qualifications, there is a whole difference in terms of culture, of medical philosophy. Even though many of those doctors who perform in top tier hospital have been trained in the US, in Australia or in the UK, many Asian doctors are taking into accounts the many peculiarities of the Asian medical philosophy to better their practice. 

What are the main difference between the occidental and the oriental system: 

The goal VS the way to the goal: 

Occidental medicine aims at curing the patient while the asian medicine focuses on the healing process itself, on a day by day bettering of the health condition. This explains the type of therapies associated with traditional Chinese Medecine or Ayurveda that will last a few days or weeks, each day consisting of different healing techniques (mixing dietetics, massage, cleansing…) 

The microscope VS the “macroscope”: 

Occidental medicine focuses on analyzing details, isolating specific parts of the body and assessing it to a series of tests. Oriental medicine is more generalist and is keen on interpreting a series of simple clues easily noticeable to make a statement on the health condition of an individual: e.g. the tongue analysis in Ayurveda, the urine and fecal smell and colors… Hence there is a strong opposition as oriental medicine is empirical and asks for extremely trained and seasoned doctors while occidental medicine is experimental, therefore results can be easily confronted. Asian medicine is very subjective as it considers all individuals as unique (the doshas system for Ayurveda, the 5 elements system for TCM), while occidental medicine is  objective depicting all individuals as similar machines sharing the same patterns (organs, nerves, bones…). The experimental approach is herefore validated as results on a significant amount of individuals are enough to extend it to any potential patient. 

The passive patient VS the active patient: 

A doctor in Europe is often seen as a protector, a kind of father that will pay heed on your health and be there whenever there is a problem. The relation with him is instable (as it is with a father): sometimes customers are putting the blame on him, bare a grudge for a bad prescription, or see him as a superhero. All in all, the patient is always passive, receiving care as a kid gets his food, clothes and toys. The oriental system places the doctor not as a father but as a partner, an advisor. A doctor is here to guide the patient, to give him his own opinion on how he could improve his health but at the end of the day, the patient has the last say when it comes to opting for the best solution for him. In this way, Asian medicine asks for the patient to be aware of his options and to make himself the choice he feels is best for him. Hence, the patient can only blame himself as he was the one to decide on which option to take. 

The straight line VS the circle: 

As previously discussed, the Oriental medical tradition considers that any trauma or organ dysfunction can generate a series of dysfunction in the whole body: this is the five elements system whereby one imbalance of an element will create a series of reaction in the other elements. This is why the healing process is important as it aims at reinvigorating all the elements and not the one affected at first. The occidental system is more based on Search and Destroy: curing as fast as possible what poses a blatant problem, even if this can arouse numerous side effects. It s a go getter approach! The body is seen as a machine; when something is broken you fix it, while Oriental medicine views the body as a vitalistic and dynamic system: when something is broken it can create a chain reaction, therefore many other things to fix.

Recently I visited a string of interesting spa in South East Asia:

• Tria integrative Wellness,
• Amezcua Wellness Centre, 
• San Carlos.

These spa are classified under the medical spa category. The concept of a medical spa consists in linking pampering to health benefits: you go to a medical spa to feel better under a precise Medical protocol. If you figure that a medical spa is a massage table with an electrocardiograph you re not very far. A medical spa will go beyond the word wellness and investigate your health conditions on the short term (medical analysis) and on the long term (preventive care), connecting a spa treatment to diet counselling and stress management.

In fact according to the preventive care theory, nutrition influences the health of your body and keeping tabs with it is a good way to avoid diseases in the long term (this theory still lacks precise documentation but is based on the belied that the synthetisation of amino acids brought by daily food intake affects the creation of neuro transmitters hence the perception of pain and mood).

Let’s take a look at the spa menus proposed by these different medical spa to better understand what it’s all about!

 First, when I arrived at TRIA (Bangkok) I was surprised because the taxi drove me to the Piyavate hospital. Then instead of turning right we took a small road alongside the massive hospital to discover a brand new faciity behind with golf cars and mercedes in the parking lot. Then inside it’s a real treat: wooden atmosphere, with top notch design. The medispa is organised in threee levels (four to come): the first one is hosting a small spa for men and for women, on the second floor you’ll find treatment rooms that are full of medical equipement and at the center a spa cuisine restaurant where you will be served vegetarian food accroding to your diet assesment. Then the second floor is composed by a pool and 4 isolated treatment pavillon

Getting an idea of TRIA: the spa Pavillon (3rd floor) + the food corner (2nd floor)

I really love their approach as it mainly focus on understanding how an alternative medicine can benefit to someone: they use reiki for fatigue, anxiety, hydrotherapy for arthritis, yoga for balance and market that under simple names such as sitting confortably for yoga, go the distance for fitness assesment. A really complete preventive care program in a spa envirronment. Hence a stay at Piyavate can be immediately followed by an experienmce at TRIA, a decisive competitive advantage that is increasingly considered by Asian hospital groups. TRIA did their soft opening last October, I m really impatient to see their operation up and running!

 Amezcua (Manilla, Philippines) has put  up a team of specialists to operate on three distinct fields: alternative medicine (acupuncture, healing touch…), recovery after surgery and aesthetics surgery. The program has an interesting twist as it converts alternative medicine treatments in preventive care screenings (for instance Meridian Stress Assessment (MSA) derived from traditional Chinese medicine that consists in measuring electrical energy throughout acupoints and meridians to estimate one’s level of Qi or the Korean Bu-Hang (where cups are placed in one’s back to see if an organ is reacting abnormally)). They also use innovative alternative medicine processes recently developped such as ozonotherapy (inhalation of pure oxygen to reinvigorate the tissues). As for TRIA it is a rather new concept, and there are eyeing to develop a facility in Koh Samui in the months to come.

 San Carlos, founded in 1993, is well known for its expertise in the field of weight control, insomnia treatment and stress management. Techniques used at St Carlos are mixing traditional Thai medicine and recent western technology. St Carlos both provides general medical care and check-ups, and wellness programs (slimming, rejuvenating, body cleansing), as well as cosmetic surgery.

Spa packages mix laser acupuncture, Ayurveda and herbal medicine… The St. Carlos Weight Loss treatment consists of a mixture of Asian herbs and pharmaceutical components combined to effectively cleanse the body and burn off unwanted fat. First, patients loose weight, then there is a time for weight stabilization

After their treatment, patients are provided with a complete individual health plan. Considering the background of the client’s health problems, spa doctors educate the clients on individual health management, including healthy dietary intake and exercise programs. St Carlos Medical centre also offers a wide range of facial care products, as well as hair treatment and food supplements, under their own brand name, St Carlos.

All in all three different approach:

• TRIA is the future of spa integration to hospital
• Amezcua is all about preventive care through alternative medicine
• San Carlos i s  a medical leader in alternative medicine

Hence if you ask me who is Medhi Spa I ll answer: “he’s the new kid on the block“

In my previous two articles, I have been talking about the possibility for Indian Hospital  to utilize Ayurveda in their healing and medical offers to gain a differentiating asset. Yet there are two hollistic medical system in Asia: ayurveda and traditional Chinese medicine that I ll call TCM to save some time.

Traditional Medicine is an ancient method of health care that combines the use of medicinal herbs, acupuncture, food therapy, massage and therapeutic exercise… Even though the concept yin yang is becoming a cliche of the occidental popular culture, TCM is really based upon this system: the interrelationship between organs is exactly depicting the yin yang theory.

This system, called the Five Phase theory, is based on the  premise that each organ either nourishes or inhibits the proper functionning of another organ (the yin against the yang). TCM aims at stabilizing the whole system for it to operate. Let’s illustrate this idea with the actual five phases

So let’s understand the whole system: for instance, deficiency in EARTH (stomach) leads to deficiency in both METAL organs (large intestine and lungs). Defficiency in METAL generates an imbalance in WATER (kidney and bladder) and in turn affects WOOD that will then affect FIRE. Any imbalance breaks down the whole chain…

Diagnosis in TCM is all about understanding if there is an imbalance of one of these five elements. Hence no x rays, no blood tests, no endoscopy… TCM diagnosis consists of four non invasive methods:

• Inspection of the general demeanor, body. language and tongue

• Question the patient about medical history, diet, lifestyle

• Listen to the tone and strenght of the voice

• Smell any body excretion, the breath or the body odor

• Palpation of the pulse of radial arteries, the abdomen and the meridian

This is actually not a far cry from ayurvedic techniques (even for the gore part), yet, the main difference resides in the meridian analysis and the will to get rid of all symptoms, even the hidden ones (as all elements are affected by the imbalance of one of them). TCM techniques are pretty obscur as they are practiced among the Chinese community in low profile places (in Singapore it is often practiced in a tiny room inside an appartement of a 16 storey building bar…)

I definitely need some guidance to find my way in this TCM shop!!

Many medical spa has taken into account the TCM approach to appeal to international custmers, but some Asian hospitals are trying to fill up the void. The Raffles Hospital hospital has just opened Raffles Chinese Medicine a clinic that emphasize TCM as a complementary medicine for a series of condition most notably stroke recovery and hypertension. Yet, the mysticism of the discipline plus the proven efficiency of TCM should entice Asian Hospitals with an important Chinese Community as their potential customers to develop such services:

• To find best practices to deliver TCM

• To propose an end to end medical follow up (post op recovery through TCM)

• To be DIFFERENT 

As stated in the previous article, Indian medicine has a great asset: its past. In fact, Ayurveda, the hollistic medicine principle derived from centuries of medical tradition, is an original medicine with a certain efficiency that can be built into a decisive competitive factor by Indian hospitals!

Previously, we talked about preventive care and diagnosis according to ayurvedic medicine. What about Disease management? there are four main methods by which and Ayurvedic physician manages disease:

• Cleansing and detoxifying (shodan)
• Palliation (shaman)
• Rejuvenation (rasayana)
• Mental Hygiene and Spiritual Healing (Satvajaya)

Cleansing and detoxifying (shodan)

This is the gore part of Ayurvedic medicine unfortunately and this can really scare off any person willing to discover ayurvedic medicine: pancha karma is all about vomiting, bowel purging, nasal douching to remove toxins from the body. The good part is that in preparation for cleansing an herbal oil massage may be performed (oil is well absorb by the skin and helps to eliminate toxins while passing through the body). herbs can also be introduced in certain parts of the body (especially the noze) to increase resistance to enzyme reaction. After the cleansing, the patient is given ghee (clarified butter) and yogurth to restore the intestinal flora.

Hi! Let me take care of your bowels

Palliation (shaman)

Shaman focuses more on the spiritual part of the healing and uses a combination of herbs, fasting, yoga streches, breathing exercices, meditation and lying under the sun (ah! that’s better than cleansing the body). in fact, the sun is not only a source of heat and light but according to ayurveda a way to better absorb vitamin D, to improve circulation and to strenghten the bones (the time of exposure required depends on your dosha type). Actually Shaman is often used as an alternative to pancha karma (see above ) for those who are mentally weak to undergo this kind of treatment (like me!). Shaman is really sweeter: one of the herbal therapies prescribed consists in consuming honey with certain herbs such as pippili (long pepper), ginger, cinnamon and black pepper…

Meditation as an alternative to cleansing

 Rejuvenation (rasayana)

Rasayana is a program of tonification which is similar to a physiologic tune up.  It is used to restore virility and vitality to the reproductive system, countering strterilirty and infertility, bringing forth healthier  progeny and improving sexual performance. Ayurvedic medicine uses three methods for rayasana: special herbs prepared as powder, pills, jellies and tablets; mineral preparations specific to a person’s condition and exercices (again yoga exercices).

Mental Hygiene and Spiritual Healing (Satvajaya)

Satvajaya is a method aiming at releasing psychological stress, emotional distress and unconscious negative beliefs. This is one of the precursors of stress management and operates in a very original and “modern” way. The categories of satvajaya include mantra or sound therapy to change vibraotry patterns of the mind, yantra or concentrating on geometric figures to take the mind out of ordinary modes of thinking and gems, metals and crystals for their vibratory healing powers.

Yantra: one type of the geometric figures to alleviate stress 

CONCLUSION 

All in all, Ayurvedic medicine is extremly original and should be put forward by Indian hospitals as an innovavtion in treatment. When people hear about Ayurveda they can barely figure out hwat it’s all about. My gut feeling is that some Indian HospitalGroups are being too conservative and too “un Indian” in their product offer for international patients. Again if the market is price driven today, I really think that it will all result to quality on a few years: ”MADE IN KOREA” used to be a problem but then Hyundai and Samsung surfaced with their different and new products to propell the cognitive perception  of Korea very high in people’s mind. To  me, the same can occur with the label ”OPERATED IN INDA“: nobody will feel confortable with it up until quality and differentiation  will be knitted to Indian medical providers

India has established itself as a prominent medical hub thanks to an important number of high tech medical facilityies and many seasoned cardiologists willing to treat international patients.

Still, as anylayman from Europe, for me India looks like a new country on the medical map trying to surf on the BPO (business process outsourcing) tidal wave.

HOW WRONG AM I!

India has in fact one of the most documented medical tradition through ayurveda. Ayurveda is an ancient holistic medicine theory having its roots in Northern India - Nepal. What is so interesting beyond the cultural difference is that ayurvedic medicine is yielding very different results from traditional European medicine:

• In terms of Diagnosis
• in tems of Disease Management

First let’s explpain Ayurvedic Diagnosis:

An Ayurvedic diagnosis starts with determining you body type among three metabolic body types called doshas(vata, pitta, kapha). Your looking for a free membership card, ayurveda is there!

According to ayurveda I m a Vata and a little bit of pitta. What about you?

One’s doshas and the characteristics that reveal it clarify why one person will react to such product (milk, chili) or event (loud noise, humidity). Ayurvedic Physicians have traditionnaly relied on observation more than on medical equipment: they will question the patient on his medical history as well as his family medical history, listen to the heart, lungs and intestines, paying attention to the tongue, the nails, the eyes. Ayurvedic medicine distincts not one but three types of pulses (vaa, pitta, and kapha). The skills required are pretty impressive as a seasoned ayurvedic doctor can distinguish twelve different radial (or wrist) pulses!

The tongue is a major diagnostic site: the discoloation or sensitivity of the surface of the tongue can hint at the dysfunctionality of an internal organ. For instance, a whitish tongue indicates a disruption of kapha and accumulation od mucus; and a black to brown discoloration indicates a vata disturbance. A dehydrated tongue is symptomatic of a decrease in the plasma, while a pale tongue indicates a decrease in red blood cells.

In a tongue you can find your lungs, your heart, your intestines and even your spinal cord

Ayurvedic medicine has also introduced urine analysis way before the occidental medicine. the color can indicate dysfunctionalities (blackish borwn indicated an imbalance of vata, dark yellow for pitta, if it s cloudy it’s kapha) as well as the smell (a foul odor indicates toxins in the system, a sweet smell diabetic condition).

In a word, Ayurvdic diagnosis is a precursor to current prevemntive care diagnostics as well as an excellent complement to the western version of diagnosis as they go through their own path while yielding similar or additive results. I personally find it a great differentiation factor if explained well and done smoothly (people would be surprised to see no medical equipment involved). A tweener version between traditional ayurvedic diagnosis and western style would certainly help Indian hospitals dveloppinig a Best Practice that will help them gaining steam on the international medical market.

Indian Hospitals are now keeping track on the evolution of ayurvedic medicine and are increasingly opening dedicated clinics under the tutellage some medical teams. Disease prevention from ayurvedic medicine can tremendeously help pre and post operative care, yet there is a lack of integration today as indian practitionners a re carefully following wetserner guidelines. Yet, one could wonder how ayurveda would be factored in if Indian practionners were chosing to follow their own way and create an INDIAN model starting from preventive medicine and going up towards post surgery medical management.

Recently I received two mails from European Entrepreneurs (one Deutch, one English) that are willing to open a medical tourism agency that were both wildly complaining about the lack of support of Asian Hospitals. What they were pointing out was the fact that hospitals were not willing to invest in their operations while these medical tourism facilitators were “working in the best interest of the hospitals”. To be honest, I find this idea totally exaggerated: a medical tourism agency is always hedging surgeries between a pool of more than 10 hospitals. Given the small volumes yielded, what do these medical tourism agency provide: 30 customers per hospital a year? Seriously, why should an hospital invest in your start up and not in another one with a real value proposition?

Tan Tok Seng to NUH: Let’s work together baby! You take the arms, I take the legs

Yet, even though these claims are too much, there is one point to put forward: hospitals could act as a regulating power for these medical tourism agencies. In fact, the industry is lacking standardization: hospitals are very different from each other and the incoming process always vary from a medical group to another resulting into an incompatibility of medical records system, filing system, reporting system…  plus, medical tourism agencies are often individuals that advice people to go to a certain hospital and take a commission for all the ground work. Yet, what about insurances? what about medical records transfer?

The critical investments that hospitals need to do is a common R&D program to ease up international patient management. Let s take Asian Hospitals: they will gain momentum (against Eastern Europe or South America) by creating a common process (as medical tourism operators will find it easier to work with them). Intercompatibility between hospitals is even more important in case of complications: for instance, one friend of mine got a motorbike accident while visiting Singapore last week (… poor guy, his knee is in shambles …).

He was transfered to Alexandra Hospital, a good but not world class hospital in Singapore where a first operation was performed. An Arthroscopy showed that the operation will be more complicated hence he was sent to Singapore’s best orthopedic clinic in Singapore @ Mount Elizabeth Hospital (a Parkway group hospital). These two hospitals are not belonging to the same group of hospital… This resulted in a messy outpatient management (my friend was still considered a patient of Alexandra Hospital two days after leaving) and the need to do again some examinations as Alexandra hospital was unable to provide the records in due time. A complication during an orthopedic surgery can always happen requiring the help of the adequate team of specialists but not necessarily belonging to the same hospital. If Alexandra and Mount Elizabeth had a common system for their international patient, my firend would not have gone through painful drills and tests for a second time in a week.

In an ideal world, hospitals in a specific place would create an association whereby each hospital will hold a speciality for international patients (hospital X for plastic surgery, Hospital Y for spinal cord surgery and hand surgery…) so that hospitals can assemble the best team of specialists in the aera and gain sizable know how while reaching important volumes. Let’s take Singapore: Mount Elizabeth could specialize in orthopedic surgery while Raffles Hospital could specialize in Cardiology, leading to only one interface and common marketing effort to attract international patients. The Singaporian Board of Tourism (STB) is already gearing towards this direction by creating its medical travel departement, yet this is a governement initiative more than an industrial association. The Public System is in fact working under two groups, but these groups are put at odds (competition should create better process) and are diconnected with Private Hospitals.

There are evident issues to this system (revenue sharing model? volume per speciality? profitability per operation?) … Readers what are your thoughts?

The main problem with medical tourism is the natural feel of isolation that stems from it. By deciding to go abroad, a patient will fill his suitcase with medical reports and cross his fingers to get the right diagnosis. In fact, diagnosis is the tumbling rock of medical travel as people fears to be misled, misunderstood by a doctor that barely speaks English. There are many portsaals to find information about health such as WebMD or Doctissimo (my personal favorite one is intelihealth by Aetna as the information is clearly displayed and very practical).

Several entrepreneurs have worked on projects tying up any individual with genuine experts on a specific medical problem allowing a more effiicient management. We have previously talked about Xoova, an online doctor registry… These Health 2.0 formats are more proactive as they ask an action - reaction process pretty much like a forum with the notable eception that some people are willing to keep their personal health issues strictly private and don’t want 120000 readers to hear about their problems.

In fact, Health 2.0 is different from Web 2.0: the community is in osmosis in optimal Web 2.0 business models (everyone is crearting contents and freely displaying to community members (think about Wikipedia). For Health 2.0 there is the desire to tap the community resource (the doctors, healthcare specialists) without any comitment to the whole community. Health 2.0 is a gated community Web 2.0

Think about a pyramid where doctor are at the top and information seekers at the bottom. To add coherency to the pyramid, Health 2.0 communities entices to create communication between information seekers. This is not a soap opera, there are no triangular relations possible: if a information seeker will contact a doctor the latter will not tell a random community member about their exchange! You have to type of movement within the pyramid:

+ HORIZONTAL –> TO Community members with no medical expertise but a common hardship (i.e. similar health condition)

+ VERTICAL –> TO Specialised doctors able to give hindsight

Here are a few examples of such communities:

 Tau med is still at a Beta stage but is quite interesting. TauMed is a community system articulated around three features: interaction with the community (by asking an open question), share an experience based on a medical experience or question and health videos. Questions a re asked among community members that are then able to vote for their favorite answer or flag an answer if find inappropriate. Community members also have the possibility to create and share their personal care journal (“Health Share”) hence having people discussing their medical issues together (we can ponder over this fact considering one’s desire of privacy when discussing medical issues). Tau Med privileges an HORIZONTAL Communication but is looking into VERTICAL communication.

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 Everydayhealth.com is a large site that reaches over 4.0 million U.S. monthly unique visitors . The site attracts a primarily female, skewing older audience. The site’s audience’s affinities are magazines (Parent & Child, AARP Bulletin, Prevention, Home), retail (Giant Food Stores, Sweet Bay, Ingles Markets, Dollar General) and specialty retail (Catherines, Marshall’s, Sharper Image, Brook’s Running). Everyday health appears to be an information center that features 33 specialized “Health centers” on specific conditions such as depression, diabetes, inflammatory bowel disease. These centers are taking the full scope of each condition: from understanding the condition, to diagnosing, preventive techniques, possible treatments, ongoing management, and related facts. Each center is independantly managed by one specialised doctor establishing a clear connection between a precise health issue and a specialist that can give advice. Hence the website only entices a VERTICAL communication.

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 IMedix is another of those start ups with a very neat presentation. I Medix only functionnality is to have people discussing about their common health troubles and NOTHING else. I don’t see how I Medix can bring up a community with so little functionality and a zero zest of fun. Let’s figure out: “Hi I m John, I’m suffering from the Dawn Syndrome. Namely I am suffering from Dementia… Is anybody there?”… Perhaps somebody will be there but it takes a lot to write about your issues. There’s no positive factor, nothing that really makes you feel willing to participate to the community. Too little elaboration, I don’t like it (still perhaps they ll improve for their official launch…).

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 MedHelp is a first entrant on the internet scene as the company was created in 1994. At that time no Web 2.0, online community blabla. So they started with a simple stone. One of the creator of the website had her mother misdiagnosed during years and when a doctor with the appropriate qualificatfions and knowledge diagnosed her mother it was too late. To avoid this Medhelp intends to connect people with qualified experts on precise health conditions. With the evolution of internet the site has brilliantly evolved spurring VERTICAL and HORIZONTAL communication: you have now Doctor forums (43 forums) co existing with Users community (81 groups). The webiste is now featuring MyMedHelp, an online personalised portal that should focus on the problems you are facing.

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The quality of MedHelp forces me to think that Health 2.0’s new entrants are jumping too quickly to the users and are not trying to build what they really need: an expertise infrastructure that is going to be tested for several years. Tthe point is that such “infrastructure” is expensive and new entrants are more willing to burn their money on web development and online marketing than to create (understably) a backbone with a far fetched return on investment.

This morning, I made my little trip through some websites to get news about the medical tourism industry and noticed that the Health Business Blog by David Williams was talking a paper called Medical Tourism: Implications for Participants in the US Health Care System backed by his two companies (MedPharma Partners LLC, a health care and life sciences consulting firm and MedTripInfo.com).

The paper is pretty optimistic about medical tourism, something that is perfectly understandable as it is both companies core market. What is interesting is the fact that David Williams is a former consultant (BCG, LEK) hence he has a systemic view on the whole industry. Let’s take a close look at what he is saying:

Here are their predictions:

A. US health insurers will start to provide coverage for medical tourism in 2008. Mini-med plans and small employers -not big health plans and blue chip companies– will lead the way.

My take: I feel it is true to a certain extent. Indeed, some US insurers have made some noise in Thailand and Singapore with medical tourism authorities and are to launch tehir new products begining 2008. Small initiatives were made by entreprneurs but you need a strong financial power to have a sustainable model. in fact, the problem with these insurance models are the adverse selecton effect and the high risk of failure (the medical travel insurance’s population are not the best insurable commodities often, though this is a different game if we are talking about corporate insurances). I ll say ok for B2B, not yet for B2C.

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B. State governments will begin to embrace medical tourism by 2010.

My take:This will be limited to a few States. Some States will bodly show their teeth as they feel they cannot acknowledge their structural problems fearing some social ruckus. Some States will certainly pave the way when 10 S&P 500 will have implemented their medical travel solutions. All in all, it’s corporate America! Still, medical travel?? What are we talking about: heavy surgery abroad or dental and cosmetic surgery? For the latter I still think it will be a taboo even though it is the real core market…

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C. Opposition to medical tourism by US physicians will be relatively modest.

My take:their two main points is to say that 25% of the US physicians are foreign born plus that medicine is a global profession. This is a little bit too easy. It is not because you are foreign born that you will feel confident sending someone looking for an angiography to india! It is not because you know some experts in neurosciences from Singapore that you will encourage someone to have an arthroscopy in Sinigapore! Actually, what medical tourism needs is a clean track record to convince doctors. A doctor will always look for what he feels is best for his patient and even though medical travel can be a last chance solution, it is not yet seen as the BEST solution

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D. Medical tourism won’t have a major, direct impact on US health care costs, but the secondary impact will be substantial.

My take:I really like what they are saying! Their idea is to point out the fact that medical travel can only help trimming a very small chunk of the US medical bill (a max of 5% of every American decides to go abroad to have heavy surgery). The secondary impat aims at the wake up call that could happen if people start shifting towards Asian and South American Hospitals. Practices will be bettered, gain of productivity substantial and new binary practices (such as telemedicine) enhanced. Viva Medical Tourism.

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To me, this last point is really interesting. It reminds me the theories of creative destruction by Schumpeter that considers competition as a way to “creatively destroy”: from the shambles of a concept or company can surface a better product/concept/operation… In the same way, the US medical industry needs to shake up: 12% increase per year on corporate medical costs is ludicrious, most notably in a period when some mid sized US companies are looking for a new breath of life or just praying to get absorbed. Yet, the main problem is that medical travel is seen as something easy to operate and to enforce while it is not, and the sector itself must endure a hearsh competition from the US hospitals to thrive and find the appropriate business model and marketing messages… The creative destruction hence goes both ways as today, medical travel agencies are not able to attract an important number of customers and must mend their way if they want to be ready for the major changes predicted by MedTripInfo. 

The White Paper can be downloaded here!!

Everyday, i have the chance of having at least 2 to 3 mails from the many entrepreneurs willing to make the jump towards medical tourism. We discuss several issues: what are the margins like, is the service fee enough to cover costs etc etc. At the end of the day I see many people with energy and hope willing to make a living helping out people to maje travel arrangements. Even though I always point ot at the lack of innovation of this sector, I genuinely think that one person will find the right formula at the end of the day.

Four Entrepreneurs on their way to relaxation…

Actually this is not my point. What is interesting with an entrepreneur is all the stress he is facing and the way he copes with it. How can he be creative under so much pressure? Poor people…. Actually, alternative medicine can help medical tourism prospective entreprneurs to simmer down and gather steam. Which methods are acknowledged as being efficient?

YOGA! Brace up entrepreneurs: Yoga thanks to its breathing techniques has proved through various studies  to be an efficient treatment furthermore if it is combined with aromatherapy (lavender is reputed to soothe anxiety but actually Kava and Passionflower (Passiflora incarnata) have proved to be more efficient. However, anxiety is a condition that can be tackled by many other treatments such as Tui Na (reflexology), balneotherapy or at a lesser degree massage. In fact, while people tend to privilege massage, scientists have proved that massage was providing short term relief (a feeling of being relaxed) but does not work durably on the body. Massage is just an erzatz of medical treatment for anxiety (Goffaux-Dogniez C, Vanfraechem-Raway R, Verbanck P. Appraisal of treatment of the trigger points associated with relaxation to treat chronic headache in the adult: relationship with anxiety and stress adaptation strategies. Encephale 2003;Sep-Oct, 29(5):377-390).

The question I am asking myself is why medical tourism is not helping patients to cope with stress through alternative medecine prior to the operation? Three hours of  yoga can provide a placebo effect enough to trigger relaxation fromm the patient… Again, the vision on medical tourism is quaint… Medical Tourism Entrepreneurs should help themselves as they would help stressed patients facing uncertainty or a complicated surgery. or simply the feeling that they are 10000 miles from home, alone, without insurance, no acquaintances to confide in, etc etc. RELAX! YOGA!

Sources:

1. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I-neurophysiologic model. J Altern Complement Med 2005;Feb, 11(1):189-201. 2. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med 2003;Jul-Aug, 65(4):571-581. 3.  Malathi A, Damodaran A. Stress due to exams in medical students: role of yoga. Indian J Physiol Pharmacol 1999;43(2):218-224.  

Alternative medecine (also called complementary medecine) are all the techniques that helps treating a specific health condition. Even though some are still lacking exposure many of us have heard about acupuncture, yoga, aromatherapy. In France, thalasso therapy started not as a relaxation opportunity for Paris city dwellers but more like an opportunity to treat several health conditions, most notably arthritis and lower back pain. Scores of studies have been brought up in recent years and today we have some ideas on the connection of alternative medicine with the management of a health condition. Again we don’t talk about curing but about pain relief.

In the case of medical operations there is an astute way of connecting surgery to local medical specialties giving teeth to the idea of medical tavel (you go to country X not only for surgery but also for post operative recovery). Unfortunately, no medical tourism company is dwelling upon post operative needs and no one is carying a precise offer. 

After acting as a bookworm I have come with a ranking of the best 4 alternative medicine for post operative pain:

1. Acupressure (shiatsu)

 Acupressure is the application of pressure to certain points along the flow of energy or “qi” in the body. Acupressure is mostly used to sooth postoperative nausea and vomiting as well as for pain management. Researches report that acupressure may be as effective as intravenous pain relievers but still further experiments have to be done to confirm such a stance. The use of acupressure would be particularly interseting after laparascopic surgery but it remains to be seen if acupressure is safe for cardiology rehabbing…

2. Hydrotherapy

 Hydrotherapy has been reported as efficient in patient rehabiliatation following knee prosthesis implantation but also in a more simple fashion for surgical wound healing. As a whole hydrotherapy in its balneotherapy form (aquagym notably) is used for orthopedic rehabbing: drills in pool, aqua balancing. Hydrotherapy proves also to be efficient for osteoarthritis and the rehabbing following herniated discs issues.

3. Acupuncture

 Acupuncture is a well famed traditional chinese medicine techniques treating a health issue by inserting needles in one’s body.  According to research, auricular acupuncture (needles in the ear) reduces pain during hip surgery - this meaning that acupuncture can actually help during surgery! in the same way other types of acupuncture have been used on patients woth cancer preceeding or folowing chemotherapy with quite positive results. Yet, acupuncture is more about managing pain than treating any specific health condition.

4. Reflexology

 Relflexology often known as foot massage or Tui Na is derivated from acupressure focusing exclusively on the foot. Tui Na helps in a more restricted fashion than acupressure but some studies have proved its efficiency most notably for knee arthroscopy or knee replacement 

I love web 2.0! I have quickly reviewed Medtrotter, and to be honest I was extremy skeptical about patients ranking their surgeon…. Yet, let s now just consider a health condition such as asthma. You are living in Charlotte, north Carolina and you are looking for some information: you got it, through a new online doctor directory called Xoova.

Xoova besides being graphically and ergonomically remakable has the notable advantage of proposing consistent entry keys. One will write its location (state, town in the US exclusively) plus a health condition among a list: the cross research will lead to a series of profile. I have for instance typed Los Angeles California and aging: I got 1439 profiles most of them being relevant on the 8 first pages ( I was lazy going onwards). With 500000 doctors featured and 20000 profiles completed by the doctors themselves, we can talk about critical size! Doctors are not ranked everyone has a chance to grab new customers!

Now is one question I would like to ask Xoova: where is the money? please shed the light on this, I really have no clue. Xoova even advertises: “physicians who have integrated Xoova into their practices report a new patient yield of 5% or better, significantly better than typical phone-based patient referral services. There is no cost, software to install or contract to sign, meaning you can create an effective online marketing tool for yourself without risk”. In fact, the model of revenue is blur: appointements online are free, registration is free (for a positive yield…). I don’t get it.

Xoova is however developing an innovative new point of entry for its database: it consists in indicating your health plan to find the right doctors. Perhaps this will lead to an interesting revenue model sharing with Xoova promoting some HMO (through their doctors) or conversly HMO communicating on their plans through Xoova. The company is planning to further extend by raising 5 million USD beginning 2008, perhaps to cash in the strong community they have been building for 2 years? 

Today, as always, I m ready for a rant. Why? Because I don t get certain points in medical tourism, for instance the notion of medical care offering. Two events happened in the last few days:

Hi! I am a medical tourism product on a website: I am slightly yellow and red, can you please find me?

+ a medical tourism entrepreneur stated that offering to the public all kind of cancer, orthopedic and cardiac treatments and surgeries for medical outsourcing was completely logical because of the long tail theory. This is absolutely nonsense for many obvious reasons:

a. not all procedures are fitting to a medical tourism model that implies relatively short stays (people don’t want to die in India far from everyone from what I know) and do not pose any problems when considerong air travel (as people know air transportation because of a difference in air pressure can cause Phlebitis as well as bruises after a heart or spine surgery for instance).

b. people need guidance and no clear cut specialisations mean no real medical ability in the eyes of many medical tourists that I have interviewed. What is the point in bringing up a catalogue with 349 references when I know that bearely 20 of the references will represent 80% of my business (the famed Pareto law). People can argue that internet advantage is to propose anything but I will counter argue that people needs first to undrestand how things are working. The more products one offers the less he is able to put up clear packages and to market them efficiently. I don t think that a list of 235 oncologic treatments with no content associated on a webpage is efficient.

The guy did not agree with me. Yet from what I have learned he only had 3 clients in 2007… Perhaps because his product mix is aweful?

+ Talking about product mix here is my second example. While travelling in Asia I came to discuss many times about Planet Hospital that thanks to its innovative products is making a lot of noise and refered as the market leader by big media outlets. However, all the interviewed hospital marketing manager had the same conclusion: Planet Hospital represented nothing for them. Namely Planet Hospital, despite its reputation, had peanuts bargaining power. How come? planet Hospital is proposing an extremly wide range of hospital and is playing a dumb game as people can opt for the hospital they prefer. Hospitals marketing managers made the following criticisms to Planet Hospital:

a. a too large pool of hospitals naturally scattered volumes and pushed people to be as much of a low cost seeker as they can. IN fact, many of planet hospital’s customers are just looking for bargains and hence are mre concerned by economic rationale than success rate and service quality

b. Planet hospital is not a marketing partner as they do not focus enough on the upsides of each hospitals and hasn’t been able to come up with a clear ranking of hospitals according to specialties. On the company’s website all hospitals seem to be inter exchangeable.

All in all, both example show that medical tourism suffers from one major problem: no marketing mind tried to put up an interesting product ix, it is still too much opportunistic and one sided. Hospitals seem to be despised by much actors and there is no clear cut marketing contribution between medical agencies and hospitals. We can even call this a rift.

Several people asked me what is the differenvce between ayurveda and massage therapy. Surfing on youtube I found this video. I must admit I am a big fan of the blond girl featured in the video!  

Whenever I see a medical tourism website I always confronted to the same problem. As medical tourism companies want to fulfill the desire of any potential customer, the latter companies are providing all kind of medical services. therefore on the same page I witness the fact that I can get a CABG as well as a BOTOX injection. What? Somebody is going to inject a bacteria in my heart? No, keep cool reader, it is just to illustrate the total lack of focus of medical tourism companies.

The direct consequence is that I don’t understand at all the recovery time needed for my operation and how to chain it with some tourism activities. There are no ready to go packages. Even though medical tourism is often a case to case problem, people cannot rasp with no clues what is going to happen during their trip. one can point out to the fact that a website will always provide us with some example, but it’s always the same one.

‘This is a story of a 50 year old man that has no insurace policies but desperately needs an angioplasty. Therefore he opts for a low cost solution in India, where the cost of an angioplasty is barely 7%. Wow! What a tradeoff! And thanks to the price differential he can travel with his wife in business class and stay 3 weeks in a 5 star hotel. Oh miracle! Great!’

 Sorry, but besides angioplasty such examples are difficult to come with and this gives me no idea about what will happen after an IPL hair removal of my chest or after a dental bonding procedure. Besides Mednomad, a portal that gives Ok information about medical procedures, I understand nothing, absolutely nothing to medical trip organisation. It seems as if people were putting cardboards where is written: ‘please drop money and I ll get richer’. Many companies have come with personal assistance models when arriving at the airport of the city where is the hospital but this is not new. It has existed for years in the medical industry and is called incoming services.

So please, medical tourism companies, innovate. i desperately need to WYSIWYG my trip. Do you have any clues?

The Web 2.0 has been on the back burner for quite a while now. Just quoting the 2.0 stuff is enough to see people advocating a new golden era. However, many econmists and web specialists have identified several hindrances to the web 2.0: the revenue model has not evolved, the bigs only can survive, the information is not homogenous, yet it is a great looking idea. Wikipedia among others is a great example of the potential success of such a trend.

Medtrotter: a new toddler in the Web 2.0 world

Medtrotter decided to be the first entrant in the Web 2.0 for medical tourism. The company has created a portal where people can give their opinion on a given surgeon or a given location. Unfortunately, we can hardly access to any data and it seems that this system is not efficient. In fact, there are little elements that push anyone to fill these questionnaires that  however are not long but is still demanding efforts. Nevertheless, there is a genuine community sustaining the system, namely people experiencing medical travel and that are willing to share their experience. Yet, is the simple assesment of a doctor a good tool to pass a judgement on medical tourism. This supposes that the concept itself is accepted, that medical tourism is well understood by everyone and that there is no need to make a clear statement on the side effects of the system (better service, better facilities…). Is grading a doctor better than reading a testimonial where a doctor and an hospital are involved?

I genuinely feel that this concept comes at a too early stage of medical tourism and testimonials are still a better tool than global benchmarking. Even though the idea is relevant, I don’t feel that this is people wan to say and want to read for the time being. Web 2.0 in medical tourism should better be developped for close knitting qualified testimonials…

Michel Rocard is quite an affluent man in the history of France. Looking at his curriculum he was the former Prime Minister of France for three years (88 to 91) before being sacked because of his bickering rivalry with francois Mitterand. Recently he became quite popular with his very phoney interviews during which he appeared as a sincere man  full of humor and nuances. In a word, he is someone that stands high in the French opinion.

BEFORE                                           AFTER

Yet, recently, while being on a tour in India for the IFUNA, Michel Rocard experienced many problems while trying to walk and he was sent to emergencies on the 30th of June in Calcutta while barely being able to speak. From what it seems, Michel Rocard had a major hematoma in the brain and a surgery was quickly performed by Dr. G. K. Prusty.

Michel Rocard now comments: ” the surgery performed on me was quite serious (…) and could have crippled me”, but it was undertaken under excellent conditions (…), I believe there will be no side effects, it is formidable“.

Form Wikipedia: “Public relations (PR) is the managing of outside communication of an organization or business to create and maintain a positive image. “ This has been perfectly epitomized by Mr Rocard who is the living and well publicised study case that medical tourism was waiting for. Actually there was another case previously when Nepal Prime Minister Girija Prasad Koirala needed medical care in 2006 (he went to Thailand). Even though in this case, the medical operation performed was an emergency one, the comoplexity of the latter and the good results expected makes it a very good ad. Plus Michel Rocard, soon to be 77, commented extendidly on the quality of the service in India, the warmth of the medical staff etc etc. He also commented that Nicolas Sarkozy a right wingist had been very with him, a left wingist (the political scenary in France is in shambles conversly to medical tourism).

In a more serious note, I feel that what medical tourism needs is PR agents. The main marketing tool used to lure medical patients is the cost effects but not the technical prowess used or the genuine difference in terms of service or sometimes or after surgery care. These PR agents can only be reputed or famed people. When thinking twice about it, everything began with Pamela Anderson and her silicon breasts that never exploded but were partially removed. For men it was a cosmetic revolution, for women a source of complexion. 30 million US citizens are actually seeking for cosmetic surgery thanks to her. But if we look at things inverted, if an Indian hospital could save Brad Pitt or Maria Carey, how would people react? By converting them into Indian pilgrims, or perhaps by taking a closer look on these hospitals.

So Brad, Maria, if you want to help the industry, you know what you have to do!!

This morning I’ve had the surprise of testing a brand new website: MXS ! Medical experts Services is a  … french…. company (this was totally not compulsory) whose purpose is to dig into eating habits. They have hence created a software that helps you to manage your nutrition through several questionnaires.

We first have to get at odds with the classical size - weight - sports related questions. But then the software really impressed me. In fact, MXS tries to understand your eating habits by probing into one typical week of breakfirst, lunch and dinners. The software then treats you to depict all these meals through a series of screens where you can precisely elect all the elements of your meal with simple tools. For instance, let’s imagin that this morning I took white bread and nutella, the software will propose me a series of bread (including white bread) and then ask me what did I put on this bread. I elected chocolate and indicated I took what looked to be one regular spoon of nutella. The interactivity of their system is great, and honestly you go through the screens quickly. When finished, the software will then analyse your meals and give a series of comments on your eating habits. Even though this is only a sampled week, the conceivers of the software supposed that a typical week of eating could be significant enough as eating habits only sightly change from one week to another.

 Another interesting application was the relative adjustement of your suppers. Let’s say I depict my breakfirst: a bowl of hot chocolate, two croissants and a banana. The software will process this information, evaluate the current nutritive elements that were ingested and propose a lunch and a dinner that suits me in order to comply to the minimal daily nutritive needs (enough vitamines of all categories namely).

On the left side, our advised menu, on the right side, the predicted nutritional ripoffs…  

Honestly, it is very simple to use, the ergonomy of the website is well studied. Thumbs up. Yet, I am confused as I don’t understand how they are making money. In their demo all the features of their offer is for free and I wonder how they are going to commercialize this product and to whom?? Perhaps another great idea with no market. Readers? What do you think?

In this Short extract from the Simpsons TV Series, we have Homer Simpson looking for 40000 USD in order to perform his heart bypass. Homer the living epitome of the average American is getting at grips with the American insurance system and unnafordable medical costs. Here is Homer looking for a handout.

In fact, Homer previously sought for medical insurances but couldn’t pass the standard interview. This perfectly illustratesd the current hyperbola going on the adverse selection topic among American insurers. In this other extract, you will witness the fact that Homer is uninsurable.

At the end of this episode, Homer finally gets a cheap surgeon, Nick Rivera, who will perform o Homer’s heart in front of an audience (in order to trim down cost for Homer). This pastiche was done about 10 years ago but still depicts perfectly the social drama attached with a heart bypass in the US. How come so little progress have been done?

PIPS (Personalised information Platerform for Life and Health Services) is another european medical project we would like to dwell upon. I really loved this project when told about it while visiting Brussels a few weeks ago. Why? Because this project perfectly encompasses the Hypocrate oath by trying to diffuse the best medical services available for all.

PIPS is one the major projects in the European Commission PIPEline

The project is an holistic approach opf medical services as it joins Healthcare suppliers, citizens, Public Organisations, drug suppliers, food industry, health policy makers etc etc. How is it working. Let me reproduce an exemple quoted from their brochure:

“Mary Johnson is a diabetic/infracted and her GP suggest to contact a specialist dor an appointement. Mary goes to Dr Brown who uses the PIPS system and prescribes Mary a therapy and a set of tests to be done at ho,e. At home PIPS reminds Mary to take her test and after having done it recognizes an abnormal state. The system may change the prescription following t he doctor’s indication and asking for approval or will alert Dr Brown who, looking at her vital signs and the results  of the questionnaire will suggest Mary to fix an appointement to review the therapy”

Simply put wow! We here have  all rolled in a dime:

+ an appointement manager

+ a knowledge manager (convening heterogeneous information into an intelligible flow)

+ an at home medical care manager with high user interaction

+ a follow up system with an active warning system able to fix a prescription (decision support system)

The sustainability of the system in the mind of the PIPS creators relies upon the involvement of all healthcare actors to create a fluid delivery value chain that can generate valuable information. PIPS has been conceived to be always auto sufficient. The preventive care generated by PIPS is for instance doubled: a primary prevenetion after a disease to reduce side effects and a secondary prevention to reduce the risk of relapse or other collateral disease. Another interesting contribution made by PIPS is the help it provides to act over the prevalent cuases of non compliance such as abandoning treatment before completion.

PIPS is a great project because it is a societal project where everybody is involved in order to help everybody. It is a great vision of medical practices where all forces are garnered in order to help all three kinds of actors involved in medical care namely experts, medical professionals such as GP looking to tie up with qualified experts on rtare condition disease and the end-user at the other end of the delivery value chain that can use this system to assist him in his everyday life according to his IT litteracy (which is simplified to the extreme..)

Let’s visit Bumrungrad through this video. You will then understand why I want to dig into the medical tourism business (sorry the video is a little bit dim)

Health-e-Child is the second software we will review. Conversly to health plus; health e child is not a health assistant but more a preventive care and medical care tool specialised in following the condition of young children.

Merger of Information, Acquisition of Knowledge: M&A is everywhere

Children are in fact suffering from a disconnection of pediatric care and medical care oriented towards adults making it difficult to have a transgenerational biomedical information plateform to build up cross modality and longitudinal information fusion (they phrase it like this) to enhance research and disease treatment on the long run, this being particularly blattant for chronic diseases or chronic pain. How about paediatric heart diseases or early brain tumors for instance? Paediatric care is not as well organised as medical care given the difficulty to make a good screening + prescription process (parents can describe the pain experienced by a child not the child himself given his lack of vocabulary when young)

I really liked this program because it helped me to understand that the assumption I have made in a previous article. In fact I was talking about paediatric preventive care education in order to underline the paramount importance of driving programs that dwell upon young children care. However the Health e Child program helped me to understand that a bigger issue was the lack of knowledge stemming from early age disease which ripple effects are hardly mastered today. Paediatric preventive care could therefore help to give more cohesion to medical care as a whole and determine the real roots of a late detected disease by consulting early age records.