Will Patients Come To Your Medical Travel Destination, Post COVID-19?

The natural reaction for countries, healthcare providers and medical tourism businesses is to wait out events, until they return to normal.

But expecting the flow of medical travellers to return to where it was before may be a major strategic and tactical mistake.

How much your country was affected, what your government did or did not do, and the post COVID-19 view of risk may heavily influence the potential medical tourist’s view of your country for the next few years.

For example, will people still want to fly long distances or will they prefer shorter trips? Will they want to leave their country at all?

Plan for the future now

This is now the time to plan for the future. You could do nothing and lock down the hatches and when things get back to normal, carry on as before. Or you could take time out, away from daily life, to make plans for how you can encourage your country, organisation, agency, or healthcare provider to get medical travellers to come to you in 2021/22, both new and existing customers.

WTTC proposals

Coronavirus puts up to 50 million tourism jobs at risk says the World Travel & Tourism Council (WTTC). When the time is right, WTTC and the global private sector will be ready to help and support governments and countries to recover.

WTTC is calling for a series of measures to be taken, to enable the swift recovery of the sector once COVID-19 is under control. It will offer its support to all governments, and has made some suggestions:

  1. Improve travel facilitation. Remove or simplify visas wherever possible, reduce the cost and improve processing times where practical, accept other visas when appropriate and introduce more efficient technologies for seamless and secure travel.
  2. Remove barriers.  Ensure that unnecessary barriers are removed or relaxed to alleviate pressure at ports and airports and implement flexible working visas for the industry in some countries with existing limitations, especially in hospitality and tour operation. 
  3. Ease fiscal policies. Reduce and remove travellers’ taxes, which increase the cost of travel, e.g. air passenger duty and airport, port, and hospitality taxes around the world.
  4. Introduce incentives. Introduce relief and incentives to support business continuity for companies, which have been most negatively impacted by the virus. SMEs, in particular, will take longer to recover. 
  5. Support destinations. Increase budgets and assign resources for promotion, marketing and product development purposes in destinations when they are ready to welcome visitors again.

WTTC reinforces the importance of strong public-private partnerships and greater international cooperation to respond and overcome the challenges faced by the sector during the recovery from COVID-19.

The tourism sector has a proven track record of resilience in the face of crises and this ability to bounce back has improved significantly in recent years.

Medical tourism planning

Unlike the more short-term problems for travel caused by politics, terrorism, weather events or strikes, the COVID-19 problem is a medical one. It will be harder for medical tourism to recover than other tourism sectors.

Hospitals, clinics and agents may be able to use modern marketing techniques to help encourage new and returning customers. But they can only do that if customers feel safe travelling to the country.

Governments and national/regional medical tourism promotional organisations will have to work hard and spend money on tackling the following issues:

  • Smaller global market :  The medical travel market is expected to be smaller in 2020 and 2021 , so what medical tourism customers there are will have a wide choice of destination. Organisations will need to work out how to maximise the effect of their marketing spend to make sure they get a share of the medical tourism ‘cake’.
  • A permanent change? The big unknown is if any change in the behaviour of medical tourism customers will be permanent or temporary. Will they look to travel domestically or to nearby countries rather than go on long-haul flights?  Any plan you make must include allowances for different longer-term results.
  • Maximise spend : The medical tourism industry has many examples of spending marketing money in the wrong places (e.g. scatter-gun promotion tactics ; exhibition stands or attending unknown “international health” conferences ). But is that spending reaching the end consumer? Are you still using outdated websites and printed brochures, when most of the world has moved to different online options to research treatments?  Are you still blogging, when competitors have apps, Instagram pictures and remote tele-consultations?
  • Target market : Are the target markets you selected in your 2020 plan the right targets now? It is easy to get locked into a habit of targeting what was the best market five years ago, rather than looking towards what will be the best markets in a year’s time. Check out opportunities by country, location, age, and a range of other factors.  
  • Your offer : Is your offer targeted, logical and realistic, or more the equivalent of trying to hit a small target with a shotgun? Is the offer now right for you and potential customers?
  • Keep informed : As well as reading IMTJ, are you using up to date research produced by your country and others? There are many ‘copy-and-paste reports’ in the market that use historic figures but offer little or no analysis for the future.
  • Accreditation : Some medical tourism accreditation organisations suggest that accreditation is the answer to attracting international patients and some governments look like they are controlling rogue medical tourism agents by bringing in accreditation.  While accreditation may help improve the standard of hospitals and clinics, there is however no proof that accreditation alone brings in international business. It is likely that the average medical traveller is less concerned about whether  their medical travel agent has or does not have a certificate, and more interested in whether they are cheap and efficient.

Beware one size fits all solutions

There is no off-the-shelf simple plan for recovery that you can follow post COVID-19. Bespoke solutions for medical travel destinations are now vital. COVID-19 will move medical tourism into the next phase, where what works and makes money for Country A, will be irrelevant for Country B to adopt.

If you want to plan for 2021 and commission your own research or specialist strategy, you must set aside enough time to work out, in detail, what you want from it.  It will then take more time for a good analyst to work out the best action plan for your destination.

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How Will COVID-19 Shape Medical Tourism Development?

COVID-19, an unknown term six months ago, has become the greatest fear of individuals and companies. And while much coverage in the media has tended to spread panic, some posts and articles, like Reuters, are now taking a more pragmatic approach.

How might COVID-19 change the shape of the medical travel market?

Like most sectors, the medical travel market includes providers of many different sizes.  Here’s how they might be affected: 

  • The small and market-sensitive: Mainly medical travel consultants, startups and small agencies (facilitators). These individuals tend to have limited budgets and cash flow, and are most sensitive to fluctuations in medical travel flow due to ‘COVpanic’. They are likely to cut back on marketing and customer services immediately, dismiss personnel (if they have any) and potentially even disappear from the market. It may also be difficult for them to restart their business after the COVID-19 crisis.
  • The medium size medical travel providers: these professionals, mainly average size clinics or agencies, are in a better position. They might consider the COVpanic just as another crisis, possibly downsize their staff, reduce their spending, and cancel their participation in events. They will be more committed to maintaining their business through the crisis.
  • The large and well-established businesses in medical travel: these professionals, mainly large clinics, hospitals, hospital groups and the largest agencies have heavily invested in an international patient business which has, pre-COVID-19, generated high revenues. They are the most resilient to a business downturn due to COVpanic. It is likely they will continue to invest in this business, and will take a pragmatic approach to foreign patient cancellations. For them, this is just another crisis that will pass. 

There is one other provider group within the medical travel sector, who could be any sized, whom I call the “wise ones”.  They will use their time when there are fewer customer interactions, for preparation and reorganisation. They will update themselves about what is currently changing in the international patient market, train their people, rewrite their business plan,  apply healthcare protocols, and search for new markets. They will also try to identify the ‘where and when’ of future opportunities once the COVpanic subsides. 

Impact on medical travel events

Event organisers are as sensitive to the impact of COVID-19 as tourism providers. Many medical travel events, especially the ones that were scheduled during the first six months of 2020 have been cancelled or moved to a future date. 

This has been influenced by the personal choice of people not wanting to travel, but also in several countries there are now national restrictions on public gatherings.

Seasoned event organisers have downsized their events (and expenses) by booking smaller halls and anticipating fewer delegates, rather than stepping out of the market entirely. Medical travel exhibitions have proved even more sensitive than conferences, as they need a high number of anticipated visitors in order to be sustained. 

In this space, we might see live streaming and use of technology to facilitate knowledge sharing and networking by remote delegates, take a more central role in medical travel events in the future.

Planning recovery after COVID-19: it’s about patient perception 

The more pragmatic media articles predict that, like other flu, health or political crises, COVID-19 will pass.  We just don’t know when. 

Some physicians believe that it will peak soon, then decrease during the summer months.

To attract international travellers as tourism picks up again, flights and accommodation costs may be very competitively priced. Treatment costs will possibly follow, along with the other related services in medical travel. The first medical travellers after COVID-19 are likely to enjoy their treatment journey at very affordable prices and with no waiting time at all.

The established medical travel destinations, whose governments and health bodies have best managed to contain COVID-19 may be seen as ‘safer’ countries for patients looking at healthcare options abroad.  Medical travel providers in these countries who have survived the COVpanic are the ones who are likely to enjoy the first fruits of the post COVID-19 era.

Finally, lessons from COVID-19 are an opportunity for accreditation companies. Healthcare quality assurance is now an even hotter topic and so far, many hospitals with certifications from high quality accreditation companies have been well prepared to handle the crisis. A line of protocols that was applied to hospitals (mainly private) has played a significant role in identifying this virus early, so protecting the rest of the hospital patients. With other hospitals, maybe COVID-19 will be the motivation  for providers to improve and become safer for the patient.

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What Is Driving Demand For IVF In The Middle East?

Childbirth is a very important part of Middle Eastern culture and seen as a government priority to help expand citizen population. As such, some wealthy states fund IVF for their citizens.  Whilst not ubiquitous, it does create pockets of large markets in the region, which are, or could be, targeted by operators and investors.

IVF ‘Oil Rush’

Candesic reviewed IVF markets in the region and found significant increases in IVF volumes in the majority of them. Underlying growth rates in the Middle East range from -3.4% in Kuwait to 24.9% in Oman, and 33.6% in Abu Dhabi, compared to growth of 3.2% in the UK and 2.8% in Germany. There are several drivers driving demand for IVF; infertility is twice as prevalent in the UAE (33%) than in the UK (14%).

Keeping It In The Family

Consanguinity, marrying close relatives, is common in the region.  Hassan Abu Saad’s study shows a clear link between consanguineous marriage and children with intellectual and developmental disability (IDD). The biological explanation is the presence of autosomal recessive disorder. Essentially, if both parents carry the same autosomal recessive gene, there is a higher chance of their child inheriting two abnormal genes and, therefore, suffering from disease.

Many Middle Eastern countries have deep-rooted cultural customs normalising consanguineous marriage. Studies suggest that between 30% and 40% of marriages in Oman and the UAE are consanguineous, with even higher rates (over 50%) in Saudi Arabia and Kuwait, compared to less than 1% in the UK.

Therefore, the risk of IDD is higher and IVF allows for embryos to be tested for specific genetic diseases prior to being implanted: this is known as Preimplantation Genetic Screening or Diagnosis (PGS/PGD). Embryos are left to develop in-vitro for around five days, after which some cells are collected and tested, allowing parents to determine whether or not the embryo is free of genetic problems before starting the pregnancy. Couples concerned about how their consanguineous relationship might affect their children often elect to have PGD testing. Given the high consanguinity rates in the Middle East, this is a significant demand driver for IVF services and is unlikely to change in the foreseeable future.

Disease Of Affluence

Obesity is another key driver of IVF demand in the Middle East, with known causal links to low sperm count in males and to hormonal imbalances and polycystic ovary syndrome in females. Obesity in either parent can cause fertility issues. It is associated with reduced ovulation rates, increased miscarriage rates, and poor response to ovarian stimulation during assisted conception. These factors result in increased time to conception, and lower implantation and pregnancy rates following both spontaneous and assisted conception.

According to the WHO, Kuwait is the 11th most obese country in the world, with an obesity rate of 37.9%, just above the US (ranked 12th) and followed by Jordan, Saudi Arabia, Qatar, Lebanon, and the UAE. Obesity reduces the probability of couples achieving pregnancy both naturally and through fertility treatments.

Lack Of Sun In The Middle East?

Vitamin D deficiency is another potential driver. Approximately 90% of Emirate females have vitamin D deficiency, caused by lack of sun exposure, as women often cover themselves for cultural and religious reasons wearing the burka or hijab and stay indoors due to intense climatic heat.  Chu et al. found that live births are more likely to occur in women who had sufficient vitamin D compared to those who did not.

The Unmentionable Hits Social Media

Improved awareness and social acceptance of fertility treatments is another demand driver. Increasing awareness of treatment options (partly due to better information dissemination via the Internet) is also contributing to more couples seeking treatment, although word-of-mouth remains the most common channel for couples when deciding on clinics in the UAE.

Brave New World

Technological and scientific progress has supported improving success rates over the last decade, which also drives demand. Middle Eastern clinics often practise the ‘freeze-all’ strategy: by freezing all embryos at the blastocyst stage, they can then select only the best embryos for cultivation after day five. This leads to a success rate above 54% for most major clinics, which favourably compares with the average success rates for US and UK players of 46% and 22%, respectively. Customers view these results as better ‘value for money’ and are more likely to try the treatment.

Using IVF for gender selection (so called ‘family balancing’) is also legal in some GCC countries and is sought even by couples with no fertility issues.  Of note, Oman does not allow gender selection, meaning some couples travel and seek treatment in the UAE.

Overall, the growing complexity of treatments (e.g., PGS/PGD and ICSI) is a market value driver, as complex treatments tend to be more expensive.

IVF and Public Funding

The availability of public funding varies significantly between countries, and even between Emirates within the UAE. The number of publicly funded IVF cycles varies. There is generous funding to encourage people to have children in Abu Dhabi, with treatments available for married couples in both private and public hospitals. Some countries, such as Kuwait, fund IVF only for certain types of treatment or under certain conditions. In Oman, funding is only available to Ministry of Health and Armed Forces employees, who are reimbursed for IVF treatments. Government funding for IVF was scrapped in 2017 and is not expected to be reinstated.

Similar to Dubai, Oman, Kuwait, and the Saudi Arabia are mostly cash markets and dependent on the number of wealthy people in the population. Even those who are eligible for public funding in these countries might have to wait months for an appointment. Thus, those with available funds are more likely to pay for private IVF treatment, especially if older and with decreasing chances of successful conception.

Patients’ perception of the value for money provided by private fertility treatments has been improving, despite the relatively high treatment costs. Given the challenging patient population in the Middle East, the treatment price for IVF ranges from US$6,750 – US$9,990 without medication, with three cycles usually being necessary. This is nearly double the price of equivalent treatment in the UK. With further payments for add-ons, such as PGS/PGD, the overall treatment may exceed US$50,000 in some complex cases.

New approaches are employed to achieve better success rates among Middle Eastern populations. These are important for not only achieving better outcomes given the local challenges, especially consanguinity, but also attracting patients to clinics. The growth in ‘word-of-mouth’ referrals is contributing to increased confidence and acceptance of privately funded fertility treatments.  The internet is another valuable channel for sourcing patients, especially those coming to the UAE from surrounding GCC countries for treatment. Candesic estimates that medical tourism in the UAE accounts for 10%, with potential for future growth given increasing numbers of patients coming from Africa and India.

A longer version of this article, including additional market statistics and analysis of investor opportunities, is published in the Dec/Jan issue of the LaingBuisson journal, Healthcare Markets.

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Targeting Outbound US Patients? Understand American Healthcare First

In November this year, Americans vote for their next President. During the election campaign there has been much discussion on US healthcare and the various health reform proposals.  Ian Youngman looks at a new report comparing the options and offers advice to organisations seeking to target outbound US medical travellers.

A new, highly detailed report  ‘Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer’ has been published by The Commonwealth Fund and The Urban Institute, written by many authors and led by Linda Blumberg.

It shows how eight health care reforms in the USA could affect insurance cover, national health care costs, and spending by government, consumers, and employers.  The reforms could mean the US could achieve near-universal cover, and even decrease national health spending, by building on the current public–private insurance system.

As the 2020 campaign heats up, it is critical that medical travel organisations and international hospitals targeting US patients understand how various health reform proposals will affect health care costs and health insurance cover in America.  To help, I’ve simplified the key findings of this detailed report.

Affordable Care Act

The Affordable Care Act (ACA) had, until recently, substantially reduced the number of uninsured Americans, increased access to care, reduced uncompensated care for hospitals and other providers, and largely eliminated discrimination against the sick in private health insurance markets. There are still significant problems as 30 million people in the United States remain uninsured, while a substantial number of others are underinsured.

While many Americans have experienced lower costs after getting cover through the ACA, others have found that premiums and cost-sharing requirements are still too high. Following a Supreme Court decision that made Medicaid expansion optional for states, low income adults in the 17 states that have yet to expand the programme have been left without any financial assistance for cover. Additional policy changes made by the Trump administration and Congress have also created new problems and exacerbated others.

The Commonwealth Fund and The Urban Institute report looks at eight health care reform packages intended to address shortcomings of the current health insurance system. The reforms run from less to more comprehensive in their cover and impact on government costs. They range from a set of incremental improvements to the ACA, to a single-payer plan similar to Medicare for all proposals. 

Eight Reforms That Build On The ACA

  1. ACA Enhanced 1: Improves the ACA’s current premium and cost-sharing subsidies and adds a reinsurance programme for the individual market to protect insurers against very high claims.
  2. ACA Enhanced 2: In addition to the above reforms, this includes restoration of the ACA’s individual mandate penalty and reversal of the Trump administration’s expansion of short-term, limited-duration plans.
  3. ACA Enhanced 3: This builds on Reform 2 by closing the Medicaid eligibility gap for adults with very low incomes in states that have not expanded their Medicaid program. It also introduces a limited auto enrolment mechanism for most people receiving benefits from the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Programme (SNAP) programmes.
  4. ACA Enhanced 4: Adds to Reforms 3 with a public plan option and/or a capping of the provider payment rates in private non group insurance plans.
  5. Universal Cover 1: The first reform plan to achieve universal cover builds on Reform 4 by enabling workers to opt for subsidised non group cover instead of their employer’s insurance plan and introducing a mechanism through which all legal U.S. residents are deemed insured. This reform features a public option in the non-group market.
  6. Universal Cover 2: Adds to Reform 5 by boosting premium and cost-sharing subsidies further.Single Payer Lite: A single-payer plan that covers all people legally residing in the U.S. and includes all the ACA’s essential health benefits. There is cost sharing for individuals pegged to income but no premiums. There is no private insurance option.
  7. Single Payer Enhanced: This plan covers all U.S. residents, including undocumented immigrants, and features a broader set of benefits than Single Payer Lite including adult dental, vision, and hearing care as a well as home- and community-based long-term services and supports benefit. There are no cost-sharing requirements. There is no private insurance option.

Reforms Review

Each reform option improves the affordability of health insurance considerably, through lower premiums and cost-sharing and broader public programme eligibility. Reductions in consumer costs are greatest in the single-payer plans. But as affordability increases, the taxes necessary to finance the reforms would increase as well.

Reaching true universal cover requires either an auto enrolment mechanism for those not voluntarily enrolling in insurance or a single-payer system that enrols the entire population in a single plan.

Employer cover falls as the generosity of assistance in the individual market increases. The single-payer options eliminate employer cover (and other private insurance) altogether.

Federal spending increases as subsidised cover becomes more generous and more people enrol. However, the individual mandate, reinsurance, and cost-containment strategies like the introduction of a public plan option, can also lower the federal funds necessary to finance reform.

If the employer insurance system remains largely intact, universal or near-universal cover can be achieved with reasonably moderate increases in federal spending.

The report’s research goes on to look at the effects on numbers covered, federal and state and employer and individual costs.

Five Issues To Consider For Health System Reforms

The report raises five issues important to consider when designing health insurance system reforms.

  • Levels of provider payment rates: Many of the reforms revolve around at least some regulation of the payment rates for health care providers. Payments to hospitals and physicians vary considerably across services, provider types, insurers, individual providers, and geographic areas. How much and how fast provider payment rates can be reduced without affecting access and quality of care is unknown. The more people enrolled in rate-regulated cover, the greater the implications of where the payment levels are set.
  • Phase-in period: Estimates assume immediate full implementation of each set of reforms. As reforms increase in breadth, the necessary phase-in period lengthens. The first years of a reform’s implementation may be focused on creating new systems related to eligibility and enrolment and developing new payment systems and regulations, lowering total costs in the budget window. The researchers assume that provider supply will, over time, expand to meet the increased demand for services. But the expansion of supply for particular services may take longer than for others, particularly under a single-payer plan. Promised improvements in access to care may not occur uniformly. The larger the population enrolled in cover with lower, regulated provider payment rates, the more important it will be to phase in lower reimbursement levels over time in order to minimise disruption in the health care delivery system. 
  • Effects on employer health care spending and wages: The researchers estimate reductions in health care spending by employers for each set of reforms. These reductions increase if moving from incremental to more ambitious reform approaches. Reductions in employer spending on health care may be passed back, over time, to workers in the form of higher wages.
  • Effects on household spending:  Depending on the reform approach and income level, households see considerable savings in health care costs, with the greatest savings under the incremental approaches accruing to lower- and middle-income families. Health care savings are very large across the board under the single-payer plans. However, households will face higher taxes with any of these reforms, and these taxes are not accounted for here.
  • Effects on total national health spending: It is possible to design a set of insurance reforms that achieves universal cover for the legally present U.S. population without increasing total national health spending. Whether or not a single-payer plan increases total national health spending depends on the extent to which use of health care services increases because of added benefits and reduced cost-sharing; the levels at which provider payment rates are set; the needed administrative costs to run the programme; and the number of people covered. Under Single Payer Lite, national health spending falls relative to oral and vision care.

Why Does This All Matter To Medical Tourism?

The ACA has been discussed for years, then built up and then partially dismantled. The most that health insurers and self-funded employers have been able to do during this time is try to keep up with legal changes, sometimes coming with no warning after a presidential tweet. So, when offered domestic or international medical tourism add-ons, most US health insurers have been unenthusiastic.

The bad news for organisations seeking to sell treatments abroad to the US corporate, business or health insurance markets is that, until November 2020 nobody will know who the President is and what party will be in power, with what healthcare and health insurance agenda. Once the government has decided what to do it has to then get the laws passed by Congress and Senate, and implement the change. At the earliest, it is likely to be 2022 before we know the details of any health insurance or healthcare reform.

There are some in the medical travel market who still suggest there is significant potential in the US outbound medical tourism. In reality the large numbers in the market are the individuals not fully protected by the healthcare and insurance system.  Many of these people that have no spare cash for healthcare, whether at home or overseas, are increasingly being swept up into various state funded or state subsidised insurance programmes.

The best advice for organisations seeking to seriously sell into the US market  is to understand and keep up with how US healthcare, health insurance and politics are permanently entwined. Those medical travel destinations targeting American patients with the “come to us as we’re 80% cheaper than in the USA” message should update their approach.

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Hard Work, But The Rewards Are High

The attraction of international clients for doctors is a quite different proposition today compared to let’s say 20 years or more ago. It might seem that I am trawling a long way into the past to make the comparison, but in fact the history of international patient flow into the UK and London in particular is relevant. Harley Street was for many years a mecca on the international medical tourism trail. The quality of care was perceived to be of the highest and we welcomed our visitors with open arms. This was at a time of a growing independent healthcare market and was definitely a factor in attracting doctors to devote some or all of their practice to the private sector. It was a catalyst for the growth of the sector.

Changing Times For The UK

But times change. Where at one time the UK would have been the destination of choice, other prime international medical capitals emerged to compete for this lucrative market. The success for a consultant rested on a number of factors, not the least of which was the quality of care that they provided and the successful patient outcome.

But as competition increased, the offering became a combination of the provider facilities, i.e. the hospital or clinic, the concierge offering and the all-important price. Foreign purchaser pressure required a concerted effort to impress with the overall package of care for the patient and their family and the value for money. Consultants regularly visited other countries to meet and greet, lecture, see patients in clinics and operate. Many patients were recruited to visit the UK through this process. So essentially it was hard work, but the rewards were high.

Payment Terms Risk

The biggest downside that emerged and remains a major hurdle are payment terms. It is common practice to wait months for payment if not years, where patients are government sponsored. Not only is this a significant cash flow issue but takes an inordinate amount of effort and time. It is a major consideration regarding the management of embassy patients. But this is only one payer group and many others are more than acceptable.

Broadening The Market

An international patient workload covers a multitude of conditions. While surgical interventions might commonly be the obvious one, there are many other planned and unplanned care needs. The management of chronic conditions such as patients requiring dialysis or medication management is not uncommon.

There is an equally large need for primary care for travellers, often requested via hotel concierges, and many hotels have agreements with primary care doctors to visit guests with urgent or unspecified medical support.

The UK has provided many ‘super specialist’ services for international patients that has been instrumental in achieving its current excellent reputation. Both doctors and hospitals have capitalised on some of the specific needs that are required. A prime example would be complex rehabilitation services that are not available, particularly in Middle Eastern countries. Such services require a high level of organisation, not only for the patient but for families, and many of the UK’s independent specialist doctors have become key in this patient flow.

As doctors consider their options in developing a private practice it is less likely today that they would factor the international patient workload as being the key to a thriving practice. They will work collaboratively with providers or embassies to be a part of a significant package of care.   Where a provider has developed a salaried model of employment, it is quite possible that an international patient workload will form a significant part of their patient workload and indeed enable continuity of care which can often be missing when dealing with sporadic and individual cases. It is also worth noting that the international workload often provides challenging and unusual pathology that doctors welcome the opportunity to treat.

The skill and expertise of the doctor is key to attracting patients to the UK and was the genesis of the market. Continued growth requires teamwork and a focus on providing excellent patient care with demonstrable outstanding outcomes to ensure the continuation of patient flow from international markets.

This article first appeared in the leading UK healthcare industry journal, Healthcare Markets.

Author : Sue Smith, CEO of the Independent Doctors Federation looks at the ups and downs of building and maintaining an international private patient business in the UK.

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Why Is Medical Tourism Accreditation So Misunderstood?

Below are five of the most often heard and repeated fallacies about accreditation within the healthcare and medical tourism sectors.

Myth #1: Accreditation is a fault-finding mission.

Myth: Healthcare providers can be a little afraid of accreditation, seeing it as a way to find things that are wrong. They labour under the misconception that assessors will walk through their hospitals or clinics pointing out everything that is wrong, real or imagined. It is perceived to be a fault-finding expedition that points fingers, lays blame, and imposes guilt on responsible parties.

Fact: Accreditation is a collaborative team-building process designed to guide organisations to become better at everything they do. Continuous Quality Improvement (CQI), patient safety, risk management, and an excellent patient experience are the four pillars of a good accreditation program.

Accreditation offers the best clinical and non-clinical practices to inspire hospitals and clinics to improve their systems and processes to benefit patients, staff, and the overall organisation. The self-assessment component of accreditation breaks down barriers among departments to create a cohesive approach to service delivery, improving the patient experience as well as the bottom line. Assessors offer advice, share examples, support and coach clients to a higher level of excellence.

Fact: Working with an appropriate accreditation company dispels this and other misconceptions about accreditation and engages the healthcare organisation in a journey of Continuous Quality Improvement.

Myth #2: Accreditation is just completing a “To Do” check list.

Myth: Assessors will show up with a check list of items, and make sure everything on the list is there. When everything on the list is ticked off, accreditation is granted.

Fact: Accreditation is a holistic approach to ensuring that the systems and processes within a clinic or hospital are integrated and functioning optimally to maximise the benefits to patients, staff, and the organisation overall. A check list approach simply cannot and does not work. For example, a check list approach would look to see if the hospital has fire extinguishers. An accreditation assessor will want to know if the fire extinguishers work, if people know where they are located, who knows how to operate them, and so on.

Myth #3: Accreditation automatically leads to more patients.

Myth: “My hospital or clinic should get accreditation because I want more patients. If I put the accreditation seal on the website and at the front door, more patients will come to us for services”. A more unfortunate scenario reported to me is that assessors have been told, by less than ethical individuals, that just getting the accreditation will result in more patients.

Fact: Accreditation is designed to improve the quality of clinical and non-clinical services for hospitals and clinics. Enhanced quality of services is one factor that individual patients as well as third party payors look for when selecting where to go or where to send people for healthcare. The benefits of accreditation, once measured and analysed, can be used for marketing purposes; however, it is the responsibility of the provider to develop and market the qualities that are sought after in the marketplace, rather than promoting the accreditation badge.

Fact: Accreditation by itself will not “auto-magically” bring more patients to a hospital or clinic. It is one component of successful marketing that depends on a number of factors including consumer choice, the organisation’s Unique Selling Proposition, and more. Accreditation is a tool, not a magic wand.

Fact: Ethical accreditation companies will never promise or represent that accreditation automatically leads to more patients.

Myth #4: Accreditation companies offer more than accreditation services.

Myth: Accreditation bodies offer more than just accreditation, such as access to mailing lists, databases, and insurance company contracts. These add-ons are promoted to healthcare organisations as free business-building services.

Fact: Ethical accreditation organisations do one thing and one thing only: provide independent, neutral, professional, and independent assessments of the quality of the clinical and nonclinical services provided by a healthcare organisation.

Fact: Developing marketing and sales is the responsibility of the hospital or clinic, not the accreditation organisation that has been selected. Accreditation organisations that offer “freebies” or add-ons like mailing lists, databases, or other promises are over-stepping their role as independent assessors. Clients depend on the neutrality and independence of assessors and can lose trust when offered promises that are misleading or “too good to be true”.

Fact:  Hospitals or clinics tempted by these extra services are very likely to be disappointed. Reputable accreditation companies are not designed to provide other services and it is likely that these will be hollow offers with little or no value to an organisation.

Myth #5: We are already doing things well and do not need accreditation because we have always done it this way.

Myth: Our hospital or clinic is already doing great and are succeeding doing what we are doing. We have always done it this way. We don’t need to change. Accreditation won’t help us.

Fact: Healthcare services around the world are changing and evolving quickly. It is challenging to keep up with the daily demands of managing a hospital or clinic. It is the role of accreditation organisations to monitor clinical research, keep informed of new best practices, evolving trends, availability of new technology, and other aspects of the delivery of the best possible healthcare and patient services. Smart healthcare providers rely on a long-term relationship with a trusted accreditation partner to fulfill these tasks on behalf of their clients.

Fact: There is always room for improvement that can bring a variety of benefits to a healthcare organisation, including happier and healthier patients, engaged staff, improved revenues, and an enhanced reputation. If a hospital or clinic is already known for its excellence, chances are it is interested in continuing the pursuit of improving its clinical and nonclinical services. Accreditation can accelerate that process, often resulting in a stronger competitive edge.

The biggest obstacle on the road to excellence is the mindset of “We have always done it this way”.  If you are standing still, then you are being left behind.

Author : Elizabeth Ziemba, JD, MPH is Regional Representative for Temos Accreditation and President of Medical Tourism Training, Inc.

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Is The Medical Tourism Sector Prepared?

World events are often complex and intertwined, requiring increased preparedness, improved management and effective recovery to maintain and increase competitiveness. This is particularly important for any form of tourism when it comes to crises, given the impact of major geopolitical events and civil unrest, terrorism, epidemics and natural disasters on this sector. While it is too early to assess the lasting effect of the Coronavirus on world tourism, the immediate impact on inbound and outbound travel from China has been plain to see.

Crises Recovery

The research by WTTC, in partnership with Global Rescue, a membership organisation providing medical, security, evacuation, travel risk and crisis management services, analysed the impact of 90 crises between 2001 and 2018, at a national and city level, examining the time to recovery as well lost arrivals and lost visitor spending. 

Of the 90 crises analysed, 32% were related to terrorism/security, 13% to disease/outbreaks; 19% to political instability and 36% to natural disasters.

The key findings from the research included: 

  • The tourism sector is more resilient than ever. Average recovery times have decreased from 26 months in 2001 to 10 months in 2018. 
  • Of the four crisis categories analysed, political instability proved the most challenging, with average recovery times of 22.2 months, minimum 10 months, while terrorist or security related incidents have the shortest average recovery time of 11.5 months (minimum 2 months). 
  • The average recovery times for natural disasters and disease outbreaks were 16.2 months and 19.4 months respectively (minimum 1 and 10 months respectively). 
  • Public-private partnerships and effective, transparent communications are critical for preparedness and prevention.

The WTTC recognised that while there is still work to be done, it felt the data from this research shows that recovery times have fallen significantly over the past two decades, and that major strides have been made.

Interestingly, political instability rather than epidemics has proven to be the most challenging crisis to overcome for the tourism sector, with the longest recovery times.

Political turmoil and civil unrest can take many forms, including violence between domestic factions, large scale protest movements, as well as coups d’états and uncertainty. An example of civil unrest includes the Arab Spring, which began as a series of pro-democracy demonstrations in Tunisia in December 2010 and spread to other countries in the Middle East and North Africa.

Political instability or civil unrest is far more damaging to a country’s tourism sector than one-off terror attacks. Unlike single terrorist attacks, manifestations of civil unrest or political instability often occur over a prolonged period of time, extending the disruption to the economy and strengthening the perception of instability at the destination. The uncertainty linked to civil unrest or political instability can impact inbound and outbound travel with people delaying their trips.

Crises Readiness and  Management

Sometimes as challenging as the crisis itself is the preparation, management and coordination of the resources needed to mount an effective response.

The report suggests that through successful public-private collaboration, effective communication and continued efforts that focus on preparedness and prevention, the global tourism industry is already making a real difference in reducing both the economic and human impact of such crises.

The report goes on to offer recommendations on how destinations can mitigate the impact of a crisis, showcasing successful examples from Kenya, Mexico, Egypt, Hawaii and Japan. It highlights the importance of tourism destinations being prepared and the need for coordinated management to ensure a successful recovery.

All-Hazards Emergency Planning

The WTTC and Global Rescue recommends that governments and private sector organisations should individually assess their own level of preparedness and have an operational “all-hazards” emergency action plan in place.

Beyond an all-hazards plan, destinations and businesses should also have a sub-set of response plans for different types of crises. Learning from any previous experience, destinations need to take stock of their capabilities and have a clear view of what will be expected of them during a crisis.

Review of these plans should be a regular, sustained activity that rigorously assesses new and previously unrecognised threats as they continue to emerge and sets out all the key information, contact details and procedures that need to be in place should an event take place.

Communication Management

Strategic communication and effective media engagement during the immediate aftermath of a crisis are critical to the sector’s timely recovery. Successful responses require proactive, honest, transparent and factually accurate communication to the extent of the crisis, with detailed information on ongoing health and safety issues. This honesty can foster trust.

The report states that it is vital for authorities to take control of the story and respond quickly, giving instructions, being consistent, open and accessible and expressing empathy. Having a proportionate response is key. It is important to be honest about the information that is known and what is still unknown; and continuously communicate to the public.

As destinations recover and rebuild their confidence, they need to re-compete for lost ground. This requires transparency and ownership of the crisis; with a clear and honest articulation of what happened, what has been done in the wake of the crisis and the promise of what a destination will do in the future.

Managing the perception of safety and security is key. This involves informing tourists when the transition from crisis management to recovery has taken place and whether they can safely travel to and around the country again.

Is The Medical Travel Sector Ready?

The medical travel sector is still an emerging market and to date has not had a strong track record in responding to crises. Governments and officials are often defensive, or do not react quickly enough, and frequently do not communicate about how the crisis is impacting healthcare organisations in the country.

However, to be taken seriously, medical travel destinations must develop ways of being ready for any crisis and dealing with it in a mature way. While medical tourism is not covered in the WTTC and Global Rescue research, this report is well worth reading as a starting point.

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Medical Travel Market Will Be Worth US $9 BN

The global medical tourism market will be worth US$54 billion and is expected to grow at a compound annual growth rate of 13% until 2025. India’s medical tourism market will be worth US$9 billion in 2020 and is the fifth largest medical tourism market out of 41 destinations.

These are the conclusions of India: Building Best Practices in Healthcare Services Globally 2019 by consultants Ernst & Young (EY India) for the Federation of Indian Chambers of Commerce and Industry (FICCI).

As healthcare becomes more expensive in developed countries, India’s medical tourism market is expanding. The key drivers of growth are affordability and accessibility of good healthcare services, availability of the latest medical technologies and accreditations, and minimal waiting time.

The report repeats a common claim that medical tourists can save up to 50% of the costs of healthcare in the USA.  TTEM’s analysis suggests however that the percentage of medical tourists travelling from the USA to India as less than 0.01%. Most medical travellers going to India are from Asia and Africa.

Key Indian city destinations

Delhi, Mumbai, Chennai, Bangalore, Hyderabad and Kolkata are the preferred destination cities for medical travellers arriving in India. 27% of India’s medical tourists head to Maharashtra, out of which 80% go to Mumbai. Chennai attracts 15% of incoming foreign patients while Kerala has 5-7%.

Bangladesh 221,751
Afghanistan 55,681
Iraq 47,640
Maldives 45,355
Oman 28,157

Source Markets of Medical Travellers to India

According to the report, based on figures from 2014 to 2017, major source markets for India is the South-East Asian countries, the Middle East, Africa and SAARC countries. More than 50% of medical tourists are from Bangladesh. The report repeats the Ministry of Tourism 2017 figures:

TTEMS’s analysis challenges the number of medical travellers from the Maldives of 45,355; as the total population of the Maldives is only 530,000 people this is disproportionately high.

The number of medical tourists on medical visas has increased from just over 10,000 in 2014 to around 480,000 in 2017. The Indian government estimates total medical tourism numbers for 2017 at just fewer than 500,000, and is expecting this amount to increase in future years.

The report says that there are 38 hospitals accredited by the Joint Commission International (JCI) and 643 accredited by the National Accreditation Board for Hospitals and Healthcare Providers (NABH).

Key market growth risks for India

The report warns that there is a need to improve on post-operative care in terms of environment, hygiene and precautions required after a patient is operated on. India is also behind many countries on healthcare regulation; there is little to stop unaccredited hospitals, clinics or medical tourism agents from staying in business and attracting medical tourists. There is also a lack of regulation of the Indian medical tourism industry, and this lack of regulation could impede growth.

The Indian national government is criticised for its lack of support for medical tourism, particularly at government-to-government level between India and patient source countries.  Too much is left to individual hospitals. There is also no grievance or redress mechanism in place for international patients to raise  complaints. There is no policy arrangement in place to insure patients in case of unexpected complications in treatment.

Of the findings in the report, Gaurav Taneja at EY India says: “Government must form institutions for regulation and implementation of medical tourism. There is a need to build a robust platform for patients to interact with different stakeholders of the industry and define a code of conduct for medical tourism business.

With a branding and marketing campaign ‘Heal in India,’ I am sure the country will elevate its existing position in rank among the most preferred destinations.”

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The Third Eye Medical Services advice on Coronavirus

For the most up-to-date response to the situation, The Third Eye Medical Services advises clients to refer to the World Health Organisation (WHO) for any queries they may have. The current sentiment is to be alert, not afraid. 

Archana Gupta, Head of International for The Third Eye Medical Services says, ‘As with any potential health outbreak or emergency, we would urge employers to seek advice from reputable sources such as the World Health Organisation, The Foreign and Commonwealth Office (FCO), their healthcare provider or specialist adviser. Such organisations will be monitoring the situation and have the most up-to-date advice.’

If individuals are concerned about symptoms they are experiencing, such as respiratory problems (fever, cough, shortness of breath and breathing difficulties) that has been linked to the virus, they are advised to seek medical advice and speak to their healthcare provider.  

At present, The Third Eye Medical Services understands that the novel coronavirus originated from Huanan seafood wholesale market, in Wuhan City, Hubei Province of China.  There have also been cases in Japan, Thailand, the US, Australia the Republic of Korea, and a handful of cases recently confirmed in France and Australia.

So far (at time of writing, 05th Feb.) there have been 24,558 confirmed cases and 493 deaths.  The case fatality rate is quite low so far (less than 3%) and mainly in elderly persons or those with co-morbid conditions.

Chinese authorities have imposed travel restrictions to prevent people travelling in and out of Hubei to reduce the spread of the disease, and the UK Foreign Office has advised against all travel to Hubei.

What to expect next :

  • Authorities are stepping up screening of air passengers from China. Temperature screening is already taking place in Australia, Singapore, Hong Kong, Taiwan, the US, Russia and Japan. The UK is expected to begin screening passengers arriving from China.
  • The UK Government has stated it is reviewing options for the return of the 200 UK nationals currently still in Wuhan, given the travel restrictions imposed by the Chinese authorities.
  • The head of the UN health agency, WHO declared on Thursday 23 January that the respiratory disease Novel Coronavirus, is not yet an official Public Health Emergency of International Concern (PHEIC), but warned that is an emergency in China.

Current advice :

  • Don’t travel to Hubei Province .
  • The FCO has advised British citizens to leave Hubei Province after the chief medical officer issued new advice recommending vulnerable people should immediately evacuate the area at the centre of the coronavirus outbreak.
  • In Shanghai, the government has stopped businesses from returning to work until 10 February.
  • Avoid crowds and minimize public gatherings if you are in the province.
  • Do not touch animals or eat game meat and avoid visiting wet markets, live poultry markets or farms, if travelling in China.
  • Seek medical advice immediately if you’re concerned about cold or flu-like symptoms and have recently visited China, or have been in direct contact with someone who has recently visited China, and inform your medical practitioner of your travel or contact history.
  • Basic hygiene measures such as washing hands is sensible.

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Bangalore Doctors Perform a Rare Bloodless Liver Transplant on a Nigerian Patient

Doctors at the Aster CMI Hospital in Bangalore have performed India’s first bloodless liver transplant on Jehovah’s Witnesses from Nigeria. The surgery was challenging compared to a normal liver transplant due to patient’s religious beliefs. The doctors could not use blood or blood products such as platelets, fresh frozen plasma, Cryoprecipitate and more. Few such surgeries have been conducted worldwide and were successful.

The patient named – Jehozadak from Nigeria was suffering from end-stage liver disease. Without a liver transplant, his chances of survival were less than 10% in the next 2 years.

The team of liver specialists – Dr. Rajiv Lochan, Dr. Sonal Asthana, Dr. Mallikarjun Sakpal, Dr. Arun V – Anesthesiologist and Dr. Prakash Doraiswamy – Intensivist, reviewed the patient’s medical history before recommending surgery and charted out a feasible pathway.

“During a liver surgery, patients lose a lot of blood which needs to be replaced for the patient’s survival. Generally, doctors keep 3-4 units of blood and a similar quantity of platelets/plasma on reserve for the patient. In this case, we had to figure out and alternative,” said Dr. Mallikarjun Sakpal, Hepatologist at Aster CMI.

The doctors used ‘Normo-volemic hemodilution’ technique where doctors took two units each of both patient and donor’s blood and were connected to the system throughout the surgery using special equipment so there is no break in the blood circulation loop. This procedure was discussed with the patient before surgery and it was in line with their beliefs.

During the surgery, the patient lost about 2 units of blood which were compensated with the use of ‘cell-salvage’ technique to collect and reuse the blood. The surgery lasts for 12-hours and two teams of specialists with close to 25 doctors were involved in this surgery.

In a period of two weeks, the patient and his brother, who was a donor, were discharged from the hospital.   

Source :

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