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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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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