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 

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.

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?

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.

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?

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…