1.A new model for medical tourism in Cyprus
Caroline Ratner examines a model for medical tourism that has been developed by The American Institute of Minimally Invasive Spine Surgery (AIMIS Spine) operating beyond borders in Cyprus. AIMIS Spine consists of pre-eminent US spine surgeons who are the primary educators in advanced minimal invasive surgical techniques and who teach other surgeons these methods throughout the US and the rest of the world. She spoke to Mr Marios Papadopoulos, CEO of AIMIS Spine, which sees its first American patients arrive in Cyprus in January.
What exactly is AIMIS?
AIMIS is a collective partnership made up of thirty top US spine surgeons, who specialise in and teach minimally invasive spinal surgery. These world class surgeons are now offering this groundbreaking surgical technique in Cyprus; until now, this specific type of surgery was only available in the US. On average, US patients flying to Cyprus will pay 60%-75% less, than if they had surgery at home and that’s including flights and luxury accommodation. By bringing the US surgeons to Cyprus, it also means that patients from other countries can now benefit from cutting edge spine technologies outside of the US, where it is usually prohibitively expensive for most foreign patients to travel to, as medical tourists.
Is AIMIS a medical tourism facilitator?
No. AIMIS is a collective partnership of surgeons. We are neither a facilitator nor a facility nor a medical travel company. It’s a new medical travel business model to provide US patients (and others) the chance to have the best American medical care for minimally invasive spinal surgery, at a fraction of the costs than if they were having the surgery in the US.
How did you get involved with AIMIS?
I have spent the past 25 years in the medical industry working with multi national companies, the past ten years in orthopaedics and the past four of which, specifically in the spine sector. Four years ago, I brought NuVasive to Greece (creative spine technology) and it became the fastest growing company in that sector. During that time, I met Dr William Smith, a top US spine surgeon specialising in minimally invasive techniques and we discussed the possibility of sending US spinal patients to Cyprus for minimally invasive surgery. Last April we presented the concept to the leading spine surgeons in MIS techniques and gradually set up a network of some thirty of the worlds’ leading MIS spine surgeons based across the US.
How will it work?
Our surgeons will see American patients in the US pre and post-operatively and come to Cyprus on a rotating basis for ten day periods. Our doctors are committed to travelling to Cyprus for a minimum of 1- 2 times a year and if necessary more, depending on patient numbers.
Have you opened your own hospital?
No. We are operating from existing private hospitals in Cyprus and plan to keep it that way for the time being. Further down the line we may look into opening our own hospital, but our objective now is to work from existing private hospitals in Larnaca, Limassol and Nicosia.
Where will non-US patients consult with doctors before and after surgery?
We are aware that the two most critical aspects determining successful medical travel are the quality of healthcare and post operative care provided to our patients. It is vital that both are of the highest level and standard throughout the whole process. AIMIS Spine offers these highest levels of American healthcare, with the most technologically advanced American products and procedures with the possibility to have any follow up required “back home”. AIMIS truly expands and stretches beyond the US not only through the specific associations and networking it has been developing, but also through the training of other surgeons, our surgeon base and other doctors associations.
We are currently working with the European Chiropractors Union and are developing a Manual of Medical Services between our surgeons and a chiropractor. This manual explains how chiropractors and our spinal surgeons can work together, so that their members can undertake pre-operative screening and carry out any post op medical services to a patient. We are officially launching this manual in June at the annual congress of the European Chiropractors Union in Zurich.
Moreover, AIMIS surgeons teach other spinal surgeons these techniques, who automatically become our Institute’s associates and we will gradually include key surgeons from most European countries in our collective environment. In this way non-US patients, through our networks, can see a surgeon trained in minimally invasive spinal surgery, in their home country pre and post operatively.
We are also about to open a multi-lingual call centre where patients can speak to trained operators who can answer their questions and advise on all aspects of the surgery and travel. It is important to us that patients can speak to a person, from wherever they are in the world, which will help patients psychologically as well as practically understand the process rather than all communication between AIMIS and the patient being online.
What about accreditation of your hospitals in Cyprus?
All the hospitals we operate out of in Cyprus are in the process of being accredited by internationally recognised accrediting bodies, such as QHA Trent and our own doctors in AIMIS partnership are also the ones who accredit hospitals in the US.
Who are your competitors?
We have no competitors as such; we are not just another medical travel company or local healthcare provider. There is no-one else doing what we do.
Why did you choose Cyprus as your base for spinal surgery?
We chose Cyprus because it is an English speaking highly developed EU country and an attractive holiday destination with a climate perfect for recuperation.
Apart from the US, where do you think most of your patients will come from?
We believe that 50% will be American patients, the rest from Russia, the Middle East and the UK. One of the reasons we chose Cyprus is because it is so conveniently located for our main non-US patients.
How are you attracting US patients to Cyprus?
If patients are out of an insurance network or have no insurance it is extremely expensive to have any type of surgery in the US so we are marketing directly to those patients.
Additionally the insurance companies don’t fully cover a lot of procedures, which makes it almost impossible for many US patients to be able to afford surgery. The average cost of spine surgery is around $150,000 to $200,000 in the US. By coming to Cyprus patients can have the same treatment by the same surgeons with same products at something like 60% below US prices whilst recuperating in the sun in luxury accommodation. This is a huge incentive for any one out of network and for medical insurance companies as well.
How about insurance claims for accidents and injuries?
Personal injury cases are potentially a big market and we are actively marketing AIMIS to people with personal injury claims in the US, creating an awareness and of course directly to the insurance companies. Insurance companies can save huge amounts of money on medical and legal costs by sending their patients to Cyprus for treatment. What is happening at the moment is that insurance companies tend to delay approval in personal injury cases, resulting in prolonged patient suffering, thereby instigating unnecessary court cases where claims costs are paid through the legal system. Through AIMIS the patient can have his surgery prior to settlement at a fraction of the costs and enforce and speed up settlement. We have already had patients who have had their operation and successfully reclaimed their costs from their insurance companies.
2.Cosmetic surgery tourism and the PIP implant controversy
The PIP breast implant controversy continues to grab the headlines across Europe. Concerns have been raised by women who have had their breast implants as “cosmetic surgery tourists”. What do they do if they have received a PIP (or a Rofil M) implant in a cosmetic surgery clinic in another country? Research by Treatment Abroad shows that UK patients may be less at risk than if they had gone for breast augmentation in the UK.
It is estimated that 40,000 women in the UK have received implants manufactured by the French company Poly Implant Prostheses (PIP). PIP implants contain low grade silicone; there are concerns about the risk of rupture of PIP implants and the effect that this silicone will have on the patient.
Reaction has varied across Europe. The French government has offered to pay for implants to be removed. The Czech, Dutch and German health authorities say that the implants should be removed. The UK government has said that there is no evidence that routine removal of PIP implants is necessary. However the NHS has agreed to remove PIP implants for free if the original operation was undertaken by the NHS (usually as part of a breast reconstruction after surgery for breast cancer). It has also said that women who are concerned about their breast implants should be able to have them removed for free by their private cosmetic surgery clinic.
The reaction from the private cosmetic surgery clinics in the UK has been mixed. Many providers such as BMI Healthcare have agreed that women who wish to have their PIP implants removed and replaced will be able to do so, at no cost.
However, the company that has done the largest number of PIP implants in the UK has said that it will not replace them free of charge. The Harley Medical Group has 13,900 clients who received PIP implants between 2001 and 2010 at their 31 clinics in the UK and Ireland. At the weekend, patients marched on the offices of cosmetic surgery clinics in Harley Street demanding that private clinics replace PIP breast implants.
The use of PIP implants in cosmetic clinics abroad
UK clinics and cosmetic surgeons pointed at the failure of the UK government to monitor and regulate the supply of implants. But some also raised concerns about patients who may have travelled abroad for their implants. According to the British Association of Aesthetic Plastic Surgeons, “Many UK women would have had them implanted when they travelled abroad to countries such as Belgium, Poland and the Czech Republic for cut-price operations.”
This prompted us at Treatment Abroad to contact our clients to establish the use of PIP implants and also of Rofil M implants (a Dutch company re-sold PIP implants under the brand name Rofil). We contacted more than twenty cosmetic surgery clinics who are clients of Treatment Abroad and asked them a series of questions (shown at the end of the article) regarding their treatment of UK patients and the use of breast implants in their clinics.
The response from the clinics was a resounding...”No, we have never used low-cost implants”. We haven’t been able to identify any of our clients who have used PIP or Rofil implants.
What does this say about the quality of cosmetic surgery clinics abroad?
Domestic cosmetic surgery providers, such as the plastic surgeon associations in the UK or the USA, often criticise surgeons and clinics abroad who offer cosmetic surgery at a lower cost. The issue of “what happens if something goes wrong?” is frequently raised. Cosmetic surgery abroad is presented as low cost, low quality and high risk.
The truth is that no-one really knows whether this is fact or fiction. There is little comparative data, if any.
But the PIP implant story presents a different view from that which is usually presented in the media. The cosmetic surgery clinics abroad that we contacted were very clear that they use the highest quality (and higher priced implants) and that they avoid cheap implants. What people tend to forget is that surgeons, clinics and hospitals that target the international patient market are usually the best in their field. Thus, the Harley Street doctors and London hospitals who attract patients from across the world have built a worldwide reputation based on expertise, not on low cost. Similarly, in outer European markets such as Belgium and Spain, it is the leading cosmetic surgeons who have sought to spread their wings by developing an international patient business. The cosmetic surgeons treating UK women are often the best in their own country.
Setting standards for cosmetic surgery clinics across Europe
CEN – the European Committee for Standardisation – is currently drafting a European Standard on Aesthetic Surgery Services. The new standard will help consumers to make better choices and create a level playing field for aesthetic surgery service providers, complementing existing legislation and filling gaps where no regulation or standards exist. The Standard is widely supported by cosmetic and plastic surgeon associations across Europe. But it will be interesting to see where the greatest efforts will be required to bring local, national practices up to the new European standard. In the UK, in an unregulated cosmetic surgery industry, standards vary. Not all clinics and providers live up to the standards expected by the plastic surgery associations. In some cases, the new European initiative will no doubt bring some UK providers (and many elsewhere) up to the standard already provided in other clinics in Europe.
Addendum: The questions that we asked
Here’s what we asked the cosmetic clinics in Europe:
Which brand of implants do your patients most often receive?
Have you used PIP implants in the past?
Do you keep a record of what kind of implant has been inserted in each patient?
Do you inform the patient of the brand of implant that has been inserted?
Do you provide the patient with documentation confirming the brand of implant that has been inserted?
Do you monitor rupture rates on the different types of implants that you use?
What is your view/experience of rupture rates with the PIP implant?
Have any of your UK patients received PIP implants?
How many of your UK patients have received PIP implants?
What action are you taking regarding the current issue:
Have you contacted patients with PIP implants as a result of the concerns?
What is your recommendation to them?
Have you offered them removal and replacement of these implants?
If you have offered a removal and replacement, how much will patients be charged for the removal and replacement?
Are you offering removal and replacement of PIP implants to UK patients who have not previously visited your clinic/s? If so, what will be the price for this?
3.The future of spa tourism
Dr. László Puczkó is managing partner at Xellum and has been working in health related travel for over 15 years, on development projects, strategies, forecasting, trends, trend definition and on planning on a regional or national level. Caroline Ratner of the IMTJ spoke to him about the report and his view of spa and wellness tourism today.
Why was the report commissioned?
The aim of the report is to identify and highlight the opportunities and issues in the global spa industry today and also to point out important opportunities for growth, especially in areas which haven’t already been exhausted or addressed. The Global Spa Summit chose us to write the report because we have an overview and understanding of both sides of the spa and tourism industries and provide a link between the two.
What do you think some of the main problems and issues are facing the global spa and wellness industry?
One of the main issues is getting the terminology right, the word “spa” has been bastardised and stretched to become a catch-all term and means different things to both consumers and suppliers of services. A lot of services are standardised, a spa where you have a facial and a massage and maybe some water based therapy, especially at European spas, is what most people imagine a spa to be but there are so many different types of spa experiences available.
Getting a clear definition of what a company is offering is crucial for both the industry and its consumers. Consumers are confused; and it can be even more confusing when a company comes up with terms like med spa and medical spa because there is no standard definition of what these terms mean but if someone wants to enter the generic service market then the term “wellness” is appropriate, this implies that it is a mid market or upmarket service, either in a hotel or health facility which includes treatments that include different types of massage, beauty treatments and usually a swimming pool. This is what most consumers expect a spa to be.
And of course one of the biggest problems facing many different countries and companies providing the same generic “spa” experience” is where are their customers going to come from? I foresee this as a huge challenge. It’s clear to me that the market isn’t really big enough. When you’re offering something generic it’s purely about price and reputation and that’s probably not going to be enough.
What is the solution?
In the report we’ve outlined ways of helping businesses and consumers understand what they are offering, and how to differentiate themselves by using the correct terminology. The market is unaware that they can use many different words to describe what they are offer and that other words would be more appropriate and help them market their product at their target market more precisely, whether it’s a retreat, a wellness cruise, an ashram, a refuge you name it, yoga camp, boot camps and so on. By precisely naming what they do potential customers will find it much easier to identify and understand the services on offer and find what they are looking for, companies need to define whether it is wellness tourism, medical tourism, spa tourism etc. We designed a grid for the report to clarify the terms because I don’t think they are interchangeable when it comes to spas, a lot depends on the location and what it is on offer.
There is so much more to the wellness experience than consumers are aware of so part of the solution is to educate consumers about what different types of wellness experiences and holidays are available and to market to them appropriately, people will seek you out if you are different from the rest.
Every country is unique and what could be very appealing to travellers is the authenticity of the whole experience of travelling to a foreign country, experiencing a foreign culture and location and the different types of experiences available in that location. This could be anything that can include resort spas in beautiful locations, ashrams, yoga retreats, lifestyle retreats (like longevity centres) and eco-spas which can be very location specific and not necessarily high end. Countries could offer fusion products, where you have an activity or healthy living experience combined with being in a unique and beautiful location.
Should people considering investing in medical tourism or spa facilities?
In the long run I wouldn’t advise investment in pure standardised medical or spa services. I would advise investment in lifestyle, wellbeing, something that’s authentic and location specific, or something that teams medical tourism with a lifestyle experience, like longevity centres, of which there are already a couple in the US, which are all about living longer and combining medical and spa treatments.
What do you think is the future for people travelling for health and wellness?
I think people will travel for benefits, not for wellness as such. I think in planning for long term people will travel for a healthier lifestyle and maybe they will do this more than travelling just for medical reasons, I question whether the medical tourism bubble could burst, I mean, is it really healthy to travel long haul for major surgery? Are people really going to do this in great numbers?
Another problem with pure medical tourism is lack of repeat business, which is the opposite of spa tourism. When you are only offering surgical treatment how many hospitals and clinics have patients that return again and again for surgical procedures? Very few people choose to have invasive surgery more than absolutely necessary, where as wellbeing and longevity treatment is something you want to do more than once. You only have your left knee replaced once but as people age they will keep going back for wellness treatment.
I think certain countries will recognise that in the longer term medical travel will not work because you just won’t have millions of patients travelling. However, evidence based medicine is a different story. I believe that this is an area that will grow, this could include a combination of invasive treatments or treatments to avoid invasive treatment with evidence based medicine, treatments that can’t cure you but can treat them, for example treatments for allergies, skin diseases or diseases you can treat with spa based treatments, like thermal waters used for psoriasis, you cannot cure these diseases but you can treat them and that’s part of longevity and that’s where the potential is.
If there are too many generic luxury spas what new business opportunities are available?
The image of what constitutes a “spa vacation” needs to change, and when it does it will bring opportunities. Many people would like to have the spa experience but think it’s too expensive but it doesn’t have to necessarily be that way. For example, in the US you have massage chains in strip malls, which are easy to access and affordable. Many spas look at the market and copy what people are doing but they are all going after the same market, could serve a lot more people if they targeted the mid-market and therefore could be just as lucrative as an upmarket spa because you have a higher turnover of visitors because the prices are lower. I believe in NO2C which means, “no clichés no copying”, people should be bold and not copy and come up with something new. We’ve lost the element of fun, spas have a reputation for being quiet, very clinical, very distant, it’s not fun, it’s all so serious and of course very luxurious but far too serious. I think there is space for someone like Virgin or Easy to recognise a gap in the market to develop the budget spa, it’s time to think differently.
4.Health Tourism....in Brightest Africa
Dr Constantine Constantinides looks at the development of health tourism in Africa, and whether Africa is in itself a destination for health tourism rather than an exporter of health tourists.
When it comes to health tourism.....let’s forget about “Darkest Africa” (Henry M. Stanley). And let’s stop thinking in terms of “the Four Horsemen of Africa’s Apocalypse”:
Those who have closely been following events and developments since the 1970’s see and are heralding the new age of the “Brightest Africa”.
Of course, I have a “soft spot for” and an “Africa” connection, so there is a clear element of bias in what I write in this article! But being biased does not necessarily make you wrong, or self interested.
During my travels as an invited and hosted speaker at Health Tourism conferences and events, I see clear evidence of non-African countries actively pitching and enticing African governments to encourage their citizens to go for treatment outside Africa, and “preferably, come to us”.
I will not go to the trouble of listing these countries; those in the Health Tourism sector know them and can list them off by heart. Those who know me (and my world outlook) are aware that I am very strongly against protectionist practices ....but often, shopping for healthcare in faraway lands just does not make sense, especially if decisions are not based on quality and cost.
Some of the countries so generously offering their health-related services to Africa are at the same time, vocal champions of development in Africa. But why are they not championing healthcare development in Africa, as well?
And what are the African countries, themselves, doing to further develop their healthcare industries and in the process additionally benefit by the network effect (Networked Countries - development in an adjacent or nearby country will rub off – and benefit yours as well).
At a recent meeting of the “Africa Group”, the African Ambassadors to Greece, I started by saying: “We are aware of, and commend the spirit of collaboration and reciprocal support which exists amongst African States and the common objective of promoting success in the Continent”.
Africa can point to a number of national, regional and even international healthcare industry successes (for an example see NetCare, a South Africa-based investment holding company which through its subsidiaries, operates the largest private hospital network in South Africa and the United Kingdom). If Africa can export its healthcare industry expertise, does it need to export patients outside Africa as well?
A combined event in Africa in April 2010 will look at the issues facing Africa in Health Tourism:
- 5th World Health Tourism Congress
- And in conjunction with the above: 1st International Health Tourism Integration Conference
5. The opportunities for Korea in medical tourism
Dec 4 2007
South Korea is a country that has come late to the medical tourism game, but it may in the long term become one of the winners. Perhaps initially attracted by the inflated forecasts that are touted around the medical tourism industry by “industry experts” and commentators, Korea has however taken a more realistic view of where its success may lie.
The recent Busan Medical Tourism Convention provided an insight into how Korea is thinking about the opportunities presented by medical tourism. In 2010, Korea is expecting to attract around 60,000 medical tourists and the target is to attract 140,000 in 2015. This is not an unreasonable target and is far more realistic than some of the numbers that we see appearing from government and tourism organisations in other countries. The “highest quality, lowest cost” strategy is not one that Korea wants to pursue or indeed should be pursuing. Korea’s research into existing medical travellers shows that quality, convenience and trust factors far outweigh cost related drivers. In terms of relative costs of healthcare services, Korea is significantly less expensive than the USA (but then every country is) but is not as price competitive as countries such as India, Singapore or Thailand. Indeed, something like a knee or hip replacement would cost a similar amount in Korea to the cost of private treatment in the UK.
So, Korea is not going to win on cost. Nor is it going to attract vast numbers of medical tourists from Europe. Its prices aren’t competitive enough and long flight times will deter potential European patients. The same may apply to patients from the USA if the much hyped US medical tourism boom begins to happen. For a US patient, the perception of quality of care in medical destinations such as Korea, Singapore and Thailand may be very similar. So, if it comes down to the cost factor, Korea will lose out.
So, from where is Korea looking to attract its patients? The drivers of accessibility and cultural match provide the answer:
Although the USA is a twelve hour flight away, cultural connections mean that the Korean community within the USA has to be a prime target. Around 1.2 million Korean Americans, many of whom are on the West coast should provide a source of patients.
Within a one hour flight from Korea is Japan, already a source of many cosmetic surgery tourists, and where healthcare costs are rising fast.
And not much farther away is China which may provide a plentiful supply of medical tourists in the longer term.
The interesting market that Korea and many countries are turning their attention to is Russia. With the movement towards a market economy in Russia, there’s a wealthy upper class that is investing abroad, taking holidays abroad....and seeking healthcare abroad.
How can Korea create a competitive advantage in the overcrowded world of medical tourism? It may not be in Western medicine; Kang Dong Hospital in Busan is a Korean hospital that combines Western medicine with “traditional” oriental medicine and provides a model of healthcare that is attractive to many in the Far East.
Another opportunity is for Korea to build on its existing strengths and the image it has created in world markets. Through the success of companies such as Samsung and LG, Korea has created a hi-tech modern image for itself. Applying its technological knowhow and skills to the medical tourism sector may prove advantageous in creating an edge over the competition. The only technology company that I have encountered at a medical tourism conference so far is Samsung.
It has been said that Korea’s success in technology and in manufacturings industries such automotive lies in its ability to copy what others are doing, learn from their mistakes, do it better and work harder at it. If Korea applies the same philosophy to medical tourism, then some of the more established destinations will be looking over their shoulders
6.Medical tourism in denial …knowing but not knowing
Dr Constantine Constantinides looks at supply and demand in the medical tourism industry and draws some lessons from the automotive industry. With the supply of medical tourism services exceeding patient demand, healthcare providers need to consider market segmentation, stratification and diversification strategies if they want to succeed.
Freud described “Denial” as a state of: knowing but not knowing.
Often, the difference between how things are and how you want them to be is so great – that you do nothing – or continue to do the same thing.
This message is aimed at both medical tourism service providers and destinations (note that I make a distinction between Medical Tourism and Health Tourism).
healthCare cybernetics is best known for “thinking and doing” – but we do a considerable amount of “watching”, as well.
And one issue we have been watching (with some bemusement) is the continuing growth of the medical tourism industry (the “supply” side), which we believe is out of step with the rate of growth – and expectations - of the market (the “demand” side).
New players continue to make forays into the industry, with the same (and now “tired and irrelevant”) slogan: "Top Quality – Bottom Price".
We have been pointing out (at least for the past two years) that quality can go no higher and prices can go no lower.
A lesson from the automotive industry
…a story goes with it
Today, every product or service has two components:
- The “Core” Component (basic purpose or function)
- The “Augmented” Component (additional functions and features)
In every industry, over time, the balance between the core and the augmented, shifts (sometimes, back and forth).
Until now, medical tourism was about selling a “core service”. i.e., the Top Quality – Bottom Price Service, and admittedly, a lot of sales and profits have been made on this basis.
But let us look at the “Core Product” analogy in the Automotive Industry (and its history).
The Ford Model T was introduced in 1908. Over a period of twenty years, more than 15 million Model T cars had been sold.
But by 1927, demand started falling. Henry (and this is where the word “denial” comes in) dismissed this (and the advisor who brought him the news), insisting it was just a market “blip”.
Of course, Ford up to then, had been right in insisting that all that people wanted was a “core product” (“Model T gets you there and back”).
“Core Medical Tourism Services”, likewise, get you there and back (think Tourism” – which means a there and back journey).
But by the 1920’s, the world was changing. People were no longer hungry, they were getting enough of staple food. And they now also had more ”disposable” money and time. It was inevitable that they would start wanting their car to be something more that a utilitarian machine. They wanted a car to be a differentiating status symbol, as well.
By the time Henry Ford came out of denial, and shut down production (for several months) to retool his factories, he had suffered a loss of $250 million.
GM, his competitor, had already predicted the imminent demand for an “Augmented Product”, and provided it, in a variety of colors with regular model changes.
A timely and humourous article appeared in Fortune Magazine entitled, “Consumer Segmentation and Stratification”:
- Chevrolet for the hoi polloi (from the Greek meaning the many – or the masses)
- Pontiac for the poor but proud
- Oldsmobile for the comfortable but discreet
- Buick for the striving
- Cadillac for the rich
By 1927, demand had swung decidedly in favor of the “Augmented Product” (both in style and size).
But even here, history teaches us that there is no “last word”.
Stagflation and the “oil shocks” in the 70’s created a demand for more “modest” cars – but ones which would still provide “distinctiveness” (read Japanese).
A healthy (rational) balance between Core and Augmented Product came into being – but even so, a viable demand for extremes persisted, and persists to this day (see the talk about fuel economy and the do, where people buy an eco-friendly car, but do not, at the same time, voluntarily, get rid of their Hummers) .
And note that not all five US car brands have survived (we have something to say about the inevitable “shake out” in Medical Tourism as well).
Health consumer segmentation and stratification
…the Chevrolets, Pontiacs, Cadillacs etc, of Medical Tourism
The demand for “Core Medical Tourism Services” is not going to disappear, but do not expect it to be the inexhaustible El Dorado that several misguided experts continue to predict.
With experience and mounting awareness, consumers are daring to be more demanding, choosy and more discerning.
Medical tourism consumers are no longer “one size fits all” (in fact, they never were, it was the popular media which portrayed them as such).
People are already restlessly looking for “that something” which lies between top quality and bottom price, what we refer to as the Deal Clincher.
And as they become more comfortable with the idea of “travel for health” they will start enquiring about the availability of other than Model T medical tourism.
What are we getting at?
…to cut a long story shorter (and give you the bottom line)
The demand for “Core Medical Services” is not likely to grow as much as predicted as a result of:
- The West’s Revenge (local providers are competing aggressively to keep patients at home)
- The Recession (contrary to simplistic thinking, people are not rushing to get cheaper treatment abroad – they are staying put and deferring treatment.
- Consumers take “top quality and bottom price” as a given (they will decide amongst those who give them the essential differentiating factor – a tangible or perceived added value).
Consumer Segmentation and Stratification
One size does not fit all.
And it is unrealistic to expect all providers to be able to satisfy the peculiar needs of all consumer segments and strata.
Thailand, for example, realized this early on and ceded the lower-end market to India.
Regionality vs Globality
Although we talk of Medical Tourism and think “Globality” (anywhere is the same) we are definitely seeing Regional and even National Preferences emerging, based on cultural affinity – and even on where a particular consumer group is made to feel more welcome and “at home”.
What if for some reason – even for one year – the demand for Medical or Dental Tourism drops?
We have been encouraging Destinations to develop into ht8 Destinations (aiming to offer services in the 8 Health Tourism Segments – and more and more are doing so).
This approach has the following advantages:
- Insurance Policy (if for some reason demand for one segment drops, you still have 7 others to rely on)
- The Long Tail Effect (increased choice leads to increased demand – a “Thank You” to Chris Anderson – Editor, Wired Magazine)
- Creates a broader industry to address a broader market (meaning more business for all)
- Cross Selling and Cross Referrals (your client can also be my client – I refer to you and you refer to me)
In some industries, up to 25% of revenue can be directly attributed to established alliances (same sector, trans-sector, national and trans-national).
Alliance formation can also be a less painful and simpler way (as opposed to mergers and acquisitions) to attain “scale”. Scale is an important factor in shaping perceptions and inspiring confidence.
And with Medical Tourism, forming alliances – even with your supposed competitor – becomes inevitable (think after-care / follow-up, back home).
Be reminded of the neologism “co-petitor” (competitor and collaborator, at the same time).
Innovation is the last competition-busting tool still available to all – provided they have the industry and market knowledge & understanding required to Innovate.
And innovation does not simply mean “differentiation” or invention. It has to be something which the consumer sees and wants – no matter what.
And finally, sophistication
What is missing – and is subconsciously missed by the discerning consumer (at destinations and provider facilities) - is the element of sophistication (and even flair).
And we do not mean kitschy opulence, marble fountains and the hanging gardens of Babylon.
Sophistication is a much subtler quality that is sought out and recognized by the wise, knowledgeable, worldly and discriminating / discerning consumer.
The word comes from sophist – Greek for wise man.
7.INDONESIA: Why Indonesians go overseas for medical care
Many Indonesians seek medical help abroad. Some 30-40 percent of foreign patients in Singapore at any one time are Indonesian.
Mount Elizabeth Hospital (www.mountelizabeth.com.sg) in Singapore is often referred to as the Indonesian Hospital due to the high number of Indonesian patients passing through its doors.
Many Indonesians seek medical help abroad. Some 30-40 percent of foreign patients in Singapore at any one time are Indonesian.
Mount Elizabeth Hospital (www.mountelizabeth.com.sg) in Singapore is often referred to as the Indonesian Hospital due to the high number of Indonesian patients passing through its doors.
When asked why they seek medical treatment abroad, many Indonesians say the health care sector in Indonesia is poor and the price of medical help abroad is acceptable considering its quality.
Neighboring countries such as Singapore and Malaysia are now aggressively promoting their health care services in Indonesia, as can be seen in advertisements with attractive slogans such as "affordable health check-ups" or "health tourism".
The Indonesian government appears oblivious to all this. It has also paid little attention to the sales of illegal alternative medicines and questionable medical techniques in their own. In cities you can see banners displayed advertising non-surgical cures for cataracts, medicines to treat cancer and programs that claim to make people lose a considerable amount of weight in a week.
The skills and attitudes of health care professionals working in Indonesia is not poor, but the system adds to the dilemma. As patients tend to go directly to specialists, the treatment they receive is often not holistic. For example, if an overweight person visited a nutritionist, they may be diagnosed with an eating disorder, while if the same patient visited a psychiatrist, they may be diagnosed with depression. It would be best for such people to visit a general practitioner before they sought more specialized treatment. But in Indonesia, people do not seem to trust GPs and go directly to specialists. Patients also often question the necessity of expensive examinations carried out by Indonesian doctors, who often fail to be communicative enough.
When patients seek a second opinion abroad, more often than not the same examinations and tests will be carried out, but will be explained to them properly in terms they understand, enabling providers to justify the expense.
Indonesian hospitals and pharmacies have no concept of customer service. Patients are often forced to wait a long time to see a doctor. Consultations also often seem hurried due to the limited time doctors have. Nurses seem just as busy, or unwilling to help, as doctors. In public hospitals, patients have to buy their own medicines or they will receive nothing and more often than not have to collect their own urine samples for testing.
In Singapore patients have scheduled appointments so they do not have to queue. In Singapore and Malaysia, Indonesian patients are happy to pay for expensive examinations as their conditions are explained thoroughly and doctors rarely keep them waiting.
Many pharmacists in foreign hospitals text message patients when their medicines are ready so they can take a stroll while waiting. This level of service does not seem to be available in Indonesia.
The government fails to see that if people stay in Indonesia to receive medical treatment, there will be more money in the government's coffers to fund development. There is a need to improve the standard and skills of health care workers by asking doctors and nurses to take competency tests. Such tests were carried out for the first time in Indonesia on Oct. 31. Doctors will also have to continually study, as their licenses will be canceled if they fail to meet minimum requirements, including participating in seminars, writing journal articles or joining discussion groups. In public hospitals, the number of nurses is not adequate. For instance, many renal failure patients in need of emergency haemodialysis are not treated due to a lack of human resources. This is life threatening.
In Indonesia the salaries of doctors and nurses is low and needs increasing. While salary rises will not stop Indonesian citizens seeking treatment abroad, at least Indonesian health care workers would have increased pride and dignity. Malaysia and Singapore will increase business, until or if something is done to encourage patients to stay in Indonesia, by offering and promoting good health care services.
Until the government acts, there is little point in Indonesia dreaming of becoming a health travel destination.
8.Medical Tourism vs. Traditional International Medical Travel: A Tale of Two Models
ABSTRACT: Medical tourism is an emerging phenomenon wherein citizens of industrialized nations bypass services offered in their own communities and travel to less developed countries to receive medical care.
In medical tourism, the direction of travel is opposite of that in the traditional model of international medical travel, where patients have historically journeyed to leading medical centers in highly developed nations for health care.
Medical tourism has transformed a one-way pipeline towards industrialized countries into a two-way highway, with patients now traveling in both directions. This paper presents a comparative analysis of the medical tourism model vs. the traditional form of international medical travel. The factor that most differentiates the two models is the availability of resources to patients. Financial resources give traditional international patients access to medical facilities of their choice throughout the world. Conversely, the absence of some resource drives patients to pursue medical tourism.
Medical tourism is a rapidly evolving trend wherein patients from industrialized nations seek health care in less developed countries, bypassing services offered in their own communities. Although the term medical tourism is sometimes used in reference to all travel for medical care, we believe that this phenomenon is meaningfully different from the traditional pattern of international medical travel (Horowitz and Rosensweig 2007). In the traditional model, patients journey from less developed nations to major medical centers in highly developed countries for advanced medical treatment. In the medical tourism model, driven by a number of forces outside of the organized health care system and traditional medical referral network, an increasing number of patients travel to an assortment of countries at variable levels of development for their health care needs (MacReady 2007; Milstein and Smith 2006). The evolution of medical tourism has transformed the unidirectional pipelines of patients traveling towards industrialized nations for health care into a complex network of two-way highways. This paper examines and compares the movement of patients in each direction. Our analysis will describe and clarify the important ways in which medical tourism differs from traditional international medical travel.
We acknowledge that the name “medical tourism” does not recognize the true nature of a patient’s situation nor does it accurately reflect the fact that activities at the destination may be limited to receiving complex medical services. Many agents, medical practitioners and other industry participants are discontented with the name medical tourism, and a number of alternative terms have been suggested, including “medical value travel” and “global health care”. The alternate terms of which we are aware do have advantages, however, we believe that each also has shortcomings. For the purpose of this analysis, we will use the term “medical tourism” because, as the most popular one in common usage, it provides an unambiguous way of differentiating this evolving phenomenon from the traditional model of international medical travel (Horowitz, Rosensweig and Jones 2007).
A FRAMEWORK FOR ANALYSIS OF MEDICAL TRAVEL
By the close of the nineteenth century, a number of important medical centers had been established in Europe and the United States. Rapid scientific discovery and medical progress in the ensuing decades stimulated a proliferation of medical facilities in developed nations, making the latest clinical techniques and technological innovations increasingly available to the citizens of these countries. At the same time, people in less developed parts of the globe had poor access to medical services. Accordingly, patients with the resources to do so began to travel to major referral centers to have medical evaluation and treatment that were unavailable in their own countries. Today many advanced hospitals in North America and Europe continue to export cutting edge medical care to a large number of international patients.
In addition to exporting medical care, the major teaching hospitals in North America and Europe also supply postgraduate medical education to physicians from less developed nations. Although many physicians remain in the country where they complete their postgraduate training, a substantial number return to their homeland where they provide medical services, as well as the knowledge and leadership necessary for local health care institutions to participate in the international marketplace.
The key similarities and differences between the traditional international medical care model and the medical tourism model occur in four basic spheres: the parties involved (patients, providers and agents), the places (origin and destination), the reasons for traveling for health care, and the patient’s access to resources (Figure 1).
THE MEDICAL TOURISM MODEL – UNDERSTANDING THE DIFFERENCES
Medical tourism is driven and shaped by the complex interactions of myriad medical, economic, social, and political forces. The characteristics of the traditional model and the medical tourism model are compared in Table 1. There are three key similarities between the traditional form of international medical care and medical tourism. First, in both models patients have illnesses, injuries or other circumstances for which they need or want medical evaluation and treatment. Second, patients in both models are willing and able to travel to get the care they need or desire. Finally, patients are unable or unwilling to receive their care within their own country.
The Parties Involved in Medical Tourism
Patient specific issues necessarily determine the need for treatment, the urgency of action, the options for international travel, and the choice of destinations. Furthermore, the patient’s personal and family circumstances are major factors in determining if, when, where and how there will be international medical travel. Traditional international patients who are unable to receive optimal care in their own country travel with the goal – indeed the expectation – of receiving the very best care available. In contrast, patients in the medical tourism model would almost certainly prefer to have major surgery in their hometown hospital or regional referral center if that were a reasonable option for them. Paradoxically, a patient may actually drive right past a suitable facility on the way to the airport to catch a flight to an unknown medical center in a faraway land. Medical tourists balance their health needs against other considerations, particularly affordability, availability and timeliness of care. Attractively low cost is the major reason that patients from highly industrialized nations use less developed countries for medical services. These patients feel forced to accept uncertainties about accommodations and quality of care, as well as the inconvenience of medical travel, in order to obtain services at prices they can more comfortably afford. The opportunity to conserve limited financial resources and protect the equity in their home mollifies uncertainties.
Patients traveling from the United States generally fit one of two profiles. The first is a middle class adult who requires elective surgical care but has inadequate or absent health insurance coverage. In an article in the New England Journal of Medicine, Milstein and Smith (2006) refer to these patients as “middle-income Americans evading impoverishment by expensive, medically necessary operations…” The other group consists of patients who desire procedures such as cosmetic surgery, dental reconstruction, fertility treatment and gender reassignment procedures. In both groups, resources are insufficient for them to comfortably buy care in their local market, but adequate for them to obtain care in a low cost offshore medical center. In the traditional international model patients are routinely airlifted to major referral centers at great cost. In stark contrast, urgent offshore surgery would not be feasible or useful in the medical tourism model.
For patients from Canada, Britain and other countries where a governmental health care system controls access to services, the primary motivation to abandon the local medical system is the desire to have timely treatment, circumventing delays associated with long waiting lists (Asian Pacific Post 2005). Because government sponsored health systems generally do not pay for cosmetic surgery and similar type services, patients from countries with such programs pursue medical tourism for the same reasons as patients from the United States.
Patients also travel to offshore medical centers to have procedures that are not available in their own countries. For example, in many industrialized countries stem cell therapy may be accessible only by participation in clinical trials. However, stem cell therapy is more readily available in the medical tourism marketplace (Breen 2007; Arom, Ruengsakulrach, Jotisakulrantana 2007). Some patients choose to have medical care abroad because of the opportunity to travel to exotic locations and to vacation in luxurious surroundings. Although some medical tourism agents and travel professionals may promote sightseeing and recreational endeavors, as the seriousness of the medical circumstances increases the importance of the tourism activities rapidly diminishes. Finally, patients undergoing sex change procedures, cosmetic surgery, and alcohol or drug rehabilitation have greater confidence that their privacy and confidentiality will be protected in a faraway health care facility.
The next party to consider in our analysis consists of physicians and other health care providers. The dynamics of the referral process are quite different in the two models of international care. In many cases in the traditional model, the patient’s physician is involved in the decision as to what country, facility and individual physician the patient should be transferred to. The local physician may be familiar with the institution and the specialist to whom he is referring the patient, perhaps having previously visited or even trained at this institution. The referring physician may know the specialist personally from previous contact. When the patient returns home, the local physician, familiar with what has transpired, is in a position to readily provide continuing care. The involvement of referring physicians in the traditional model of international medical travel is in contrast to the near absence of such involvement in the medical tourism model.
There are several reasons why physicians may refuse to become involved in this patient-directed endeavor. First, doctors in developed nations, unfamiliar with the practitioners and practices in less developed countries, are reluctant to have their patients pursue care by unknown providers in distant lands. Second, the local physician may deeply believe that it is untenable to choose a provider for potentially risky medical therapy based on anything other than medical considerations. Finally, physicians in highly litigious nations may be particularly reluctant to endorse offshore treatment because of concern about vicarious liability. If a patient were to have an adverse consequence, plaintiff’s counsel would likely pursue any possible case of vicarious liability against the well-insured local defendant before attempting to win (and collect) a claim against a provider in another country.
In the traditional model, the foremost reason for travel is medical care and the role of travel professionals is limited to the usual scope of their business. In contrast, medical tourism agents have identified and developed a new, high-growth business line directing patients to offshore medical centers for a wide array of health care services. In addition to arranging travel, medical tourism agents help patients select a country, a facility and a practitioner. They determine prices and collect payment, assemble and transmit medical records, and organize medical concierge services at the destination. Finally, they arrange for postoperative follow-up in the patient’s own community after they return. Essentially functioning as facilitators or brokers of health care services in the medical tourism marketplace, these agents fulfill the role that the physician does in the traditional model.
Places – You’re going where?
A fundamental difference between the traditional international model and the medical tourism model is whether the patient is traveling towards or away from a highly developed country. In the traditional model, industrialized nations are exporting health care expertise and services to patients from less developed countries. In the medical tourism model, the direction of trade is generally opposite. Consequently, industrialized countries are now purchasing (importing) health care from developing countries. One notable exception to this general direction of travel is in reproductive tourism where patients may travel towards industrialized nations with favorable laws and regulations in order to gain access to eggs from paid donors (Leigh 2005). In this situation, financial considerations are overshadowed by the patient’s desire to obtain specific benefits, as long as she has the requisite resources to pursue this goal.
Many factors converge to determine a country’s competitive position in the medical tourism marketplace. Clearly, the availability of certain clinical services and the quality of care delivered are essential for a nation’s long-term success in this endeavor. The ability of physicians and ancillary staff to communicate accurately in the language of their foreign patients is one of the many variables that determine success in a destination’s goal of becoming a preferred medical tourism destination. A country or specific facility may be able to achieve competitive advantage in the marketplace by leveraging various non-clinical factors, including proximity to target patients and the ease of travel between the two locations. Developed physical infrastructure, political and legal institutions, and market economics are essential for a country to establish a competitive position as a medical tourism destination (Bookman and Bookman 2007). The quality of the airport and the local transportation and telecommunication systems, as well as the availability of suitable accommodations, will not be overlooked by medical tourism agents and their clients. Some destinations have been able to derive marketplace prominence due to luxurious accommodations and easy access to desirable vacation resorts and tourist attractions.
The principal reason why care in medical tourism destinations is available so inexpensively relates to the disparity in the level of national economic development between the patient’s country of origin and the destination country. The per capita gross domestic product (GDP), based on market exchange rates (MER), for key countries of origin and destination in the medical tourism industry are shown in Figure 2. The per capita GDP, converted to US dollars using the MER, is a proxy for the average wage levels in these particular nations. Because these relative wages can be quite low in developing countries, American patients greatly enhance their financial position when they change dollars into the currency of the destinations where they purchase medical care. In addition, low administrative and medicolegal expenses for overseas practitioners and facilities also contribute to the reduced cost of offshore medical care.
Medical institutions in poor countries may derive substantial benefit by providing services to medical tourists. The foreign-source revenue earned can be reinvested into facilities and equipment and used to attract high quality physicians. The improved physical assets and professional skills enhance the institution’s ability to better serve foreign patients as well as local residents who otherwise would have limited access to modern medical facilities and services. To ensure that the residents of destination countries actually derive benefits from having a local medical tourism industry, appropriate macroeconomic redistributive policies must be developed and enforced by governmental authorities (Bookman and Bookman 2007). Chinai and Goswami (2007) express an opposing position about medical tourism, warning that this business may compromise the availability and quality of care for local residents by adversely impacting workforce distribution.
An important insight is that modern well-equipped hospitals in some areas of the world serve the dual role of regional referral centers for patients from poor neighboring countries and, concurrently, function as low cost medical tourism destinations for patients from highly developed nations. This fact is well illustrated in Southeast Asia where hospitals in India, Malaysia, Singapore and Thailand provide tertiary health services to patients from nearby less developed economies such as Bangladesh, Indonesia, Myanmar and Nepal. At the same time, these medical facilities provide advanced care to people from distant industrialized nations including Britain, Canada and the United States.
Finally, it is noteworthy that a number of highly developed nations, including Canada, Germany, Italy and Israel, are attracting foreign patients from other developed nations, as well as from less developed nations, under the banner of medical tourism. Although travel between highly developed countries allows certain patients to circumvent waiting lists for various medical procedures, within our analytic framework, this activity more closely resembles the traditional international medical services model than the medical tourism model.
Benefits Sought – Why Leave home?
In the traditional international medical services model, the patient’s dominant motivation to travel is to obtain the best possible care available. In the medical tourism model, the reasons to embark on international travel are more complex. In this situation, the patient balances health needs against many other considerations, and medical concerns may even be subordinated to other issues such as allocation of personal resources. The five major reasons why people pursue medical tourism are shown in Table 2.
The primary driver for patients from highly industrialized nations to travel to less developed countries for medical services is affordably low cost. The second reason that patients choose medical tourism is to avoid waiting lists, a particular problem for residents of Canada, Britain and other countries with National Health Systems. In 2005, the waiting times for hip and knee replacement were 21.8 and 28.3 weeks, respectively, in British Columbia, Canada, in contrast to service within a few days of referral in most medical tourism destinations (Asian Pacific Post 2005). Some patients travel to offshore medical centers to have specific procedures that are not currently available in their own countries. Stem cell therapy is one of a number of procedures available in some medical tourism destinations but unavailable or restricted to clinical trials in many industrialized countries.
For some patients, having health services abroad provides an opportunity to journey to exotic locations and to vacation in luxurious surroundings. For people who travel abroad for general health evaluations, routine diagnostic studies, and limited surgical or dental procedures, the pleasurable non-medical aspects of the trip may be highly valued. Similarly, the prospect of recovering from cosmetic surgery in a luxurious beachside resort is attractive to many potential medical tourists, particularly when the package can be purchased for less than the price of the operation in one’s own community. On the other hand, a patient who, for parsimonious reasons, travels to a distant country for major surgery for a life-threatening condition isn’t likely to be concerned about visiting the local tourist attractions. Finally, some patients seek offshore medical care to protect their privacy and confidentiality. In a faraway country, there is little concern that privacy will be violated or that medical records will be viewed by any of the parties who have access to such in the United States.
The Pivotal Role of Resources
The overarching issue that most differentiates the traditional international medical patient from the patient in the medical tourism model is the availability or unavailability of resources. In the traditional international group, the availability of financial resources provides the patient ready access to health care facilities throughout the world. In the medical tourism model, it is the absence of some resource that generally drives the decision about foreign travel for medical services. Although traditional international patients may not have personal wealth, they may have support available from health insurance benefits, government programs or philanthropy. Approximately 47 million Americans (16 % of the US population) do not have any health insurance and many others have reduced benefits because of preexisting conditions (National Coalition on Health Care 2007). Furthermore, health insurance may provide limited benefits for fertility treatment and almost never covers the cost of cosmetic surgery or gender reassignment. It is predictable that medical tourism will become evermore popular among patients who lack insurance funding for desired care, and for those who are encumbered by waiting lists and other bureaucratic obstacles. Whereas children constitute an important patient group in the traditional international medical care model, the literature on medical tourism makes almost no mention of pediatric medical or surgical services. Governmental support and philanthropy is more likely to be available for children requiring specialized medical and surgical care, obviating the need for parents in developed nations to take their children to offshore medical centers for pediatric care.
In countries with long waiting lists for medical services, the time and/or patience to wait for care is reasonably considered a resource that is lacking for those patients who want prompt treatment for painful or potentially dangerous conditions. In medical tourism, certain assets can be exchanged for others and value can be amplified because of differences in economic development between the countries involved in the transactions. For example, consider a patient in Ontario, Canada with painful arthritis who is scheduled for knee replacement surgery six months later. The resource that he lacks is access to timely care. However, he may be able to “buy time” using another resource, namely, money. Because of his location, this man could purchase orthopedic surgery in nearby New York State, if he is able and willing to pay the price for such. But if this patient decides that he is cannot take on this substantial expense, he can arrange surgery in a medical tourism destination where his costs would be much lower. Indeed, he can have surgery in Asia within a few days (buying time) at approximately 10% of the cost he would pay in New York, thus amplifying the purchasing power of his existing financial resources.
In addition, the inability to access biological resources drives transplantation tourism and reproductive tourism. Patients travel to distant medical centers for organ transplantation or fertility treatment because they are unable to get donor organs and donor eggs, either due to allocation issues or social and legal impediments in their own countries (Leigh 2005).
Patients in the medical tourism model generally have limited financial resources. If a patient has abundant resources, then the cost of care would not be a concern and there would be no need to contemplate offshore services. On the other hand, because a patient must have access to enough money to allow travel and payment for care, medical tourism is generally not a feasible option for the most impoverished members of society.
MEDICAL TOURISM – COMING OF AGE
The insurance industry will have an increasing impact on the growth of medical tourism. Insurance professionals are collaborating with employers to find ways to reduce the burden of employee health care by utilizing foreign health care destinations. Insurance companies can offer attractive incentives to beneficiaries who are willing to travel to overseas medical destinations, including waiving deductible and out-of-pocket health expenses, and paying for travel for the patient and a family member. Insurance provider networks are being expanded to include physicians and hospitals around the globe, with the expectation that a majority of large employers’ health plans will include offshore medical centers within a decade (Milstein, cited in Van Dusen 2007). Countries that have long waiting lists for certain procedures will increasingly address their backlog by sending patients to low cost foreign medical facilities, thereby avoiding the difficulty, delay and expense of expanding local capacity.
Innovative practices in medical tourism are being introduced into the marketplace. Physicians and medical facilities within the United States are now accepting referrals from medical tourism agencies and providing highly discounted services to American patients (Van Dusen 2007). Although domestic medical tourism cannot capitalize on the economic disparities between industrialized and less developed nations, onshore providers do have important logistic and marketplace advantages. The concept of providing care to unfunded poor patients by directing certain services to lower cost hospitals in foreign destinations warrants exploration because of the potential to substantially extend the resources of philanthropic organizations and relieve the burden on domestic health care facilities.
Medical tourism will likely have a substantial impact on the availability and delivery of health care services in developing countries as well as industrialized nations. The health care system and medical community will be transformed as consumers increasingly recognize that their purchasing options transcend national borders. Medical tourism destinations will prosper by offering international patients maximum value in the form of high quality care delivered by well-trained service-oriented professionals in comfortable modern accommodations at affordable prices. With maturation of the marketplace, the differences between the two models described in this paper may, in fact, become blurred. In time, the very best medical centers will evolve into highly respected international referral destinations. These select medical facilities will increasingly serve the role of traditional international medical referral centers, rather than that of medical tourism destinations.