The private sector of Singapore’s medical tourism industry is looking beyond the Lion City to grow their business.
ParkwayHealth, controlled by the US-based private equity firm Texas Pacific Group (TPG), has plans to set up several multispeciality hospitals in India.
The group is also tying up with some of the leading healthcare providers in India apart from its plans to build hospitals on its own.
Currently, it has an agreement with Apollo Hospitals Group and has bought a 50 percent stake in the Khubchandani Hospital in Mumbai that is jointly owned by the Mauritius-based Koncentric Investments.
ParkwayHeath plans to initially invest approximately US$83 million in Khubchandani Hospital. Starting with five or six hospitals in large cities, the former has plans to set up 300-400-bed multispeciality hospitals all over the country.
The Khubchandani Hospital, which will be a 1,000-bed facility, is expected to be operational by 2011. The agreement with Apollo Group is intended to help ParkwayHealth develop hospitals across West Bengal. This joint venture currently runs Apollo Gleneagles Hospital, a 325-bed multispeciality hospital in Kolkota. This hospital will cater to Eastern India and neighbouring countries like Bangladesh, Myanmar, Nepal and Bhutan.
Another group that believes while some patients will come to you, you can get many more by going to them is Singapore Medical Group (SMG).
SMG originally entered the medical tourism market through the Lasik Surgery Clinic (LSC), a specialist centre that treats myopia.
The company’s business model, which draws a clear line between management and medicine, has been so successful that SMG has exported the model to the Philippines. LSC Manila is a joint venture with STI Dela Santos, which owns the largest nursing school in the Philippines in Alabang. SMG operates LSC Alabang with Bumungrad Thailand, while LSC Angeles City is a joint venture with Angeles University Foundation.
Although it is not a traditional market for Singapore companies, the Philippines is an English-speaking country of 85 million people and refractive surgery is in its infancy. No, we rank No. 1 there in volume with all three LSC clinics combined, said SMG founder Dr Cheryl Baumann.
After lasik surgery, SMG pioneered sports medicine in Singapore by partnering with Changi General Hospital to set up the Singapore Sports Medicine Centre. SMG then went on to open The Dental Studio, focusing on cosmetic dentistry, the Singapore Aesthetic Centre, which offers weight management and dermatology treatment, Singapore Vision Centre for patients with eye conditions other than myopia and oncology in The Cancer Centre. This year, SMG expects to establish presence in Japan, China and Vietnam.

RevaHealth.com will continue the expansion of its health clinic search engine. Having originally focused on niche healthcare markets, the company is now expanding into wider local and national healthcare markets and plans to move into the Far East and American markets later in 2009.
Dublin-based RevaHealth.com, the registered business name of Global Medical Treatment Ltd, has received a €1.25 million (US$1.62 million) investment, led by Mianach Venture Capital and supported by Enterprise Ireland.
RevaHealth.com is a search engine that helps users find and compare health clinics worldwide. Founded in 2006, it currently stores information on over 60,000 clinics in the UK, Ireland and 50 other countries worldwide, but only around 1,000 of these are featured clinics which pay for detailed listings.  
Users can search for clinics by treatment and location and easily compare their options before contacting their chosen clinic.
"More consumers are going online to research their healthcare options. RevaHealth.com provides a valuable service that gives consumers an easy way to find and compare health clinics worldwide. We now intend to take our proven business model to a wider market," said RevaHealth.com founder Caelen King.
The first expansion is into Singapore.
King said: "People find it difficult to source clinics in Singapore that offer the particular treatment they are looking for, be it a coronary angioplasty, an eyelift or tooth implants. RevaHealth.com lets visitors easily find and compare over 160 clinics in Singapore, helping them save time and money in finding the best clinic and treatment for their needs."
RevaHealth claims to be the world ’s largest medical tourism search engine. Despite being challenged by IMTJ to substantiate this claim on monthly site traffic or other criteria, the company declined to do so.
It did offer less than convincing off the record information that attempted to justify this claim. As the responses mentioned leading competitors by name and even refuted that these companies were medical tourism search engines, RevaHealth’s claims was put to competitors.
Competitors commented that their traffic figures were higher than RevaHealth’s.
Medical tourism has more than its fair share of people making bold yet unsubstantiated claims, and the moral of the story is that if you make claims to be the largest or the best, then, you had better be able to back them up when challenged. Failure to do so just plays into the hands of those opposed to medical tourism who regard parts of the industry as no better than snake oil salesmen making empty claims they cannot substantiate.

At the first International Medical Tourism Congress held in Amman between January 30 and February 2, industry insiders said medical tourism in Jordan is gaining momentum due to its contribution to the national economy.
Fawzi Hammouri, president of the Private Hospitals Association and director of Specialty Hospital, noted: Medical tourism experts at the World Bank have ranked Jordan number one in the Arab region and the fifth in the world as a medical tourism hub. The number of foreign patients seeking treatment in the Kingdom stands at over 200,000 per year. We are seeking to maintain and improve this bright image even more through reaching new markets in Europe, Asia and the US.
Added Abdullah Bashir, director of Jordan Hospital: "Jordan has achieved an advanced status in the field of medical tourism due to the sector’s medical, human and technical potential, which earned the country an outstanding reputation in the region and the world. Jordan has become the first centre of transformation in the region in medical tourism and aspires to compete on the international level. For one, our hospital provides integrated qualitative services that attract patients from the region and the world."
Laith Al Qasem of Usaid Jordan Economic Development Program (Sabeq) also noted that once international hospitals’ accreditation is in place, the sector’s competitiveness will increase the number of patients coming into Jordan.

The International Society for Stem Cell Research (ISSCR) convened a task force of researchers, ethicists, doctors and regulatory officials from 13 countries to set guidelines for clinics offering stem-cell experimental therapy to patients without appropriate transparency, oversight or patient protections.
In a report published last month, the US-based group ISSCR noted the growing number of international clinics that are marketing unproven, costly stem-cell therapies to medical tourists and "exploiting patients’ hopes.
China is a country where the task force has particular concerns.
Task force member Laurie Zoloth said: "There is this tension between the slow progress of medical science and the desperation of patients and the swiftness with which disease overtakes them. Combine that with a flat world and the Internet, it is a recipe for stem cell fakery. Americans could be lured into other countries because of their recognition that stem-cell research might be held back here."
The number of patients who have travelled abroad from the US and other countries for stem-cell therapies is unknown, though anecdotally, it appears to be in the thousands.
The proliferation of clinics marketing purportedly effective stem-cell interventions online has many experts worried.
The ISSCR December 2008 study of stem-cell clinic web sites found that they claimed to treat a range of diseases that go beyond the scope of the early evidence of stem cells’ efficacy, while playing up the benefits and talking little about risks. The study, published in the journal Stem Cells, found that the average price tag for the treatments, excluding travel and lodging costs, was US$21,500. What doctors want is not just patient testimonials, but real data that proves various treatments work.
Study group members agree that stem-cell medical tourism and innovation outside the clinical-trial context are not necessarily bad. The guidelines stand in stark contrast with stem cell clinics that claim success with hundreds of patients, yet, never publish results in peer-reviewed journals.
The new professional guidelines say clinics providing unproven stem cell-based therapies must have:

A written plan for the procedure that includes the scientific rationale and any pre-clinical evidence of proof of principle for efficacy and safety.
A full characterisation of the types of cells being transplanted and how they will be administered.
Clinical and administrative leadership support for the clinical experiment.
Voluntary informed consent for patients.
An action plan for adverse events.
Insurance coverage or other financial resources to cover complications.
Systematic and objective tracking of outcomes submitted to the scientific community for critical review.
A timely move to a formal clinical trial after experience with a very small number of patients.

The cost of receiving medical care in Turkey is so low that it is attracting foreign patients. A surgery that would cost 5,000 euros (US$6,292) in many European countries can cost as little as 500 euros (US$657) in Turkey.

Europeans’ wallets have shrunk as a result of the global economic crisis, pushing them to seek ways to lower their medical costs. That search has put Turkey on the map as a popular destination for those wanting lower-cost healthcare.

One thing that also plays to Turkey’s favour is its high standards in medical care as no less than 24 hospitals and clinics have JCI status, more than in almost every EU country.

In 2007, the number of foreign patients in Turkey was 150,000. Last year, the number of foreigners treated in Turkey increased by 40 percent to 200,000. Dr Dursun Ayd?n, president of the Association of Improving Health Tourism (AIHT), said: "Europeans prefer Turkey mostly for cosmetic surgery, invitro fertilization, dental treatment and laser eye surgery. The technology used in Turkey is just as developed as European technology and our doctors are also very successful."

AIHT was founded in 2005 and consists of members from health and tourism sectors. In 2008, it printed 5,000 copies of a planned annual health tourism guidebook. The book included details of all hospitals, clinics and others in the health tourism sector in Turkey. The free 160-page guidebook is available in both Turkish and English, and has the support of the Ministry of Health and The Ministry of Culture and Tourism. =

Turkey mostly receives patients from the Netherlands, United Kingdom, Belgium and France. There has also been an increase in Middle Eastern patients who have begun to prefer Turkey to Europe. Currently Turkey’s medical tourism market is worth around US$500 million, and it has the potential for many times that.

Hospitals gravitating toward health tourism have been quite happy with the growing business and they foresee 2009 to be even brighter than last year.

Dr Hasan Kus of Anadolu Health Centre noted: We treated 570 foreign patients in 2007. That figure rose to 1,102 last year. Nearly 30 foreign patients a day visit our hospital. Most of our foreign customers are from Romania, Kosovo, the United Kingdom, the Netherlands, Ukraine, Bahrain, Azerbaijan, Russia and Bulgaria. Most of them are here for treatments in medical oncology, radiation oncology, brain surgery and orthopaedics. Cosmetic surgery, in- vitro fertilization and dental treatment are also in high demand."

At the Ac?badem Healthcare Group, which saw at least a doubling of numbers in 2008, Meri Bahar added: "Many foreigners find Turkey attractive both for its lower medical costs and the quality of the health care they receive. Medical tourism in the country is growing like a snowball."

The World Eye Group receives 2,000 foreign patients every month, according to Selin Peker. The number of foreign patients has increased 20 percent since October. Most are from Germany, the Netherlands and Scandinavia.

Dubai wants to be the medical hub of the Gulf region by 2015. The logic is that once all the hospitals and clinics are built, its citizens will stop going overseas and medical tourists will start visiting the emirate.

Dr Ayesha of Dubai Healthcare City (DHCC) said: "Dubai has already set itself as an internationally recognised tourist destination. It will become an international hub for medical tourism soon as all the major healthcare projects are near their completion dates.

DHCC, the world’s first healthcare free zone, aims to become an internationally recognised location of choice for quality healthcare and an integrated regional centre of excellence for clinical and wellness services in the Middle East. The number of visitors to DHCC has exceeded 90,000 with a good percentage from other Gulf regions.

I believe the numbers will grow tremendously once DHCC is fully operational by 2011. The increased cost of travel coupled with decreased purchasing powers of patients might have an impact on the number of patients coming in. Though, we do not foresee a significant change in healthcare tourists from other GCC countries. There might even be an increase due to decreased travel to US or Europe for healthcare needs. Currently, we have 122 percent growth rate of patients incoming and we are working in association with the Department of Tourism, doing some road shows and other media campaigns to raise awareness of the healthcare services available in the UAE to the outside world, Dr Ayesha said.

By 2012, DHCC may have a superb range of new hospitals and clinics, but it will need to demonstrate to the outside world that they offer excellent quality of care at prices that can compete with Asian and European destinations that already attract medical tourists.

Dubai might face an uphill struggle. Based on figures from he upcoming 2009 World Health Tourism Congress:

    The ministries of health from the Arab World are the biggest spender of medical travel in the world. Some of them have annual budget in excess of US$200. Each one of them has a medical committee that decides what hospitals and clinics to deal with worldwide.

    Insurance companies in the Arab World tend to send a lot of their clients to be treated abroad. They have a network manager who decides where to send clients.

The Ministry of Tourism (MOT) plans to extend its Market Development Assistance (MDA) scheme to cover Joint Commission International (JCI) and National Accreditation Board of Hospitals (NABH) certified hospitals.
The MDA scheme offsets overseas marketing costs for travel companies earning foreign exchange. With the MDA scheme, eligible hospitals will be able to apply for financial assistance to cover publicity through printed material, travel and stay expenses for sales-cum-study tours and participation fees for trade fairs and exhibitions.
MOT director Dr Prabhakar Dubey said: The MDA scheme for medical tourism is under active consideration and will be applicable only to accredited hospitals. It should be finalised very soon. This will apply to about 60 hospitals.
Added Pradeep Thukral of Asia’s leading healthcare group Apollo Hospitals: "The ministry is prompting all players to form a government-industry partnership to strengthen the Indian healthcare brand overseas. Efforts will be made to launch uniform pricing bands and to combine medical packages with travel products.
The potential for this is huge. On average a medical traveller spends about US$7,000 as opposed to a holiday traveller who spends US$3,000. It is the right time for the government to provide an impetus to this industry and to learn from countries like Singapore and Thailand, which have collaborated with hospitals to attract patients.
In India, 11 hospitals have JCI status and at least 18 are known to be at various stages of seeking or achieving it.
On the other hand, the official NABH website lists 23 hospitals and 60 at various stages in the process of achieving accreditation, but it is not up to date. Latest figures show 25 private and 108 state hospitals have achieved NABH status, and over 100 are in the pipeline.
While most JCI hospitals and large healthcare groups are in the medical tourism business, many with or seeking NABH status are not and do not plan to be.

The existence of quality healthcare in Guam can boost tourism and stimulate the island’s economy.
Once the new hospital project is built, Guam will be an attractive destination not only to regular travellers but also to those needing medical treatments, according to Lionel Chadwick, president of Chadwick and Associates, a consultancy firm based in Monterey, California.
Speaking before members of the Guam Chamber of Commerce, Chadwick discussed the economic impact of the US$135-million private hospital being planned by the Guam Healthcare and Hospital Development Foundation, a group founded by volunteers from the business, finance and healthcare sectors.
Once built, the new private hospital would make life on Guam a lot easier,
Chadwick said, "Healthcare is an economic stimulus. It can promote medical tourism. At the early stages of the new hospital, it may not be able to compete with other hospitals in Asia, but it will attract residents to come back. Off-shore medical travels will be reversed."
Guam is an island in the North Pacific Ocean, about three-quarters of the way from Hawaii to the Philippines. The economy predominantly relies on tourism (primarily from Japan) and the US military bases. The island was ceded to the US by Spain in 1898. The military installation on the island is one of the most strategically important US bases in the Pacific. Although it has a civilian government, the country is a US territory, with a small civilian population.
The Government of Guam maintains the Guam Memorial Hospital in Tamuning, a free hospital for local people. In addition the US Naval Hospital is located in Agana Heights.

A revised bill now mandates the country’s 44 largest hospitals to allocate five percent of their total 2,046 hospital beds for overseas-based foreign patients, according to South Korea’s Ministry for Health, Welfare and Family Affair.

The new rule takes effect in May and aims to help attract 100,000 medical tourists to South Korea by 2012.

The bed limit rule does not apply to other hospitals or private hospitals or clinics, which can admit as many people as they wish. Many medical tourists come for cosmetic surgery or other treatments that do not require an overnight hospital stay.

About 17,500 foreign tourists received medical services in local hospital facilities from January to August last year, according to data from the Council for Korea Medicine Overseas Promotion, which has 35 member hospitals and clinics. The estimated total for 2008, including cosmetic surgery, is expected to exceed 40,000. The Council has set out to work with large tourists agencies to attract foreigners.

The government explained that the quotas were aimed at providing quality services for a reasonable number of foreigners coming to the country for treatment and ensuring there was enough hospital beds for domestic patients. It added that most medical travellers are likely to use single rooms, which Koreans do not use often.

The ministry expects such plans to boost medical tourism, which the government has been seeking as a new growth engine.

South Korea claims to be less expensive than the US and other developed countries, but until recently, the majority of foreign patients’’ in Korea had been of Korean heritage with foreign citizenship. For cosmetic surgery, the story is different as the overwhelming majority of medical tourists coming from China, Russia and Japan.

The Philippine Department of Tourism (DOT) recently released the official number of foreign patients who visited the country for medical treatment and finally gives a more realistic accurate picture of its inbound medical travel business.
In a report on 2008 tourist arrivals, the Philippines welcomed 1,071 overseas-based patients who generated about Php108.8 million (US$2.3 million) in revenues for DOT-accredited medical tourism facilities.
The majority of the 885 tourist-patients came from Guam, Palau and Saipan. Other markets were Japan, Korea, and the USA. Average gross receipt per foreign patient was Php101,582 (US$2,136), said DOT.
These figures show the country has a long way to go to before it can become a serious player in medical tourism. But the publication of official medical tourism figures is an indication that the industry is maturing.
For years, the size of the industry has been the subject of heated debate. The Philippines has long been a battleground between those claiming – purely on estimates with no actual figures – that the country was in the top half-a-dozen destinations and those that rebutted the figures.
At one extreme was the Department of Health that said that 250,000 foreigners went to the Philippines in 2006, mostly for cosmetic surgery, while others placed the number to 400,000.  Furthermore, politicians attempting to hype the business claimed 100,000 or 200,000. But again, these were figures plucked out of thin air.
At the opposite extreme were academics who argued that the figures were grossly inflated.  Once you take out Filipino workers returning home and expatriate retirees, the figure was only 2,000 to 3,000 a year. There were arguments too about where medical tourists came from.  Several people and organisations claim, without supporting evidence, that the main markets were the USA and Europe.
To its credit, the government saw that these public debates and other problems, such as illegal organ transplants and recent medical scandals are undermining efforts to build the country’s medical tourism business.
In October 2008 the government began a programme to actually count the number of medical and health travellers. And the government and healthcare facilities in the country participated in major medical tourism fairs in the Middle East, Europe, and the United States.
The DOT will host the fourth annual World Health Tourism Congress in Manila next month, which hopefully gives the industry the springboard it needs.
Over the last few years, the country’s medical tourism industry has seen countless committees, conferences and politicians pontificating on how to attract medical tourists.

The 2008 figures clearly show that the talking must stop and some professional marketing and advertising must be put in place.

Association of Private Hospitals of Malaysia (APHM) board member, Dr K Kulaveerasingam, is projecting a 15 percent increase (compared with the past average of 20-25 percent) in medical tourism receipts for 2009 as fewer foreigners are expected to visit the country for medical treatment. On numbers, this would translate to 485,000 tourists, much lower than earlier APHM predictions of over 600,000.

Due to the economic slowdown, some medical tourists may postpone treatments which are not serious such as cosmetic surgery and even hip and knee surgeries, he said.

The number of foreigners visiting the country for medical tourism has more than tripled since 2003 to hit a total of 341,288 in 2007.

For the first nine months of 2008, over 282,000 foreigners came to Malaysia for medical treatment.

According to the 2007 figures, 72 percent of the foreign patients were from Indonesia, 10 percent from Singapore, 5 percent from Japan, 3 percent from Europe and 3 percent from India.

Penang, Malacca and Johor Baru are the favourite destinations. Penang Health Association chairman Dr Chan Kok Ewe expects flat growth for medical tourism for the group this year due to the slowdown and relative market saturation.

Although we think the outlook is less encouraging, we should use this slack period to prepare for the next growth phase. To do this, we have to cultivate new markets.

The majority of medical tourists visiting Penang are of Indonesian origin, who select Penang because of its proximity to north Sumatra, convenience of travel, and ease of cultural and language adaptation.

As part of the plan to expand market reach, Malaysia is targeting new markets such as Vietnam, Cambodia, the Middle East, United States, Europe and Canada.

APHM is collaborating with the Tourism Ministry to publish in July the Malaysian edition of Patients Beyond Borders to promote Malaysia as a medical tourism destination globally with special focus on the US.

APHM is also working on a video on Malaysian healthcare that can be used to promote Malaysia overseas, and brochures that take a more countrywide view of Malaysian healthcare.

Research also shows that a medical tourist spends double the amount of normal tourist US$362 compared with US$144 per day.

Industry players together with government agencies will have to work hard to ensure that Malaysia can compete with Singapore and Thailand. Sime Darby Healthcare chief executive Elaine Cheong Pek Yin, said one of the ways for Malaysia to better compete is to have a central government agency with dynamic marketing and promotion.

Sunway Medical Centre chief operating officer Ch’ng Lin Ling points out that the Health Ministry and Tourism Malaysia will have to team up to promote the image of Malaysia and it is important for travel agents to further promote Malaysia in healthcare.

Korean agencies that refer foreign patients to hospitals could soon be opening up, when the proposed amendment to Korean medical law takes effect. Korean hospitals will be allowed by May to hire agencies to attract foreign patients through their doors. The medical tourism community is worried that the new law still has many restrictions. They say proposed limits on who can act as an agent and the number of patients will be an unnecessary obstacle.

Only tourist agencies can refer foreign patients, but not health insurance companies. In some countries such as Russia, insurance companies commonly refer patients to hospitals. Questions remain on whether the agencies can be in Korea or overseas, medical tourism or travel agencies or if there is any licensing.

The handful of current agencies in Korea, have promoted cosmetic surgery only.

The government said it would boost the local medical industry, but at the same time the restrictions are hindering further development of the country’s industry, said Brian B. Woo, chief executive of Doctour, a Korean medical tourism agency. Singapore agency FlyFreeForHealth has just completed a review on hospitals in Korea and health packages in Korea are now being developed.

Opening a foreigner-only hospital is an option, but difficult as medical laws that apply to domestic hospitals also apply to foreigner-only institutions.

There needs to be a different set of rules for foreigner-only hospitals. Under medical law, a hospital needs to have a certain number of sickbeds in order to purchase magnetic resonance imaging equipment. This kind of regulation should be relaxed, said Yun Dong-hun at Incheon’s Inha University, which is about to build a foreigners-only hospital.

Among other restrictions, agencies can only bring in foreigners who live outside Korea, not those who live in the country. That restriction would cover any non-Korean who has been in the country for over 90 days, as well as ethnic Koreans who hold foreign citizenship but live here. Most foreign patients coming to the country are issued three-month tourist visas, posing difficulties for those who need extended treatment.

Chung-Ang University Medical Center has set in motion plans to aggressively attract foreign patients seeking high-quality surgery at relatively low costs. New director-general Ha Kwon-ick has revealed plans to upgrade the quality of the hospital to make it one of the top five medical centres in the country and promote the country’s medical expertise worldwide.

The hospital, owned by the Doosan group, is a member of the Council for Korea Medicine Overseas Promotion, the body in charge of promoting medical tourism. A new building with a centre specialising in thyroid and stomach cancer and brain and heart diseases is to be built by 2011. Before that, a 400-bed cancer hospital should be open by the end of 2009.

Spas in casino hotels have hit the jackpot as the most profitable spas in the world. World-class facilities are situated within hotels with hundreds or thousands of rooms, catering to a captive free-spending clientele that appreciates pampering. Operators are now extending the concept to include wellness centres with a wide range of services including cosmetic and dental surgery.

The trend is exploding in Asia. Macau has recently surpassed Las Vegas in terms of annual gambling revenue, and its gargantuan Venetian Macao Resort Hotel not only features the impressive V SPA, but also will soon see a MaloClinicSPA, the largest integrative wellness centre of its kind in the world. The centre will offer the most comprehensive array of world-class medical treatments, spa services and wellness programmes in the region.

Owned and managed by Lisbon-based MALO CLINIC Health & Wellness Group, the MaloClinicSPA’s aims to offer an integrative, all-inclusive approach to complete wellness, covering seven professional areas – oral rehabilitation and dental cosmetic, preventive and curative medical care, spa, total beauty, cosmetic anti-ageing, leisure & fitness, and life long wellness. Treatments will be developed and delivered by a team of the highest trained doctors and healthcare professionals in a first class, healthy and comfortable environment.

Dr Paulo Malo explained: It is a brand new concept in Asia Pacific, marking the future of health and wellness by merging diagnostic and clinical services with spa treatments and wellness care all under one roof. We aim to provide guests the highest quality wellness service to address their individual needs in a trusted, relaxing spa environment."

The new centre will consist of four key areas; clinic, spa, beauty salon and a leisure and fitness area. A multi-disciplinary team of 50 medical doctors and licensed healthcare professionals will include dentists, clinical and traditional medical doctors, pharmacists, lab specialists, spa therapists, physiotherapists, public health specialists, psychologists, nutritionists, and sports and fitness specialists. It will be opened in two stages, with the entire facility scheduled to be in full operation by late summer 2009.

The MaloClinicSPA is Malo’s first foray into Asia and represents a foothold into this dynamic market. Placing a spa in a casino hotel was a gamble when first done in the USA in the 1980s. Now casino spas include the largest and most expensive spas ever built. Singapore recently legalized gambling; Sentosa Resort & Spa is adding a casino, Banyan Tree plans a casino-spa resort, and the Marina Bay Sands project is in the pipeline. Casinos that gambled with luxury spa facilities have seen huge profits from them, so there will be more in-casino luxury spas in 2009.