Discovering Medical Tourism

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.

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?

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..)

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.

There is an ongoing dream among medical specialists: it is that people can take care of themselves and well manage their health status at any moment. In the following days, I will try to list some very interesting initiatives regarding this matter, namely web based projects for weight control, diabetic control and so forth serving as a lifestyle assistant

Health plus: minus weight!

Health Plus is the first project we will dwell upon. It specialises in fighting against obesity which affects 200 million European citizens  and which costs nearly 5% of the healthcare expenses in Europe. This program is organised around two thnigs:

+ an experimental approach through the monitoring of certain populations by creating and diffusing food frequency questionnaires and food registration diaries.

+ a practical approach whereby health plus helps providing personalised nutritional programs to support any user defining and implementing a personal nutrition plan

What is very interesting about Health plus is its action for pediatric nutrition action. In fact, together with the University of Parma, the Health plus program is building up a plateform among children aged from 6 to 12 to asses their eating ande lifestyle habits (though testing effects are quite important when testing young children habits) in order to design and test corrective measures on the long run.

This kind of preventive care actions make particularly sense, as we are not talking about self care but care under the tutelage of the parents with long term benefits as young children will benefit from his early nutritional education. Preventive care systems should really focus on pediatric applications in order to create sustainable results and ease up the diffusion of self care habits.

The medical secret is experiencing hard times in the US. For instance, three years ago, Bill Clinton underwent heart surgery in the New York’s Presbyterian hospital, Even though he went there through a fake identity, some people tried to crack the security system and elicit some confidential information. A local sportsman even got crazier “attentions”. The director of that same hospital states that he thwarted 1500 attempts to rip some medical information about this sportsman from his own employees!

Many companies are currently adapting themselves to carry out a 100% informatics medical approach by transferring all medical procedures online (for instance, Intel , Google, IBM, Wallmart). The latter companies have all expressed a strong interest in putting up personal medical dossiers for all its employees. However, the generalization of such systems will take time. According to a research done by the General Hospital of Massachusetts, in 2005, 1 out of 4 medics  were using such electronic medical dossiers (against 89% in the UK) when they could access to it and 1 medic out of 10 (!!) were using technology while making an impacting decision such as diagnosis, prescriptions…

Besides there is a genuine fear of people usurpating the identity of someone to get some medical information. In 1996, the Congress voted for a law that states that such misdemeanor is a criminal infringement.  Yet, cases have not led to real punishement…

However a looming debate is not on piracy but privacy. The underlying question is what kind of information one could keep secret and what the doctor should keep for them. Let’s take a practical example: I am a woman that got raped at the age of 19 and got pregnant in the process. I needed to abort (what a scenario Uh?). However I don t want my relatives to know about this last fact. Hence I need to cover up part of the medical fact related to the rape which is the case with the redtape cluttered system.

More extensively, companies are now asking for people to fill up medical dossiers before getting employed or even while employed. In a funny fashion, the people entitled to getting these insurance related information are HR managers often also in charge of sacking employees. This puts up a system whereby people will be less willing to give all the information they have in hands on their health status.

Medical tourism is directly concerned by such measures and problems. In fact, as we have stated in an article before, medical tourism needs an electronic follow up to be efficient. The current debate on electronic medical dossiers leads to know which kind of information can be retrieved or filled during a medical check up in Asia and poses the problem of a common software (or at least format) between all hospitals…

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?

People use to be amazed by the fixtures some civilizations have found in order to tackle medical hazards. At an ealy age of civilization (back in 2000 BC according to paleontologists) The Chinese were extremely creative as they were able to classify all kind of foods and associate them with illness or symptoms. For instance, duck is causing hemorrhoids and mango can cause urinary burning. If some solutions prescribed can only consist in abstinence of the trouble-causing food, Chinese were very innovative when it came to finding effective medicines made out of natural components.

The most renowned of them all is the ginseng whose alleged effect is to accelerate the blood circulation and increase blood supply. It can simply be cooked in chicken soup. A funnier remedy is bird nest, coming from oral secretion of swiflets that helps beautify the skin of women or improve appetite. Its ingestion is delicate as it should not be associated with fruits that nullify the effects of bird nest if taken the same day. Bird nest can be cooked with pork soup or steamed as a dessert. In the same way apricot jernels are known to be an excellent remedy to cough (or even dried duck gizzards…). 

Even though these examples are quite extreme, I must admit I have always been fascinated by how early civilizations have studied fooding and tried to establish general principles. The nutrition philosophy created by cantonese is not an isolated example as we all know the famed Kosher principles (ruminant animals etc etc) or the Halal methods of slaughtering. All these dietetic traditions have proved to have coherent results and the beliefs exposed through the Chinese medicine have been scientifically validated in many cases.

Medical call center is perhaps one of the most interesting niches in the call center business as it only represents 3% of the total activities of call centers in Europe and in the US (acc. Euromonitor) yet it is expanding at a very high rate.

The underlying question is dual: is customer satisfaction high with medical call centers and are medical call centers efficient? Some experiments were done to analyse this second point

In July 2006, PHT Corporation, the market-leading provider of electronic patient reported outcome (ePRO) solutions made an experiment in partnership with Temple University School to investigate the potential clinical benefit of using call centers, staffed by pulmonary medical personnel, to support and follow up with Pennsylvania residents suffering from chronic obstructive pulmonary disease (COPD).

A bunch of friends indeed…

COPD is not an isolated chronic pain but a real health issue. According to the Pennsylvania Department of Health, COPD was responsible for 8 million office visits, 1.5 million emergency room visits, 726,000 hospitalizations, and 119,000 deaths in the year 2000 throughout the United States.

This trial is unique because it is evaluating the impact patient access to a call center may have on reducing hospitalizations and deaths due to COPD exacerbations and on improving patient quality of life, lung function, and everyday activity levels.

The technology used (the LogPad), implemented by PHT on Palm, automatically calculates a graded score from baseline and triggers an on-screen alert telling the patient to contact the call center if certain thresholds are reached. At the same time, a software, PHT StudyWorks allows call center personnel to review real-time reports online, enabling them to prepare for a subject’s call or to identify and contact patients who triggered an alert but chose not to call.

Reactivity is the key benefit of this new kind of medical call center. In fact, many people who have access to a call center at an instant T can feel that the exacerbation they suffer from at this very moment is not the right trigger even though they are in real dire straights. Hence, improving the classification and quantification of symptoms that herald an exacerbation may greatly benefit those who suffer from COPD.

The medical call centers is hence well adapted for chrnoic pains because of its abaility to closely follow up subscribers. Yet, is the medical information delivered satisfactory and/or efficient?

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.

According to a nationwide survey of 1000 adults conducted by Opinion Research Corp, Americans spend twice as much time researching car and computer purchases than they do in selecting a doctor, and 6 in 10 say they probably wouldn’t change their ways even if price and quality information on healthcare providers was readily available. It looks that the convenience factor is predominant yet one can wonder if this convenience is not correlated with the implicit message sent by the word doctor.

I am a huge fan of some consumer behaviour theories one of these being the famous ELM model (Elaboration Likelihood model) by Richard E. Petty and John T. Cacioppo:

 

A simple chart done by one of my friends at HEC to explain the ELM model

According to the ELM model one can take two routes when facing a decision problem: the central one which is rationale and the peripheral one which is affective. The  most important underlying concpet is the involvement of an individual when making his decision.

The model defines the elaboration likelihood (EL) of the communication situation as the probability of message- or issue-relevant thought occuring in the consumer’s head. From the consumer’s point of view, it is about engaging or not in extensive issue-relevant thinking to evaluate an issue. According to the ELM model, the involvement or elaboration likelihood (EL) conditions choice in the following way:

+ When the EL is high, the central route should be particularly effective.

+ When the EL is low, the peripheral route should be better.

Medical tourism to gain credibility and striking power should be able to take the central route hence rationalize the decision process by identifying (or creating) key factors to be evaluated by someone opting for the appropriate surgery practice. The involvement is in fact low when talking about surgery knowing that the final decision is normally handled by a professional and there is little need (besides cost) to jump from one specialist to another. The medical service is indeed a long term involvement on which there is only one element that pressures us to decide: trust. And trust is on the peripheral route… Plus the peripheral route is a bumpy one as changing doctor is a stress factor that is added to the primary and ultimate anxiogene factor: the surgery itself.

 Opting for another route thanks to medical tourism communicating through the tourism angle

Medical tourism revamp the central route by introducing new factors to be rationnaly evaluated such as: medical follow up through the trip, intrinsic quality of tourism services… Decision making will not only take into account the trust we have on a system but the rationale evaluation of the various benefits brought by medical tourism. Hospital accreditations, incentive programs proposed by companies or monospecialisation (best hospital for appendicetomy for instance…) can only help to opt for the central route… 

There has been a sprawling development of medical centers in Asia but more specifically of aesthetical centers with the need of bringing differentiated quality to potential customers. The practice of cosmetic has proved to be very profitable stirring the proliferation of smaller centers whose practitioners pose as real cosmetic surgeonseven though in a country such as Phiklippines seven years of residency education at a reputable hospital are needed to pretend such a thing.

Creating barriers of entry is a new challenge for aesthetic centers. There are several ways of upgrading the quality of a center:

+ recruiting seasoned surgeons

+ showing dedication to care, prevention and decease treatment, the primary functions of doctor in an aesthetic center

+ using breakthrough technology 

The Aesthetic and Dermatology Center that has opened in March 2007 in Manilla is a perfect example of this upward trend through the use of new technologies to complement the surgery such as Aesthera, a machine used for hair removal and skin rejuvenation or the LPG machine (named after its designer, French engineer Louis Paul Guitay) to prepare the body before liposuction, or to contour the body after the procedure. This example put forward the high degree of penetration of new technology; innovation is an important differentiation factor of medical procedures in Asia as some treatments are approved and available in Asian hospitals months before their actual diffusion in the US and in The UK

The new paradigm … not the old woman!

Defining a new paradigm

The Health industry is gaining foothold on the Medical industry as a new paradigm surfaces. In fact, the new trend is not to wait to get sick or spend on chronic care but get to grip with our pitfalls at an early stage through medical screening. Indeed, Medical check ups appears as the real centerpiece of this new paradigm. However,  the cost of an extensive medical check up is extremly high in the US and some parts of the check up are not available in some hospitals. On the other hand when looking at Asian Hospitals we find that the top JICT accredited hospitals are well equiped to treat demands of extensive check ups and offers a real cost differential.

Hence, Medical tourism should focus in a near future on light medical procedures such as Medical Check ups to open the total array of services connected to medical tourism. Medical check ups appears as the stepping stone of the industry, but how?

Tourism Quality has been a well documented matter for the last several years. However, before getting started we should ponder over the notion of quality. Tourism Quality has three components that must be sustained through:

(1) internal customer satisfaction

(2) external customer satisfaction

(3) the efficiency of processes

Satisfaction implies that we must translate subjectivity to objectivity. Expectations vary widely from one customer to another. Controlling these various factors should help extending the life time value of a customer that is calculated as follows (Christopher, 1998):

Life time value = average transaction value x yearly frequency of purchase x customer life expectancy

Hence, we should make sure that the purchasing act is repeated and that the level of satisfaction is sufficient and the level of disturbance low enough to arouse a long life expectancy per customer.This LTV should be factored in the Consumer Value Equation (CVE): 

Value = (Results produced for the customer + Process quality)/(Price to the customer + Costs of acquiring the services)

 

Quality ‘inn’ Medical Tourism: How to reach the stars?

Looking at medical tourism, how can this niche maximize value?

The results produced for the consumer are very important: it is a mix of preventive care that will trim down their risk of catching a decease for instance plus the opportunity to visit new and exotic places highly valued by tourism specialists and by collective imagination. The cachet of Thailand or of Bali by itself deems a psychological high price tag.

The process must flow: the value perceived of this flow will be conditioned by the quality of the incoming services provided by the medical tourism agency.

On the other side, medical tourism achieves an interesting benefit automatically: cost cutting! As we have seen it several times already, the expenses linked to the medical procedure are slashed, and easily covers additional costs generated by tourism activities.

All in all, getting a hedge on medical tourism Value will consist in providing the best incoming services possible.  We also have to take notice on the sustainability of these services and understand that the customer is part of the process and therefore that any improvement in the delivery service must be accepted by him.

Another night surfing to discover the wonderful world of podcasts. And oh my I meet this fabulous trend of medicasts: medical podcasts. Podcasting is a practical way to keep in touch with a center of interest: you only need to subscribe to a podcast to receive a regular flow of information.

nevertheless we have various kind of medicasts: the ones that talks about complex medical procedures, for specialists only, and the other one talking about self care, health awarness.

Tech medecine and its author Joshua Schwimmer has recently posted extensive desciptions of some of these podcasts. the most interesting examples I have come through being: the Health Update podcast made by Jane Brody, columnist of the New york Times and the John Hopkins Health News podcast by Dr. Rick Lange, chief of clinical cardiology at Hopkins, and Elizabeth Tracey, director of the Hopkins Health NewsFeed. These are two interesting podcasts as they offer non technical information that can be used to monitor ourselves the evolution of our health status or get information about medical practices.

before getting to the PRM, let’s here from MY hospital

What is interesting beyond the existence of such podcasts is the array of utilisation of the latter most notably from a marketing point of view. The podcast has generated what some has called ‘narrow casting’ (Dr. Johnathan Sterne - Mc Gill University) namely, podcasts bty imposing an active elective step (subscribing or not), implicates in heavier mode the podcast auditor. Podcasting helps to better target a more attentive audience.

Marketing of private hospital through basic advertising channels perhaps has met its limitations and medical podcasting could be a new way to market an hospital as a whole and its doctors and surgeons. the direct ripple effect could be to accentuate the identity of an hospital by promoting a community effect that goes beyond the patient doctor relation.

However, this practice is not risk free: the expectations that a podcast should meet in terms of quality is way higher than what an add in a magazine should reach. The qualitative work that sustains a podcast has to be satisfactory enough to generate positive feedback or the backlash could be impressive… Medicasts propagated by hospitals should hence focus on one objective: bring practical and simple information to its audience while still keeping at bay its promotion scheme.

Still we can ponder over the possibility of using podcasting/videocasting for the sake of promoting medical tourism activities….

While talking about medical tourism with one of my friends achieving a degree in computing sciences at Centrale Paris, the latter told me to check out Voluntis a specialist in medical follow up. I found this advice extremely interesting as I was still wondering how medical tourism could work without a good follow up service. 

Voluntis is a specialist of PRM, patient Relationship Management. Besides the fact that it is a French technology (Yes!!) sponsorised by the ANVAR, the PRM is a multi channel medical device that brings coaching, medical advice and regular check ups through various instruments most notably SMS, mobile applications, call centers… This company created in 2001 has developed Medpassport, the core software that permits to diffuse this medical education and coaching service.

Using a PRM: feeling healthier?

Quoting Pierre Leurent, the CEO of Voluntis: “This innovative paradigm offers the unprecedented opportunity to bring value to the key health care stakeholders at the same time: pharmaceutical companies, payors, physicians, pharmacists and patients”. Indeed, when looking at their customers we find companies such as AstraZeneca, Sanofi-Aventis, Roche, Bayer or Respironics. 

A PRM mainly serves to assess dynamic health issues such as chronic pain and be able to follow timely any negative evolution. The PRM helps to increase the reactivity of a follow up team, however I wonder how a PRM could be used to track preventive care issues.. Could we design such a tool as an interactive device to check out a medical tourist?

We will try to further investigate this technology in the following weeks by directly meeting with Voluntis and understand how it could fit with the development of medical tourism activities…

The Blue Ridge example seems to be an isolated one but as Lyn Fox, executive Vice Director of Sales at Global Healthcare choice has stated it in an interview for  the employee benefit plan review, the whole is waiting for one S&P500 company to opt for a medical tourism incentive formula to have a huge tidal wave of US companies jumping on the bandwagon. Mercer Human Resources is for instance rumored to draft one stop shop medical tourism solutions for three major S&P 500 companies for mid 2007.

Corporate Cultures and medical tourism

 

When a company is opting for medical tourism, the company is making two strategic moves:

+ They send their employees overseas during a longer period than usual

+ They provide service to an employee through a medical tourism agency that will make all the required arrangements to combine a tourist activity with the medical process.

However, the relation of trust is very engaging for any employee as conversely is the bold approach of the company. Medical tourism is a genuine social revolution for any company considering it. At this seed stage, a company using medical tourism solutions is relying on:

a. A hard nose will to innovate - make a difference and create buzz by all means

b. A dedication to entrust employees with responsibilities (they make the decision to go overseas not the company) - a paternalist approach?

c. A desire to control costs while still keeping its social duties (medical does not hinder health care but provide another solution) - boost profits from top management to basic workforce

The press releases throughout the world about medical tourism are often quoting one example. I would like to also talk about it: the Blue Ridge Paper Factory study case!

Blue Ridge Paper Products is a manufacturing firm in Canton North Carolina, with 2,100 workers. In 1999, while the company’s health care costs were increasing at 18 percent a year,

Blue Ridge was bought by a venture capital firm. As part of the company’s transition to a 45 percent employee stock ownership program, the union agreed to a 15 percent wage cut and seven-year wage freeze. However, between 2000 and 2006, employee healthcare costs for the company rose over 75% to a staggering 24 million USD.  

An innovative policy derived from a voluntarist corporate culture

The relative weight of the healthcare benefit system was denting profit growth and slowing down recruiting processes.

 

Blue Ridge had to find a way to trim down healthcare costs that were rocket soaring. The company did so by launching for instance a diabete management program that waived copays on medicine. However in 2005 the healthcare cost was still increasing by 3,5% therefore Blue Ridge visited overseas hospitals and worked with IndUSHealth to find more cost cutting solutions.

 

The latter company produced a DVD encouraging people to go to

India in order to perform their surgery. By doing so, employees will get a 100% reimbursement plus travel expenses for themselves and a companion and the employee can receive up to 25% of the savings garnered fro; the outsourcing. For instance, one of their employees in 2006 decided to remove his gallstones and have his rotator fixed. The company will save about 80000 USD on both surgeries while the employee will receive a 10000 USD bonus for the trouble. 

How can one decently say no?

In this short log we will try to convert medical tourism into a theory of finance problem (sorry for those for whom the word finance gives pimples):

A customer using medical tourism services has to model by himself all the real options and put a good price on it (see previous article). This price is made out of both the price of a heavy surgery operation and the intrinsic cost derived from the pain and suffers generated by a dwindling health (the pricing of this last element is however extremely correlated to the perception every individual has on its own body).