Discovering Medical Tourism

Serge Fabre, my dear business partner, was now sure of his decision: it was LASIK at Excellence. Bye, bye glasses, aurevoir les lunettes, adios gaffas.

One morning he went to have a preliminary check up. The verdict came within two days: his right eye needed more correction than the left, he was a little bit of everything eye wise, here is the price tag, are you willing to proceed Mr Fabre? Serge was really tired of his glasses and when he understood that recovery time will take only 3 to 4 days he was 100% ok.

After a mere 5 days, the operation was set up. It was very fast according to him with almost no sensation. No blood, no sweat, no tears… Where is the drama!!! but after, I had the biggest laugh of 2008.

Serge came the following day to our office with dark pitched sunglasses, the one that Jack Nicholson was wearing in Easy Riders… I had my own Ray Charles at the office. He didn t want to take them off fearing to hurt his eyes. Actually he just had to  firmly protect his eyes for a day before going out in the daylight, with his 80 s glasses. From transparent high tech looking glasses, to these pre Ronald Reagan Ray Bans, what a rip off! I immediately ran to the shopping center to buy a leather jacket and a motor bike, we had something great  going on.

I Know, I could have find a better picture (look at this shirt!), but at least you can witness his nasty grin, saying: Ain’t I sexier now?

I must admit that after he was feeling confident enough to get rid of his dark glasses, I had the impression of seeing a new man. His face changed, became rounder (to me), he looked younger, sharper and even… wiser. What an aesthetical makeover thanks to Lasik. Serge told me he was feeling strange without his glasses on, as if his nose was lighter but needed to be heavier (I translate litterally, sorry if it sounds strange). but wow he lost 50 years in the process and looked again like an angel! He was seeing even better than with his glasses and told me: “If I knew how good I could feel, I would have done better”

Here is our first customer being extra extactic over his first procedure.

Now Serge, tell us, what will be your next medical tourism experience. take a look to our catalogue on Bemyspa.com someday….

I talk, talk, talk about medical tourism: but many people can object me, “till you never tried it, you never know what it’s all about”

My partner Serge Fabre, though in his late 50s is an indiana Jones of the modern ages when it comes to experiencing his business. As a tourism expert he travelled to all kind of destinations from Las Vegas to the jungle in Burma. Now that we are willing to indulge in Health Tourism he told me: “Raphael, I am going to see by myself if what we are offering to our customer is worth it”

So now we had to think hard about what he could do in terms of elective surgery: an aesthetic operation? He is, I must admit, still a Don Juan, so he does not feel any particular needs. Perhaps some more abs, but he swims regularly so it s ok… Dentistry? Not really, his teeth are perfect. Hair implants? I would like to see him with hiars (look at his bonze like picture)… Eyes? Oh yes, that s it, get rid of these horrible glasses Serge, please!

Serge with glasses. He looks happy, but like an old owl is happy, like a monk preaching his past experiences, not living them. By the way, I am sorry for all the readers that try to understand what Serge is doing on this picture I have no clue!

So we were thinking about a destination to try. We have our offices in Singapore but were looking all around Asia. Serge then visited a few places to inquire about LASIK procedure. He got from a friend a price from l’institut Rotschild in Paris has a benchmark. We went to several places in Bangkok and Singapore exclusively. It was an easy experience, without any stress. In the cab in Bangkok I asked Serge if he realized that he was going to have a surgery performed on him, and he seemed very serene as if he was on a shopping trip looking for a tie. I like dramas so I must admit I was disappointed to see him so confident

We never got a precise price, as the price will depend on the amount of correction to do on each eye, as they are also independant (the left could be in a worse shape than the right). However, the price ranges given by the hospital were all below what he could have get in one pof France’s best clinics. In Singapore, he has visited many facilities following the advice of friends and ended opting for Excellence, a top notch clinic in Singapore. Serge will tell you, it’s a very very nice clinic, you feel great being there. A 5 star hotel like facility, a notch above what we have seen ini other places. But furthermore what played a major role was the fact that many people referred to this clinic as one of the best. We don’t know the truth about it but it didn’t matter, Serge was happy to go there.

The price? It was 20% more expensive than what he could have gotten in Thailand. But he was willing to have the best price on quality ratio, so there was no problem. And it ended up costing 35% less than in France, which is not neglegible on a four figure operation… so what wasthe outcome?

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“

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?

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!!

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.

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!!

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?

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)

Don’t play with the American administration. Michael Moore has investigated in Cuba thus violating the political ban on Cuba. A wicked ploy from a frail administration unable to admit well rounded criticism. Liberty of speech aiming at people suffering from a disrupted medical system… nonsense?

 

 

Here is the official trailer of this movie talking about what we are fighting against: inefficient medical systems

No! Michael Moore is not in cahoots with DmT (Discovering-medical tourism)!

In fact, though we suppose he has gone by this blog to create his new movie called ‘Sicko’ (currently demonstrated in Cannes), Michael Moore is really focusing on the demand side. To quote his blog, “if people ask, we tell them Sicko is a comedy about 45 million people with no health care in the richest country on earth.” As per usual, Michael Moore has gone quite far with this movie, irking the Bush administration that tries to clampdown on him through litigation.

Michael Moore has dropped his latest bomb in Cannes

For instance, Michael Moore has visited some hospitals in Cuba where some rescuers of the 9/11 have found suitable care, theUS being too expensive ofr them and the government having poorly supported these heroes. The Bush administration therefore raised the problem of the embargo that should prevent Moore to shooting parts of his movie in Cuba. Yet, Farheneit one of previous movies has grossed more than 200 million US and won the Palme d’Or at the Cannes festival. We are talking about a famed and respected Bush basher, people will go to the theaters…

What else do we see in that movie? What we have been talking in this blog for several weeks, namely that besides the 45 million non insured Americans, the rest of the population is submitted to arbitrary decision from their insurance companies, leading to restrictive treatments or even elective treatments in the “authorized” hospitals. We have also several testimonials about insurance companies digging into legal details to break their insurance policies to gain profitability. US HEALTH is perhaps is a worse shape than the US ARMY.

Dear Mr Moore, if you read me, please let’s talk about how the world can help this systemic trauma of the US society, how medical tourism can offer a sustainable low cost solution instead of putting people in the streets under a heavy burden of debts…

In my previous post I was just observing a high increase of old people among the Singaporean population while hinting that this could force local authorities to revamp their hospital room offer in the future. Yet, I must admit I needed to do extensive research to get a better grasp on the Singaporean medical system.

In which ward was this Superhero? A, B1, B2, C?

In fact, the medical system is two fold: we have on one side the Public System (7 Public Hospitals + 6 specialised clinics) and on the other side Private hospitals (among which the Parkway’s hospitals). However the quality of the service is not only ventalited among hospitals (havoing one top class hospitals then mid class than low class) but even inside the hospitals. In fact, there is a system called ward class to classify the kind of services that one is entitled to. There are 4 classes, A, B1, B2 and C, A being the best (suites with all the confort and care you can imagine) while C is basic accomodation (5 beds dormitories) and basic care. Why such differences?

 These differences mainly come from the Philosophy of the Singaporean governmenent for whom Medical care is not based on equality but on equity. Every one should be able to access to care but in the same way every one can opt for the kind of care they want. In fact, not all the rich people are opting for Ward A: out of the 20% richest people in Singapore only 60% are going to A and B1 hospital (and conversly 3% of the 20% poorest people in Sg are going to ward As).

The social system is associating a compulsory saving system (Medisave) but there is still a co payment to make, so going to Ward A does not strictly depends on the amount one has on Medisave but on his will to get the best care and accomodation possible (there is a minimum threshold  that varies from one ward to another)

Hence, every hospital have to make sure it contains the right segmentation of wards. Rate of occupation in Public Hospitals are very high already (76%) but quite low for Private Hospitals (below 60% in general) as they have opted for the highest ward classes. Private Hospital really needs international patient to be profitable. In fact, a public hospital though run like a professional organisation is nonetheless a non profit (I mean officially speaking). The polical clout is way more sizable than any other subject, yet we can ask ourselves if the Singaporian medical system is equitable for all international visitors… (as usual check out for part 2!) 

A few days ago I remembered one very trite fact. Before 1965, Singapore was still part of the Third World and quickly positionned itself as one of its leaders. I read about an innovative public management with highly paid top public servants many public private collaborations, an efficient central planning. But what really shocked me was that in 1965 the average  age in Singapore was 18,8 years old, while now it’s 32,7. Now, the demographic transition is well consumed as Singapore will have 1/4 of its population beyond 60 year old in 2030!

The Tan Toc Seng hospital - A new fashionable hangout for old people?

This ageing population is posing huge problems as Singapore hasn’t yet adjust to the high health cost implied. In fact today; Singapore has an extremly low private health expenditure barely toping the 2,5% of GDP against Mamoth expenditures such as in the UK 17,8% in 2004 or Australia 34,2%. Even though this is mainly due to the little amount of second opinion requested, the welfare system(that is not equalitarian but socially oriented) or even the small number of hypocondriac people (compared to some European countries), this small figure is stemming from a healthy population. This figure should indeed soar up to 5% by 2030, exactly the same figure  than in 1965.

All in all, Singapore has been viewed for years by the World Health Organisation as the 5th or 6th best medical system in the world. The central planning is perfectly channeling its demographic evolution while promoting the expansion of medical tourism activities (Singapore is expecting 1 million medical tourists per year in a short horizon). The number of beds should grow as the City  State establish itself as the best medica hub in the World but is gearing towards a bicaphal approach: geryatrics and the outsourcing of general medical procedures… Not exactly the same thing…

Phillippines is currentlyt the fifth medical tourism player in Asia lagging behind Singapopore, India, Thailand and Malaysia. However, the government is strongly stressing the importance of developing this sector as it is perceived as a strategic tourism niche for the years to come. The country indeed benefits from its position (midway to India, not far from Japan and Korea) and its culture (english speaking population) to lure many tourists

At the Hospital Queen Elizabeth it’s all thumbs up to climb the ladder

Yet, the medical sector is far from impressive when compared to top notch countries such as Singapore. The government is now strongly pushing for more private initiatives in the medical sector and better human resource development in cahoots with getting well trained doctors and surgeons in their hospitals, the country itself being threatened by overmigration (mostly towards the U.S.). Being a low income country is indeed not the main problem: when looking at Cuba or Sri Lanka we are confronted with excellent medical systems retaining excellent practitioners. When looking at those systems we had four key factors:

+ A compulsory community service through which any medical diploma led to servicing the public sector

+ Strong incentives aiming at keeping doctors.

+ The development of polyclinics.

+ The development of an independent pharmaceutical industry (Cuba developed its own vaccines and drugs)

 

Medical tourism only started two years ago, in 2005, but has already met sizable success. The overall income related to medical tourism was topping the 200 million USD threshold for the first year of operation (I didn’t find anything yet for 2006, but I imagine that this figure must have grown). In fact, at the fall of 2006, Philippines held its first medical tourism congress in Pasay City. I didn’t attend this Congress but I daresay it looked like an Allstar game, just by judging by the participants: Philippine Public Private Partnership ambassador, Philippine’s Health, the Trade and Industry Secretary and Presidential Committee on Health and Wellness Chairman, the Philippine Economic Zone Authority (PEZA), the Philippine Retirement Authority (PRA) Chairman… and the President himself. I guess that tourism in

Philippines is close knitted with medical tourism.

In fact the type of customer it can bring is extremely varied going from Asian retirees in maxi real Estate programs for ageing populations or American uninsured workers looking for a combination of cheap treatment and English speaking environment.

Quoting the president: “Cost is competitive and quality is high. Filipino professionals can serve the world right here at home, as we provide more jobs downstream and cut down poverty”

I recently met Luc de Rancourt, a specialist in IT dedicated to medical services (Director of Koira) with whom we extensively discussed about online medical follow up and telemedicine. Though he is mostly an expert of the French medical system, Luc de Rancourt gave me extremely interesting insight on the current debate in the US about medical follow up and personal health dossier and opposed it to the current situation in France.

One of the major question marks ongoing is the possibility of transitioning from an inefficient paper system to a fully informatics system in the medical sector. In fact, informatics offers many advantages such as historical follow up of a person, easy transmission of files, coordination of prescriptions, adverse medicine listing… Even though it bears a high cost but poses little technological hindrances, the diffusion of a medical electronic dossier has been quaint mainly because of what Luc de Rancourt calls a psychosociological barrier

One of the 192 medical follow up softwares available in France: the market is atomised!

Coloc Singulier

The French example is a good epitome of this psychosociological barrier. In France, there are two kinds of practionners: doctors in hospitals and private doctors that work as “profession liberale” (which is a specific professional status that is common to lawyers, doctors and other specific professions). In fact private doctors are acting under the rule of “coloc singulier” that points at the fact that a doctor is master of his diagnostic and prescriptions and by any means has to be accountable for his decisions. A patient when entering the office of a doctor fully trusts the latter and empowers him with the right to diagnose and treat him. A doctor cannot doubt cannot show any signs of weakness. One of the major consequences of an onine dossier is that people can trace medical decisions and possibly sue a doctor if a diagnostic was wrong and had ripple effects on the patients. Online medical dossiers jeopardize the quality of the service given by doctors as they will be less likely to take any risks and will stick to minimalist diagnostics.

Paramedics vs doctors vs doctors

In France, paramedics have a limited scope of action as they must abide by the decisions of doctors. For instance, they cannot make deliberately an injection if not directly asked by a doctor. This lack of flexibility makes the doctor the real center of the follow up system. An electronic outsourcing of medical information will have a limited impact as it cannot lead to a quick paced and easy flowing decision. However, in the UK and in the US, paramedics have way more power so France appears as an outlier. Another significant fact is the lack of communication between doctors. Doctors are not that used to communicate between themselves and many people can just witness redundant procedures when switching from a doctor to another while seeking medical advice.

People love their doctors

Some people just feel at ease with their doctors (people don’t like to change often their doctors) and the latter give them perks to thank them for their fidelity. Each year in Corsica, a famed French Island because of its rebel attitude, the average number of medical leave days is 13,8 days per worker while it only reaches 4 days per worker in Paris. As we can see, disorganization is not playing only against people but can help to spur a French national sport: absenteeism!

The psychosociological barrier hence comes from both patients and doctors. This system is working for both parties so why mend it? Yet, just an historical medical approach will be of a big help for the industry, so why not considering it?

Here comes the earthquake. 7.2 on Richter’s scale!

First you need an hospital

Bumrungrad International is perhaps the leading hospital in medical tourism. The Thailandese hospital offers 554 beds, 30 speciality centres, 900 medical specialists and over 800 nurses. It is Thailand’s first JCI-accredited hospital and serves more than one million patients yearly from 190 different countries.  The hospital reports that it has served 60000 patients form the US in 2006! The hospital features not only 5 star hotel services but also a genuine F&B center with the likes of McDonald and Starbucks just to quote some.

Then take a major US health-insurer with 1.3 million members

Shake it.

You’ll have BlueCross BlueShield of South Carolina forming an alliance thourgh Companion Global Healthcare with the private medical centre by which it will direct members interested in overseas medical treatment to Bumrungrad assisted by a US-based contact centre managed by World Access, a travel-insurance and international healthcare-assistance company.

 

The US in Thailand… A Mc Donald In Bumrungrad hospital

I really feel that this move could ultimately lead to medical outsourcing… In fact, the main problem with medical tourism is the lack of backing by national insurance programs with an important number of affiliates. Before this major move, only little networks were offering complementary insurances at  a low cost. Now, there is a genuine will to do whatever it takes to reduce the bill and to trigger it by gaining a critical volume. When looking at Bumrungrad we have the impression that sky is the limit…

Ayuveda is an ancestral series of medecinal techniques coming from

India. The term is coming from ayus meaning life and veda which points to knowledge, therefore ayurveda is the “knowledge of life”. This term couldn’t be as meaningful with the recent evolution of research two examples can be pointed out.

Many companies are rushing into the Ashwagandha business. Ashwagandha is an herb used in Ayurveda coming from the Indian medicinal plant withania somnifera. Researches have proved that is genuine effects on fertility troubles or to alleviate symptoms associated with arthritis or even to treat memory loss. There are many developments in

Japan in order to fully understand the causes of these effects on the human body, as researchers wonder how this medicinal mixture could have so many effects.

Ganesha is very knowledgable indeed

Triphala is also gathering a lot interest as studies have proved that this medical formulation could act like an anticancer agent (according to researcher it could target cells in tumors while sparing normal cells). Triphala even looks like a miracle cure as other research led to observe that it provides protection against both gastrointestinal and hemopoetic death Ayurveda is now a new found field of research for researchers: while studying Triphala, researchers have come with the observation that the cytocide effect could be due the action of gallic acid and that its induced anti stress effect is due to its anti oxidant properties.

These discoveries come as a relief as ayurveda use to be the object of many deviant practices due to the inability of certain practitioners to come out with well mastered dosing leading to a high level of metals and minerals in their mixtures causing toxicity. Auyurveda was heavily dented when the journal of the American Medical Association discovered that 20% of the Ayurvedic preparations made in

South Asia contained high levels of toxic heavy metal such as the famed arsenic. This sudden peak of interest should help to perfectly understand the underlying chemical effects of each component of the ayurvedic preparations and furthermore perhaps lead to normative practices.

Radioactive miracle cures… perhaps not a good idea after all

However, I really wonder if the toxic metals are not generating the positive medical effects also. We should remember in the history of mankind that one example of toxic cure was devised. After seeing that radium could cure some cancers some people tried to devise special cosmetic cures. The most famous one was called fontaine de jouvence: it was a water tank where radium was dissolved in water. This item was widely diffused in the thirties from a therapy invented at the Plombieres les bains spa in France. Some con man further digged into that breach by inventing some creams that could cure cancer (like the company Tho Radia whose motto was: “Stay old if you want”) or even weight losing belts. The short term effect was a skin rejuvenation indeed, the long term effect was a series of natural disasters (skin cancers among others)… Yet, radium was expensive hence its dosing was not that important.  However there is no official statistics on the consequences of he use of radioactive products

The last days were extremely interesting for me. I was really wandering in the medical tourism jungle, checking which definitions people had in mind. I remember writing the ‘About this website’ page a week ago and I was so unsatisfied by this page that I decided to shelve it and rewrite it later. 

Every time I have a debate about medical tourism, people portray this industry as an unethical way of making money using the despair of people who can’t afford surgery in their country, plus a dangerous production system with all the infamous stories of botched mammoplasty or rhinoplasty.

Yesterday during a dinner, I tried to argue with a cardiologist that medical tourism is not boiling down to low cost procedures but is a wider access to unknown techniques perfectly mastered in Asia. These techniques range from ayurveda to tsubo chiatsu to Lasik surgery etc etc. I acknowledge the cost differential (we were talking about angioplasty) but for me, he was focusing on a non sustainable medical tourism. 

I am using the words ‘non sustainable’ because I feel that the existing business models of medical tourism are all one shot models:

+ heavy medical procedures motivated by a low cost effect or long waiting lists

+ no follow up stemming from the procedure + no customer relationship management approach. 

It is a run and gun approach that certainly has people smearing about the association of words ‘medical tourism’. But again there is hardly any tourism implied by this method> I have pinned this idea as medical travel. Let’s call it INDUSTRIAL medical tourism (as an input -output chained process)

 Yet, this is definitely not the vision I have about medical tourism. NOT AT ALL !

To me, medical tourism in Asia is an open window leading to the best healthcare procedures in the world, innovative techniques to solve rare condition techniques, the best preventive care solutions, unheard of manipulative therapies plus an opportunity to enjoy a tourism experience and so forth. Perhaps my definition is wrong but this is what medical tourism sounds to me. One could argue that I am speaking about health tourism…

 

Medical and Health Tourism as we define it as a longer life expectancy and a higher volume than the classical model

When considering biological methods such as herbalism or manipulative techniques such as psychotherapeutic postural integration or ayurveda are we only talking about health? These techniques are a genuine front end to medical procedures so how can they be restrained to mere health procedures… Medical tourism must be a sustainable experience and therefore must entice repeated visits: diversifying methods, proposing long term follow up (using tools such as the PRM we have previously reviewed) 

Here is my real first tentative definition of Medical Tourism, that we will call from now on Medical and Health Tourism: 

 ‘ an experience of medical and healthcare techniques culturally connected to a specific place or technically knitted to an hospital for preventive, aesthetic or curative needs ’ 

Experimenting these techniques boils to an exploratory approach that is tied up with traditional tourism (going from one place to another to try out a technique etc etc) but with the particularity of positively affecting our body  Talking about how angioplasty could cost only 10000 USD is definitely not the goal of this blog.   

Discovering medical tourism is going to take a major u turn. In order to carry out a clearer perspective on what we consider medical and health tourism is we will from now on stress upon THIS definition of medical tourism by digging into health and medical procedures specific to Asia and all the techniques that can make medical tourism a sustainable tourism.  

Finally the medical tourism map is working! It is still in its infancy so keep an eye on it

The newest features is a list of hospitals and spas in Asia. It will be gradually completed by articles specially dedicated to the latter during my future trips in Asia. I think I am going to fly to Singapore in mid June… You can access this page thanks to the toolbar in the header…

Tomorrow we’ll talk about online medical resources. but now it is the first of May and as you know, people just want to go out on this particular day…

The European Union is now taking a close look to the evolution of the medical tourism industry. In fact, MPs at the European Parliament considers the patient safety as part of their responsibilities, hence, on Tuesday 27 February, European Health Commissioner Markos Kyprianou officially discussed new health strategy to counter balance the will of patients to fly out of Europe to find better medical services.

With regard to patient mobility, he said that his department was currently examining the responses to the consultation exercise on health services and that the Commission initiative was based on the need to consolidate legal security, following various Court judgments which stated that the rules of free movement also applied to health care.

The Commission discussed the possible creation of centres of excellence for the treatment of particular illnesses on the European Territory in order to propose specific answers to rare condition treatment seekers as well as to better the output and the productivity of certain medical centers. Specialisation of centers is indeed a productivist thinking yet it remains to be seen if this is the best solution available.

Going to Poland to get your teeth fixed: a European Union approved move?

Several MPs, like German Social Democrat Dagmar Roth-Behrendt, have called for the future regulation to cover issues such as: information for patients, the quality of care and providers, centres of excellence, compulsory exchange of experiences and directions on patient average waiting time before treatment (this being a touchy issue as waiting times vary from one illness to another)

Another intersting point was raised during this session by French (yes!) UMP MEP Françoise Grossetête. She warned of discrimination that could arise with mobility: in fact, people don’t all have the same access to information, nor the same ability to move to receive treatment or benefit from the services of a particular recognised professional. A possible answer to this concern is to institutionalize health information and officilaly sponsor mobility to guarentee better access to saefty. If medical tourism is not exactly the model promoted through these discussions, the European Union is now really seeing medical travel that could be a move against a system where insurance companies forced patients to go where treatment is cheapest.

Complaints are rising in the US because of the lack of price and quality informlation and health care.  A study from the National Center for Policy Analysis (NCPA) (february 2007) says the complainers are causing the problems they are so vexed about because unlike in other market qualitative information and transparen,t price are services that are available only if the end customer pays for it.

“The primary reason no one knows what doctors and hospitals charge prior to treatment is that they do not compete for patients based on price,” said NCPA President John Goodman, who co-authored the study. “When they don’t compete on price, it turns out they don’t compete on quality either. In a very real sense doctors and hospitals are not competing for patients at all.”

At the end of the day, hospitals have little stake when trying to lure patients. In fact, the orientation of a customer depends on a problem of convenience as an insurer will decide to send a customer to an hospital according to its localisation ans its belonging to the network. This game is hampering the development of the overall quality of healthcare services as insurers typically do not pay for many services that would lower overall health care cost and would improve the quality. 

The NCPA study lists down the following downfalls resulting from this lack of competition:

+ No Integrated Care:

+ Taking responsibility for the treatment of a patient’s case from beginning to end.

+ No Patient Education resulting in no self care:

+ No Telephone and E-Mail Consultations:

+ No Electronic Medical Records: 

All this downfalls can be perfectly adressed by medical tourism as international hospitals have to create genuine competitive advantages and online solutions in order to justify the outsourcing of the medical procedure. 

 

Selling the competitive advantages of a foreign hospital to make a difference as an insurer

When looking at Phillipines, actually 5th competitor among Asian medical tourism players, thlocal hospitals must find innovative solutions to compete with mega groups such as Sunway, Parkway or Fortis. What makes this study about the American Health particularly intersting is that the elements listed above are excellent leverage to make a difference for any hospital or for any medical service provider. 

In fact, even though the game played by insurers bypasses hospitals, insurers cannot dodge the competition between each other. If American hospitals cannot provide them competitive advantages to make a difference an Asian hospital could give an insurer a clear cut hedge if the latter decides to give credit to medical tourism strategie. Some insurers are now pondering over the fact of proposing medical tourism as an option, referring all the specific features of these foreign based hospitals as differentiating factors.