The perception that Indonesians go to Malaysia just for the cheapest price deal is too simplistic, says a fascinating and detailed research report on Indonesian medical travel.

’More than medical tourism; lessons from Indonesia and Malaysia on South to South intra-regional travel’ by Meghann Ormond and Dian Sulianto’ looks at medical travel flows between Indonesia and Malaysia.
The study concentrates on motivations, preparation and practices. Using 35 detailed interviews of Indonesians going to Malaysia for healthcare, it fleshes out how things work beyond the basics. The authors asked about treatment, accommodation and transport, as well as length of stay.
One key point it highlights is that the idea of medical tourists traveling across the world for the cheapest care is out of date as most medical travel is regional, often between easy to reach nearby countries. The ease of travel determines where in the country medical tourists go, as does how comfortable they are with the final destination.
The report also highlights that people from Laos go to Thailand mainly because it is a short trip across the border and they go there even for basic healthcare, as the Laos system is very poor. Rather than being welcomed, this cross-border trade is causing problems for some hospitals as many Laotians do not have the means to pay and hospitals are being over-burdened.
Regional medical travellers vary in terms of socio-economic group, medical condition, ability to travel, distance travelled, destination, length of stay, number of people with them and type of hospital they go to.
While cost is a factor for some, other drivers are availability of healthcare, quality of equipment and doctors, and recommendations.
With a dearth of quality healthcare in Indonesia, the growth of a prosperous middle-class, increased affordable cross-border transport and ease of border crossing- an increasing number of Indonesians (maybe as many as a million) go to Thailand every year for healthcare, but they tend to stay for a shorter time and spend less than other nationalities, partly as much of this is outpatient care.
Two out of three travel to the state of Penang, a quarter to Melaka and the rest to Sarawak. The case studies were only of people going from Indonesian Borneo to hospitals in the Sarawak capital, Kurching. They can get there by air, sea or land.
In deciding where to go, many use a medical travel agent. Each of the three private hospitals in Kuching has official local representatives with offices in Pontianak that register customers, schedule their consultations and testing, and provide the hospitals with customers’ records and medical conditions. They may also provide payment options (allowing patients and their families to settle Malaysian hospital bills in Indonesian currency or transfer additional funds) and transport to and from Kuching (transport ticket purchase, own transport services, etc.). This type may receive a combination of base salary and commission from the hospitals for each customer served. Numerous commission-based agents arrange not only transport and accommodation but although they do not have medical training may conduct the investigation of customers’ ailments, identifying what they deem to be the appropriate specialist for their ailments, registering them and accompanying them to the consultations, even interpreting for doctors and their patients. Those not using an agent tended to be seasoned medical travellers; had friends and family in Kuching on whom they could rely; wished to avoid the extra fees charged; or desired greater independence in selecting facilities, doctors, transport and accommodation. Diagnostic, treatment and medication costs were widely regarded by medical travellers as similar across Indonesia and Malaysia. Care in Kuching entails the additional burden of transport and accommodation costs as well as sometimes temporarily closing their businesses or taking leave from work or care responsibilities to go abroad. Yet all travellers found the additional financial burden to be worth it: as it was better healthcare than they get at home.
Before travelling, they budgeted for consultations, treatment and medication as well as transport, lodging and food. As credit cards are rare and since only some hospital linked agents offer facilitated payment and money transfer options, cash payments are predominant. Travellers require time to amass the estimated amount and exchange currency before leaving Indonesia. Numerous hotels, guesthouses and private homes are available for rent by day, week or month, for travellers on tight budgets are near the private Kuching hospitals. Many low cost cross-border coach services compete with one another and as do freelance medical travel agents for patient custom. Indonesian and Malaysian low-cost airlines have even added new routes and additional flights to respond to medical travel demand. To minimise costs, most travellers opt for land transport (cross-border economy coach services, shared vans and taxis.). Most stay in low-budget accommodation of economical hotels, privately rented homes or guesthouses owned and run by Indonesian agents or at family and friends’ homes. It is common to secure accommodation in Kuching only after learning from their doctors how long they need to stay for testing and treatment.
Travelling with family and friends to Kuching allows patients to get logistical, physical and emotional support,
The study concludes that by focusing marketing efforts on further away patients, the development of promotional campaigns, travel infrastructure and attractions that interest and engage higher-spending medical tourists are all ignoring the lower spending but far more numerous nearby medical tourists that are the basic customer base of most hospitals. Campaigns focusing on low –cost may miss the point that it costs many of these people more to get treatment in Malaysia than it would in Indonesia, so price is not the main driver.
The authors argue that by concentrating attention on higher-status tourists that stay longer and spend more than conventional leisure tourists that authorities and hospitals miss that international medical travel is mostly intra-regional in character, and driven by local economic and political conditions in both their source and receiving locations.
The study suggests that much promotion and research into medical travel ignores the importance of unpaid care-giving travel companions, and how the ability of friends and relatives providing free accommodation influences where people go.
It points out the flourishing informal economy of unlicensed agents, the purchase of prescription medication in Malaysia for family and friends in Indonesia, and local travel enterprises are mostly ignored.
The study argues that proximity, cross-border support networks, and confidence in the quality of diagnoses, treatment and medication are much more important than price. Intra-regional medical travel becomes a feasible way to manage chronic health needs, with people commuting on a routine basis for treatments, check-ups and refills. But research and promotion on international medical travel is focused on long-haul journeys for expensive treatments and surgeries. The frequent, short-distance and typically outpatient medical commuting is a much bigger component of medical tourism than the vision promoted by national bodies of long-distance travel for cheap care. Politics, socio-economic factors and diverse geography are mostly ignored and make medical travel look much simpler than the reality is.

An Irish dental practice is slashing prices to attract new clients and prevent patients from the Republic of Ireland travelling overseas for treatment.

MyDental, based in Ballsbridge, Dublin, has drastically reduced prices to attract new patients. The practice promises to match lower fees charged in Northern Ireland to discourage patients from the South crossing the border or going to European countries to take advantage of lower costs.
The clinic found that prices it charged were not competitive when compared to clinics over the border or in Europe. But by lowering prices it is encouraging Irish patients to stay at home for treatment. The clinic insists that quality of products used is not reduced but that the lower prices increase numbers so lowers overheads. It points out that comparing treatment prices alone is not accurate as customers also need to take into account time off work, costs of travel and accommodation.
MyDental in Dublin’s Ballsbridge maintains it can match any price offered in Northern Ireland for treatment as it keeps outgoings to a minimum. Gerard Egan, clinical director argues that when all costs are taken into account then the practice can usually come in cheaper than travelling to Europe .In good economic times there was a flood of Irish dental patients going to Europe but numbers have fallen to a trickle
Egan stresses that the quality of work and materials used are the same as any other clinic, but argues he can save a patient about a third by buying in bulk from suppliers and laboratories.Growing numbers of patients are now visiting them from Northern Ireland and a large number of clients are Europeans working in Ireland, particularly Latvians and Lithuanians.
The clinic has seen the new low-cost model work so well that it plans to open two new clinics, a second in south Dublin and one in Munster, next year.

Government backed and EU funded marketing is promoting low-cost medical tourism to Poland. The key target regions include Scandinavia, Germany, and the UK. Poland points out the easy availability of low-cost flights, cheap accommodation, and attractive tourist cities such as Krakow. Scandinavians mostly seek cosmetic surgery.
According to Magdalena Rutkowska of Poland’s medical tourism development programme, which is 75% funded by EU money, 320,000 medical tourists went to Poland in 2012. 42% had cosmetic surgery, mostly breast implants. 33% had dental and 9% had obesity-related treatments such as gastric bands. Fertility treatment is now getting business too.
To make it easier for customers, an increasing number pf clinics and hospitals are offering packages that include transport to and from the airport, and accommodation in apartments or hotels.
One target of the promotional body is UK health insurers. It hopes to persuade them to send customers to Poland, but with the recent failure of medical insurance tourism insurance plan Passport2health, that is going to be an uphill struggle.

The number of foreign patients treated in Korea rose 32.5 % to more than 211,000 in 2013, according to the Ministry of Health and Welfare. Exactly how many of these are medical tourists is not revealed. A conservative assumption that three out of four are medical tourists would mean around 150,000 medical tourists in 2013.
Korean hospitals and clinics revenue from treating foreign patients rose 47 % to 3.93 trillion won in 2013 from 2.67 trillion won in 2012. Each patient spent 1.86 million won on average ? up 10.7 % from 2012.
This reflects the growing popularity of Korean clinics among foreign patients, partly thanks to the government’s active medical tourism programme.
The ministry counted patients who received medical treatment without national health insurance. They include patients who went to Korea for medical treatment and cosmetic surgery, travellers who needed treatment and residents who have no national medical insurance- including some Koreans, expatriates, foreign workers and US military personnel and their families.
Nearly 10 % were hospitalized for 12.3 days on average while 8.7 % just had health checkups. Dermatology and cosmetic surgery were the most common areas for foreign patients. 9% visited dermatologists and 8.6 % saw cosmetic surgeons. Internal medicine topped the chart, accounting for 24.4 % of patients.
Chinese patients were the biggest foreign spenders as they accounted for 26.5 % of the total number and spent a combined 1.02 trillion won in 2013. The number of Russian patients increased 46.2 % to 24,000, replacing the Japanese as the third-largest group after the USA. Russian patients spent more than Americans at 87.9 billion won .The US figures include a large number of US military, expatriates and travellers.
Chinese patients tend to visit cosmetic surgeons and dermatologists while Russians have health check-ups and get treated by gynaecologists and dermatologists. Patients from the United Arab Emirates spent the most per person on average at 17.71 million won, followed by an average of 4.56 million won paid by patients from Kazakhstan.
The number of patients from the Middle East rose 237 % to 1151. 350 were sent to Korea by the Dubai government under an agreement between the two countries. Korea aims to get up to 1000 from Dubai via the government this year, having already treated 290 between January and April. With Dubai spending millions heavily promoting medical tourism it seems very strange that the Dubai government is increasing the numbers of patients it sends overseas.
The number of Russian tourists travelling to South Korea is expected to double to 350,000 this year after the introduction of a visa-free regime in January and this will increase medical tourism numbers from Russia. Half of all Russian tourists go to Seoul.
Park In-seok of the Health Industry Bureau comments,” We expect the number of international patients to continue increasing with the visa waiver programme for Chinese people, and an increasing number of Russian medical tourists as Korean hospitals have pursued marketing activities in different regions of Russia.”
The health ministry forecasts 250,000 foreigners will receive medical services in Korea without national health insurance in 2014. The long-term goal is to get a million foreign patients per year by 2020.
One of the busiest medical tourist locations in Korea is Gangnam District in Seoul, which specializes in cosmetic surgery. The number of medical tourists who visited Gangnam was 19,135 in 2010, 24,535 in 2011, 34,156 in 2012 and 43,000 in 2013, more than a 25 % growth each year.
Busan plans to attract medical tourists to the big hospitals in the city. The hospitals in Western Busan including Donga University Hospital, Kosin University Hospital, Busan Adventist Hospital and Kang Dong Hospital have formed a medical tourism group. Busan University Hospital is expected to join the group as it seeks more medical tourism business. Gangwon Province in the East has set up a medical tourism promotion group that goes to China, Russia and other countries to promote medical tourism in their province. Daegu, Korea’s fourth largest city has an advertising brand of Medi-city Daegu and Jeju Island is promoting medical tourism.

Whether patients are prepared to travel to another country for treatment under the EU cross-border directive, and whether the sending country is prepared to implement the rules, is being tested.
If British patients from Kent are not prepared to make the short hop across the channel to Calais, and if the NHS puts up administrative barriers, then all those hospitals expecting a substantial increase in business will be disappointed.
Brits channel hop to buy antiques, drink and cigarettes, but whether they trust French doctors with their health, nobody yet knows.

Centre Hospitalier de Calais is advertising for business from the nearby English county of Kent in the hope that patients will opt to have their operations done in France, under the EU rules on patient rights for cross-border healthcare.
Kent patients need approval beforehand from their local NHS hospital for some 144 treatments, have to pay the bills and then seek to claim the costs back. Under the NHS they do not pay anything. The NHS has made it clear that it may consider travel costs, but no patient has the right to get these paid. The NHS also makes it clear that it will not pay for any costs of traveling companions and patients must pay all hospital and hotel bills for accommodation, but cannot reclaim these from the NHS.
Calais hospital has 502 beds, parking for 350 cars, and mostly private, en suite rooms with the latest technology for MRI and CT scans. It offers a range of treatment including cosmetic and reconstructive surgery and vascular surgery. The NHS does not pay for cosmetic surgery.
The Centre Hospitalier de Calais is targeting residents of the Calais region and also for European neighbours. The site at Virval is south east of Calais, and offers easy access from the city centre and the ring road surrounding the city.
Kent residents seeking treatment in France are limited to what the cost of treatment is in their home county. How this is interpreted is going to be of interest to NHS hospitals across the UK. One key problem is that NHS hospitals do not publish a price list so patients will not know in advance how much they can claim. If the price in France is higher than the UK, then the patient pays the extra. If the price in France is lower than in the UK, the patient does not keep the difference, but still has to pay travel and accommodation and food costs- as these are not offset against any medical savings.
Significantly, local NHS hospitals have refused to comment to Kent papers running stories on the Calais bid. Although regulations from the Department of Health are detailed, and the theory is understood, how they are interpreted at local NHS level is still a mystery to both hospitals and patients. How a hospital calculates the cost of an operation where the patient is charged nothing has yet to be solved, as it is unclear whether the costs should or should not include pre- treatment costs and aftercare.

FindMeHealth is a new independent comparison website for private healthcare, offering free consumer information on healthcare services’ quality and price. The aim is to make it easy for patients to find the right healthcare specialist and surgery treatment, compare prices, and book treatment online.
It uses a hotel like five star system to rate surgeons and consultants that allows potential patients to see the records, experience and qualifications of different surgeons and how much they charge.
The aim is to make private healthcare more accessible and affordable to customers through the use of information to transform the relationship between patients and health professionals by providing trusted and comparable information on quality and price to help people book private outpatient consultations with consultants online in a quick, easy and convenient way. Important to the service is making it easy for potential patients to compare like for like treatments across a range of providers, based on reliable health outcomes information and customer feedback, so they can make an informed decision and ultimately choose the right treatment and provider.
Similar to how hotel and travel websites work, key to the site is the use of featured reviews from patients. Dr Mark Ratnarajah, co-founder of FindMeHealth says that to solve the problem of bogus and malicious reviews, all comments will be carefully scrutinised and vetted.
It expects to have 4000 to 5000 UK surgeons on, each with a free listing. They are not charged for that listing but can advertise on the site. The website follows the model of other new competitors by only charging them a fee if a booking is made by a patient. The prices quoted are the actual prices charged for that patient, not indications or average procedure prices. It does not direct patients only to those who pay to advertise.
Patients do not need a GP referral as long as they are paying for the outpatient consultation themselves. Future plans include adding in-patient treatment and other healthcare.
Although the UK has seen other small sites launch in recent months this one has massive financial backing from Ed Wray and fourteen other professional investors. It is already planning the next stage of investment. Ed Wray explains: “FindMeHealth can help put consumers back in control and to make better choices.” Ed Wray helped found the world’s largest online betting exchange Betfair in 2011 that has five million bets a day, and is a director of leading UK peer to peer online lender Funding Circle.
The initial target market is the estimated quarter of a million self-pay private patients, a market worth £500 million-plus a year or 15 % of the total UK private healthcare market. Ratnarajah plans to expand the service to cover the rest of the private healthcare market in due course.
The launch has no public intention of yet including treatment outside of the UK, but for anybody targeting UK medical tourists with outpatient treatment such as hip or knee surgery, cosmetic surgery, or fertility treatment, it means that these customers now have an easy way to compare UK prices against anything overseas hospitals and clinics offer. Dental care is not yet included.

One of the biggest problems facing US domestic medical tourism is that comparing prices is very difficult. When hospitals, clinics or agencies seek to promote medical travel from other states, convincing patients that the price is competitive is an uphill struggle. But a new portal will change that.
Three of the biggest American health insurers have joined to create a price comparison site, and others are expected to join the initiative as several have expressed interest. It is good news for domestic US medical tourism, and a wake up call to overseas hospitals and agencies that quote sky high US prices, in comparison with their own, that continuing to use the highest prices, when customers can check US prices for themselves will just take away any credibility they have.
Aetna, Humana, and UnitedHealthcare– have teamed up with non-profit Health Care Cost Institute (HCCI) to launch an online portal in early 2015 where they will publish information on healthcare prices; the price of treatment, not the price of insurance.
Price transparency is a serious cause for concern within US healthcare as a lack of price transparency means that customers cannot easily tell if they are getting a good deal from their hospital. People expect to pay more in a big city than in a remote town, but prices vary hugely between almost identical hospitals.
Insurers are not doing this out of the goodness of their heart, as they see it as a way of pressurizing hospitals to reduce costs and obtaining US wide price information. It is also to their benefit that consumers can make a more informed decision when obtaining medical care .More comparison tools will be added over time.
The simplest explanation of the start point of the HCCI online is that it will upload price information that insurers have internally. So the more health insurers join in, the better the data will be.
It will take time to build as pricing data will come from commercial health insurance schemes, plus Medicare Advantage and Medicaid health plans. US healthcare reform encourages the publishing of government-funded healthcare cost data but states that like to be awkward could refuse to take part just to make a political point.
HCCI accepts that pricing information alone is unfair, so cost data will be supplemented with quality and other information to provide consumers a transparent and comprehensive destination to make more informed decisions about health care.
“Consumers, employers and regulatory agencies will have a single source of consistent, transparent health care information based on the most reliable data available, including actual costs, which only insurers currently have,” says David Newman of HCCI.
For hospitals and clinics this will offer new and accurate information about costs and quality that allows them to see information on competitors.

Romania is promoting health tourism, while medical tourism is bringing a much-needed boost to the economy.
The Spa Tourism Employers Association (OPTBR), backed by the National Tourism Association (ANT), has in partnership with the National Institute of Gerontology and Geriatrics and the Ana Aslan Foundation a pilot programme to promote health treatment and to revitalize the famous Romanian brand Ana Aslan. The Romanian Medical Tourism Association (ARTM) and is another partner promoting the project.
The aim is to repromote the power of the Ana Aslan brand, which concentrates on spa treatment for older customers. Part of the pilot is finding ways to use modern phrases rather than off putting promotion terms such as geriatric treatment. This is aimed not just at foreign tourists, but at the large internal Romanian spa tourism market that is expected to grow as the economy recovers.
The pilot has two programmes ’Live Young’ and ’Relaxation. Rebalancing. Revitalization’ at the O3Zone Hotel, in the Central Romanian resort of Baile Tusnad resort. Customers will have free access to the swimming pool, jacuzzi, dry and wet sauna and to the gym at the spa centre. Ana Aslan therapy includes preventive or curative treatment with products personalized to the patient. Treatment is or a wide range of problems associated with the degenerative process specific to women: rheumatism, peripheral circulatory disorders, depression, hypertension, and atherosclerosis.
On medical tourism, Dragos Raducan of the Federation of Employers from Romanian Tourism (FPTR) explains,” There are no official statistics, but from local medical tourism sources we estimate that 2013 saw over 20,000 medical tourists in Romania.” This is mostly for cosmetic surgery and dental treatment, with some medical treatment. The association estimates that they spend over EUR 60 million on health services, accommodation and food.
According to the National Association of Travel Agencies (ANAT), a medical tourist spends, on average, between EUR 1500 and EUR 2000 for treatment plus EUR 1500 on accommodation and food. Most come from the UK, Germany, France, Italy and Israel and are aged between 40 and 60, according to ANAT.

On the morning of 20 May, the chief of the Royal Thai Army declared martial law across the whole of Thailand. There is an increased military presence and soldiers have taken over TV and radio stations, and blocked off roads in the capital, Bangkok, and in neighbouring provinces. The army insists that its assumption of responsibility for national security was not a coup, but as government has not been consulted about the army’s decision, it is effectively a military coup.

The situation is evolving and any company sending people to Thailand should monitor local news and social media for developments. Tourists have been warned to allow extra time for journeys, including to the Bangkok airports.

Any agency sending medical tourists to Thailand must consider what would happen if a medical tourist gets innocently caught up in the situation.

Several governments have warned their citizens to think again before travelling to Thailand. The UAE has warned citizens not to travel to Thailand, which may affect the established medical tourism flow from the region.

Insurance organizations have warned that because the intervention is a military one, many travel insurances could no longer be valid nor provide full cover.

Martial law supersedes the Internal Security Act, which had previously been imposed by the government. Martial law provides an enabling framework for the Royal Thai Army to take action it deems necessary to enforce law and order, and instructions can change rapidly.

Political demonstrations continue in and around Bangkok and elsewhere in Thailand, including Phuket. There have been indiscriminate attacks involving weapons and explosives at protest sites and at protest marches causing casualties and deaths. Attacks have taken place during the daytime and at night.

Protest action has caused significant disruption to roads in affected areas, with knock-on effects across the city. The situation is unpredictable and further protests are expected.

By law tourists must carry a passport with them at all times. Tourists have been arrested because they were unable to produce their passport. There is a nationwide curfew for all residents and visitors; all need to be indoors between 10pm and 5am.

The military measure caught the Tourism Authority of Thailand (TAT) by surprise as they were about to launch a range of tactical campaigns aimed at Europe and the Middle East to retain tourists confidence and ensure the growth of the country’s tourism industry .The campaign is on hold.

While many areas in the country are unaffected, many medical travelers either go to Bangkok, which is at the centre of the troubles, or go through airports that are being affected by political demonstrators. Airlines are taking decisions by the hour.

With an increasing number of countries warning citizens to be cautious about traveling to Thailand, it is inevitable that the numbers of tourists and medical tourists to Thailand will fall in 2014.

Mario Hardy at the Pacific Asia Travel Association in Bangkok predicts that visitor numbers will fall by at least 5% this year, “Tourism is a huge income for the country, so this military intervention is not helping. It is not good for Bangkok and not good for tourism in Thailand.”

The Tourism Authority of Thailand insists that international visitors can continue to travel in the destination as usual, “All public transport and tourist attractions, including airports, tourist sites and shopping malls, are currently open and operating as normal.”

With tourism accounting for 10% of the country’s gross domestic product, keeping hotels and shopping malls open and busy is key for South-east Asia’s second-largest economy. Because of the troubles, even before the military action, in the first four months of the year, foreign arrivals dropped 5 % — about 400,000 —compared to 2013, figures from the Thai Department of Tourism show.

Bangkok hospitals report lower medical tourism numbers for 2014. Bangkok Dusit has seen a drop of more than 30 % in patients from the Middle East this year. Bangkok is suffering from a dramatic drop in visitors, a trend that is indicative of a much great problem in Thailand’s tourism industry. Those reliant on tourism in the city are noting the especially clear absence of Chinese visitors. Even before the military intervention, the first 4 months of 2014 has become a disaster for Bangkok tourism. Tourism arrivals at airports fell 38% on 2013 and Chinese numbers are down 48.1%, Russian numbers are down 40% and Indian, Japanese and South Korean arrivals at least 30% down. Many tourists are staying away because of the state of the economy and a lack of spending confidence and some are calling this the worst tourism crisis in a long time.

Thailand is now also in danger of losing its crown as the world’s top destination for medical tourism if foreigners looking for low-cost, quality healthcare are frightened away by the political unrest.

The Tourism Observatory has carried out a conceptual study on the possibilities and directions of a joint health tourism strategy for the three Baltic countries (Lithuania, Latvia and Estonia)
The report provides a summary of research undertaken on health tourism in the Baltic States identifying which resources and products are common to the region as a whole and which are unique to each country.
The Baltic States have had a fairly successful collaboration in tourism (especially promotion) for several years. Collaborations and clusters are seen as being useful tools for sharing good practice, improving quality and branding.
A Baltic Health Tourism Cluster was established in 2013. Following attendance at the launch of the Cluster, Laszlo Puczkó undertook a study involving several respondents from each of the Baltic countries from the health, wellness, spas, medical and/or tourism business sectors.
This analysis sought to help the countries identify what is specific in their health tourism resources, attractions and products at the same time as working towards collaboration and a common regional brand for health tourism.
The results of this study, which is available for purchase, will form the basis of a joint Baltic Health Tourism Strategy.
Lithuania has seen a boom in medical tourism. Body Bureau, a London-based agent and pre-assessment clinic that specialises in infertility treatment, health screening and dentistry, says that healthcare visitors from the UK to Lithuania have increased by 19.5% over the last two years. It says that within this timeframe the total number of patients visiting Lithuania from abroad was up by 42.3%, although it does not say where these figures come from. One Vilnius-based infertility clinic, Northway, reports a doubling of patient numbers in the past year.
Aaron Zukauskas of Body Bureau explains, “Vilnius is one of the most affordable, capitals in Europe and has a lot to offer, including a beautiful old town. Lithuania is rated one of the top countries in the world for the quality of its health and hygiene. This helps make the country very attractive for people who want to improve their health, or get quality healthcare services.”

In an effort to expand the local niche market of medical tourism, The Palace and The Victoria hotels have teamed up with private hospitals, Prestige Cabs and UK medical tourism agency Linda Briggs.
Linda Briggs will arrange for British medical tourists seeking medical treatment in Malta to stay at The Palace and the Victoria hotels for pre-surgery and post surgery recovery. For certain treatments, Linda Briggs will also fly in leading surgeons from France and other European countries.
Together with its local partners, Linda Briggs is promoting Malta as a five-star medical destination, offering a complete service to patients needing surgery. As part of an added service to customers, Linda Briggs is offering insurance cover underwritten at Lloyds of London that will cover travel and some costs related to surgery, as well as any emergency treatment needed in Malta during recovery.
Linda Briggs comments “For this venture to succeed, we needed partners who are committed and who will leave no stone unturned to provide the high level of service that is now expected in this sector.”
Discovery Channel recently filmed a programme showing the positive side of cosmetic surgery, and featuring a Botox® party at the Limes Bar at the Fortina Spa Resort in Malta. The event was organised by Linda Briggs.
There have been many historic links between Malta and the UK, and a long standing link between Malta and Italy. A more recent link is the Malta/France one with more French people traveling, retiring or even setting up businesses in Malta. Malta is still working out how to best take advantage of these links in developing cosmetic and medical tourism.

PlacidWay has published ’2014 Medical Tourism Global Consumer Demand Survey Analysis’. The research based on a global sample of potential and actual medical tourists, analyzes the consumer’s behavior when making medical tourism decisions and the consumer specific needs, perceptions, and desires.
Pramod Goel of PlacidWay explains,” It is important that medical providers, medical tourism groups and governments trying to promote medical travel, align their healthcare solutions by understanding the nature of demand and developing a specific message as well as the specific programme, closely mapped to consumer demand,"
The purpose of the new report is to identify how medical consumers think, what are their needs, how will they buy, where do they seek information, what is important for them when considering traveling abroad for medical care, what are their income levels, why would they go abroad for healthcare, and who is the medical consumer or medical tourist.
The research gathered information from those who have already traveled abroad for medical care, and from people who are considering going overseas for healthcare, and analyzed the what, how, where, when, who and which of the perceived medical travellers.
The objective of this research is to understand consumers buying behavior, their needs, and their perception of the medical tourism. The study also identifies how factors such as age, gender, and geographical region have an impact on medical travel.
The analysis sheds some light on medical tourism industry from consumers’ perspective and answers questions: o Who is the consumer?o What is the consumer’s demographic composition?o Which treatments would the consumer consider important to buy globally?o Why would the consumer travel abroad to receive medical services?o Where would the consumer go to get such treatments? o Where would the consumer go to find useful information? o How much is the consumer willing to pay for medical services abroad? o When is the consumer ready to make medical travel decisions?
Pramod Goel concludes, "As the medical tourism industry matures, by understanding consumers we may bring equilibrium to the supply and demand equation of medical travel. We will be able to institute appropriate educational elements to propel the demand. We can customize medical travel products and services to meet and expand consumers’ expectations from this industry."

Israeli police are investigating doctors from Tel Aviv Sourasky Medical Center suspected of using public hospital facilities for private surgery on medical tourists to Israel.
The issue was uncovered in December of last year by the Channel 2 investigative programme Uvda. Following the televised programme, the health ministry said that medical tourism was going to be investigated to strengthen the public health system. But so far nothing has happened; it seems that the authorities and politicians are waiting for the police to act.
The Uvda programme showed hidden camera footage of senior brain surgeons from the hospital agreeing to bypass waiting lists to fit in patients from the former Soviet Union who were willing to pay them tens of thousands of Euros. In the two cases shown on the programme, doctors were caught on film speaking to a female producer posing as an agent representing fictional patients in the former USSR looking to fly to Israel for treatment.
It was thought that the programme had been forgotten and the accusations not proven. But the Israeli police have spent six months collecting evidence. The basic accusation is that doctors have, with or without agreement from local hospitals, been using hospital facilities to treat overseas medical tourists and that these substantial payments have been in cash, and are illegal.
The police are not widening the net at this stage, nor getting involved in political arguments on medical tourism or the prices charged. What the police have accused the three very senior doctors from Ichilov Hospital in Tel Aviv of is failing to declare income and failing to pay tax on cash payments.
The police are trying to determine how many patients were brought to Israel for the unapproved treatments, and how many doctors took part.
The doctors questioned could face charges of fraud, tax evasion and bribery.
Medical tourism is a major income earner for Israel’s hospitals, with tens of thousands of patients traveling to the country each year.
That the police made a highly visible and public swoop on all three doctors suggests that they have fairly solid information. By concentrating on the tax angle it becomes easier to establish innocence or guilt, and for a jury to understand the charges. What the police will now do is to follow the money, follow the information and see who they can charge with what, and leave the health authorities and politicians to deal with the wider debate on the legality of medical tourism in public hospitals, and the problem of medical tourists being charged double what locals pay.
The outcome could have a significant impact on medical tourism in Israel.

The Florida Legislature ended its regular election session with legislators unable to pass a bill to promote medical tourism.
The House and Senate bill would have allowed Florida tourism bodies to create a five million dollar marketing plan to entice tourists around the globe to think of Florida as a medical destination.
The proposal designated $3.5 million to Visit Florida, the state’s main tourism driver, to set up a four-year plan to promote healthcare options, providers, services and specialties. An additional $1.5 million in state funding would have been allocated to establish a matching grant program to support local and regional economic development organizations with medical tourism.
The Florida House of Representatives has passed its budget that included $71.3 million to Visit Florida, the state’s tourism marketing agency.
The medical tourism bill will now have to wait until late in 2014 to get reconsidered.
The knock back means that it will be harder for the state to achieve the target of 100 million tourists in 2014, as the politicians allowed a budget of less than three-fourths of the money that the state governor said was needed to reach that goal.
Visit Florida, the state’s tourism arm, estimates that Florida attracted 26.7 million visitors in the first quarter of 2014, a 2 %increase from 2013. For all of 2013, the state welcomed 94.7 million tourists, a 3.5 % increase over 2012.
The state governor had asked lawmakers to increase funding for Visit Florida, the state’s tourist marketing arm, by more than $36 million, to $100 million. Instead, as part of the proposed $77.1 billion spending plan for the budget year that begins July 1, legislators included $74 million for Visit Florida. The funding level approved by lawmakers does represent a $10.3 million increase from the current year. The requested funding for Visit Florida included $5 million for medical tourism.
The new medical tourism bill sought to give Visit Florida $3.5 million to craft a marketing plan aimed at people seeking medical treatment, from specialized surgery to routine procedures or cosmetic surgeries, and another $1.5 million to provide matching grants to local and regional economic-development organizations that have medical tourism marketing programmes.
The state governor and Visit Florida could still seek to promote medical tourism by using general funds, but the organization appears understandably reluctant to get in the middle of a wider battle for control between the governor and state politicians.

The Sovereign Investment Authority of Nigeria recently told the World Economic Forum that 30,000 Nigerians spend $1 billion annually on medical tourism.
60% is spent in four major areas of healthcare: cardiology, orthopedic, renal dialysis issues and cancer.
This is a much lower figure than has appeared previously in the international media.
The plan now is to get overseas hospital groups to build new hospitals in Nigeria, and while this could benefit Indian hospital groups who have overseas building plans, it is not such good news for the Indian hospitals that Nigerians go to.
Recent high profile terrorist events may make overseas investors wary of long term investment in a country that despite being the richest in Africa, seems reluctant to spend that money on healthcare. The biggest problem is that Nigeria is not one cohesive place but a mix of rival tribes, rival states, rival policies and rival interests.
While it makes long-term sense for Nigeria to build new hospitals to stop better off locals spending healthcare cash overseas, expecting that development to come from overseas investors when the national government clearly has many problems in controlling what happens within the country, is perhaps a hope to far.
Even if Nigeria can alter the direction of medical tourism in the long run it now seems clear that outbound medical tourism for the rest of the decade is going to stay high and perhaps even grow. Any suggestions that Nigeria could become a major medical tourism destination anytime soon are require a significant leap of faith.

The Dubai Health Authority has met with private hospitals to discuss the rollout of the medical tourism strategy later this year. Hospitals were told what they must do to be included in the new promotion.
The government is ensuring that all relevant organisations including the immigration department, airline industry, hospitality sector, public and private hospitals will work together to ensure medical tourists receive excellent treatment and hospitality.
All hospitals and clinics interested in being part of the medical tourism initiative will have to fill out a detailed medical tourism eligibility form and submit all documents to the Dubai medical tourism department within DHA.The documents will then be evaluated by the medical tourism committee and hospitals will receive platinum, gold or silver membership based on their score. The committee will look into detailed aspects of each applicant including the specialities they would like to promote, details of the doctors who provide those specialties, and the number of procedures they have conducted. This information will be verified with the DHA health regulation office as part of the secondary verification check.
In addition to medical facilities, DHA will also evaluate hospitals on the basis of the comfort and ease they provide patients. This includes checking whether they have translators, chauffeur services, hospital transport, and other services that would all be part of the medical tourism package.
Hospitals must agree to offer pre-priced all-inclusive medical tourism packages that will include treatment, visa, travel costs, hotel accommodation and recreational activities for families who accompany the patient.
Only successfully approved hospitals and clinics will be part of a new Medical Tourism Club; and the DHA will only promote club members. It will be interesting to see what happens if hospitals and clinics, most of whom have spent substantial amounts of money investing in Dubai Healthcare City, either decide not to apply join, not to offer packages, or are turned down by the DHA committee, or are unhappy at the star rating they get.
The first packages will be launched in September and will be and wellness and preventive services package. This includes medical check ups. These packages will be promoted on a new DHA run medical tourism website that will include all details and hyperlinks of approved clinics and hospitals. There is some confusion as the latest information from the DHA says that the website will not be ready until between October and December 2014. The medical tourism packages will target patients living outside the UAE and the Middle East region in general. Dubai’s goal is to attract large numbers of medical tourists. This very tight control over product, service and pricing is an approach that no other country has attempted. Many of the authorities and organizations are effectively, as is DHA, state controlled; so it will be interesting to see how, or indeed if, private hospitals and clinics, particularly those owned by overseas investors, are happy to work in this state controlled way.

Both Kuwait and Saudi Arabia are seriously considering making health insurance compulsory for all visitors. It will almost certainly be required that travelers buy their cover from companies authorized within each state, as this is how they have arranged other compulsory health insurance schemes. Details and timing are awaited. The plan, to stop visitors using local hospitals for free except in real emergencies, may restrict hopes of inbound medical tourism.
Saudi Arabia has decided to implement mandatory health insurance that must include cover for medical assistance and evacuation in emergencies for foreigners intending to visit the Kingdom. Hajj and Umrah pilgrims are exempted from this requirement.
The Council of Cooperative Health Insurance has yet to confirm the date from which the new requirement apply. It is also not yet confirmed whether insurance can be arranged by any travel or health insurer in the country the visitor is travelling from, or whether it has to be arranged by a health or travel insurer licenced within Saudi Arabia. Once the new rule is implemented, only those foreign visitors who have taken out proper health insurance policies will be eligible to apply for visit visas in Saudi diplomatic missions abroad.
Many visitors entering the Kingdom on visit visas are parents of expatriates who are aged or suffering from chronic diseases, and their medical expenses are high. Many women join their husbands on visit visas and deliver babies, which is expensive for Saudi hospitals. Visitors who are insured will be protected from medical costs arising out of treatment for sudden unexpected sicknesses, infections and accidental injuries.
Only a handful of Saudi insurers can handle this type of cover and if insurance has to be bought locally it is likely that there will be an increase in premiums. What has to be sorted out is what insurers refuse to cover people for because of age or existing illnesses. They could be banned from refusing cover, or visitors deemed to old or ill may simply be refused entry to the country; the local insurance market suggests that the latter is the most likely.
While making travel insurance compulsory for all visitors may seem easy in theory, in practice it is far from the case and any country has to balance whether the money it saves on healthcare, is worth the money lost from reductions in visitor numbers.

KuwaitVisitors to Kuwait could soon be forced to buy health insurance for the duration of their stay after the Kuwaiti parliament’s legislative committee accepted the proposal put forward by MP Khalil Al Saleh that also stated visitors could only be treated in private hospitals.
Access to health services is controversial in Kuwait, where two-thirds of the population are expatriates and the country has not built a new hospital for some time. The health ministry intends to build nine new hospitals, although it made a similar pledge more than a decade ago which has not been fulfilled. Last year, it segregated access to hospitals, banning expatriates from attending public facilities in the morning, except in an emergency. Kuwait provides free medical services to all citizens, while expatriates pay an annual health insurance fee of $175 plus partially subsidised charges for certain procedures.
If Kuwait follows other countries, the traveler does not get a free choice of insurance, as they have to choose one or selected insurers within the country itself, which is likely to be the route that Kuwait takes as it ties in with how they regulate health insurance
Other Gulf states are considering similar restrictions but are waiting to see what Kuwait and Saudi Arabia do If they both implement the rule without damage to trade or tourism, the others will copy an idea that seeks to restrict access to hospitals. Cuba has had a similar rule for years, with no problems for the country but a headache for US insurer AIG who have been prosecuted for breaking US sanctions by offering travel health insurance to Canadians. The UK is seeking to apply new compulsory health insurance rules to certain classes of visitors.

Australian health insurer, nib, is considering becoming a medical tourism agent for its customers, but not offering insurance cover for medical tourism as the main reason that Australians go overseas for treatment is cosmetic surgery, something that health insurers do not cover.
The insurer has 18 branches across the country and if it cannot increase income in a very competitive market for health insurance, then it will have to close some. This is why ideas for producing extra income, such as becoming an agency for Australians seeking cosmetic surgery overseas, are being considered.
Mark Fitzgibbon of nib explains, ’’If you’re going to go overseas for surgery you want to deal with a company you trust. Australians are spending a lot of money on cosmetic surgery by going overseas. Everyone is making money out of it: the airline, the travel agent, the credit card and loan companies, as well as the clinics overseas. So we are exploring the prospect of having a role in assisting people making those decisions, because they know our brand.’’
While globally, insurers are not keen on insuring medical tourism, there are other insurers around the globe that have dabbled in helping customers go to another country for treatment such as cosmetic surgery that they do not insure; as there are then no conflicts of interest.
A new dental tourism venture is targeting Australians. Dental Abroad, based in Auckland, New Zealand is seeking to take Australians to New Zealand for dental care. A weakening New Zealand dollar and cheap airfares have helped make the venture viable. It has been set up by a dentist and a technician who makes dental implants. It offers Australians a net saving of 20% to 30% on the dental cost in Australia. The company promises that work done in Auckland will be of a higher standard than in other countries where dental tourism is popular, such as Thailand.
The company specializes in the larger complex restorative cases involving 3 or more teeth requiring crowns, bridges or cosmetic veneers. Implants are made in house to high quality controls and standards, with a 3-year guarantee. Only internationally recognised brands of implants and fixtures are placed.

A special edition of the UK journal, Clinical Risk published by the Royal Society of Medicine, looks at how the combination of an under-regulated market, increased marketing and overwhelming media hype have created a perfect storm that threatens patients and practitioners alike. The journal’s editor argues that cosmetic surgery patients are at more risk than ever before.
Dr Harvey Marcovitch, who commissioned leading experts in the field to write for this special issue says, “Patient safety is this journal’s main aim and there can be no area of medicine where patients in the UK are more in need of protection. We need tight control of advertising of cosmetic surgery, including internet advertising. We need proper regulation of the industry and we need both surgeons and GPs to manage patient expectation.”
In ’Clinical Risk in Aesthetic Surgery’, Nigel Mercer of the British Association of Aesthetic Plastic Surgeons (BAAPS) calls for tighter regulation in the UK, “There has been a massive increase in marketing, including discount vouchers, 2-for-1 offers and holidays with surgery. In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ’2-for-1’ advert for general surgery? If we have to sell anything, we should sell our advice, not procedures. If we cannot self-regulate then regulation will eventually be imposed. All cosmetic treatments are medical interventions, and every medical intervention has a complication and failure rate.” .He also suggests that there should be a Europe-wide ban on advertising all cosmetic surgical procedures, including on internet search engines.
In ’France Sets Standards for Practice of Aesthetic Surgery’: French surgeon, Alain Fogli describes the strictly defined guidelines for cosmetic surgery in France which include: – surgical procedures can only be undertaken by surgeons who are registered specialists and deemed competent; neither possession of a general medical degree nor that the practitioner is experienced are sufficient qualifications; a ban on all forms and methods of publicity and advertising, direct or indirect, in whatever form, including the Internet”
In ’Minimizing Risk in Aesthetic Surgery’ Foad Nahai of the International Society of Aesthetic Plastic Surgeons (ISAPS) says, ” Regulations governing the training of all cosmetic surgeons are sorely needed. Governments are reluctant to become involved, as they see this issue as a dispute between various physician groups and not a public safety or patient safety issue. Since by law any physician is allowed to practice cosmetic surgery, attempts by individual physicians or plastic surgery organisations to restrict those who are not qualified is viewed as a restraint of trade.”
In ’Improving the Safety of Aesthetic Surgery’ Rajiv Grover recommends careful pre-operative counselling, thorough documentation and exploring with the patient what degree of correction and scarring is realistic, and not being falsely optimistic about the likely outcome.
In the UK, although there are measures and standards to help regulate the industry, some cosmetic surgeons operate outside these regulations. Some treatments and procedures are unlicensed for cosmetic use, but can be given at the discretion of doctors, or by some clinics. Invasive cosmetic surgery and laser treatments are regulated.Some cosmetic surgical procedures are not covered by current regulations, such as botox injections and injections of aesthetic fillers.
Surveys by the International Society of Aesthetic Plastic Surgery show that England has one of the poorest controls of cosmetic surgery in the world, says Dai Davies from Plastic Surgery Partners. He believes that the UK is one of the worst regulated countries in the world and says, “practically anyone can perform risky treatments (such as injectables) that should only be performed by qualified doctors. The industry is out of control.”

A Toronto hospital piloting medical tourism has run into a media storm of protest that could kill the project, as it had been trying to pilot quietly without publicity.
Despite targeting a very small number of patients (ten in 2014) it has sparked a debate about the costs of Canadian healthcare, access to healthcare for Canadians and how healthcare in Canada is and should be financed. Critics range from those decrying all medical tourism to those who say Canadian hospitals should only be for Canadians. There have been very few supportive messages.
The reason for the pilot is that Canadian hospitals are working to ever more restrictive budgets, and need to either find ways of substantially reducing costs or new revenue streams. As health insurance is not legal in most Canadian provinces, hospitals have to rely on state funding or self-paying Canadians.
All Canadian hospitals treat foreign patients in emergencies, and a handful, including Toronto’s University Health Network; raise millions treating international patients on a referral basis.

Sunnybrook Hospital’s board has approved a one-year international patient programme and so far it has had two patients; a Barbadian woman who paid $60,000 for radiation treatment for breast cancer, and a Jamaican man who paid $20,000 for radiotherapy for prostate cancer.
Sunnybrook is planning to treat fewer than 10 international patients in a one-year pilot phase so is not openly soliciting medical tourists. Michael Young of Sunnybrook explains, “This is part of a number of initiatives from our new department of business development. Through our website we are beginning to advertise that we are open for business. The profitability of this could be as high as $1-million annually. It could be much more than that, but the limiting factor will be our spare capacity.”
Critics argue that patients from abroad could displace tax-paying locals or pave the way for rich Canadians to buy their way to the front of the queue. In 2013 McGill University Health Centre in Quebec performed cardiac surgery on a Kuwaiti woman whose government paid the $200,000 cost, and the province’s health minister called it “unacceptable” and vowed not to let it happen again, except on compassionate grounds.
Sunnybrook has vowed not to displace Ontario patients. The hospital plans to treat foreigners only where it has extra capacity or staff on standby, as it does on its burn unit. The profits could be used, for example, to prevent closing operating rooms. Budgets for Ontario’s hospitals have been frozen for three years, while the running costs keep rising.
Ontario has no plans to stop hospitals attracting medical tourists but Quebec plans to do all it can to prevent local hospitals targeting foreign patients.
The Canadian healthcare system is under pressure, with rising waiting lists and insufficient finds. Province controlled regulation means that in some provinces health insurance is legal, in others it is not, while in some provinces private healthcare in hospitals is allowed, while in others it is not allowed or strongly discouraged. Some provinces have even made noises about banning medical tourism, although it is doubtful that they have the legal powers to do this.
As evidence of what local hospitals are doing on medical tourism slowly emerges, it has provoked another debate with some evidence that hospitals are, or are being encouraged, to charge foreign patients double what they do for Canadians.
Canada is a microcosm of the global debate on medical tourism. There are only a finite number of doctors, nurses and hospital beds so a surgeon performing surgery on well-to-do foreigners is not available at that moment to treat locals; so is the hospital using spare capacity, or using local capacity for foreign patients to boost revenue? Should foreigners be charged much more than locals? Can money from medical tourism allow hospitals to keep operating rooms open longer and thus reduce wait times for locals; or is this using resources that increase waiting times?
In Canada there is an underlying problem for the healthcare system — as governments, both federal and provincial, have cut funds. This triggers another debate as to whether throwing money at any health-care system will fix it, or whether ways of changing how hospitals work and where people are treated is a better long term solution; as is happening in the excellent Scandinavian systems.
For Canada, the only certainty for hospitals and medical tourism is that if they do not seek new revenue they get criticized for not having enough resources to treat locals, and if they do embrace medical tourism they get criticized for treating foreigners rather than locals. So whether any individual hospital administration will promote medical tourism may depend very much on how far they can tolerate sustained criticism in the media, from patients, and from politicians who are ultimately responsible for signing off what state provincial funding they get.

Leading Australian and New Zealand health insurer nib has launched a domestic and overseas cosmetic surgery and dental offer, nib Options for Australian consumers only, offering treatment in accredited facilities. The launch was supported by a marketing campaign, fronted by leading GP and television personality Dr Ginni Mansberg.

nib Options is a fee-for-service product which will provide safe and reliable choices for consumers wishing to undertake cosmetic and major dental procedures in Australia or overseas. It is not in any way linked to the health insurance offering.
Customers have a choice during the early assessment stage about where they would like to seek treatment, with nib Options accessing leading Australian cosmetic surgeons as well as fully qualified cosmetic surgeons and dentists in overseas facilities. The insurer refuses to name the clinics, but according to the website it appears that at present all it has is one cosmetic surgery/ dental clinic in Phuket, Thailand, and one or two clinics in Australia.
Mark Fitzgibbon of nib explains, “This is all about helping Australians to choose from a borderless network of surgical excellence as well as providing safety assurance. While receiving cost-effective treatment is also a factor for consumers, we know that the most powerful attraction is providing safety assurances that only high quality hospitals, surgeons and dentists will be involved. Such safety assurances cannot be made lightly, so we have devoted a lot of time and effort to ensuring nib Options will successfully deliver what it promises based on our brand reputation and capability. The hospitals and dental facilities we are dealing with are internationally accredited.”
Fitzgibbon adds, “Over time, I am confident that more and more Australian and overseas surgeons and doctors will want to partner with us once they see the benefits it will bring to their practices. This fits very neatly with our commitment to helping people finance their health care. We are helping the customer at every stage starting from the initial consultation through to travel arrangements, accommodation, the actual surgery and afterwards. Some people will have neither appetite nor ability to travel overseas for a procedure while others will take the travel option so they can also recuperate quietly. For those Australians who do travel overseas for medical treatment, we want to give them peace of mind by making the experience safer and more reliable.”
All the costs involved in undertaking surgery, both before and in the post-operative phase, as well as the aftercare promise are bundled into one overall package price.
The Australian and overseas packages also include an after care promise to assure customers that nib Options will be there to help them through a process for any further follow-up treatment and care, for up to 12 months after the surgery, should they need it.
nib Options is a fee-for-service product, it is not health insurance. It is a bundled, one-stop service from the initial medical consultation assessment, actual surgery and post-surgery care, as well as travel arrangements, accommodation, concierge services for consumers who go overseas. The use will have no impact on nib health insurance premiums or products. Customers can choose treatment in Australia or overseas; they have a choice during the early assessment stage about where they would like to seek treatment.
At launch the service is limited to dental treatment and cosmetic surgery in Australia and Thailand. Cosmetic surgeons in Australia have to be members of the Australian Society of Plastic Surgeons. ACHSI, the International arm of the leading Australian accreditation body Australian Council on Healthcare Standards will conduct the audit on potential international clinics.
As to be expected from their previous track record on seeking to defend high Australian medical prices, the service has been roundly attacked in the media by the Australian medical establishment. The onslaught rather backfired when Australian Medical Association president Steve Hambleton went too far, and was widely ridiculed across the Australian media for his “When you travel overseas and eat lettuce or a salad you could return home with a multi-drug resistant bug in your bowel. That could start to hurt you if you have complications from surgery and end up in intensive care and we might not be able to treat the infection.” cartoons depicting dangerous foreign lettuce quickly followed.
More than 3,000 people visited the nib Options website in the first three days of its operation and nib had to put on additional call centre capacity. 30 % were interested in overseas cosmetic surgery, 50% in overseas dental care and 20% in Australian cosmetic surgery.

A consumer survey on potential medical tourists visiting a medical tourism show is never going to be representative of Russian consumers, but it does bring insights into what Russian medical tourists want.
Many countries are targeting Russia as a source of business, but often know little about how healthcare works in Russia, or that many so-called Russian customers are Russian speaking but come from other states that used to be part of the USSR.
The object of the survey was to find out who are these Russian medical tourists, what do they want, and what do they spend?
The 3,524 visitors attending the Moscow Medshow in March provided an opportunity to conduct a major survey into the requirements and tendencies of the Russian client/patient. 422 people answered questions.
How much would you be prepared to spend on medical treatment abroad?11% are prepared to spend more than 25,000 euro on their treatment abroad, 36% say that the cost of their treatment could be between 10,000 to 25,000 euro, and 53% say that their budgets for treatments are at a maximum of 10,000 euro.

When are you looking to have medical treatment?42% planned for treatment within 2-6 months. 22% have chronic conditions and are looking to travel at the earliest opportunity.

What specific treatments are you looking for overseas?63% are looking for diagnosis and subsequent treatment, 9% are looking for surgery abroad, and 6% are interested in cosmetic surgery, while 7% are looking for dental treatment. 15% express interest in spa and preventative medicine.

What countries are of most interest for your treatment abroad?Two countries, both with long involvement in the market, lead the list: Germany recorded 32% followed by Israel with 22%. Others are Hungary at 6%, Spain at 5%, Switzerland at 5%, and Czech Republic at 4%. Bulgaria, Austria, Turkey, and China each scored 3%. 36 countries were indicated as medical tourism destinations of interest .The results may suggest that Russians from this region prefer to go to European countries, but those thousands of miles away in Eastern Russia may prefer Asia, and Arab states, or they too may prefer Europe. It may be something countries should research before targeting the Russian market.

What is your primary reason for visiting the Moscow MedShow?41% were visiting the exhibition to gather first-hand information on what medical treatments are available abroad, their costs, and conditions. 17% have a specific condition that required treatment and are looking for direct meetings/contacts with hospitals/clinics. 9% are looking for information and details on preventative medicine, while 33% are there out of professional interest.

Age and genderThe age of Russian looking for treatment abroad revealed some interesting statistics, as 46% are 30 to 50, 40% over 50 and 14% under 30.58% are female and 42% male.

It has been many years coming, but the government’s medical tourism initiative is finally happening, with a more realistic approach. Originally it promised thousands of new jobs, and thousands of new tourists.
The latest target, although still based on little more than guesswork, promises up to 3,000 jobs in the next four years, during this four-year term, about 50% less than what some officials had hoped.
Puerto Rico is a self-governing territory of the USA, with a population of 3.7 million. Tourism is an important money-earner; the island receives up to three million visitors each year and is a port-of-call for cruise liners.
Being a United States territory, no passport is required for travel for US citizens, and the cost of treatment is less than half of that on the mainland. It has a few medical centres offering cosmetic surgery, cancer treatment and a full range of medical treatment. But the public healthcare system is overstretched and there is little investment in private healthcare. American medical travellers have the same legal recourse as they do in the U.S.
The administration is hoping to do deals with US health insurance plans and target markets where there are significant Latino populations. It is not exactly a sophisticated strategy. And the politicians have not even agreed to spend money to set up a medical tourism promotion board, so a strategy based on a new body to promote the region could again fall at the first hurdle.
There is a significant US military contingent at bases in Puerto Rico, but the US Military health system (TriCare) sends its troops and dependents home to the mainland for medical care of any significance – even maternity care because basic obstetrical care is insufficient to meet TriCare standards.

For 15 years, Malaysia has steadily worked towards building a strong healthcare tourism sector. In the last 10 years, revenue from healthcare tourism increased tenfold. This makes it one of the fastest growing sectors in the country.
In 2012, growth was 16.2% and in 2013 this was 15.8% .The Malaysian government is optimistically targeting 10 % annual revenue growth in both 2014 and 2015.
The biggest source of business is nearby Indonesia partly due to the lack of health care in Indonesia, partly due to price, and partly due to the comfort that Indonesians have in going to a fellow Muslim country with halal food.
Another key source of business is Singapore, due to the overcrowding in Singapore hospitals and the much higher medical costs in Singapore.Just over half of Malaysia’s business is in the state of Penang. The state recorded revenue of RM370 million in 2013, a 20% increase on 2012.
Dr. Mary Wong Lai Lin of the Malaysian Healthcare Travel Council (MHTC) comments,” Malaysia is the only country in the region where healthcare tourism is promoted by the government.” The ministry of health plays an important role in ensuring that private health facilities country adhere to all the necessary safety and quality requirements by regulating them through the Private Healthcare Facilities and Services Act 1998 and Regulations 2006.”

Construction of China’s first special zone for medical travel will begin later this year.
The Boao Lecheng International Medical Travel Zone is at Boao Town in Qionghai city and covers an area of about 20 square kilometers. The areas in the plans include the Dale area and Xiaole Islet area. The Xiaole Area will consist of three projects: the Bole Zero-carbon Pavilion, a healthcare centre and a redevelopment project. Projects in the Dale Area include an advanced cancer treatment center, an international conference center and a healthcare infrastructure facility. As the first healthcare project in the zone, construction on the advanced cancer treatment center will begin this December and will be in use within 3 years.
Construction cost of the zone is estimated to reach US $ 16 million, and most of the projects are expected to be ready by 2016.Hainan province is constructing China’s first special zone for medical travel, in order to attract domestic and international medical tourists. Traditionally in China, people prefer to stay where they are and seldom travel, but an increasing number of people are breaking with tradition. Particularly for older retired Chinese, when winter comes, they pack up and go to Hainan, China’s tropical island province, to avoid the cold in the north.
At present Hainan is a good place for winter retirees, but there are few local medical services and amenities. Included in the new development will be traditional Chinese medicine and many wellness options.
Lu Zhiyuan of the Hainan Tourism Development Committee says Hainan Island has a unique advantage for developing medical tourism,” The island has very good air quality, very pure water, blue sky and ocean."
There is some confusion as to whether it is mainly a health and wellness destination and whether it really will have any potential to target overseas visitors. As with any Chinese state development, all statements are super optimistic and any criticism or awkward questions are promptly crushed.
In many ways it is all an experiment. The government is allowing several privileges and policies in the trial zone. Overseas medical institutions are allowed to set up business within the zone. Other preferential policies include lower taxes for imported medical instruments and medicines.

The Colorado Senate is waiting for the state governor to regulate the travel insurance industry in the state for the first time.
House Bill 1185 requires the Division of Insurance to issue licenses for limited-lines travel insurance, typically purchased by tourists wanting to hedge against a last-minute trip cancellation or seeking coverage if they need to be evacuated from a vacation for medical reasons. This would include policies bought by Americans in the state going to another US state or another country for medical treatment.
The Senate was moved to act after getting complaints from people who had bought travel policies from unregulated companies, only to find that they did not cover everything they expected.
The bill is expected to become law sometime later this year. This is part of a general trend where an increasing number of US states are either producing regulations that are wider then US federal regulation, or where the Federal government is slow to act; this year there has been a flurry of state based regulation on various consumer issues including peer to peer lending and equity crowd funding. There is a common theme, on areas where consumers are being asked to pay relatively substantial sums of money to businesses offering services where the business has specialist knowledge that the consumer lacks.
The question now is, which will be the first state to regulate medical tourism agencies?

Arizona-based company American World Clinics (AWC) has had agreement to build a private clinic in Costa Rica that will mainly offer health care services to foreign retirees and medical tourists.
AWC is investing $150 million in the construction of a 12,000-square-metre clinic scheduled to open in 2016 in San Rafael de Alajuela on the main road connecting San José with the Pacific province of Puntarenas.
It will offer general surgery plus specialty care in orthopaedics, cardiology, urology, oncology, and cosmetic surgery. AWC estimates the hospital will have the capacity to perform up to 18,000 surgeries annually. The project also includes construction of a five-star, 100-room hotel operated by California company K-Hotels, and a retirement community for 400 people. It is being funded by New York financier National Standard Finance.
AWC plans to locate in highly desirable locations throughout the world. The first location in development is Barbados, with other potential locations including the Bahamas, Canary Islands, the Dominican Republic, Uruguay and Spain.
Gran Canaria in Spain is a possible location for a new clinic, while Madrid is another option.

The Expatriate Health Coverage Clarification Act of 2014 has been passed by the U.S. House of Representatives. The bill clarifies that the Affordable Care Act does not apply to expatriate health insurance plans, such as those plans offered by major US insurers to US expatriates working overseas.
The bill had previously been defeated but success was due to changing the wording to clarify that the definition of an expatriate is someone who spends at least six months outside of the USA.
The measure is aimed at helping U.S. insurance companies that are at a competitive disadvantage with foreign firms that do not have to comply with ACA requirements such as free preventive care and a ban on lifetime coverage limits.
Expatriate health insurance plans offer high-end, very wide cover to executives and others working outside their home country, giving them access to a global network of health care providers. But if ACA rules were to apply to U.S. insurance companies offering these plans, those rules raise costs and put non-U.S. insurance companies at a competitive advantage. Members of both parties agree that these plans should therefore be exempt.
There was widespread agreement on the need for a fix under the health law for US – written expatriate plans that can be sold to Americans working overseas and foreigners working in the USA or elsewhere.
But senior Democrats and the White House opposed the bill on the grounds that legal permanent US residents could be sold expatriate plans that do not meet the basic requirements of the health law. Further changes are expected as it moves through the Senate, to fill these legal loopholes.
The relevance for medical tourism is that in the past several attempts have been made to sell insurance plans, often written outside the USA, that include elements of medical tourism- with these plans being targeted at people from a particular country who work and live in the USA but may consider treatment elsewhere.
The new law makes it clear that plans underwritten in the USA or elsewhere targeted at US expatriates working anywhere in the world, are legal under the Affordable Care Act.
It also makes it clear that specialist plans aimed at expatriates of any nationality working in the USA are also legal.
Medical tourism agencies thinking that this offers a new opportunity to target the Diaspora of a particular country are going to be disappointed.
The new law does not change the basics that the Affordable Care Act rules apply to people living and working in the USA; they do not have to be US citizens.
The tax authorities run certain aspects of the ACA and their ruling is simple; a temporary expatriate working for a few months in the USA does not have to comply with the ACA. But even if they are an expatriate of another country who settles in the USA, without becoming a US citizen, they must comply with the ACA. Only the tax officials of the IRS can rule when a temporary expatriate becomes a US resident, but tax lawyers advise that the maximum term is 12 months, and if it clear that the person is becoming a permanent resident then effectively the IRS will allow them a few months to settle in and then treat them as a US resident; the IRS does not have to wait 12 months to do this. And the new law now rules that expatriates can only work for 6 months in a year in the USA before ACA rules apply.
So if a medical tourism agency or insurance broker wants to link overseas treatment to an insurance plan, as the expatriate may prefer treatment in their home country, then they can now do this without breaking the ACA. But they cannot also offer that plan to people from that country who are resident in the USA, unless it complies fully with all the rules and regulations on cover and pricing as required under the ACA. Even then it may not be legal, because insurance in the US is regulated on a state by state basis and it is up to the commissioners in each and every state that the plan is marketed in to decide whether or not that plan and the offering agency and the insurer, are doing so legally.
Even cross- border plans between the USA and Canada, and USA and Mexico, have problems, as while California accepts their legality, Texas does not.
For any other insurance plan offered from outside the US targeting citizens of a particular country, the chances of it complying with the requirements of the ACA, IRS and state insurance commissioners is very slim.
The big US insurers of expatriate insurance plans are very relieved at this new law, but even then, just because it is legal in the USA, does not make it legal in the country the US expatriate is working and living in; as an increasing number of countries are tightening the rules on what insurers can offer from both within their country and as offshore insurances targeted at people in that country. All the big US insurers have looked at, researched and even piloted combining domestic or international health insurance with medical tourism, and without exception they have walked away from the concept, other than for Mexican cross border plans.