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.

Source : www.imtj.com

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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.

Source : www.imtj.com

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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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