The island of Cuba, just 90 miles from Florida’s coast, has had a fifty year dispute with the USA.The cash-strapped state has suffered from an embargo that prevents trade with the US.
But with a new president, a new day may be dawning. US entrepreneurs are planning for the day when the embargo is lifted. Tourism firms have the promise of new regulations promising greater access. Although Cuban-Americans have been able to go there since April, the big unknown is if or when other Americans can travel there freely.
More foreign visitors would provide access to the quick cash that it needs to jump-start the economy. The island received 2.3 million visitors in 2008, according to the Caribbean Tourism Organization. If the U.S. government dropped its travel restrictions entirely, the island could expect more than one million additional visitors a year.
The island has about 50,000 hotel rooms, and while it is making improvements, its phone system, electricity and water supply infrastructure are struggling. Cuba needs the infrastructure to attract investors, but it can’t pay for the infrastructure until it gets the investors.
Cuba’s mild weather, proximity to the United States and surplus of trained doctors and nurses could make it ideal for Cuban-American retirees and those requiring long-term medical care.
The Cuban economy has benefited from the promotion of health tourism. This is despite the fact that Americans, but not Canadians, could be punished by fines and imprisonment for travelling to Cuba without a special licence that was harder and harder to get during the Bush era. The official position is unchanged but in practice special licences are easily obtainable now and penalties are not imposed.
Cubanacan Turismo y Salud (Cubanacan Tourism and Health), the   state owned travel and tourism agency oversees more than 25 of Cuba’s hotels, luxury resorts, restaurants, and other tourism properties used by health tourists. Sol Melia manages a quarter of the hotel stock but all hotels are government-owned.
Although the citizens of Cuba are often ill-afforded a decent standard of healthcare, health tourists are offered top level care at prices that are often far below those in North America. All overseas medical tourism agencies have to go via Cubanacan Tourism and Health. The company varies in how many overseas patients it says it deals with, as the answer can depend on which country you are from. Figures vary from 3500 to 9000 patients, from 40 countries.
Cuba says it can handle the surge of American travellers expected if restrictions to the island are lifted. The number of American visitors would increase slowly if the ban were lifted because it would take time for airlines to develop routes and for operators and agents to put together Cuba packages, Cuba plans to build 30 new hotels with 10,000 rooms by 2014, regardless of whether or not the travel ban is lifted. Cuba has a network of specialist medical and health centres that deal with foreign clients, but bed capacity is limited.

It is easy to forget that India is more than just a country offering cut-price surgery. The size and breadth of the medical and health tourism market is staggering. Spa and traditional medicine are at least as important as modern medicine.
The popularity of the Indian spa industry is increasing every year, making the country one of the most popular spa destinations across the world. The Indian spa industry, with over 2300 spas, generates revenues around US$ 400 Million annually. India has 20-25 major spa centres, mostly in the Southern states such as Kerala and Karnataka. Hotel chains are undertaking major renovations to update their spas in order to meet the needs of Western tourists. These include vichy showers, lockers, hydrotherapy tubs and steam, sauna and multipurpose rooms for massage and facials.
In India, there are 380,000 registered medical practitioners of the ayurvedic system as compared to about 700,000 modern medical systems. Ayurvedic and medical tourism industries will be beneficiaries of the 2010 Commonwealth Games, according to The Associated Chambers of Commerce and Industry of India (ASSOCHAM). Major hospital chains and ayurvedic/spa centres are gearing up to attract large number of visitors.
A paper by ASSOCHAM on the opportunity for ayurvedic and medical tourism during the Commonwealth Games, predicts opportunities from tourists from UK, Canada, Australia, Malaysia, South Africa, Singapore, Sri Lanka and elsewhere. 200 ayurveda, spa and herbal centres will provide services to tourists and athletes during the games.
In September, ICRI-Health of Delhi held a workshop on medical tourism in India .The aim was to understand the healthcare set up in India from the perspective of international patients. Also covered was the role of medical tourism agencies and how to evolve a link between them and hospitals. ICRI Health is offering a two-year full time MBA in healthcare management with the option of specialization in medical tourism in the final year.
India: Medical Tourism Destination 2009, the first ever trade show in Canada by leading Indian hospitals, wellness and medical tourism players, is to be held in Toronto, from November 20th to 22nd 2009 at the Metro Toronto Convention Centre. The conference is supported by The Indian Medical Travel Association (IMTA), the Embassy of India in Canada, Ministry of Tourism and medical tourism agency Surgical Tourism Canada. Canada is seen as a good market for promoting medical tourism to India as the healthcare delivery system is under strain and waiting lists are growing. There is also a large population of Indian origin in Canada

The Beauty and Healthcare Tourism Promotion Association of Kaohsiung City will visit Beijing to attend a cross-Taiwan Strait medical tourism alliance conference in late October to promote its health care services. The association consists of representatives from local medical institutions, clinics, hotels, the catering industry and restaurants, and travel agencies. The Association’s president, Tsao Shi-bin, says the association will use the occasion to promote southern Taiwan’s health care and tourism sectors to Chinese government officials and representatives of civic organizations.
The main purpose of their planned trip to Beijing is to introduce the quality medical tourism services offered by the many mid- and small-scale clinics in the southern port city and spark interest among Chinese tourists seeking micro cosmetic surgery and health checks in Taiwan. The conference in Beijing came after the association signed an agreement on medical tourism cooperation with a private health care group in China in July. Under the pact, Chinese tourists will enter and leave from southern Taiwan when they visit the island for medical tourism.
To help increase the market share of Taiwan medical travel programs in Taiwanese-American and Chinese-American communities in the USA, Dr. Wu Mingyan of Taiwan Task Force for Medical Travel (TTFMT) has signed cooperation deals with medical tourism agencies in Los Angeles.
TTFMT, established by joint cooperation of Taiwan Nongovernmental Hospitals & Clinics Association, Taiwan External Trade Development Council and Chung-Hua Institution for Economic Research to promote medical travel programs, has been supported by the Overseas Chinese Affairs Committee of Taiwan. The committee is in charge of connections between overseas Taiwanese and Chinese and their descendents and the government of Taiwan. The committee chairman believes that tens of millions of Taiwanese and Chinese and their descendents who live abroad would benefit from Taiwan’s affordable high quality of medical services. He supports and promotes Taiwan medical travel, as the success will help bring the relationship between the emigrants and Taiwan even closer and help Taiwan develop its medical business.
The committee will promote Taiwan medical tourism through all of its overseas branch offices. The issue will also be addressed in all of the committee’s services, activities and programmes. The focus is on the affordability of health check-ups and specialised surgical treatment. Specialist treatment includes living donor liver transplantation, cardiovascular treatments, craniofacial reconstruction surgery, joint replacement surgery and artificial reproductive techniques. Surgery in Taiwan’s costs about one fifth of the price in the United States, and one sixth of the price in the UK. Tonsil removal surgery costs $500 to $600 USD in Taiwan but the same procedure would cost ten times higher in the United States. Similar differences exist for endoscopies, colon fiber mirror, cancer tomography and other examinations; PET costs half the price of the US fee.

However many thousands or millions there are traveling overseas for medical treatment, the majority will either have no travel insurance or have travel insurance that if claimed on, is likely to refuse to pay out on finding that they are medical tourists. Across the world many travel agencies and medical tourism agencies are arranging insurance for medical tourists, unaware that standard travel insurance schemes do not provide cover for medical tourists. Part of the problem is misinformation, even from insurance trade bodies. If your car was on fire, and you rang an insurance company, you would be surprised if they would insure it and pay for the fire damage. As the most expensive area that travel insurance covers is medical treatment, why do people expect insurers to cover medical tourists just as they would holidaymakers?
The UK pioneered specialist medical travel insurance, with Health Traveller from Marcus Hearn, followed later by specialist company Angelis Insurance. Two or three US based products followed, including Seven Corners with a product that also targeted UK based medical tourists. Now a major UK travel insurance provider is taking existing players on with its own cover, for UK residents and expatriates, underwritten by major travel insurer AXA.
P J Hayman has launched Free Spirit-travel for treatment, travel insurance for UK nationals, resident in the UK or elsewhere in the EEA or the Channel Islands, travelling abroad for surgical, dental or cosmetic treatment. Special features include an upper age limit of 74, and cover for complications occurring after 48 hours and up to 31 days whilst abroad.
Prior to the launch, PJ Hayman organized a survey of 1300 British adults. This suggests that despite common elective, cosmetic and dental surgery costing up to 89% less overseas, the majority of UK consumers are too worried about something going wrong to travel abroad for treatment. The biggest fears for most people when considering treatment abroad are the potential side effects after surgery (20%) followed by risks involved during surgery (18%)post surgery complication costs (16%), whether the organizer or provider is reputable (13%) and costs (10%).
Worry about complications (31%) is the most commonly cited reason for why 74% of the UK population is unwilling to go abroad for surgery. Concerns about standards (28%), distrust of foreign medical practices (21%) and not wanting to be so far from home (15%) are also seen as major barriers to foreign treatment. Of those who would consider travelling abroad for treatment, both men and women rated dental surgery as the most popular potential procedure.   Laser eye surgery and breast surgery are popular options, followed by hip replacement, liposuction, and facelifts.
Peter Hayman says, With the cost of treatment abroad an average of £1256 lower than in the UK and with many reputable companies operating overseas, the option of foreign surgery should not be ignored. To put any fears to rest, it is important that those considering surgery abroad should undertake thorough research before making their decision and also ensure they take out appropriate travel insurance to cover them in the unlikely event that anything goes wrong.

Zurich University Hospital has stopped treating North American medical tourists from the USA and Canada, fearing million-dollar claims from litigious patients if operations go wrong. Other Swiss hospitals are cautious as to what they treat Americans for, but have no outright bans.
The ban applies to patients from the US and Canada who come to Zurich for elective treatments. The hospital is not prepared to put itself at risk of legal actions or incur a significant increase in its own medical indemnity premiums. The concern is not that these patients are self-financing, but the propensity to sue within different healthcare systems; litigation for medical negligence is far more common in the USA than in Switzerland. The ban does not apply to North Americans living in Switzerland, nor to emergency treatment.
Of the 170,000 patients Zurich University hospital treats annually, 3,000 come from abroad. Only 30 are North Americans; and these are mainly emergencies. Most medical tourists come from Europe, the Middle East or Russia.
In some hospitals in the Valais region, medical tourists have to sign a specific consent form that states that the limits of responsibility are fixed in Swiss civil law, and legal action can only be taken in Switzerland. This is not uncommon, even for patients based in Switzerland, as it stops patients from shopping across Europe. Switzerland is not part of the EU so is unaffected by rules allowing patients freedom of legal action and medical treatment across the EU.
Switzerland was one of the first health tourism destinations, as early as the 19th century when wealthy travellers came to spas. For years before medical tourism became an industry, local hospitals and clinics have treated wealthy people seeking specialist and discreet attention.
Switzerland has a reputation for healthcare excellence. Zurich-based think tank Gottlieb Duttweiler Institute carried out a study on Switzerland’s potential and concludes that the country could do more to attract wealthy foreigners looking for specialist treatment.
Up to 30,000 foreigners a year are treated in Swiss hospitals, but this includes business and holiday travellers, plus expatriates living there. So the actual number of medical tourists is lower but unknown. However, there are another 150,000 travelling every year for health spa holidays. There are 321 hospitals in Switzerland. 68% are public, 38% are private.
Private Swiss clinics advertise surgery in in-flight magazines while agencies specialising in organising medical treatment for foreigners offer a deluxe service covering everything from interpreters to visas. People travel to Switzerland for a broad range of treatments and procedures, cosmetic surgery included. Agency Swixmed is a local medical tourism agency that offers treatment in local hospitals. For the last decade Swiss Leading Hospitals (SLH), a federation of 18 hospitals in Switzerland, have been offering a combination of top-class medical treatment and five-star hotel accommodation. Switzerland competes on quality of care and has little interest in attracting medical tourism business with low prices.

The International Medical Travel Association (IMTA), a non-profit association registered in Singapore, has been notified that the Medical Tourism Association (MTA), a non-profit association incorporated in Florida, has filed a legal complaint against the IMTA for unfair competition and trade name infringement.   The complaint was filed on September 10, 2009 in US District Court for the Southern District of Florida.

In a statement released to its members, Ruben Toral, IMTA President, says, This makes no sense.  The IMTA was clearly the first organization of its kind to serve the medical travel industry; there are over a half dozen associations with medical tourism in their name; and the organization is not engaged in any commercial activity whatsoever. " 

Mr. Toral cites the Indian Medical Travel Association and the Asian Medical Tourism Association as examples of two recently formed organizations that would qualify for trade name infringement using MTA standards.

Based on registration documents filed in Singapore and the US, the International Medical Travel Association was registered in Singapore in October 2006 and the Medical Tourism Association was incorporated in May 2007

IMTA’s official statement says, It is unclear why the MTA singled out the IMTA, whose officers and board members perform their duties on an unpaid, voluntary basis.  Several attempts were made to settle this issue amicably, but were unsuccessful and the continuous threat of litigation made it difficult for the organization to carry out meaningful initiatives around quality, liability and continuity of care.  

IMTA adds The IMTA views the action taken by the MTA as a potentially dangerous precedent for the medical tourism industry, and creates a framework that moves dispute resolution from the boardroom to the courtroom.  The IMTA is in communication with its membership on how best to address this issue, but views litigation as both unnecessary and unwarranted.

Footnote
Readers should note that IMTJ has no relationship with and is not a member of either the MTA or the IMTA and is independent of both associations.  IMTJ also reminds any readers that wish to comment on this legal action to bear in mind that this is now a live legal action that could come to court soon.

Bangkok’s Bumrungrad is often held up as one of the first hospitals in the world to focus on medical tourism. Thailand’s Bumrungrad International Hospital has been attracting patients from America, Europe, Australasia, and Asia and across the Middle East with a combination of lower-cost, state-of-the-art medical care and five-star hotel service. It claims more than one million patients, including 40% from 200 countries visit every year for outpatient or in-patient treatment. However, some have expressed doubts about the validity of these medical tourist figures due to the way in which patient numbers are counted at Bumrungrad; it is suggested that multiple visits to the hospital by a single patient are reported multiple times, thus inflating the patient numbers.SouthEast Asia’s largest private hospital plans to increase inpatient admission numbers by 30% over the next few years and double capacity for outpatients.The private hospital was opened in January 1997. 2001 saw the United States put visa restrictions on people from the Middle East; so many Middle Eastern patients sought alternatives. The hospital saw about 12,000 Middle Eastern patients in 2001 and by 2008 this had increased to more than 100,000. The hospital sees 3000 outpatients including 1200 who are non-Thai. The international patients are medical tourists, business and other travelers, and expatriates living in Thailand. International patients make up 42% of patient volume, but 55% of revenue. The hospital has developed services for international patients. The International Medical Coordination Office [IMCO] has 25 doctors and nurses. Annually, 600,000 patients are Thai. A large number of patients are either expats in Thailand or the region or come from surrounding countries including Vietnam, Cambodia, Burma and Bangladesh, who come for advanced treatment. Then there are 30,000 patients a year from North America, under 30,000 patients from Europe and under 30,000 from East Asia, which includes Japan and China. Over 100,000 patients a year come from the Middle East and those are mainly the Gulf countries, principally the United Arab Emirates, Qatar and Oman. There are growing numbers from Africa and Australia. In Southeast Asia, the Middle East, Africa, and emerging markets like Mongolia and Ethiopia, patients go for advanced care that they cannot find at the hospitals in their country. Medical tourists from the US mostly go due to the cost being from 50% to 80% less expensive than for comparable procedures in the US. Bumrungrad was the first hospital in Asia to be JCI accredited in 2002 and has been reaccredited three times. This year, the hospital has signed up for the International Quality Indicator Project (IQIP), being the first hospital in Thailand and one of the first hospitals in Asia to sign up. The International Quality Indicator Project (IQIP) assists healthcare organizations in identifying opportunities for improvement in patient care. Nearly 180 healthcare organizations in 12 countries use the IQIP tools to collect, analyze, and compare clinical and administrative health care data.The hospital owns 31.5 % of Bumrungrad International Limited (BIL), with other investment partners in Dubai and Singapore, and private investors in Bangkok. BIL is an investment and operational arm outside Thailand. BIL is majority owner a hospital in Manila, Asia Hospital International. It has a five-year management contract with the government of the United Arab Emirates to manage the Al Mafraq Hospital in Abu Dhabi that includes planning a 600-bed hospital to replace the existing hospital.

An increasing number of Chinese and Japanese women head to Korea for beauty treatments and cosmetic surgery, encouraged by a vogue for Korean actresses among Asia’s young people and a Korean pop culture boom in the region. Many Korean clinics have websites in Chinese and Japanese, as well as English and Korean.
A dermatology clinic in southern Seoul sees 10 Chinese women a month for cosmetic treatment. More than 90 percent of the patients are professionals or family of executives of large Chinese corporations or high-ranking government officials. They range in age from their 20s to 50s. Korean doctors say most Chinese patients seek dermatological treatment and cosmetic surgery together. Some Chinese women travel twice a year to get their Botox injections renewed. Chinese patients will make the trip from Shanghai to Seoul several times if their surgery has to be done in stages. The Korean cosmetic surgery boom is expanding its reach to Japan. More Japanese are traveling after Japan’s Nihon TV made a programme on a clinic in Seoul.
How long the boom will go on for is debatable as more Chinese doctors and clinics offer Korean style makeovers. Another problem is that cosmetic surgeons in Korea are furious that the Ministry of Strategy and Finance plans to impose VAT on all cosmetic surgery not covered by national health insurance. Under the current law, medical procedures are exempt from VAT. But as of next July, procedures like eyelid surgery, breast augmentation, nose jobs, wrinkle-removing surgery and liposuction will be subject to VAT. Surgeons say VAT is unreasonable as it is a medical practice that treats physical complex of patients. For example, breast augmentation surgery may be equivalent to depression treatment for a woman with small breasts, and liposuction may be done not only out of desire to be more beautiful but also to treat obesity. The government is not convinced by these arguments.
Surgeons fear VAT will depress the booming price sensitive market as it is likely to raise the cost of surgery by 10 percent. Hwang Young-joong, president of the Korean Association of Plastic Surgeons, says, "The government action is contradictory as it encourages surgeons to attract more foreign patients while putting a dampener on the market with the introduction of new tax."
Cosmetic surgeons claim the issue is fairness. If the rule is to charge VAT on procedures undergone with the goal of looking more beautiful, then hair transplants, eyesight-corrective LASIK surgery, straightening of teeth, and anti-wrinkle Botox treatment should also be subject to VAT. Clinics offering these services are less than thrilled as the government has taken the suggestion on board as it sees more ways to increase tax revenue by adding VAT to these procedures. Lee Sang-yul, in charge of VAT at the Ministry of Strategy and Finance, says, "All European countries that have VAT impose it on cosmetic surgery. We have not set the range of procedures yet, but we will now expand the range gradually."

Medicare is a key area within US health reform. Medicare does not pay for treatment overseas. Medicare has very strict guidelines on what hospitals it uses and how it pays them, so any country hoping for a Medicare paid medical tourism boom is going to be disappointed.
Of the 800,000 American citizens living in Mexico, 200,000 are over 60 years old and at or near eligibility for Medicare benefits. Last year, Paul Crist founded Americans for Medicare for Mexico (AMMAC), a non-profit organization dedicated to bringing Medicare coverage to seniors living in Mexico. Crist has lobbied 85 members of the U.S. Congress and prepared a 34-page proposal in which he outlines the pros of extending Medicare to Mexico, Medicare is now spending $6700 per year per beneficiary in the United States. For the same care in Mexico, my estimate is that it will spend only $3400 dollars, which translates to a very substantial saving. His argument is that if Medicare is extended to Mexico, the programme would only work with hospitals approved by JCI.This is one reason why there are now 10 JCI hospitals in Mexico, over 20 in the pipeline, and most new ones are built to JCI standards. Crist argues that if Medicare is accepted in Mexico, the 64 percent of American retirees currently flying back to the United States for expensive care would opt for treatment nearer their homes, cutting Medicare overall costs by a minimum of 22 percent.
Although the health sector is regulated and certified by the Mexican General Health Commission, the task of getting JCI certification for private hospitals is of prime importance. One of the main reasons for pushing for certification is that the North American Free Trade Agreement obligates the Mexican medical system to be on a par with the United States and Canada, allowing for the free flow of patients from border to border and for fair trade. The logic is that as long as hospitals are prepared to accept the delays and detail of the Medicare system, it makes sense for Medicare to accept JCI hospitals in Mexico. Crist argues that Mexican hospital standards are similar so Medicare should accept all hospitals. That argument falls on the basis that if the standards are similar, why are Mexican hospitals keen to spend substantial sums of money in getting JCI accreditation?
Whether Mexican heath care meets Medicare’s quality standards and payment system is debatable. The US government is concerned that creating a Mexican medical exemption might be too complicated and costly to implement and would open the door for Americans in other countries.
The approval of Medicare would greatly benefit hospitals such as Christus Muguerza, a Texas chain that now has seven hospitals under construction across Mexico. Even without a Medicare deal, most Americans seeking overseas treatment seem much happier travelling the short distance to Mexico than hopping on a plane to Asia .It is easy to forget that in the US, Hispanics are now the largest racial group.

Earlier this month, health tourism was the main topic of programme on a major German television channel. The presenter followed health tourists from Germany and USA searching for treatment in Bangkok, Thailand. The documentary dealt with questions about legal aspects of health tourism, quality of care and patient safety. The camera crew followed a TEMOS assessors’ team during its certification visit at the Bangkok Hospital Medical Center.
Telemedicine for the Mobile Society (TEMOS), the network based in Germany that certifies hospitals for quality, is a subsidiary company of German Aerospace Centre (owned by the German Government). It has already certified 31 facilities in South-east Asia, Eastern and South Europe. The TEMOS certification system and the respective standards were established in 2006 as the result of problems insurance companies worldwide were facing with respect to the management of international patient cases.
TEMOS has no interest in the USA or Canada, but is focusing expansion plans on countries with a high number of medical tourists from Europe in general and Germany in particular. Mainly this will be South/East Europe and Asian countries, especially India, Indonesia, China, and Korea.
The company is going to release a new product ’ TEMOS Health Tourism’ for TEMOS -certified hospitals in the third quarter of 2009. Certified hospitals will get free access to tele-lectures, e-courses and relevant partners from research, insurance and assistance institutions from Germany and other European countries. TEMOS will also offer consultancy for implementing second opinion treatments in hospitals. TEMOS is working with German doctors, travel agencies and medical tourism agencies to encourage them to direct health tourists to TEMOS certified hospitals.
The TEMOS Quality System is different from other certification   or accreditation systems on the market. Applicants for certification have to prove that they are able to treat international patients on a high quality level. Most of the hospitals applying already have a national or an international accreditation. Even before the process begins they must have a quality system in place, be interested in medical and non-medical aspects of patient care and international patients or intend to do so in the near future. The evaluation begins with a detailed self-evaluation form, which collects data about staff, infrastructure, communication, medical disciplines, quality management and more. This is followed by on-site evaluation visit lasting two to three days; depending on the size and complexity of the respective facility All TEMOS assessors are medical doctors with international experience in medicine and quality in medical care worldwide. Within eight weeks after the audit, the applying facility gets a comprehensive individual report with recommendations on how to optimize its services. Once any outstanding items are resolved, the hospital is presented with the certificate. The first re-certification is due 3 years after certification has been granted. It will again include an on-site evaluation visit and a detailed report afterwards.
TEMOS has developed special quality criteria, which partner hospitals and clinics in the TEMOS network have to fulfill. These criteria are based on the needs of tourists in foreign countries and have been developed in cooperation with leading assistance companies and experts in travel medicine.