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If Disney ran a private hospital group how would it go about its business?

What would Mickey do?Spanish IVFSpain is a new mecca for medical tourists seeking IVF solutions - we ask why

A problem like the US

W I N T E R 2 0 1 8 | V o l u m e 1 | I s s u e 2

Insurance and employer funded medical travel can’t seem to get a grip in the United States - just why is that?

Independent. Intelligent. Insightful

In focus

Chinese countingWith the boom in Chinese medical tourism, we count the numbers at stake

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Providing insight into the medical travel sector

New content categories make it easier to find what you need IMTJ articles provide informed comment and insight into an industry where much of what you read on the internet is driven by marketing hype and is unashamed promotion. We invite some of the best brains in the business to contribute and share their knowledge with like-minded people. We’ve categorised our content so that it’s easier for you to access. Want to know everything that’s going in the cosmetic surgery tourism market? Select it from our Sectors menu. Looking for the latest on medical tourism agencies and facilitators, choose from the Topics menu.

Expanded resources help you to share your knowledge and build your reputation Events and presentationsWe have a new service for those who are running a medical travel related event. In addition to our event calendar, we provide a facility for conference organisers to share presentation content with IMTJ subscribers, and extend the impact of their event. And if you have a recent presentation that you’d like to share with the industry, we’ll publish it online.

Educational and academic resourcesMedical travel is beginning to gain “academic status”. We’re beginning to see real research going on in the sector. Some educational institutions are developing programmes in medical travel. We plan to offer a facility for researchers and students to access an online “library” of references on the sector and to share their academic papers.

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Introduction

THE REALITY OF THE VOLUME OF AMERICANS

TRAVELLING ABROAD FOR MEDICAL CARE HAS

NOT DISCOURAGED CONTINUED SUPPORT

FOR INFLATED NUMBERS AND EXPECTATIONS

Insured in the USA...?Selling international medical tourism benefits to a US-based health insurance provider is difficult. Why has adoption been so slow?

Welcome to the second print edition of IMTJ.

In addition to pulling together the biggest news stories from the sector in recent weeks, our Infocus pieces cover a diverse range of hot topics from US medical insurance to Spanish IVF to what we can expect from China’s continued growth in the industry.

We hope you enjoy this compendium of unique IMTJ content and look forward to your feedback.

imtj.com | WINTER 2018 | 3

Irving Stackpole, Elizabeth Ziemba p20

The number one source of news, views and insight into medical travel

www.imtj.com

Subscribe now...A new business model… subscriber only content

Get in touch

Many of you will benefit from the free content that we deliver through IMTJ. But the new IMTJ offers premium content on a subscription basis. Access to valuable resources such as the Country Profiles is on a subscriber only basis. Profiling your business in the IMTJ Directory requires a subscription. There are different levels of subscription to fit your information needs and your budget.

For more information on International Medical Travel Journal:

www.imtj.com International Medical Travel JournalIntuition Communication Ltd3 ChurchgatesWildernessBerkhamsted HP4 2UBEngland

+44 (0) 1442 817817

+44 (0) 1442 817818

[email protected]@imtj.com

Providing insight into the medical travel sector

New content categories make it easier to find what you need IMTJ articles provide informed comment and insight into an industry where much of what you read on the internet is driven by marketing hype and is unashamed promotion. We invite some of the best brains in the business to contribute and share their knowledge with like-minded people. We’ve categorised our content so that it’s easier for you to access. Want to know everything that’s going in the cosmetic surgery tourism market? Select it from our Sectors menu. Looking for the latest on medical tourism agencies and facilitators, choose from the Topics menu.

Expanded resources help you to share your knowledge and build your reputation Events and presentationsWe have a new service for those who are running a medical travel related event. In addition to our event calendar, we provide a facility for conference organisers to share presentation content with IMTJ subscribers, and extend the impact of their event. And if you have a recent presentation that you’d like to share with the industry, we’ll publish it online.

Educational and academic resourcesMedical travel is beginning to gain “academic status”. We’re beginning to see real research going on in the sector. Some educational institutions are developing programmes in medical travel. We plan to offer a facility for researchers and students to access an online “library” of references on the sector and to share their academic papers.


ContentsIndependent. Intelligent. Insightful

4 | WINTER 2018 | IMTJ - LaingBuisson

Editor in Chief, Keith Pollard

COMMUNITY

Visit IMTJ onlineimtj.com

Join LaingBuisson’s linkedin group linkedin.com/company/LaingBuisson

Follow us@imtjonline

In the medical travel sector, IMTJ has established a reputation as the independent and trustworthy voice of medical travel and the place to go when you really need to understand the industry. We avoid the hype. We question the claims and practices of industry proponents. We give you facts.

In this second print edition of IMTJ, we provide a flavour of the analysis and insight that you will find in our twice monthly e-newsletter, and in the extensive resources that we provide online to our subscribers at www.imtj.com. If you ‘re not an IMTJ subscriber, now is the time to sign up!

IMTJ welcomes contributions from those with knowledge and experience of this developing market sector. Get in touch if you wish to share your insight and understanding through IMTJ or at one of our international conferences.

‘Projections show that obesity rates are expected to rise in the USA, Mexico and the UK.’ Ian Youngman

10 Incountries Poland Lublin’s bid UK gender selection ethics Thailand Qatar travellers impact Singapore an end to referrals Georgia inbound ambitions China IVF boost on the cards? Dubia Emirati numbers fall USA Chinese visitors drop India inbound sources weighed up Vietnam US$2bn spend

6 News China rising numbers Canada untested stem cells Iran inbound and outbound Israel new bill controversy Associations not measuring up

38 Inmarkets The latest stats on medical tourism markets across the globe 42 Inbusiness Business news from around the world

Iran in numbers - inbound and outbound,p7

Canadian businesses providing untested stem cell treatments,

p6

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14 Infocus Irving Stackpole and Elizabeth Ziemba look behind the lukewarm uptake of insurance funded medical travel in the USA

24 Infocus Ian Youngman counts the numbers circulating around China’s medical tourism boom

27 Inconference Maria D. Georga runs through the must-haves of a good medical tourism conference

29 Infocus Vincenzo Pavone explains why Spain has become a leading force in IVF treatment

Chosen provider of independent sector healthcare market data to the ONS

The voice of professional publishers

babylon’s Ali Parsa continues to grow his empire,

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Features

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News

CTA report says the numbers of Chinese travelling abroad for health tourism is rising; more than 2 million travelled overseas to wellness centres or for massage and yoga exercises in India and Thailand in 2017. Japan, South Korea, US are also top destina-tions.

Tour packages and destinations highlighting health enhancement have emerged as popular choices for Chi-nese travellers, according to a report by the China Tourism Academy, and reported in China.org.cn.

Health tourism includes ‘things re-lated to medical treatment and staying well and featuring traditional Chinese medicine’, according to Zhu Haidong, director of the international cooperation department of the State Administration of Traditional Chinese Medicine.

Zhao Zihe, researcher at the tourism academy, said health tourism emphasises slow-paced activities, pressure release and health preservation rather than a tight sightseeing schedule common with traditional tourism.

Chinese visitors bound for Hong Kong, Macao, Taiwan or foreign countries for health reasons represented 2.2% of all outbound visitors in 2017. And the num-

ber is expected to increase this year, the report said.

More than 2 million Chinese trav-elled overseas to wellness centres or for massage and yoga exercises in India and Thailand last year, the report said.

Japan, Thailand, South Korea and the United States are listed as the top des-tinations for travellers from the Chinese mainland. They also go to Taiwan.

Health tourism has also boomed on the Chinese mainland over the past few years, the report said. Online travel services provider lvmama.com said that Guilin, Guangxi Zhuang autonomous region, and Haikou, Hainan province, are the most popular mainland travel destinations in the health market due to their agreeable climates and advanced medical equip-ment.

Traditional Chinese medicine and ther-apies such as acupuncture and massage - as well as exercise, such as tai chi - also help attract foreign visitors and travellers from Hong Kong, Macao and Taiwan to the Chinese mainland, the report said.

About 2% of visitors from Hong Kong and Macao sought traditional Chinese therapies in 2017, while 0.9 percent of foreign travellers to the Chinese mainland bought tour products focusing on TCM

last year, according to the report.Huang Luqi, vice-president of the China

Academy of Chinese Medical Sciences, believes the future of China’s health tourism is bright, especially for traditional Chinese medicine (TCM).

‘Tour programs for TCM services are a new pattern combining Chinese culture and TCM industries. It will benefit travel-lers both physically and psychologically by maintaining wellness through tradi-tional medical practices - acupuncture, for example.’

Zhang Dongping, a researcher at lvma-ma.com, said health tourism products will drive the development of a quality tour-ism market because travellers motivated by health require much higher quality services than other tour products.

2.2% of Chinese outbound visitors are health tourists

Thirty Canadian businesses are providing untested and potentially unsafe stem cell treatment to 43 clinics across Canada, according to a study published in Regen-erative Medicine.

In an article reviewing the study in BioNews, Dr Leigh Turner, the researcher and bioethicist at the University of Minnesota, said ‘I’m very concerned about the risks associated with businesses making dramatic claims about stem cell treatments for a wide range of diseases and injuries without doing the careful, costly, and time-consuming work needed to develop a compelling evidence base for such representations,’

Most of the companies sold treatments based on autolo-gous stem cells, made from the patient’s own cells. The companies sold the treat-ments as targeting a range of diseases, including neurolog-ical conditions, lung diseases, immune conditions and sexual dysfunction. Some also sold treatments for cosmetic proce-dures.

Clinics charged as much as CA$3,500 (US$2,725) per injec-tion. Many charged smaller additional fees for injections at secondary sites.

Dr Turner has previously studied the market for un-proven stem cell treatments in the USA, where there have been more investigations into

unlicensed stem cell clinics. In 2017, the FDA launched a crackdown on these clinics.

However, the marketplace for unproven and unlicensed stem cell treatments has not received significant national attention in Canada, Dr Turner said.

Canadian businesses providing untested stem cell treatments

For further IMTJ analysis and global news in this

sector visit imtj.com/medical-travel-sector/stem-cell-treatment/

TM

Dr Leigh Turner, University of Minnesota


Iran inbound... over 300,000 medical travellers

Iran’s Ministry of Health says the country attracted over 300,000 medical travellers during the past Iranian calendar year ended March 2018.

Medical tourist arrivals in the country have nearly dou-bled in the first three months of the current Iranian calendar year, corresponding to spring 2018, from a year earlier, claims the Ministry of Health.

The ministry’s medical tourism department says that based on official statis-tics, the country attracted over 300,000 medical travel-lers during the past Iranian calendar year ended March 20 2018.

Iraq and Afghanistan provide the vast majority of medical tourists to Iran. The increase in number of Iraqi travellers is driven by foreign

currency rises as Iran’s econ-omy is facing pressure from the re-imposition of US-led sanctions.

The ministry believes that Iran has the capacity to annu-ally earn $7 billion in medical and health tourism, though the sector now brings in less than $1 billion.

166 hospitals in Iran hold special licenses to treat medical tourists as they meet quality standards set by the ministry of health.

The government has agreed to convert Iran’s Cultural Her-itage, Handicrafts and Tourism Organisation, a leading pro-moter of medical tourism, to a tourism ministry.

International research organised by LaingBuisson and RLA has found a big difference between what medical travel associations and clusters say is important in their work, and what they measure to assess their success.

A new report on the current challenges faced by medical travel associations and clusters around the globe has just been published.

The report summarises findings from a survey jointly funded and run by interna-tional healthcare experts, LaingBuisson and health and wellbeing management consultants, RLA, which targeted 250 medical travel associations and clusters around the world. The survey is the first of its kind in the medical travel sector.

The results show a big difference be-tween what associations and clusters say is important in their work (co-ordinating medical tourism interests with govern-ments), and what they actually measure

to assess their success (inbound patient numbers and treatment volumes).

While both are important, time spent lobbying government does not often lead to more international patients. The survey findings suggest that medical tourism associations and clusters are not effectively measuring the success (or not) of their work.

The report also reveals that many medical tourism associations and clusters operate on an annual budget of less than €50,000 (US$58,000), a tiny investment for the complexity of tasks expected of these organisations by their members.

László Puczkó, Director of Industry Intelligence at RLA and author of the report, says:

‘The survey identified a number of major challenges faced by medical travel associations and clusters in 2018. Not only is there a discrepancy between the work they prioritise and what they meas-

ure; there is also scope for improvement in how they are funded, in developing the breadth of their membership and in their relationship with other Destination Man-agement Organisations in their region or country.’

Commenting on the survey results, LaingBuisson International Executive Chairman, Keith Pollard says: ‘We’ve seen a significant growth of new associations and clusters entering the international medical tourism market in the last few years. Their success and survival rates however are random at best. Our report makes three recommendations for a better way ahead for the global medical travel industry, including better industry co-operation, clearer performance meas-ures and further sector education and capacity building.’

The full report is available to download from www.imtj.com

Medical travel associations aren’t measuring efforts

Iran outbound... falling currency hits medical travel Iran’s falling currency is causing many Iranians to cancel vacations, business trips and medical treatment abroad.

The Iranian rial has lost almost three-quarters of its value against the US dollar since January to hit a low of about 140,000 to the dollar in Septem-ber. Goods and services priced in dollars are now more costly, making travel prohibitively ex-pensive for many middle-class Iranians. As their currency weak-ens, fewer Iranians are going overseas. This includes falling numbers of medical tourists.

Iran is also struggling with a deepening economic crisis, with falling currency, double-digit unemployment and high infla-tion. The economy has wors-ened since the US re-imposed sanctions in August, including on Iran’s foreign currency trade. More US penalties on Iran’s oil and banking sectors are set to start in November 2018.

Airlines and travel agencies are being badly hit as outbound

bookings have dropped. Major European airlines are com-pletely or partially cancelling flights to and from Iran. State carrier Iran Air has cut flights to Dubai, Hamburg and Sweden’s Gothenburg.

According to local travel and medical travel agencies, medical travel abroad by middle-and-upper-class Iranians has signifi-cantly reduced.

Iran does not release any statistics on travel abroad so reliable figures on outbound tourism, let alone outbound medical tourism, are hard to establish.

The benefit of a falling currency is that Iran is increasing numbers of inbound medical treatment, as relative prices drop. According to the World Travel and Tourism Council (UNWTO) most travellers to the country are from the Middle East, rather than the US or Europe, so sanctions have little effect. UNWTO estimated inbound travel numbers at 4.9 million in 2016.

For further information on inbound medical tourism

to Iran, visit the IMTJ Country Profile

TM

AD_IPC_IMTJ ELITOUR A5_08_05_18_OUT.pdf 1 08/05/2018 19:43


News

The Knesset has now passed a bill to regulate medical tourism, with meas-ures to ensure that foreigners who go to Israel and pay privately for medical care get the care they need, but not at the expense of Israelis. Critics say the bill is not detailed or stringent enough, and there is no set date for it to be-come law. The aim is for it to be active from early 2019.

In Israel, medical tourism has become a profitable export industry that brings in foreign currency and supplies taxes, em-ployment and a financial boost to medical institutions.

The new bill regulating medical tourism was passed after more than a year of heated discussion and the result has been criticised by all sides as not being as de-tailed or stringent as the original wording.

The final version includes some but not all of the long list of items in the origi-nal wording that would have required compliance from hospitals and medi-cal tourism agents. The bill also seems tougher on medical tourism agents than on hospitals.

Hospital requirements now in placeThe regulations on medical tourism for

hospitals include:• Medical tourism must not harm

the quality of medical treatment given to the Israeli patient

• Hospitals must provide the health ministry with a comprehensive report on medical tourists treated at the hospital and the income received

• There is a ban on higher payments to doctors or hospitals for treating medical tourists than for treating Israelis

• Medical tourists will only be treated in the afternoon and not during regular hospital hours, aside from emergencies or other exceptions. The sanction for treat-ing a medical tourist during public morning hours is a 50,000 shekel (US$13,680) fine

• All medical tourists must wear an identifying tag when in hospital

Excluded from the final bill

One rule excluded from the final bill was that hospitals would be restricted on how many medical tourists they could

host, based on data regarding the waiting time for carrying out various procedures in the hospitals and infrastructure avail-ability.

Instead, the Health Ministry has the option of allowing individual hospitals and doctors to charge more for overseas patients. It is also giving powers to restrict the number of medical tourists to specific hospital treatments, if there are concerns about the impact on the availability of treatment for Israeli patients.

Another part of the original bill that didn’t make it was the plan that sought to redistribute the profits from medical tourism from the big city hospitals to smaller provincial ones. The health min-istry is now tasked with working out the profits that should go to the periphery and report on this without committing on time or a specific sum or percentage of the income. There are strong suspicions that this will quietly disappear.

Medical tourism agent regulations still uncertain

To regulate the business of medical tourism agents, a register will be com-piled of medical tourism agents, with set preconditions for those wishing to register.

The full details on rules on agents are not yet available but it is reported that the original plan that anyone operating as a medical tourism agent would have to possess certain minimum qualifications, has been dropped. What is known so far is that medical tourism agents must be over 21 and have no criminal record.

Agencies cannot make one service contingent upon another, so obtaining medical services contingent upon reserv-ing a hotel room via the agent is not legal.

Agents can only contact doctors via the hospital or clinic, not direct.

A disciplinary committee for medical tourism agents, headed by a judge, will be established, and can fine agents who break the rules.

It is not yet known if other new rules on agents are in the bill or not. These were that agents had to:

• Operate fairly towards both the patient and the medical institution where they are to be treated

• Maintain medical confidentiality and privacy

• Ensure reservations are made in writing. The patient must sign the original price quote from the medical institution, to ensure that the medical tourist is given the complete information for informed consent before leaving home

• Reveal any personal interest that the agent has in a medical insti-tution

It is also not yet known whether the new law will keep the original bill text requiring all medical tourism agencies to divulge the volume of business and number of foreign patients they attract to Israeli hospitals.

No authority in Israel has full data on medical tourism. The Health Ministry has only partial data that includes the state hospitals’ revenue. Private hospitals refuse to divulge, even to government enquiries, how much they earn from medical tour-ism, but estimates range from US$100 to $300 million for procedures performed for non-Israelis.

Controversial bill to regulate medical tourism

Visit the IMTJ Country Profile of Israel for further analysis of the country’s medical

tourism industry.

TM

Inside the Knesset, the legislative branch of the Israeli government

Incountries


The Eastern Europe Health and Medical Tourism Sum-mit took place in Lublin, Poland on 12 June. The event was organised by the Strategy and Investor Relations Department of the Municipal Administration of the City of Lublin and the Lu-blin Medicine – Medical & Wellness Cluster.

Initial feedback suggests that the event managed to gather delegates from around 25 counties, mainly from East-ern Europe, with more than 350 attending and another 1,250 viewing through live streaming. In common with many international medical tourism events, city, hospital and clinic tours were on offer to delegates during the days and evenings of the confer-ence, where Lublin medical care, history, tourist attrac-tions and local gastronomy were promoted.

The Summit itself included a dedicated section on collab-oration of health and medical tourism clusters across Eastern Europe. Representatives from Poland, Croatia, Latvia and Ukraine showcased the effectiveness of their nation-al clusters, all working with common goals.

There is a lot to be said for further Eastern European co-ordination when it comes to promoting the region for medical tourism. Eastern European countries have many similarities, especially the former USSR states. In addition to Russian still being widely spoken, they have a lot in common regarding culture, economic indicators and poli-

tics. This in some ways makes it easier for them to identify what it takes to develop as a ‘region’ of countries, agree a strategy and find a common way for measuring their results.

Also, the health and medical travel services within each of these countries have different features and therefore target different patient markets. Since they’re not competing for the same potential custom-ers, there is an even stronger case for a regionally coordinat-ed approach.

Can Lublin be the regional medical tourism coordinator?

Lublin has much to be proud of. It is a picturesque city of approximately 350,000 people, with a well preserved old town and many green spaces. It boasts a high standard of living and has, as a university city (including the Maria Curie-Sklodowska University and the Medical University of Lublin), a high proportion of professionals, academics and Polish and foreign students. Uniquely, this latter group were actively involved in the Medical Tourism Summit, who were recruited as volunteers to help with interpretation services and meeting organisation.

Perhaps it is not surprising then that Lublin was identi-fied as one of the best cities for business in Poland by the Financial Times’ foreign direct investment intelligence service (fDi). The foreign direct investment ranking also

placed Lublin second among larger Polish cities in the cost-effectiveness category.

While certain infrastructure still needs upgrading (notably the national road system con-necting Warsaw with Lublin), there has been substantial investment – probably of EU funds – in projects in and around Lublin. New buildings include the contemporary Lublin conference centre, plus hospitals like Ikardia and several other medical facilities, which demonstrate commit-ment to the development of the medical sector.

The Medical Tourism Summit and Lublin’s attempts at regional coordination also has the full backing of local authorities and patronage from various state depart-ments including the Ministry of Health and the Ministry of Sport and Tourism. Lastly it helps to have a passionate advocate for Eastern European collaboration, who for Lublin is Marzena Strok-Sadło, a sen-ior advisor in the Department of Strategy and Investor Rela-tions in the City of Lublin and management board member

of Lublin Medicine – Medical and Wellness Cluster.

However, like many of their neighbouring countries, there is still a need in Poland to adopt international health-care practices. This includes the application of foreign languages in medical build-ings where, although brand new, don’t seem to have been created with an internation-al audience in mind. There is also lack of clarity on the actual numbers of medical tourists coming to Poland, which questions the actual size of this potential market (a common issue across the Eastern European region). In 2016, for example, The Polish Association of Medical Tour-ism claimed that there were 488,000 medical tourists to Poland however the Institute of Research and Development of Medical Tourism published a figure of 155,000 for people going to Poland in search of healthcare services that year.

The future success of an Eastern European collabo-ration on medical tourism, and Lublin’s role in this mix, remains to be seen.

Could Lublin become the regional co-ordinator for medical tourism?

PolandLublin hosted the Eastern Europe Health and Medical Tourism Summit last month. It was held to promote the city and Poland as a medical travel destination, but it was also an attempt at positioning itself as coordinator for the region in delivering Eastern Europe health and medical tourism projects. Maria D. Georga, Regional Manager for Treatment Abroad and IMTJ, was at the event and shares her view

Lublin’s old city


An investigation by the Daily Mail has identified ‘at least’ four doctors in private IVF clinics who are offering the first stages in gender selection in the UK, and then sending patients to Cyprus, Crete or Dubai for the final procedure. Gender selection is illegal in the UK, unless for medical reasons to prevent serious hereditary diseases.

The investigation suggests gender selection is becoming more popular. It identified at least four UK doctors willing to

arrange blood tests, scans and medication in the UK before the couples travel abroad for the final procedure. The article identified clinics and hospitals in Northern Cyprus, Crete and Dubai offering gender selec-tion services.

One doctor interviewed said that this procedure is popular with couples of Indian or Chinese heritage, who it is claimed prefer boys. Another reason given for interest in the service is family balancing.

Sex selection for social reasons is against the law in the UK under the Human Fertilisation and Embryology Act of 2008. A code of conduct drawn up by the watchdogs states that, for legal reasons, clinics must not ‘participate in any other practices designed to ensure that a resulting child will be of a particular sex’.

This clause has not been tested in court so it is not known whether ‘other prac-tices’ would include helping patients who go abroad for

the procedure. The article says that it would appear however that giving advice and carry-ing out tests is not unlawful as long as the treatment is carried out abroad.

The Human Fertilisation and Embryology Authority has launched a probe into this in-vestigation, saying it would be extremely concerned by the promotion of the practice.

Investigation into UK gender selection serviceUK

According to the Gulf Times, last year, over 616,000 tourists from the Middle East visited Thailand. Qatar is seen as a top performing source market for health, wellness and medical tour-ists to Thailand.

A number of Thailand hospitals, beauty clinics and wellness centres, with delegates from the Tourism Authority of Thailand (TAT), gathered in Doha recently to promote the Asean country’s numerous health and wellness offerings.

‘The event showcased key insight into Thailand’s medical tourism industry and the recent improvements that have been made. Qatar is one of our key markets for medical tourism and we hope to keep building on this by keeping the local community here informed of the latest developments in the industry in Thailand,’ TAT Middle East director Pichaya Saisaengchan said.

Qatar is one of the top performing source markets for health, wellness and medical tourism in Thailand and TAT hopes that the road show will help to build on the already significant number of Qatari visitors heading to Thailand for health and wellness pur-poses.

Last year, over 616,000 peo-ple from the Middle East vis-ited Thailand. The figure is set to increase this year as more people across the Middle East look to Thailand for unique travel experiences.

Qatar key source of medical travellers

Thailand

According to the Singa-pore Independent, the Min-istry of Health has said it is putting an end to foreign patient referral contracts and has instructed all pub-lic hospitals to terminate their contracts with foreign agencies that refer patients from abroad to local hospi-tals in Singapore. This could affect inbound medical tourist flows, particularly of Indonesian patients.

The Independent article says that foreign agents work with local hospitals to refer foreigners to seek treatment in Singapore. These agents help potential patients find a local hospital that is the best fit for them and help to arrange specialist appoint-ments. They apparently earn up to 8% per cent of a foreign patient’s hospital bill as a commission fee for their services.

One of the largest such foreign agencies is HCM Medika in Jakarta, Indonesia. It has sent about 15,000 Indo-

nesian patients to hospitals in Singapore and Malaysia over 11 years. Its website says ‘As official partners of hospitals in Singapore and Malaysia, all our services are free of charge. No hidden cost or mark-up.’ The agency’s servic-es are provided free of charge to foreign patients, since the hospitals allegedly pay the company a commission.

Some of the Government hospitals in Singapore that have used such foreign agencies include the Changi General Hospital, Singapore General Hospital and Nation-al University Hospital.

The Ministry of Health has now told hospitals that they are no longer allowed to ‘actively market themselves to foreign patients’ since the priority of public healthcare institutions must be to serve Singaporeans’ healthcare needs. MOH’s decision comes after the public hospital bed crunch across Singapore in recent years.

End to foreign patient referrals to local hospitals

Singapore


Incountries

Georgia

Over the last 13 years, Georgia’s healthcare system has undergone reform which has improved health indicators and narrowed the gap between Georgian and European standards, according to a 2016 Healthcare Industry Overview report by Georgian Investment Bank, Galt & Taggart.

Zero taxes on healthcare, combined with low salaries and associated costs, have also attracted foreign investment into the sector.

Private providers account for the vast majority of Georgia’s total hospital supply and private provision is improving in quality and quantity.

The largest healthcare services provider (also the largest pharma player and the second largest medical insurance provider in the country), is the Georgian Healthcare Group (GHG). Its healthcare services business, Evex Medical Corpora-tion, has, through mergers and acquisi-tions, gathered 54 healthcare facilities, including hospitals, clinics and medical centres. These deals have made Evex the largest healthcare service provider in Georgia, and they are now leading the

reform of the private healthcare system in the country and attracting more medical travellers.

Evex takes its market-leadership role se-riously in setting standards and reforming heath, by making their group an example for all healthcare investment in Georgia. Among their immediate plans is to put all their major hospitals (for example, Regional Hospital in Tbilisi) through an accreditation process, adopt the use of international languages and train their staff in international best practice.

Current provision for international patients

According to a recent report in the Georgian Journal, in Q1 of 2018, 13,900 foreigners visited Georgia for medical and recovery purposes, 61.2 % higher than the same period in 2017. Of this number, 8,600 had medical treatment, the most popular of which were dentistry and cosmetic surgery. No source was given for these numbers.

Medical tourists usually come from countries to the east of Georgia and near-by countries such as Saudi Arabia, Kuwait,

Iraq, Azerbaijan, Russia and Armenia. Em-igrants from the US, Russians, Armenians and Azerbaijanis living in England also tend to go back to Georgia for medical and dental treatment. A flow of inbound patients from post-Soviet countries is not surprising; Georgia was known as the centre of medicine in the Soviet era, and almost everyone in the country speaks Russian.

Healthcare communication remains relatively challenging however for English (or non-Russian) speaking international patients.

Travelling to Georgia is easy for most foreign visitors, as the visa process is straightforward (passports are only stamped at the Georgian airport), unless the traveller comes from Iraq, Pakistan or India where they have to follow the complete visa process application before travelling. Flights to Tbilisi and Kutaisi make it easy for international patients to reach the hospitals.

An international visitor to Georgia will find a combination of interesting historic sites, delicious local cuisine and ancient wine-making techniques, genuine Georgian hospitality, and low prices.

Inbound medical tourism ambition

Georgia’s private healthcare sector has improved, but is it good enough to attract more medical tourists? Maria D. Georga, Regional Manager for Treatment Abroad and IMTJ, travelled to Georgia to assess progress


This might help to detract from ongoing weaknesses in infrastructure and the ageing Soviet-era buildings.

The use of the same international rate card (price list) for all incoming patients, regardless of where they come from, is also an attraction. Many other desti-nations are known to vary their prices according to source market and this practice can lead to loss of prospective international patients and loss of profit.

Another attraction is a second opinion service (using the wide network of estab-lished Georgian doctors working abroad), as a way of ensuring that the best option has been selected for the patient.

‘What makes our medical service reliable is the participation of the entire multi-disciplinary medical team to the finalisation of a medical treatment plan along with our standard second-opinion policy with Georgian diaspora doctors from well-known hospitals in Europe and USA’ said Dr. Koba Kiknavelidze from Evex’s West Georgia Oncology hospital in Kutaisi.

Beyond dentistry and cosmetic surgery, other treatments that a foreign patient can find currently in Georgia are: oncolo-gy, radiology, liver and kidney transplan-tation (still a legally grey area in medical tourism), infertility treatment, bone marrow transplantation, orthopaedics and bariatric surgery. Evex also claims to sell a large number of ‘checkup’ packag-es to patients from the Middle East and post-Soviet countries.

Medical tourism and health tourism potential

The Georgian National Tourism Ad-ministration says that for Q1 of 2018, the number of international visits to the coun-

try amounted to 1,463,561. This is 15.5% higher than the same quarter in 2017. The majority of the visits were by citizens of Azerbaijan, Armenia, Turkey and Russia.

While there is, as yet, no cross-sector medical tourism association in Geor-gia, GHG sees longer term potential in developing the medical tourism sector. It says that the improving healthcare facilities and standards have the potential to develop health tourism by attracting citizens of neighbouring countries and, conversely, retaining the Georgians cur-rently seeking treatment overseas in the long run.

It sees Georgia as highly price compet-itive compared to other medical tourism destinations, and offers various health tourism advantages (including benign cli-mate, mineral waters and healthy resorts such as Borjomi or Tskaltubo).

GHG believes there are potentially attractive segments for medical tourism in IVF, plastic surgery, ophthalmology, ‘trans-plantology’, orthopaedics and oncology.

‘We are a country of 3.7 million people but during 2017 we managed to attract 4.5 million tourists to Georgia’ says Anri Kapanadze, commercial director of Evex. ‘The tourists’ increasing preference for our country has helped us identify an oppor-tunity for health tourism as well.

In combination with the government’s decision to eliminate tax in health, we have managed to become attractive for foreign investments and keep competi-tive prices in healthcare’.

Mr Kapanadze claims that Evex treated 5,000 foreign patients last year and has ambitious plans to treat 30% more this year.

They are keen to target international patients from Kazakhstan, Kyrgyzstan, Uzbekistan, Ukraine and Russia.

Georgia has much potential for health tourism development, and to a limited degree, medical tourism. How well these targeted source countries will respond to Georgian efforts in attracting foreign patients will depend on whether Georgia manages to adjust to and sustain interna-tional practices and service levels.

There is much more to do however to come up to the standards found in the best European and Asian countries.

Treatment Price (GBP)

Laser eye cataract surgery £700

Abdominoplasty £3,653

Kidney transplant £16,700

In Vitro Fertilisation from £2,650

SOURCE IMTJ COUNTY PROFILE

GEORGIA Treatment prices

For independent, in-depth analysis of medical tourism in Georgia, visit the

IMTJ Country Profile at imtj.com

TM

AccreditationJoint Commission International and China Resources Healthcare Group have named the JCI-CRHG Academy of Hospital Management, a joint venture of the two organisations, as the exclusive provider for JCI advisory services for health care organisa-tions in Mainland China (PRC), Hong Kong and Macao. The JCI-CRHG Academy of Hospital Management provides accreditation technical assistance, preparation, resources and training, allowing Chi-nese health care organisa-tions to have one official source for all JCI advisory services. In China, 93 facilities are accredited by JCI. JCI will continue to perform accreditation surveys separately. The use of JCI advisory services is not necessary to obtain accreditation from JCI, nor does it influence the granting of such accredi-tation. In the US, DNV GL Healthcare has certified Hillcrest Medical Centre in Tulsa, Oklahoma for palliative care services. It is the first provider DNV GL Healthcare has certified since it introduced a certification for palliative care providers earlier this year. The hospital is affiliated with Hillcrest HealthCare System, which operates seven acute care hospitals across northeast Oklahoma as well as the Tulsa Spine and Specialty Hospital. The Medical Travel Qual-ity Alliance has awarded medical tourism certifica-tions to Zulekha Hospital, Dubai, and Salut Empordà Healthcare Figueres Hos-pital, Spain.

Inbrief


Incountries


China

The changing Chinese laws on having more than one child could lead to an explosion in the number of Chinese couples seeking IVF, according to Mason Hinsdale, Managing Editor of Jing Travel.

Destinations have been stepping up to tap into a potential new wave of Chinese medical tourists.

Since 2016, Chinese couples have been allowed to legally have two children without paying fines or encountering other penalties, ending decades of the One Child Policy. Chinese authorities may even revoke restrictions on the number of children a family can have altogether. This suggests that there could be an explosion in the number of Chinese couples seeking in vitro fertilisation (IVF) procedures.

IVF procedures are available in China, and it is estimated that approximately 200,000 babies are born in China via IVF. Still, travelling abroad for better-quality medical care and more advanced medical treatments is increasingly popular in China, and there’s no reason to believe this trend won’t hold true for fertility treatments too. Countries adjacent to China, and even across the Pacific, have noticed the huge potential of marketing high-quality IVF options for Chinese fami-lies as a source of revenue.

Malaysia and Thailand: tar-geting Chinese IVF patients

Among the destinations that have a head start on reaching out to this market, Malaysia stands out. Sherene Azli, the chief executive officer of the Malaysia Healthcare Travel Council (MHTC), told the South China Morning Post: ‘One thing about Malaysia that we are proud of is that the in vitro fertilisation success rate is among the highest in the world. The world’s average success rate is 50 %, but Malaysia’s success rate is about 65 % on average.’ China’s estimated IVF success rate is also 50%, although this figure can vary wildly depending on the source.

The Malaysian government has en-gaged in efforts to attract Chinese medi-cal tourists seeking medical treatment, in-cluding introducing a new e-visa scheme for medical travellers. The new visa will allow Chinese medical tourists to stay in Malaysia for 30 days, and the period can

be extended if documents provided by a doctor illustrate a need for extra time. Ma-laysia has budgeted some US$7.4 million to market itself as a medical tourism hub in the region, with China being the most important market.

Despite Malaysia’s high-quality hospi-tals and clinics, Chinese citizens tend to view the country’s level of development unfavourably compared to China. Azli also noted that some Chinese couples might not be willing to travel to Malaysia for these treatments because they view the country as less advanced and less de-veloped than China. Ironically, Malaysia is generally regarded as a more developed nation than China, at least according to the United Nations’ Human Develop-ment Index (HDI). HDI utilises a variety of metrics to rate a country’s economic and social development, including life expec-tancy, education, and per capita income. As of 2015, China was ranked 90th among all countries in terms of HDI, while Malay-sia was ranked 59th.

Regardless, perception is more impor-tant than reality when it comes to market-ing anything to tourists, let alone tourists seeking medical treatment.

Thailand is another destination seeking to attract Chinese IVF-seekers. Phayathai 2 International Hospital, a private hospi-

tal located in Bangkok has built a new fertility wing set to open next year in part because of increased demand from Chinese couples. In 2014, the hospital even sent a roadshow to Shenzhen to market its fertilisation treatments in Chi-na. Phayathai 2 International Hospital isn’t alone and is joined by several prominent Thai hospitals hoping to tap into the same market, and the Tourism Authority of Thailand (TAT) is coordinating with clin-ics and medical professionals to boost the country’s appeal as a medical destination.

Canada and the United States could also be major beneficiaries of IVF tourism

Beyond Thailand and Malaysia, South Korea, Taiwan, the United States, and Canada have all been tapped as potential IVF hubs for Chinese citizens. Of course, Chinese medical tourism for birth services isn’t a new phenomenon for Canada and the United States. The United States has been a popular fertility tourism destina-tion, especially for tourists from devel-oped nations. The United States’ tends to have fewer restrictions on fertility treatments and enjoys a high success rate for such medical procedures.

Still, costs for fertility tourism in the United States and Canada are substan-tially higher than in most of China’s neighbours, and only the most cash-rich Chinese fertility tourists will go to North America for such medical procedures. This gives destinations in East Asia a distinct competitive edge, even if they can’t com-pete in terms of reputation.

Article first published on Jing Travel.

Two-child policy: an international IVF boost?

‘Countries adjacent to China, and even across the Pacific, have noticed the huge potential of marketing high-quality IVF options for Chinese families as a source of revenue.’

Incountries


Ctrip estimates a 42% drop in bookings to the US for the Golden Week holiday, due to rising tensions between the two countries and a weak-er yuan. Japan, Thailand, Hong Kong, South Korea and Singapore are the top out-bound travel destinations for this travel period. This could have a corresponding impact on medical tourism flows for the rest of this year.

According to an article on Jing Travel, the National Day holiday/Golden Week travel period from October 1 to 7 saw an increase in travel, both domestic and international, despite rising concerns over the trade war with the US, slowing economic growth, ris-ing public and private debts, and other issues.

Jing Travel says that na-tionalism has a big impact on

where Chinese tourists choose to go, and the Chinese govern-ment has now stepped up its media campaign against what it sees as an aggressive US government. Boycotting desti-nations seen as anti-Chinese is common in the Chinese tour-ism market during high-profile diplomatic disputes.

The article says that prelimi-nary data from Chinese online travel agency Ctrip showed that Japan was the destina-tion with the most booked trips heading into the holiday. Thailand came in second, falling from the top spot last

year, with Hong Kong, South Korea and Singapore taking the third, fourth and fifth spots, respectively. South Korea saw the most impressive turnaround from last year; the country ranked 17th last year because of a travel ban.

The US dropped from fifth place last year to 11th, the preliminary data indicated. The exact drop is hard to cal-culate, but one estimate from Ctrip-owned OTA Skyscanner puts the decline in Chinese flight bookings to the United States for the holiday at 42% compared to the same period last year. An estimate from ForwardKeys claims arrivals to the US have fallen 5% so far this year and 8.4% year-on-year in August.

Full numbers won’t be avail-able for some time, especially for international destinations.

42% drop in Chinese visitors to US

USA

The Dubai Annual Statistical Report 2017 compiled by the Dubai Health Authority (DHA), states there were 1,582 overseas patients sent abroad by the health authority in 2017. In 2016, the number of patients sent abroad was 1,994. Over 30% went to Thailand.

According to the Khaleej Times, millions of dirhams were spent on the treatment of Emirati patients overseas even though the number of patients sent abroad in last year was lower as compared to the previous year.

The total expenditure on overseas treatments in 2017 was Dh623 million with an average cost of Dh2.7million per patient. A total of Dh3.45 million was spent per patient

in the UK, Dh4.24million in Germany and Dh1.17million in USA. In 2016, the total expenditure was also Dh623 million with a slightly higher average spending per patient at Dh3.12 million per patient.

In 2017, Thailand was the most sought-after destination for overseas treatments by the highest proportion of patients (31.5%). In 2016, Germany was the most popular destination with (28.6%) patients seeking treatment. However, in 2017, Germany came in second

place with 21.9% followed by the UK at 21.4%.

Oncology treatments were the most sought after (24.2%) of the total overseas patients, replacing neurology in 2016. Neurology and neurosur-gery was sought by (17.1%) followed by orthopedic, and cardiac surgeries 11.3% and, 6.2%, respectively.

Millions of dirhams are sep-arately being spent by other health authorities such as the Ministry of Health, Health Authority of Abu Dhabi (Haad) and the military, though exact figures were not available.

The number of people escorting patients was higher than the patients themselves. A total of 647 people went to Thailand as escorts, 621 to Germany and 609 to the UK.

Fewer Emiratis sent for treatment abroad

DubaiUS spa bloom: ISPA surveyThe International SPA Association (ISPA) has released its annual findings of five key US spa industry finan-cial indicators, which show that the industry continues to experience record growth in overall revenue, number of spa visits, number of spa lo-cations, revenue per visit and total employees. ISPA commissioned PricewaterhouseCoopers to conduct the annual study, the initial stage of which looks at five factors: total revenue, spa visits, spa locations, revenue per visit and number of employees for the US spa industry. The data continues to show a healthy and robust industry highlighting eight consecutive years of revenue growth with total revenue exceeding US$17 billion in 2017. The number of spa visits increased from 184 billion in 2016 to 187 billion in 2017 (1.6% increase). The number of spa locations increased from 21,260 in 2016 to 21,770 in 2017. Revenue per visit increased from US$91.3 in 2016 to US$93.7 in 2017 (2.7% increase). The total number of employees increased from 365,200 in 2017 to 372,100 in 2018 (1.9% increase). More than 500 new spas opened in the USA in 2017. This is rapid growth and evidence of an indus-try in robust health. The headline figures do not show details of US as against overseas visitors. The complete study will be released at the 2018 ISPA conference in late September.

Inbrief

‘The number of people escorting patients was higher than the number of patients themselves.’

‘Boycotting destinations seen as anti-Chinese is common during high-profile diplomatic disputes.’


India

India once had dreams of attracting many thousands of Western European and Americans for cut price medical care. This obsession lasted for many years, until reality struck and targeting shifted to key markets in Asia, Eastern Europe and MENA countries.

Federal government figures from the Bureau of Immigration and Ministry of Tourism for 2017 show that this change of emphasis has worked.

Big increase in medical tourists, Bangladesh dominates

Overall, the number of medical tourists saw an increase of more than double in these three years. While 233,918 med-ical tourists went to India in 2015, this increased to 495,056 in 2017 and 427,014 in 2016.

Bangladeshis accounted for 55% of medical tourists to India in 2017, and according to tourism ministry, the inflow of medical tourists from Bangladesh increased by 83% in the last three years. While 120,388 Bangladeshis went to India for medical treatment in 2015, and 210,142 in 2016, this number increased to 221,751 in 2017.

The number of medical tourists from Afghanistan was 27,505 in 2015 and 61,231 in 2016. The number fell to 55,681 in 2017. Other countries from where India received a considerable number of medi-

cal tourists include Iraq, Oman, Maldives, Yemen, Uzbekistan and Sudan.

For the Seychelles, only five people ar-rived on medical visas in 2015, compared to 939 medical tourists in 2017.

Pakistan saw a decrease in the number of medical tourists from 3,632 in 2015 to 1,785 in 2017. The number increased marginally for people from developed countries: USA (615 to 649), UK (609 to 755), France (56 to 97) and Germany (52 to 109). Kuwait sent more than 1,000 of its citizens to India in 2017 for medical purposes compared to 265 in 2016.

Market value estimate

Although there are no official figures for medical tourism income, the latest government estimates are that the sector was worth US$3 billion in 2015 and is pro-jected to be $9 billion by 2020. However, this would put the revenue per medical tourist at around US$12,800, which seems unrealistic for a low-cost medical tourism destination.

Previous Indian figures have been based on medical visa numbers, but not all medical tourists apply for medical vi-sas, so the new figures are based on total medical tourist numbers. The Maldives figure is suspicious, as the total popula-tion of the Maldives is only 445,000, but it could be that it is for the Maldives plus other offshore islands.

Sources of inbound medical tourists

Country Price (GBP)

Bangladesh 221,751

Afghanistan 55,681

Iraq 47,640

Maldives 45,355

Oman 28,157

Yemen 11,903

Uzbekistan 8,309

Nigeria 5,530

Pakistan 1,785

Kuwait 1,000+

Seychelles 939

United Kingdom 755

USA 649

Germany 109

France 97

SOURCE INDIAN MINISTRY OF TOURISM AND BUREAU OF IMMIGRATION

INDIA Incoming medical tourists

Foreign investment in Vietnam’s private healthcare sector has surged. The amount spent on treatment abroad shows clear opportunity for quality domestic healthcare services.

According to Vietnamnet, foreign investors are putting high hopes on the Vietnamese healthcare sector. The market has seen foreign investors pour trillions of Vietnamese dong in merger and acqui-sition deals in the country’s healthcare sector this year. Notably, South Korea’s Sun Medical centre acquired Nha Khoa My, an international network of dental clinics which has been operating in Vietnam for 15 years. Also earlier this year Polish Adamed Group spent US$50 million to

acquire 70% of Davipharm shares. This is the biggest Polish investment affair in Vietnam so far, made in anticipation of the Vietnam-Europe Free Trade Agreement, expected to be signed this year.

Managing Director and Chief Invest-ment Officer of VinaCapital Andy Ho said that it is estimated that Vietnamese people annually spend over US$2 billion for medical treatment overseas, clear evidence of the enormous opportunity for quality domestic healthcare services.

The outlook for foreign investors in the healthcare sector is positive as Vietnam’s population is ageing quickly, with 10 % at or above the age of 60 in 2017 – in 15-20 years, the elderly will account for one-third

of the total population. Rapid urbani-sation is also stimulating demand for quality healthcare within Vietnam while overcrowding in government hospitals is expected to intensify, resulting in long wait time and a shortage of beds.

Business Monitor International (BMI) reported that Vietnam’s healthcare expenditure was estimated at US$16.1 billion in 2017, which represented 7.5% of the country’s GDP. BMI forecasts that healthcare spending will grow to US$22.7 billion in 2021, recording a compound an-nual growth rate (CAGR) of approximately 12.5% from 2017 to 2021.

Vietnamese spend US$2bn on treatment abroad

For a detailed analysis of medical tourism in India, visit the IMTJ Country

Profile

TM

Vietnam

Incountries


It is often reported that medical tourism is a multi-bil-lion dollar global industry. Clinics, hospitals and entire countries are actively trying to attract medical tourists through costly advertisement campaigns and other promo-tional efforts. But what about the friends and family who accompany them?

Accompanying a friend or relative for healthcare overseas — which often means taking care of their every need — can be physically, psychologically and emotionally exhausting.

There is no formal guidance

on what they can expect while they are abroad. No formal resources to prepare them to do things like change wound dressings in hotel rooms or navigate airports with some-one recovering from surgery.

These friends and family are, in many ways, ‘shadow workers’ in a multi-billion dollar global industry. The unpaid care work they provide to medical tourists is invaluable and yet, in Crooks’ opinion, the industry does little to protect them.

The team’s collaborative re-search shows that one tangible action is to develop resources

to help these individuals make informed decisions, become prepared travellers and caregivers and stay safe and healthy.

Crooks’ has put together a one-page information sheet that offers nine specific factors for friends and family to care-fully consider before accompa-nying a medical tourist abroad.

To find out more and obtain the paper, Are you thinking about accompanying a medi-cal tourist abroad as a caregiv-er?, visit valoriecrooks.org

Resource helps ‘shadow workers’

Canada

Mongolians opt for Seoul treatment

According to the Korea Herald, Seoul City claims that 9,600 Mongolians visited Seoul in 2017 to receive medical services. Mongolians accounted for the fifth-highest number of medical tourists to the city.

www.treatmentabroad.com

THE MOST COMPREHENSIVE ONLINE GUIDE TO MEDICAL TOURISM

Helping you to grow your international patient business

• Search• Compare• View profile• Enquire

The number one source of news, views and insight into medical travelwww.imtj.com

Based on interviews with Canadian medical travel companions, Valorie Crooks, Professor at Simon Fraser University and her team have published an information sheet to help these ‘shadow workers’ become prepared members of medical tourists’ support networks

INFOCUS

The American approach

Selling the concept of medical travel to US-based insurance groups is not an easy task - but with such a large potential audience why has adoption been so slow?

THE INSURANCE GAME

WINTER 2018



Infocus

Why do so few US health insurance companies offer international medical travel benefits? Irving Stackpole, president of Stackpole & Associates Inc, and Elizabeth Ziemba, president of Medical Tourism Training Inc, unpick the issues

Why don’t US health insurance plans include medical travel?

Selling international medical tour-ism benefits to a US-based health insurance provider is difficult. Despite many years of trying, few

health insurance companies offer med-ical travel benefits. Why has adoption been so slow?

US outbound travel for medical care: a realistic view

Expectation of a mass exodus of Amer-ican healthcare consumers to high-qual-ity, lower-cost destinations was much talked about ten years ago. In 2007, a Deloitte report stated that by 2015, at least 10 million, and possibly as many as 24 million Americans, would be travelling abroad to consume medical care1.

The driver for this outbound medical travel was to be insurance companies, who would see the logic in support-ing a market that promised to deliver high-quality medical services at signifi-cantly lower cost than in the US.

Reality has not met expectations. Poor data, difficulties in consumer acceptance and the role of US-based health insur-ance have all been identified as barriers. The most realistic estimates indicate that in 2015 between 2.5-3.2 million Ameri-cans travelled for medical services2. Still a respectable number but far below the earlier predictions.

The reality of the volume of Americans travelling abroad for medical care has not, however, discouraged continued support for inflated numbers and expec-tations. For example, the Medical Tourism Association (MTA) in a webinar, Medical Tourism and Obamacare: Self-Funding Employers in Search of Benefits to the Af-

fordable Care Act, suggests that, because of rising healthcare costs, US employers will be enthusiastic to add international medical travel benefits to their health-care programs.

Why is it so hard to add medical travel?

There have been several barriers to growth. First, there may be no other single market in the world that is more complex than US health insurance. Add-ing a medical travel feature to insurance coverage in this complicated market is extremely difficult.

Second, US health insurance operates in a patchwork of convoluted, interrelat-ed, state and federal legislation and reg-ulation. Political arguments about health insurance and amendments to health-care regulation are generating uncertain-ty, which means insurance providers are not sure which way markets will turn.

Then, add to this complex mixture the perception of the average American, who not only believes the US health-care system is the best in the world, but who is generally uninformed about the quality of medical services elsewhere. This means US employers are reluctant to invest the extra time and money needed to educate their employees on the bene-fits of medical travel.

When logic fails: the obstacles in US health insurance

The logic of medical tourism is that if health insurance companies can save


A DEEPER LOOK AT JUST A FEW

ASPECTS OF THE US HEALTH

INSURANCE SYSTEM

ILLUSTRATES THE OBSTACLES TO LOGIC AND

MEDICAL TOURISM PROPONENTS

money by using high quality, lower cost medical care, why wouldn’t they sign up? And if employers are paying expensive medical bills (which many do), why wouldn’t employees opt-in for high quality, low cost care outside of the US, while saving the company money?

Unfortunately, we do not live in a per-fectly logical world. A deeper look at just a few aspects of the US health insurance system illustrates the obstacles to logic and medical tourism proponents.

In 2010, before the passage of the Affordable Care Act (ACA, or Oba-macare), 16% (48.6 million) of the adult population was without health insur-ance. Five years on, over 90% of the population has health insurance, with the majority 18–64 age group getting their insurance through their employ-ers (see figure below). Changes to the healthcare eligibility rules proposed by the Republican administration will likely result in more people losing insurance coverage.

Under current US law, employers with over 50 full time equivalent (FTE) em-ployees are required to provide health coverage to full-time employees, or else pay a tax penalty.

In reality employers have three op-tions:

• Offer no insurance benefits for some employers - it may make more financial sense to pay the

penalty than to offer health insurance

• Offer private health insurance through a third party such as UnitedHealth, Humana, Aetna, Cigna and others

• Choose to become self-funded (looked at in more detail below)

Employers with less than 50 FTE em-ployees are not required to provide any health insurance. Those employees may opt to buy health insurance privately or go uninsured.

Self-Funded Health Insurance and potential medical travel benefits

Approximately 69.8 million (61%) of employees are members of insurance plans which are self-funded3. The per-centage in self-funded plans increased from 49% in 2000 to 54% in 2005, but has since remained steady: 60% in 2011, and 61% in 2016.

Of firms offering fully-insured plans, 6% reported that they were considering self-funding because of Obamacare4.It is now estimated that the average

9.1

90.9

67.2

55.7

16.3

37.1

16.3

19.6

4.7

0 10 20 30 40 50 60 70 80 90 100

UNINSURED

WITH HEALTH INSURANCE

ANY PRIVATE PLAN

Employment based

Direct purchase

ANY GOVERNMENT PLAN

Medicare

Medicaid

Millitary healthcare (1)

SOURCE THE UNITED STATES CENSUS BUREAU CURRENT POPULATION SURVEY 2016 ANNUAL SOCIAL AND ECONOMIC SUPPLEMENT

PERCENTAGE OF PEOPLE BY TYPE OF HEALTH INSURANCE COVERAGE 2015


Infocus

NOTES1 Medical Tourism. Consumers in search of value. Deloitte 2007. See: https://www.scribd.com/document/47990763/Medi-cal-Tourism-Consumers-in-Search-of-Value2 Lunt, N. Ed. Handbook on Medical

Tourism and Patient Mobility. Horsfall, D. and Hanefeld, J. Edward Elgar Publishing 2015.3 Based on Kaiser Foundation, as reported

in Quora Healthcare Marketing. See: www.quora.com

4 KFF / HRET ibid.5 See: http://www.nytimes.com/2013/02/18/us/al-

lure-of-self-insurance-draws-concern-over-costs.html?_r=1&. 6 Self-funded employers that secure reinsurance contracts have been

estimated at over 25%. See: Deloitte – Self-Insured Benefits Plans 2013.http://

www.dol.gov/ebsa/pdf/ACASelfFundedHealthPlansRe-port033113.pdf Accessed 10/23/2-147 U.S. Employers Follow Path to Successful Overseas Surgeries. See: http://www.tmcnet.com/usubmit/2013/10/08/7465335.htm. Accessed 11/09/148 World Medical Tourism Congress: Piece de Resistance for U.S. Employer Savings. See: http://www.medicaltourismcongress.com/blog/us-self-funding-employer-savings/. Accessed 11/09/14

9 Georgia Firm Adds Medical Travel to Cut Costs, Provide Options for Employers. See: http://www.companion-

globalhealthcare.com/news.aspx?article=51

self-funded plan covers 300-400 employ-ees5.

In self-funded plans, the employer provides insurance to its employees with its own funds, and assumes all, or a significant portion of the risk for paying medical claims.

Self-funded plans are important for the medical travel markets. These plans are exempt from many of the state and federal insurance restrictions, so employ-ers can be flexible about what they offer, including medical travel benefits.

Influence of stop-loss carriers on medical travel benefits

So that employers can manage the financial risk of self-funding claims, they buy ‘stop-loss’ insurance or reinsurance from an insurance carrier6. While the stop-loss carrier may not have direct control over what the employ-er-funded benefits plan will include, the risks in the plan benefits are the direct concern to them.

For example, if an employer has a con-tract with a stop-loss carrier, the contract may preclude referring insured employees to a foreign medical services provider or any provider which does not meet US credentialing or accredi-tation standards. It is usual and customary for health insurance plans to stipulate that medical claims will be paid only to providers (hospitals, clinics and doctors) which meet state, federal or private (e.g., Joint Commission) credentialing requirements. If employ-ers are self-funded, these accreditation requirements may be waived, but if the stop-loss carrier does not accept these waivers, the employer may see the risk as too great because the stop-loss carrier

will not insure against the risk.In addition, more small companies

are looking to self-funding to reduce their share of the burden of medical costs. Because small companies are not able to assume the same levels of risk as larger ones (the self-funded market is dominated by large employers, with the average size over 300 employees), stop-loss insurance rates are increasing. This may limit expansion of self-funded health insurance into the small employer market.

Self-funded plans with Medical Travel Benefits

Adoption has been slow, although some employers have added medical travel benefits to their self-funded plans. Examples include Hannaford Super-markets based in Maine (2008), HSM

Solutions, a Hickory, North Carolina furniture manufacturer (2008)7,

Casino and Hotel of the Blue Lake Rancheria tribe in Northern Cal-ifornia (2013)8 and IDMI Systems

Inc., a software company in Warn-er Robbins, Georgia (2014)9.The

willingness of these companies to adopt a medical travel benefit plan may prompt others and serve as an example for similar plans.

Summary

While logic offers a compelling argument for employers and health insurance companies to offer and cover medical travel benefits, the realities of the US market have prevailed. Consum-ers are uninformed about the quality of services offered outside the US borders. The investment of time required by employers to educate employees and the conservative stance of US health insurance companies are obstacles facing the medical travel sector. The complexity of US laws and regulations are yet another factor slowing adoption of medical tourism.

In the second part of this series, the structural, cultural, and financial obsta-cles to change as well as the opportuni-ties that do exist in the US market will be detailed. Our goal is to offer a balanced perspective on this misunderstood topic, neither hyping its potential nor painting it as totally unrealistic. The true opportu-nities lie somewhere in between.

imtj.com | MAY 2018 | 23

Global medical tourism is increasing annually. What is changing rapidly is each country’s share of the total market, and the nature of medical tourists that they are attracting. Countries thought of as suppliers of medical tourists – the US, China, Russia and the Gulf nations - are turning the tables and becoming major destinations.

This new report discusses the dynamics of medical tourism, providing insights into the supply chain, business models, products and the targeted consumer, and how the rise of medical tourism portals is having an effect. The report includes an additional section on the impact of Brexit on cross border healthcare from the UK.

Reasons to buyTrying to keep up-to-date with the ever-changing world of medical tourism is a challenge for every destination and healthcare provider involved in the international patient business.

Organisations must refine their medical tourism strategy in response to a changing market. To do that, they need to know the latest on which countries are doing well or badly, who is going where, the treatments they are seeking, why they are going there, and how political, economic, social and technological change are impacting the medical tourism market.

The Medical Travel and Tourism global market report provides extensive insight into what is happening now, and what the future trends may be. In addition to the report, purchase includes online access to IMTJ’s constantly updated Country Profiles: a unique database giving a high end overview of healthcare systems and services while also listing up to date statistics on population, healthcare workforce, healthcare expenditure/provision/activity and the values of both inbound and outbound medical tourism.

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MEDICAL TRAVEL AND TOURISM GLOBAL MARKET REPORT

What the report includes Overview

International Medical Tourism Global Figures

Top 20 Medical Tourism DestinationsTop 25 Outbound Sources

Top 20 Health and Wellness Destinations

International, Regional and Domestic Market Commentary

Agencies and FacilitatorsCustomer Profiles

Products and ServicesInsurance

Cross-Border Healthcare

Appendices include:International Organisations

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• C-suite professionals working inhealthcare markets around theworld

• Hospital and clinic groupsoperating internationally

• Travel agents• Banks and other financial

institutions

• Investors and private equity• Insurers• National government policy-

makers• Lawyers• Policy advisors• Think tanks• Management consultants

Who is the report for


Infocus

As incomes in China have risen in recent years, so too has the amount of international travel undertaken by its 1.4 billion

residents. China has been tourism’s top market since 2012, and it will soon be the world’s largest source of interna-tional travellers.

Over the first six months of 2018, 80 million worldwide outbound border crossings were made by Chinese passport holders, representing a year-on-year growth rate of 16.4%, according to the China Outbound Tourism Research Institute (COTRI).

At the beginning of the year, COTRI forecast that 2018 would see a total of 154 million Chinese arrivals in all destinations worldwide, which would represent a 6% year-on-year increase against 2017’s total of 145 million. Following the robust growth seen between January and June 2018, the end of year forecast has now been revised to 160 million annual border crossings made by mainland Chinese passport holders, consisting of 75 million arrivals to other Greater China destinations (47%) and 85 million in destinations in the rest of the world (53%).

By 2020, it is predicted nearly 190 million Chinese will travel internationally, and they will spend US$350 billion per year.

Main flows to Hong Kong, Thailand, Japan, Vietnam

These latest figures built upon an already successful April-June (Q2) period, during which Chinese nationals made 42 million border crossings around the world, a 15.9% increase on 2017. During this period 42.4% (17.8 million) of mainland Chinese travellers

went to the other Greater China regions, mainly Hong Kong Special Administrative Region (SAR), Macau SAR and Taiwan. For the full first half of 2018, these visits accounted for 45.9% (36.7 million) of the travelling total.

Hong Kong alone saw 11.5 million mainland arrivals in Q2 2018, 1.5 million more than Q2 2017. Macau’s total of mainland visitors grew by 600,000 (+13%).

With 2.1 million and 1.2 million mainland arrivals respectively, Japan and Vietnam both saw year-on-year increases in Chinese visitors of 30% between April and June, establishing themselves as the fourth and fifth most popular outbound destinations for Chinese, by volume of tourists.

Vietnam has, in fact, experienced its most successful half-year period for Chinese outbound tourism to date, with over 2.5 million Chinese arrivals between January-June, accounting for 30% of all international arrivals. This is 36.1% higher than 2017’s equivalent figure of 1.9 million. This remarkable growth will accordingly see Vietnam overtake South Korea, pushing it into

the top five most visited outbound destinations among mainland Chinese travellers for H1 2018, behind Hong Kong and Macao in Greater China, Thailand and Japan.

South Korea recorded a significant 52% year-on-year increase in Chinese arrivals following the end of the moratorium on package groups, the origins of which came from the political fallout surrounding Seoul’s hosting of the US THAAD missile system. There is still some way to go to meet previous arrivals levels - the 1.1 million during Q2 2018 is still significantly lower than the 2.1 million seen in Q2 2016.

World Tourism Cities Feder-ation vs UNWTO

China’s interest in global tourism is great enough to have set up the Beijing-based World Tourism Cities Federation (WTCF). This could be a new rival to the World Tourism Organisation (UNWTO), as China apparently feels that this United Nations Spain-based subsidiary is too linked to Russia, the US and Europe.

WTCF says global tourists made 11.9 billion trips last year overall, which generated US$5.3 trillion in tourism dollars and accounted for 6.7% of the worldwide GDP. It has released a market research report on Chinese Outbound Tourist (City) Consumption (2017-2018), which systematically analyses the new changes and new trends of China’s outbound tourism market.

WTCF aims to help overseas tourism cities and related tourism institutions understand Chinese outbound tourists. The report explains Chinese outbound tourists’ behaviour and habits and their specific travel requirements. It also

How to tap into the Chinese medical travel market

Chinese outbound travel numbers are exceeding all predictions. Ian Youngman, healthcare and insurance industry specialist, looks at outbound tourism flows, and the different approach needed to attract Chinese medical tourists

BY 2020...190 MILLION CHINESE

WILL TRAVEL INTERNATIONALLY SPENDING US$350 BILLION PER YEAR


includes suggestions to overseas cities on how improve and strengthen the provision of related tourism products and services, to attract Chinese tourists and achieve organic and healthy development in the global tourism market.

Emerging types of Chinese outbound travellers

The growth of Chinese visitor numbers in eastern and south-eastern Asian destinations serves as both a reflection and consequence of China’s increasing impact globally. Regional governments, such as those of Vietnam, Thailand and South Korea will need to approach the topic of Chinese outbound tourism in a holistic manner that balances key economic, political and domestic social factors.

With rising disposable incomes, more of these Chinese travellers are eschewing the group travel trend of previous years to create their own trips. Chinese international travel has tripled in the last 10 years to 130 million trips in 2017, with affluent, increasingly adventurous consumers setting the pace of travel retail, hotels and hospitality. Singles, younger generations, and those from smaller cities are travelling, making China a powerful, and moving, target.

A recent survey by J. Walter Thompson Intelligence found there are 12 emerging types of Chinese travellers, including tourists travelling in multigenerational groups, those who enjoy trying novel cuisine, business people, young women who like to travel solo or with their friends, adventurous sport-loving travellers, and medical tourists.

Ctrip dominates travel online

How do these Chinese adventurers across all ages and demographics book their travel? Increasingly, it’s online. Destinations aiming to attract Chinese travellers must think about China’s domestic online marketplaces, rather than solely relying on their existing distribution channels.

A common mistake made by businesses targeting the Chinese customer is to assume that they use the same social media channels as most

customers in America, Asia and Europe. However, as revealed in another recent IMTJ article on Chinese buying habits, 48% of international travellers and 30% of overseas Chinese residents have said they rely on WeChat and Weibo before making purchases of international goods and services.

While consumers in Europe, the US or other parts of Asia are used to Google and Facebook, it’s Baidu, China’s biggest search engine that has extensive reach across the Chinese internet sector. Other Chinese companies, such as Tencent and Alibaba, have evolved into much more complex platforms than Facebook, Amazon and Alphabet. In a recent speech former Google CEO, Eric Schmidt went so far as predicting that the internet, as we know it, will split in two within the next decade, with one side led by China.

In the rapidly expanding world of international outbound travel from China, Shanghai-based Ctrip, China’s largest travel company, is a major player. Many destinations however still do not consider it as an obvious distribution partner.

In the first three months of 2018, Ctrip earned US$170 million, 19 times more than its earnings during the first quarter of 2017. It plans to expand its overseas revenue from 2% to at least 20% in the next five years, especially by moving into such Asian markets such as South Korea and Japan, as well as the UK and US.

In other countries, people tend to use

a combination of smartphones, tablets and computers to research their travel, but most often they complete their bookings on a computer. Generally, only about 6% book on a mobile phone. In contrast, the Chinese are heavy mobile device users, with 25% of travellers completing their bookings on a smartphone, according to Worldpay.

The Ctrip mobile app, recently rebranded as Trip.com, has been downloaded more than one billion times. Travellers using the app can book 800,000 hotels in more than 5,000 cities. The app also offers real-time flight tracking and reservations within China. Available in Chinese, English and seven other languages, the app does not only offer bookings. Users can also post and read 30 million hotel, flight, train and other reviews.

Medical tourism potential

There is currently very little on Trip.com on health or medical tourism. The Chinese middle classes are however seeking international treatment to keep themselves healthy. It is only a fraction of the total number of outbound Chinese tourists, but it has massive purchasing power.

So, who is going to work with this organisation to pick up on this huge missed opportunity?

The staggering rise of Chinese outbound numbers must presumably include an uplift in outbound medical tourists. The question is (always): how many? The rise has been so rapid that historic China-specific data is not enough. Another problem is that if Chinese nationality alone is used to count medical tourists or, more broadly international patients, then it is almost impossible to differentiate between Greater China regions (e.g. Hong Kong, Macau and Taiwan) and mainland patients.

To get more Chinese health and medical tourists, businesses need to understand what they need and how to access them using the online and mobile devices that the Chinese use.

SINGLES, YOUNGER

GENERATIONS AND THOSE FROM

SMALLER CITIES ARE TRAVELLING, MAKING CHINA A POWERFUL AND MOVING TARGET

Read the IMTJ Country Profile on China for furthr details on estimated

outbound and inbound medical tourism flows.

TM

26 | MAY 2018 | IMTJ - LaingBuisson

The IMTJ Medical Travel Awards celebrate excellence in the medical travel, health tourism and international patient markets. Enter now.

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+44 1442 817817

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Inconference


International medical tourism and medical travel conferences, exhibi-tions and workshops are promoted as a way of helping you to build knowl-

edge and enhance your international network.

However, are most of these events really adding value for their delegates’ businesses? After attending many such events either as a delegate or as a speak-er, I’ve come to realise that only a small number really deliver what they promise. Here’s how I choose whether to attend or not...

Is this actually an ‘international’ event?

I’ve seen a lot of organisers promoting ‘international events’, by simply rebadg-ing a local event as an international event. The reality is that the conference usually takes place in the local language, the majority (near to 100%) of the delegates are locals and there are no net-working opportunities at all with foreign professionals or buyers. In most cases, the quality of promotion of these events outside of the host country is poor. Just ask yourself ‘how can these organisers

believably support foreign buyers or patients if they can’t even communicate effectively in an ‘international’ language, or run a conference to international standards?’

Is it really a ‘medical travel’ event?

Many organisers still confuse medical travel events with medical conferences, which is why I look at the amount of clinical content on the agenda. While the fine detail of open heart surgery or a breast augmentation is acceptable for

There are now so many international medical travel and medical tourism conferences, exhibitions and workshops, but are they delivering what they promise? Maria D. Georga, Regional Manager for Treatment Abroad and IMTJ, shares her views

Deciding which medical tourism conference is best

medical conference participants, dele-gates at medical travel events are often not interested in this level of clinical infor-mation (let alone seeing all the pictures!). Attendees interested in medical tour-ism are not just clinicians; they include business managers, agents and politicians and have a diverse content interest.

A knowledge tank or just a promotional opportunity?

Another big failure during international medical travel events is when organisers don’t set strict expectations with their sponsors. I’m wary of the number of pres-entations by sponsors because I find that when sponsors take over, the delegates lose out. A classic example is a presenta-tion from, say, a local hospital group, that doesn’t include any useful knowledge on lessons learnt or the detail of a successful medical tourism case study. Instead, it’s one long self-promotion which assumes all delegates are potential buyers for their business.

Are agendas and speakers visible before you buy?

For some medical tourism events I’ve looked at, there is a promise of ‘excep-tional speakers and content’, but unfortu-nately nobody can see the speaker names or further detail unless they buy the pass. The reason for keeping this hidden is simple: the organiser hasn’t worked it out yet. Serious international event organisers develop their agendas well in

advance; key speakers are clearly visible to prospective delegates in advance, so buyers can make an informed decision on whether they attend.

Will I learn something new?

I’m very cautious about medical tourism events organised by commercial event companies. Running a successful event for this sector requires industry expertise and a strong network of interna-tional contacts. I’ve seen non-specialist organisers openly plagiarise (and in one recent case, literally copy and paste) agendas from other medical travel confer-ences and present this content as ‘new’.

Having worked in this industry for many years, I’ve also seen the rise of ‘par-asite’ events. Commercial organisations, looking to profit from a well-respected high-profile conference, arrange their own event for the sector just beforehand. They might even promote their event using similar pictures, delegate packages and content wording, to persuade some-one new to the sector to attend their conference instead. Again, agendas may be hidden or speaker details are sparse. Buyer beware.

What does your pass buy?

I find that organisers offer expensive passes for VIP ‘invitation only’ events. Tempting though this may be… that you’ll get access to something important (although often there’s not much informa-tion as to why it’s so exclusive), this is of-ten a ruse to just subsidise the event. You may get into an impressive venue and location but it’s likely a large cut of your pass price will remain with the organiser, who will be using it to offer discount or free passes to others to desperately bump up numbers.

In other cases, I’ve seen commercial organisers (often those mentioned above who simply plagiarise content) hike the price of the pass but then minimise costs by hosting only a small number of speakers, with no extras offered. I went to a one-day event recently, with just five speakers and not even a glass of wine at the end!

Save your money and get real value

So, a few final pointers that will help save your money and time and let you get value from participation in a medical travel event:

Check the event history. Is there a histo-ry behind it, how many years has it been running, or is it just an ‘event attempt’?

Check out the organiser. Are they med-ical travel specialists or event organisers just ‘passing by the neighbourhood’? Someone dealing with engineering conferences one day simply doesn’t have the knowledge or the contacts to run a successful medical travel event the next.

See if everything is transparent. You should have a clear idea of the agenda, key speakers and all other opportunities surrounding the event.

Read ratings and reviews. If the organiser has made sure that no reviews have been posted publicly, this might be something to worry about.

HAVING WORKED IN THIS INDUSTRY FOR MANY YEARS, I HAVE SEEN THE

RISE OF PARASITE EVENTS...

COMMERCIAL ORGANISATIONS HOSTING THEIR

OWN EVENTS DAYS BEFORE

WELL-RESPECTED HIGH-PROFILE CONFERENCES


Infocus

Visit IMTJ Events for a listing of the medical travel events taking place in the

next few months

TM


Infocus

In 2016 the UK’s total expenditure on healthcare was £192 billion, up 3.6% on the 2015 total of £185 billion. More than 70% of this expenditure is accounted for by public spending, with the growth in spending increasing to 4% between 2015 and 2016 (up from 3.1% in 2014-2015), and with the Government announcing a further £20 billion for the NHS in June 2018, this looks set to rise further.

Nevertheless, the figures point to an increased role for the independent sector, whether as a provider of services directly to private payers or as a partner to local authority and public health services in delivering health and social care services.

LaingBuisson’s UK Healthcare Market Review gives a valuable overview of the operating landscape for health and social care service providers across all parts of the market. It looks at current market values and capacity, recent trends, market concentration, leading players and funding sources as well as at key issues for the future. It also covers UK healthcare expenditure in context – benchmarking per capita spending in the UK against other EU and G7 countries

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Infocus

Egg donation plays a significant part in reproductive medicine in Spain. Donated eggs are now one of the most important IVF treat-

ments in the country and it’s growing. Recent data from the Spanish

Fertility Society has shown that egg donation represents approximately a third of all IVF cycles performed in Spain. The country is the undisputed leader in Europe for egg donation, with around 50% of all European do-nation activity being performed there and Spain is recognised as a key global destination for infertility treatment.

In addition, the evolving pan-Eu-ropean IVF landscape has led some countries, such as Italy, to adopt regulations that make them a net importer of human eggs for reproduc-tive purposes. Other countries, such as the UK and Belgium, have adopted an ‘intermediate’ position where they

are aiming at achieving self-sufficiency but are not there yet. In the context of these changes, Spain is moving quickly towards a business model in which it becomes a net exporter of hu-man eggs. With egg donation in other European countries either relatively small in volume or practically difficult to establish, and despite the recent opportunities to buy human eggs from abroad, a significant number of inter-national patients still travel to Spain for IVF treatment with donated eggs.

Anonymity seen as an im-portant factor

There are several reasons why the volume of egg donations is high in Spain. Unlike in some countries where there have been moves in the oppo-site direction, donors in Spain for both sperm and eggs remain anonymous.

Vincenzo Pavone from the Institute of Public Policies (IPP) of the Spanish National Research Council (CSIC), explains how Spain has become Europe’s leading destination for egg donation

Spain’s reproductive services50% of European egg donation happens in Spain...why?

SEEN AS THE AVANT-GARDE OF INFERTILITY

TREATMENT, SPANISH CLINICS

ARE STAFFED BY EXCELLENT

PROFESSIONALS BUT STILL OFFER

REASONABLE PRICES

32 | APRIL 2018 | HM - LaingBuisson32 | WINTER 2018 | IMTJ - LaingBuisson

The UK market for fertility treatment (principally in vitro fertilisation (IVF) but also intra uterine insemination (IUI)) is experiencing accelerating growth, with volumes growing by around 3% per year. Key drivers currently include the greater acceptability of IVF as a route to having a family, especially as the number of people delaying starting a family is rising and more same-sex couples opt to have families. Success rates, which have improved by a factor of 2.5x since 1991, are also encouraging more childless people to turn to IVF.

As of 2016, the market was worth £320m, made up of 68,000 IVF cycles and 13,500 IUI cycles. The market is served by 82 fertility clinics and 30 satellite clinics, making it fragmented and the largest groups account for less than 25% of the cycles. While major hospital groups such as HCA, BMI and Nuffield are involved in the market, they do not seem to be growing their presence.

There remain also a large number of owner-managed clinics, many of which were established in the high-growth years of the mid-1990s, meaning that some owners may be considering exiting. This offers opportunities for would-be investors.

Future growth is likely to be fuelled by further innovation. Clinics and clinicians are always looking for ways of improving their success rates and to add value for their clients. Innovations in genetic testing are reducing the risk of passing on inherited diseases, yet pre-implantation genetic diagnostics still only account for around 1% of IVF cycles. Also, by international standards, the UK has low treatment rates pointing to scope for future growth as confidence in IVF, its success rates and benefits increases.

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Dynamic and innovative – growth is accelerating in the UK IVF market


Who is the report for

FIRST EDITION

IN VITRO FERTILISATION UK MARKET REPORT

What the report includes Market

DefinitionSize

SegmentationFunding

Supply and DemandDrivers of demand

Business modelsOperational statistics

Performance measuresGovernment Policy and Regulation

PayorsMajor Providers

InvestorsMarket Potential

AppendicesThe Process of IVF

CCG Funded CyclesRegulators

Professional and Patient Associations Financial Appendix

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This is the same as the organ donation system, where anonymity is also com-pulsory. Interestingly, current research literature suggests that if anonymity rights are lifted, levels of donation are not necessarily reduced. More data is needed to prove this, however, and clinics in Spain strongly believe it would have a negative impact.

Donors are paid

Economic compensation for egg donors in Spain also encourages supply. The target egg donor market is women aged between 18-25 years old (possibly up to 28 years in some circumstances) and €1,000 is paid per donor cycle, which generally requires 2-3 weeks. While this might not seem a large amount for some, for many it is comparable (or even more attractive) to income they may get from other types of jobs for a similar length of time. Egg donation has thus become an attractive and acceptable means of complement-ing the income strategy for this target group in Spain. As a result, it remains unclear as to whether egg donation as a practice actually corresponds to what the law describes as a ‘free, altruistic and voluntary’ act.

Active donor recruitment: ‘bring your donor friend’

Finally, proactive egg donor re-cruitment activity supports the high supply. Large IVF clinics in Spain with centres across the country are likely to have their own pool of donors and a sufficiently large egg bank to meet most levels of demand. They may only

need to maintain a website and rely on word of mouth for donations. However, for smaller clinics and when supply is low (for example during student exam times), other donor recruitment strategies are used. These include radio advertising, leaflets, recruitment drives at Universities and heavy use of social media. Some clinics even run ‘bring your own donor’ schemes, offering a €100-150 incentive to the introducer.

High demand drives more supply

The volume of egg donations is supported by the high level of demand for IVF treatment in Spain, and there are some other reasons for this demand success. There are many good, well established IVF clinics spread across the country, and in the Mediterranean area in particular, which is a very pop-ular tourism destination. Seen as the ‘avant-garde’ of infertility treatment, Spanish clinics are staffed by excellent professionals but still offer reasonable prices.

Due to the relative abundance of do-nated eggs and the variety of genetic characteristics found in the Spanish population, clinics also have a stronger chance of matching customers’ require-ments with available eggs.

Has Spain reached a peak level of egg donation?

With the increase in elective personal egg freezing, will Spain’s egg donor market decline? While things might change, I’d say not yet. Women choos-ing to freeze their eggs tend to be older

than the target donor market. Many women between 18-25 are not yet thinking about having babies, so the donor landscape may not be changed by new egg freezing options. But if the economic situation in Spain improves, which is something that most people and particularly this group have yet to see, then perhaps less donors will come forward. In this case, clinics might then have to rely on other groups, like foreigners resident in Spain, Latin American groups or other types of legal residents in Spain.

Vincenzo Pavone is a researcher from the Institute of Public Policies (IPP) of the Spanish National Re-search Council (CSIC). With a PhD in Social and Political Science from the European University Institute (EUI), he has been principal investigator, over the last ten years, of two na-tional projects on assisted reproduc-tive technologies and regenerative medicine.

DUE TO THE ABUNDANCE OF EGGS...CLINICS

HAVE A STRONG CHANCE OF MATCHING

CUSTOMERS’ REQUIREMENTS


Infocus

Obesity Opportunity or problem?

Ian Youngman, healthcare and insurance industry specialist, looks at a major new report on global obesity and considers the opportunities and risks for medical tourism

According to a new report from insurance group SCOR called, Obesity - The Health Challenge of the 21st Century, obesity is a

serious problem in both developed and emerging countries.

The growing global problem

For the first time in history, more peo-ple worldwide are suffering from obesity than from starvation. According to the World Health Organisation, 2.3 billion adults were overweight, and 700 million people were obese in 2015, a substantial and rapid increase compared to the prior decade.

Obesity affects the entire world irrespective of age, income and country. While the USA, Australia and the UK are still at the top of the list of nations affected, the countries that have seen the biggest increase in the number of obese and overweight people are in the Middle East and North Africa.

Projections for the future show that obesity rates are expected to continue to rise, particularly in the USA, Mexico and UK where 35-50% of the populations are expected to be obese by 2030.

These rates are also predicted to increase more dramatically in countries with historically low obesity rates, such as Switzerland and Korea.

Over 50% of men over 50 years old worldwide are overweight. There could be as many as 70 million obese children around the globe in 2025.

Obesity is the result of a prolonged mismatch in the balance of energy, with energy intake exceeding energy expend-iture. Three main factors combine to arrive at this imbalance:

Genetic - 50 genes connected to obe-

sity have been identified. Certain genetic mutations mean that some people do not secrete leptin, which is the hormone of satiety. Genetic factors increase the possi-bility of people becoming obese.

Environmental - certain situations can favour obesity: low education, high availability of food, sedentary lifestyle, pollutants, gut microbiota, drugs and poor sleep patterns.

Hormonal - thyroid insufficiency and menopause frequently coincide with a weight gain.

Obesity is the direct or indirect cause of many illnesses, the most serious of which are type 2 diabetes, coronary heart disease, cerebrovascular incidents (strokes and transient ischemic attacks) and cancer.

Obesity can also be associated with many other conditions such as respiratory impairment, sleep apnoea, bone and joint illnesses (the main one being osteoarthri-tis) and psycho-social problems such as

depression, which are both a cause and a complication.

Complications also result from obesity such as skin diseases, digestive disorders, pancreatitis, biliary diseases, and hyper-tension.

Solutions and treatment opportunities

The obvious solution to obesity is bet-ter diet and more exercise, while bariatric surgery (involving one of sleeve gas-trectomy, gastric band or gastric bypass surgery) is the only effective treatment for morbid obesity. It leads to a reduction in long-term morbidity, thanks to beneficial effects on hypertension, diabetes, dyslipi-daemia, sleep apnoea and bone and joint disorders.

Every year there are 200,000 bariatric operations in the USA and 95,000 in Brazil, with 50,000 in France, and while more health insurance schemes and health systems will offer surgery in their own country, there may be limitations or longish waiting lists.

Currently most bariatric operations are paid for by the patient, and this is where medical tourism can meet this growing problem area.

There are however many restrictions and requirements before surgeons will operate in Asia, Europe and the USA. Complication rates range from 10% to 22%, and the global mortality rate is less than 1%, but this does vary by country. While we are quite familiar with reports of complications from cosmetic surgery, hor-ror stories are emerging about medical tourists in difficulty or even dying from obesity surgery.

THE COUNTRIES WHICH HAVE

SEEN THE BIGGEST INCREASE OBESITY

ARE IN THE MIDDLE EAST AND

NORTH AFRICA


Who will control treatment quality at global and na-tional levels?

Unfortunately, this is anoth-er sector where a handful of ‘make a fast buck and ignore the consequences’ medical travel agents, unqualified or un-skilled surgeons, and poor quality clinics are a problem for the image of medi-cal tourism.

Will those businesses and nations promot-ing the mes-sage ‘come to Country X and get prices 60% below what you pay at home’ do anything when customers suffer complications or die when they should not?

When researching surgery stories of ‘where did it all go wrong?’, I am no longer amazed at the number of medical tourism organisa-tions, regulators and politicians who are not leading or taking ownership of the surgery quality issue.

I’d be interested to know just how many medical travel agents properly inform their customers of the relatively high risk of complications or even death from bariatric surgery. Even with the headlines, clinics rarely seem to get closed or prosecuted.

As the SCOR report and OECD figures show, obesity is a huge (pun intended) global problem and a significant chance for medical tourism to offer high value treatment in this area.

It will be a challenge for the whole sec-tor however to face up to the associated risks and counter the bad publicity aris-ing from malpractice and incompetence.

Insight

Customer-centric healthcare How would Disney run a medical tourism business?

Professor Fred DeMicco looks at how Disney’s approach to guest services, management and leadership principles could be applied to medical tourism

Disney takes a very wide view of its competition. It’s not Universal Studios who bother them, but ‘any competition that

the customer compares us to’. This could be anywhere where customers witness a high level of service and an outstanding customer experience.

Competing on a basis of achieving a positive guest experience at all points of contact is equally applicable to the healthcare sector. Fred Lee, in his pop-ular book If Disney Ran Your Hospital,

sums this up well: ‘In the battle for the supremacy of perceptions in the pa-tient’s mind, our competition is anyone the patient compares us to. Unfortu-nately, they do not compare us to other hospitals’.

Perception counts

A 2003 Press Gainey Associates Patient Satisfaction Report identified the top drivers for patient satisfaction, which included how well the staff worked

together to care for the patient; overall cheerfulness of the hospital; responses to concerns or complaints made during the patient stay; amount of attention paid to your personal and special needs; nurses kept patient informed; nurses attitudes towards patient requests; and skill and friendliness of the nurses.

Hospitals and clinics however still spend much of their time on their assessment of clinical outcomes, rather than on how the patient judges the out-comes. As the above survey shows, this

‘You can design, create and build the most wonderful place in the

world – but it requires people to make the dream a reality’

Walt



judgement involves evaluating the total experience of the healthcare facility not solely the clinical medical experience.

Focus on outcomes and perceptions

From a patient services perspective, for higher guest satisfaction and loyalty levels, the focus should be on both im-proving outcomes and perceptions. Im-proving outcomes include building team responsibility, eliminating carelessness, stressing what the medical team should be doing and process mapping. Building positive perceptions involves prioritising personal responsibility, being tuned into patient perceptions, improvement of staff behaviours and attitudes, stress what staff should be saying, seeking to impact impressions, and best possible thinking.

At Disney, employees are referred to as ‘cast members’ and all customers are ‘guests’. Cast members are taught to be ‘assertively friendly’ and to know what to say, via practising scripts and storyboarding, to make the best positive impression. Managing the moments of truth between guest and cast member interactions creates a powerful positive impression.

If Disney ran your hospital or clinic, nurses for example would begin to believe that they are judged not so much against the standard of other nurses, but against the standards set by the nicest people providing customer services, anywhere. The same goes for the food service staff, housekeepers, receptionists and doctors.

Courtesy is more important than service efficiency

The four most important areas that Disney stresses to newly hired cast mem-bers are, in this order: Safety, Courtesy, Show (sensory impressions) and Efficien-cy (Process).

Safety as number one aligns well with hospitals, but the other areas particu-larly related to patient satisfaction (e.g. courtesy) are often not clearly defined in healthcare sectors and thus not always carried out in service delivery.

This is why Disney places courtesy higher than efficiency.

Four out of five for Guest Satisfaction is not enough

Many hospitality and healthcare facilities use a 1-5 Likert scale to assess patient satisfaction with their hospital visit. If a ‘1’ means not satisfied, then pro-viders generally see everything above a 4 as a satisfied patient.

But Disney doesn’t show the full range of guest satisfaction scores to its cast members, only the percentage of guests giving ‘5’s to satisfaction (i.e. excellent). This is because Disney sees only scores of 5 are linked to loyalty and thus the likelihood to return as a guest. In fact, a guest who gives a 4 is about six times more likely to defect than a customer who gives a score of 5.

Disney sees loyalty, not purely satisfac-tion, as the most important factor need-ed to protect the organisation against future competition in a complex market.

An example of this is a hotel staff member cleaning all guests’ windshields in the parking lot and placing a note on the windshield saying, ‘Clean windshields on us - have a great day!’. By doing something memorable, guests remem-ber this, which in turn generates a buzz or story for others to re-tell, thus building

loyalty. A patient who is merely ‘satisfied’ has no story to tell, as everything went as expected.

For hospitals and clinics, to get patients to become loyal and sing the praises of the healthcare facility to others, true compassion must be shown by the staff. According to F.Lee (of the above noted book) there is nothing quite as powerful in patient satisfaction scores as a phone call placed to the home of a discharged patient. If it comes from the nurse or doctors, this is a powerful mes-sage of compassion and concern.

Conclusion

These are just a few of the service elements that Disney would focus on if it did indeed run your hospital or clinic (who’s to say it won’t happen in the fu-ture?). Every healthcare manager should be reinforcing the principles of service excellence learnt by hard graft in the hospitality sector, and start using some of these suggestions to build loyalty.

IF DISNEY RAN YOUR FACILITY,

NURSES WOULD BELIEVE THEY ARE JUDGED AGAINST THE

NICEST PEOPLE PROVIDING CUSTOMER SERVICES

ANYWHERE

Frederick J. DeMicco, Ph.D., RD, CGSP spent a part of his career at Disney World, Orlando at the Contemporary Hotel and Wilderness Lodge Resort Resort and in healthcare at the Massa-chusetts General Hospital in Boston. He completed his Ductorate degree at Dis-ney University. He is editor of Medical Tourism: Hospitality Bridging Health-care (H2H) and Wellness, published by Apple Academic Press.

38 | MAY 2018 | IMTJ - LaingBuisson1 | MEDIA PACK | LaingBuisson

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INMARKETSWINTER 2018

INDEX

1 | MEDIA PACK | LaingBuisson

Healthcare Markets is the leading journal covering

the UK independent healthcare sector. Drawing

upon LaingBuisson’s unique data, the title combines

high-quality journalism with in-depth analysis and

contributions from key industry associations and sector

experts. Digital and print subscriptions include access

to an online archive dating back to 1998.

For further information on these titles visit laingbuissonnews.com where you can sign up for a trial, or contact our account managers on [email protected] or +44 (0)20 7841 0045

Ten print editions - delivered through the year

News insight - taking stories beyond the headlines

In depth features - written by authors with a deep

understanding of the markets

Interviews - with leading healthcare figures

Unique data tables - presenting LaingBuisson figures on

market sizes

Special supplements - including roundtable reports, cost

surveys, infographic posters

Online archive - news and features dating back well over

a decade

Online bonuses - including a healthcare sector deals

table with links to accompanying news coverage

News e-alerts - delivered to your inbox

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and seminars, with fixed ‘early bird’ rate

5% discount on all additional LaingBuisson product or

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Aier Eye 46 Malaysian Healthcare Travel Council 41, 53

AirAsia 41, 53 Malaysian Ministry of Finance 41

Airbnb 50 Max Healthcare 49

Alantra 53 Mayo Clinic 48

Ashfield Healthcare 54 McDermott Will and Emery 46

Aspen 49 MD Medical Group 53

AXA Insurance 51 Mediclinic 53

babylon Health 48 Memira 46

BookDoc 49 Moorfields Eye Hospital 45British Association of Aesthetic Plastic Surgeons 43 Narayana Health 54

Clinica Baviera 46 NHS Digital 53

Create NYC 54 NHS Partners Network 53

Ctrip 50 NMC Health 49

DabaDoc 51 Nordic Capital 46

Dubai Health Authority 40 Ober Scharrer Gruppe 46

Dunyagoz 46 Optegra 45

Eight Roads 45 Oshen-King Faisal Hospital 51

Elite Aftercare 43 Palamon Capital 46

Fidelity International 45 Prudential Corporation 48

Fullerton Healthcare 51 SmartAnalyst 54

GoFundMe 40 TELUS 48

Google DeepMind 47 Tencent 51

Grupo Palace 54 Tenet Healthcare 49

Health City Cayman Islands 54 Thomas Cook 42

Instituto Valenciano De Infertilidad 53 UDG Healthcare 54

Lexum 46 UnitedHealth 50

Life Healthcare 49 WeDoctor 51

INMARKETS


Crowdfunding sites are help-ing people with advanced cancer spend money on unproven and alternative treatments abroad. The BMJ asks: is it fuelling quackery?

The BMJ has published figures that show how crowdfunding for alternative cancer therapies has soared in recent years. The figures, collected by the Good Thinking Society, a charity that promotes scientific thinking, show that since 2012 appeals on UK crowdfunding sites for cancer treatment with an alternative health element

have raised £8m (€9m; $10m). Most of this was for treatment abroad.

JustGiving’s own figures show more than 2,300 UK cancer related appeals were set up on its site in 2016, a sevenfold rise on the number for 2015.

For example, hundreds of thousands of pounds have been crowdfunded for UK patients’ treatment at the controversial Burzynski Clinic in Texas, US, which US authorities have pursued for years over its marketing of unproved treatment and

research trial failings.Good Thinking wants the

crowdfunding sites to vet cancer appeals and ‘reject outright proposals that refer to specific drugs that have been discredited, extreme dietary regimes, intravenous vitamin C, alkaline therapy and other alternative treatments.’

GoFundMe, the platform that features most prominently in Good Thinking’s dataset, said it is already ‘taking proactive steps’ in the US to make sure users of its site are better informed and will be doing the same globally over the coming months.

Are crowdfunding sites funding inappropriate international treatments?

According to the Khaleej Times, the Dubai Health Au-thority (DHA) has launched Autologous Stem Cell ther-apy and has set up a Stem Cell Scientific Board to issue relevant guidelines. The DHA is apparently adopting an ‘incremental approach’ toward the regulation of au-tologous stem cells, via this Board. International interest in stem cell treatments is increasing, but the evidence base for its effectiveness is still limited.

The Khaleej Times states that, to promote health tourism, the Dubai Health Authority has introduced stem cell therapy for aesthetic and degenerative treatments. According to the article, a senior official said the aim was to promote innovation and advancement in the field of medicine and contribute towards evidence-based practice.

The authority will introduce guidelines through a new Stem Cell Scientific Board for those seeking to offer

Autologous Stem Cell therapy (cells derived from one’s own fat and blood).

Stem cell therapies have been used since the 1980s and there is hope that it may offer the potential to treat challenging diseases or conditions for which few treatments exist. Although the evidence base is limited, many research institutes across the world are investigating how stem cells can offer new effective therapies to treat degenerative diseases.

Dr Marwan Al Mulla, chief executive officer for the health regulatory sector DHA, said: ‘The authority has recently established the Stem Cell Scientific Board which is tasked to delineate the requirements for provision of the autologous stem cell therapy in Dubai. We have started with the professional and facility licensure requirements and the board will be soon issuing a detailed guideline.’

‘We want to ensure that while Dubai today is a global

destination for health tourism being at the forefront of cutting edge innovation; plays its role in finding a solution to provide high-quality and safe aesthetic treatments in addition to the treatment of degenerative diseases using the stem cell technology,’ he explained.

He said that as regulator, the authority has a responsibility to ensure patients are kept safe from unregulated treatments.

‘We also have to pave the way for new medical advancements while physicians have an ethical, moral and social responsibility to progress the field of medicine,’ said Dr Marwan.

‘This includes being clear and upfront with their patients on the efficacy, safety, and cost effectiveness of treatments including the autologous stem cell treatments and reporting outcome data to the Stem Cell Scientific Board to ensure the next generation of physicians and researchers are able to progress with the evidence

based practice in this field of medicine,’ he added.

Dr Hanan Al Obaid, director of health policy department at the DHA, said: ‘We are adopting a risk-based and science-based approach to ensure we also strengthen our research capacity. We welcome investors who offer autologous stem cell therapy that will be ethically approved by the Stem Cell Scientific Board.’

The DHA is adopting an incremental approach toward the regulation of autologous stem cells. ‘Therefore, we have set out interim requirements for healthcare providers to follow and will be introducing detailed guidelines for autologous stem cells therapies through the Stem Cell Scientific Board. All healthcare facilities must ensure they acquire the necessary written approval for their health facility and health professionals to provide the treatment,’ she said.

DHA launches new stem cell therapy


W I N T E R 2 0 1 8

UK crowdfunding; Dubai stem cells; Malaysian numbers

The Malaysian Ministry of Finance expects the num-ber of medical tourists to increase significantly to two million by 2020, following the tax exemption for medi-cal bills. In 2017, one million medical tourists visited the country, 600,000 of whom were from Indonesia. Top medical travel contributing states are Penang, Kuala Lumpur, Selangor, Melaka and Sarawak.

A 6% goods and services tax was imposed on medical bills for foreign patients but these are now exempted, and medical tourists do not pay the sales and service tax.

Deputy Finance Minister, Datuk Ir Amiruddin Hamzah confirmed in a speech earlier this month that Malaysia earned RM1.3 billion (US$314 million) in medical travel revenue in 2017, with an estimated RM4 billion (US$967 million) from other non-related healthcare expenditures such as transportation, accommodation and tourism activities. The government hopes to double this figure to RM2.8 billion (US$676.9 million) by 2020. The industry recorded annual growth of 16% a year.

Malaysia is targeting to get at least one million health tourists from Indonesia by 2020, according to the Malaysia Healthcare Travel Council (MHTC). In 2017, one million medical tourists visited the country and 600,000 were from Indonesia.

Top inbound medical tourism states

Penang was the top destination of the healthcare tourists with 60% visiting the island for treatment. The state’s healthcare travel industry generated US$121

million in revenue in 2017. Among the medical fields that Penang is known for are cardiology, orthopaedics, oncology, neurology, in-vitro fertilisation, ophthalmology and dentistry. Other top medical travel contributing states are Kuala Lumpur, Selangor, Melaka, and Sarawak.

AirAsia Indonesia flies to Penang twice daily from Jakarta, thrice daily from Medan and thrice weekly from Surabaya. A deal between the airline and MHTC will see both parties jointly promoting Penang as the country’s top destination for Indonesian medical tourists.

The health ministry regulates the prices that private hospitals can charge patients so medical tourists know they will not be overcharged.

MHTC aims to develop Malaysia as a hub of

excellence for cardiology and fertility treatment. The National Heart Institute is well known around the world and Malaysia is also known for its fertility treatment success rate.

Targeting Chinese medical tourists

Many Chinese couples in their 40s need reproductive care to conceive another child, so by promoting Malaysia’s success as a fertility hub more Chinese couples may opt to go there for treatment. The success rate of IVF treatment in Malaysia is high, at over 55%.

The Malaysian government has engaged in efforts to attract Chinese medical tourists seeking medical treatment, including introducing a new e-visa scheme for. The new visa will allow Chinese medical tourists to stay in Malaysia for 30 days, and the period can be extended if documents provided by a doctor illustrate sufficient need for extra time.

Despite Malaysia’s high-quality hospitals and clinics, some Chinese couples might not be willing to travel to

Malaysia for these treatments because they perceive the country as being less advanced and less developed than China. Malaysia is generally regarded as a more developed nation than China, however perception is more important than reality when it comes to marketing to medical tourists.

Malaysia expects 2m medical tourists by 2020

TM

‘In 2017, one million medical tourists visited the country and 600,000 were from Indonesia’

Kuala Lumpar, among the top contributing Malaysian medical travel states

Quoted in Belarus News, Dmitry Kalistratov, head of business, pricing and state property at the Health Ministry, says that in 2017 Belarus’ export of medical services rose by 6.2%, thanks to the launch of the five-day visa-free travel. Good growth came from the UK, Ireland, the US, Lithuania, Latvia, France and China.

Belarus: inbound medical tourist rise

For a detailed 2018 analysis of inbound

medical tourism to Malaysia, visit the IMTJ Country Profile

TM


Should tourists have to buy health insurance?Egypt and Oman are looking to make all tourists buy health insurance, but Ecua-dor is reversing the rule.

An increasing number of countries have or are planning to make it compulsory for all tourists to buy health insur-ance locally. There is rarely any exclusion for medical travellers, however no current compulsory policy will pay for planned medical treatment.

The debate on imposing mandatory insurance has been elevated recently, after UK global travel firm Thomas Cook announced the with-drawal of all its customers from a hotel in the Red Sea resort of Hurghada, Egypt, after the death of two British tourists and reports of a raised level of illness among guests. There have also been repeated incidents involving individual tourists from other Asian, African and Arab countries.

In Oman, the plan is for

all visitors to buy health insurance, and those without insurance may be forced to buy cover at border posts. Since Oman is actively seeking to increase its tourism, this plan may be shelved so that it doesn’t put off potential visitors.

Egypt is preparing to im-plement the first compulsory insurance law for tourists, to boost confidence in Egypt as a destination. The mandatory insurance policy will cover the risk of personal accident, death and total disability, as well as medical treatment expenses while the tourist is in the country.

Egypt’s Financial Regulatory Authority (FRA) is carrying out an actuarial study that includes data on the numbers of foreign tourists and the types of accidents they have experienced in past years. The actuarial study will be completed soon, depending

on the data obtained by the Authority from the Ministry of Tourism and Interior and the Central Agency for Public Mobilisation and Statistics. This is to be used to determine the value of premiums and collection methods.

The study includes the possibility of contracting with a global insurance company to provide the compulsory insurance through a tender by the FRA, as well as the possibility of treating tourists through the Egyptian health insurance law in public or private hospitals.

Ecuador is instead revers-ing its mandatory health insurance. Foreign tourists entering the country now no longer need to take out health insurance, according to new law that came into effect in August 2018. Through the elimination of health insur-ance, the ministry of tourism says they are seeking to maintain the country’s tour-ism competitiveness without increasing costs for the people who go to Ecuador. The gov-ernment is increasing its sup-port for the inbound tourism industry of the country.

Concerns about the number of birth tourists coming to British Columbia from China has persuaded Canada’s opposition Conservative Party to support ending citizenship by birth-place.

The South Morning China Post reports that Canada’s opposition Con-servative Party has voted at its conven-tion to end citizenship by birthplace if neither of the child’s parents holds Canadian citizenship or permanent residency, in the face of a growing Chinese birth tourism industry in British Columbia.

The non-binding policy resolution was supported by delegates including Alice Siu-Ping Chan Wong, the MP for Richmond Centre in BC. Richmond is at the centre of the practice of birth tourism, driven by mainland Chinese

parents.Newborns with non-resident mothers

at Richmond Hospital made up 22.1 per cent of all newborns at Richmond Hospital in the 2017/2018 financial year. Those 474 such births represented an increase of 23.8 per cent compared to 2016/2017. Nationwide figures could not be obtained.

Vancouver Coastal Health, which runs nine hospitals in British Columbia, does not record the nationality of foreign mothers. But it says the ‘overwhelming majority’ of non-resident mothers list mainland China as their billing address, and most of such births occur at its hospital in Richmond, the most ethni-cally-Chinese city in the world outside Asia.

In 2016, the BC Ministry of Health’s audit branch identified 26 ‘baby houses’

– tourism operators accommodating pregnant Chinese women intending to give birth in Canada. Many openly advertise their services, which are legal. They typically provide pregnant Chinese women with accommodation and prenatal care, then help apply for passports for the newborns.

At Richmond Hospital non-residents must pay for all medical costs and make a pre-payment deposit of C$8,200 (US$6,295) for a vaginal birth and C$13,300 for a caesarean. But some bills for extended and specialist care run far beyond the pre-payment: one non-res-ident mother, Yan Xia, is being sued by Vancouver Coastal Health for fees and interest that could amount to about C$1.2 million. She could not be located and has not responded to the lawsuit.

INMARKETS

Canada’s opposition party seeks to end Chinese birth tourism industry


W I N T E R 2 0 1 8

Egyptian insurance plan; Canadian birth plan; Turkish butt-lifts

The recent death of a British patient following a Brazilian butt-lift operation at a clinic in Turkey leads doctors to encourage proper research before choosing treatments.

It has not yet been con-firmed how the patient died in this case, however according to The Guardian, a study in the US found one in 3,000 pa-tients die from this particular procedure.

Bryan Mayou, a consultant plastic surgeon and member of the British Association of Aesthetic Plastic Surgeons, is quoted as saying: ‘The people who died had a postmortem and they all died from the same thing, a fat embolism – so the assumption is fat injected in the wrong place and injected into a vein’.

Mayou also said the NHS was dealing with a rising num-ber of patients with compli-cations from plastic surgery procedures that had gone wrong, some of whom had gone abroad to save money.

Mayou advised people to properly research their chosen surgeon so they know they will receive a good standard of care. He also emphasised the importance of aftercare.

The British woman died after surgery at the cosmetic surgery clinic Elite Aftercare in Izmir. Several British reality television stars have under-gone cosmetic procedures at the clinic. Its Instagram page says that the Brazilian butt lift package costs £5,000

including aftercare. Its web-site warns that any type of surgery should not be taken lightly as there are risks in all procedures.

Regarding the death, Elite Aftercare gave this statement: ‘We are devastated that one of our clients has passed away during surgery. We also understand how worrying this news is to all our clients who are currently booked in for surgery and also potential new clients who are consider-ing surgery. We are saddened and disappointed that, before the cause of death has been officially established, there has been significant unfounded speculation in the. We understand that an official post-mortem will be undertaken shortly, which it is hoped will objectively estab-lish the cause of death. We are treating this matter with the seriousness and gravity that it deserves and are taking all reasonable steps to protect and reassure our clients. We can assure you that all our preliminary investigations have not raised any concerns over surgical competence or standards of care. We remain open for business and fully engaged with the investiga-tion to ensure that our clients’ needs remains at the centre of what we do so that they can be assured that surgical com-petence and the standards of care that are offered by Elite Aftercare remain of the very highest order.’

UK woman dies after Turkish butt-lift treatment

TM

To improve access to private health insurance for citizens living in regional and rural Australia, new legislation will allow private health insurers to offer travel and accommodation benefits under hospital cover from April 2019.

Australians living in regional and rural areas sometimes need to travel to larger urban centres or capital cities to receive specialist medical and hospital treatment not availa-ble in their local town.

From 1 April 2019, insurers will be able to offer travel and accommodation benefits under hospital cover, instead of only under general treat-ment policies. This change is designed to improve the value of private health insurance for consumers in regional and ru-ral Australia and is part of new legislation on private health insurance.

Allowing travel and ac-commodation benefits to be included in risk equalisation calculations will help insurers

to better spread their risk and give them an incentive to offer higher travel and ac-commodation benefits. It will not be mandatory for private health insurers to offer travel and accommodation benefits.

Currently only half of all private health insurers offer benefits for travel and accom-modation for customers who must travel to access specialist medical and hospital servic-es. Only those with top level cover can claim travel and accommodation general treat-ment extras cover and the benefits offered have not kept pace with costs.

This will benefit regional and rural patients and their carers who need to travel away from home for hospital treatment.

Insurers can pay Australians for domestic medical travel

According to Business Review, data from the NIS shows that 6,475 tourists came to Romania for med-ical treatment during the first quarter of 2018.

Individuals who travel to Romania for medical treat-ment spent RON 4,100 (EUR 883) on average, according to the NIS, as published in the Business Review.

Overall, they spent RON 26.5 million (EUR 5.7 million), of which RON 10.2 million (EUR 2.2 million) was on medi-cal services.

NIS figures show a record 2.75 million foreign tourists in 2017. For the first half of 2018 numbers are static with many of the 1.59 million tour-ists from Europe. The main sources of foreign tourists in Romania in 2018 so far are Bulgaria, Germany, Israel Italy, France and Hungary.

Of the medical tourists in Romania, one in four is estimated to be Romanian diaspora. Most patients are from Italy and Spain, two countries with large Romanian communities.

Romania’s NIS claims 6,475 medical tourists during Q1 2018

INBUSINESS


Private ophthalmology services attract investor attention across Europe

The UK private ophthalmology market could be ripe for disruption and, across Europe, investment in ophthalmology has become very topical. Dr Michelle Tempest and Patrick Bansch of health and social care consultancy, Candesic take a closer look

Ophthalmology has been in the UK headlines this year, as the NHS announced it would no longer fund the ‘removal

of lesions from eyelids’. Although this procedure is not an emergency, nor is it high volume or high tariff, it prompted discussion about what English citizens expect their NHS to provide.

What will be the consequence if cancer-ous lid lesions are missed because they are not removed and not examined under a microscope? Are people more willing to self-pay for ophthalmological services after the ‘psychological Rubicon’ has been

crossed, as many people already pay out-of-pocket for eye tests on the high street? In summary, could this be the start of eye care consumerisation?

Ophthalmology is different: retail could cash in on complex care

Ophthalmology has a unique care pathway and is an outlier when compared to other sub-specialties. The reason is twofold:

Most referrals do not come from prima-ry care via GPs; they come from optome-

trists often sat in high street opticians.The bulk of eye care can be delivered

in an outpatient setting with only a small percentage of procedures requiring inpa-tient acute hospital.

Currently, there is a clear drive to deliver more care in the community. Ophthalmology also has one of the lowest revenue per inpatient bed of all specialties, mainly as few patients need to stay overnight. So, this naturally begs the question: why is so much ophthalmology still being delivered within the walls and packed car parks of acute hospitals?

FIGURE ONE - GROWING DEMAND FOR OPHTHALMOLOGICAL SERVICES ESTIMATED NUMBER OF PEOPLE IN LONDON (000s), LIVING WITH...

SOURCE ONS; NEHEM; CANDESIC RESEARCH AND ANALYSIS


UK demand is growingThe Royal College of Ophthalmologists

describe an impending ‘perfect storm of increased demand, caused by more eye disease in an ageing population requiring long-term care’. There is an increase in demand including common conditions such as:

• Age-related Macular Degenera-tion (AMD), slow deterioration of the cells of the macula leading to the loss of central vision

• Cataracts, clouding of the lens leading to a loss of vision

• Glaucoma, a disease that results in optic nerve damage, and sub-sequent loss of visual fields

Figure one highlights the 2.2% annual rise in demand within London alone. While across England the wait for getting a cataract removed has increased from an average of 60 days in 2009 to 70 days in 2017, in London, cataract waits are around 50 days, thanks to waiting time reduction initiatives by Chelsea and Westminster, Moorfields, Barts, and North Middlesex NHS Trusts.

Finding the self-pay tipping point for cataract surgery

Waiting for cataract surgery is remi-niscent of the ancient parable about the boiling frog. The premise is that if a frog is put suddenly into boiling water, it will jump out, but if the frog is put into tepid water which is then brought to boil slow-ly, it will not perceive the danger and will be boiled to death.

In some ways this explains the uncertainty surrounding how cataract consumers act. Cataracts tend to devel-op slowly and visual deterioration is so gradual that there is no exact tipping point when a patient may decide to get out their wallet and self-pay for surgery.

For private providers, cataract surgery is a key revenue driver, either from pri-vate pay (PMI/self-pay) or lower margin, high volume NHS lists. Richard Evans, co-founder of Morgan Rossiter, which deals in healthcare PR, recently stated that ‘consumer reactions in healthcare are not black and white. Even when they decide not to use the NHS, there remains variation in the weight customers put on ease of access, same day or rapid treat-ment, high-quality care, and follow up’. Overall, any trend towards rationing NHS healthcare services will push more peo-

ple to self-pay and the National Institute of Health and Care Excellence (NICE) has already warned that ‘restricting cataract surgery until people are almost blind cannot be justified’.

London at the forefront of ophthalmology

There are around 40 private providers in London spanning both the independ-ent sector and NHS private patient units (PPUs) and around 240 consultant oph-thalmologists who practice privately.

The famous NHS Moorfields Eye Hos-pital PPU is the well-established market leader in London. Figure three highlights that Moorfields has almost double the number of consultants of its next com-petitor and Figure four outlines its stark volume lead in terms of private cataract procedures.

The second largest private provider, measured by the number of consultants who work there, is Optegra, with around 50 private consultants and two London based hospitals.

Optegra is backed by Eight Roads (Fidelity International’s investment arm) and is the UK’s largest network of eye hospitals.

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… a nd waiting time, in the last 3 years, has on average been relatively flat na tionally, though strongly declining in London.

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FIGURE TWO - HISTORIC EVOLUTION OF NHS CATARACT SURGERY ACTIVITY AND WAITING TIME

SOURCE NHSE DIGITAL; CANDESIC RESEARCH AND ANALYSIS

NUMBER OF FINISHED ADMISSION EPISODES, ENGLAND AND LONDON (OOOs)

AVERAGE WAIT IN DAYS, ENGLAND AND LONDON

… a nd waiting time, in the last three years, has on average been relatively f lat nationally, though strongly declining in London.

Ca taract surgery activity has been increasing s ince 2009, with an a cceleration in the last three years…

HMBusiness feature from LaingBuisson’s HealthcareMarkets


INBUSINESSIt also has an international presence

following a string of acquisitions in continental Europe (Memira, Lexum). Optegra traditionally focused on private ophthalmic care, but more recently it has been applying and winning NHS tenders, such as the Eastern Cheshire CCG tender, which resulted in Optegra’s Manchester hospital becoming the only referral centre for NHS non-emergency eye surgeries in the region. It also secured the Barnet CCG tender for community ophthalmology services. TED Europa reports this to be worth c.£11.7m over five years, based on fixed tariffs.

Sharon Lamb, partner at McDermott Will and Emery, said: ‘It’s important to realise that while there has been a spate of NHS tenders for ophthalmic care, most eye surgeries are services that are subject to a patient’s constitutional right of choice.

This means that patients have a right to choose their provider wherever that provider is located in the country. In ad-dition, providers who meet CCG require-ments are entitled to be listed on choice networks even if a procurement has been run.

Despite this, wait times have still increased in some parts of the country raising interesting (and concerning) questions about how and why choice is or is not working in practice.’

Growing European investor and acquisition appetite

Across Europe, investment in ophthal-mology has become very topical. Services aside, which benefit from a roll-up play, an increasing number of technologies are seeing strong interest from investors who see the space as an attractive niche that is underpinned by favourable dynamics.

In 2016, GHO, the healthcare-focused PE house, formed a speciality pharma-ceutical company centre around oph-thalmology. The platform is underpinned by the acquisition of the international commercial operations of NicOx (France) and Visufarma (Italy). The new entity aims to bring ‘global innovations’ to European eye health by commercialising a wide portfolio of products and devices.

Within services, Ober Scharrer Gruppe (OSG), the largest German ophthalmol-ogy treatment provider, went through a highly contested sales process this year before being acquired by Nordic Capital in March. Other prominent M&A moves in the sector include China-based Aier Eye’s acquisition of an 87% stake in Spain-based Clinica Baviera for €147m in 2017.

Dunyagoz, the Turkish ophthalmology hospital group, is also rumoured to be exploring strategic options to help it ac-celerate growth— the group is looking to become one of Europe’s largest eye care clinic chains as well as actively expand its geographically footprint in the Middle East. To date, Dunyagoz operates 23 hospitals in Turkey, Germany, the Nether-lands, and Azerbaijan.

The increasingly high multiple paid for ophthalmology assets will require savvy investors to re-think levers that need to be activated for substantial value crea-tion. Roll-up strategies require significant time, often beyond traditional private

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M oo rf iel ds O pt eg ra E ye H os pit al L on do n Cl ini c We llin gt on H os pit al B M I S t J oh n & St E liza b eth L on do n Me d ica l S t T ho m as C lar em o nt cl ini c P ar ks ide H os pi ta l R oy al Fr ee H os pi ta l K ing E dw a rd V II's H os pi ta l S ist er A gn es B up a Cr om w el l P or tla nd H os pi tal E ye D iag n os tic C en tre H CA L is ter H os pi tal A dv an ce d Vi sio n Ca re C lin ica L on do n A rn ott E ye A ss oc iat es C he ls ea & Wes tm in st er Ho s pit al C ha rin g Cr os s Ho sp ita l H ar ley s tre et C lin ic U ltr ala se H ar le y L on do n Vis io n Cl ini c O pt ica l E x pre s s S u rge ry G uy 's H os pit al 9 H arl ey s tre et C ad og an C lin ic C en tre f or Si gh t - Q ue en A nn e T he M ed ic al Ch a mb er s Ke ns in gto n(T M C K)

H igh g ate P riv a te We ym ou th S tre et T he L on do n Br idg e 1 01 D iag n os tic s C ity o f L on do n M ed ica l C e nt re L yc ah ea lth T he P rin ce ss G ra ce

Moorfields

Optegra

The London Clinic

HCA The Wellington Hospital

BMI*

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FIGURE THREE - LONDON’S PRIVATE PROVIDER LANDSCAPE (PART ONE) NUMBER OF OPHTHALMIC CONSULTANTS PRACTISING AT EACH PRIVATE/MIXED PROVIDER

FOR PRIVATE PROVIDERS, CATARACT

SURGERY IS A KEY REVENUE DRIVER,

EITHER FROM PRIVATE PAY OR LOWER MARGIN

HIGH VOLUME NHS LISTS

NOTES *INCLUDES BMI HENDON; BMI BLACKHEALTH; BMI CAVELL AND BMI LONDON INDEPENDENTSOURCE CANDESIC RESEARCH AND ANALYSIS


equity firms’ holding period; OSG’s former owner Palamon Capital Partners held the asset for seven years, operating a buy-and-build strategy that tripled the size of the business during the holding period.

AI potential for market disruption worldwide

The ophthalmology market is ripe for disruption on many levels. One example is because ophthalmology is a speciality heavily reliant on retinal images for diag-nostics, which means digital technology could ‘learn’ to read images similar to what is happening in the radiology sector. Photographs of the back of the eye can be labelled for signs of disease by human experts and then fed into artificial intelli-gence (AI) algorithms.

Moorfields has successfully collaborat-ed with Google’s DeepMind to provide a blueprint for how such technology can aid clinical assessments. The aim is for AI to augment diagnosis, especially for early detection, by analysing retinal scans. DeepMind’s algorithm has been pains-takingly ‘trained’ on massive data sets of retinal scans provided by Moorfields. This wealth of information provided by the scans along with their expert reports has allowed AI to recognise AMD, diabetic retinopathy and glaucoma and is now readying for clinical trials.

Rolling this out across England and internationally will not only create more equitable eye care but also drastically re-duce human hours spent assessing scans. The details of this are beyond the scope of this article, but emerging healthcare tech/digital developments are areas we have observed increased activity in.

Watch this space

The ophthalmology market is one to watch. It’s one with a wide range of investment opportunities but equally one where it’s important to delve into both macro and micro trends.

London offers a market microcosm set for disruption. The macro demand trends

are clear: an increase in disease burden due to ageing populations alongside investment and consolidation. The op-portunity is clear: supply remains heavily reliant upon hospital settings yet com-munity-based sites and even some retail optometry providers are looking to cash in on more complex care. Also, London is at the forefront of practical application of evolving technologies. We must all open our eyes to the fact that AI is here to stay and will increasingly augment clinical care rather than replace staff.

Dr Michelle Tempest, partner, Candesic

Patrick Bansch, engagement manager, Candesic

MoorfieldsPrivate

The LondonClinic

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FIGURE FOUR - LONDON’S PRIVATE PROVIDER LANDSCAPE (PART TWO) CATARACT SURGERY VOLUMES ACROSS PRIVATE PROVIDERS (RELATIVE VOLUMES, LONDON)

NOTES *INCLUDES BMI HENDON; BMI BLACKHEALTH; BMI CAVELL AND BMI LONDON INDEPENDENTSOURCE CANDESIC RESEARCH AND ANALYSIS

HMBusiness feature from LaingBuisson’s HealthcareMarkets


INBUSINESS

UK’s babylon health partnership with Telus HealthCanada’s TELUS is launching an AI powered healthcare app in Canada with the Lon-don-based virtual GP pro-vider babylon Health, which has cornered the UK market on AI healthcare services since its launch in 2013.

The free app, which consists of a symptom checker and face-to-face medical appointments, will be rolled out after more details are released later this year.

An advisory council of healthcare professionals is being set up to support the app’s phase-in, with input from government health bodies, TELUS has said.

The companies say the app will improve access to care for people living in remote areas of the country and for those with mobility issues.

babylon’s ‘mission’ ‘is to put an accessible and affordable health service in the hands of every person on Earth’ through its virtual applications.

In April, the company announced that it had broken into the Chinese market for the use of its services in mainland China – and more recently formed a partnership with medical insurer Prudential Corporation Asia to give its customers access to its

technology.Dr Ali Parsa, babylon’s

founder and chief executive, said: ‘Canada is building a reputation worldwide for innovation and desires to be at the cutting-edge of development.

‘TELUS’ consumer-centric approach coupled with its success in creating a more connected healthcare ecosystem through the use of innovative digital health technology solutions makes them the perfect partner for Babylon as we begin to serve this great country.

‘Together, we will build on the brilliant work that

Canada’s federal and provincial governments, Departments of Health and clinicians are doing to tackle issues of primary care access and affordability.’

Juggy Sihota, vice president of TELUS, added: ‘Our partnership with Babylon, through a globally-leading virtual care solution, will enable people to get access to healthcare anywhere and anytime they need it.

TELUS provides digital support services, including a medical records system and analytics platform, in the healthcare sector in Canada.

US$648m development in Arizona, USThe Mayo Clinic is increasing patient beds and adding up to 2,000 clinical roles to cater for more patients with complex health conditions.

According to GlobalHealthcare, The Mayo Clinic is set to cater to the number of increased complex health conditions within the US with a new, five year, $648m expansion project.

Named the Arizona Forward Project, it will encompass a significant increase in the number of inpatient beds, as well as creating up to 2,000 new clinical roles to better support patients.

‘Mayo Clinic’s presence in Arizona has propelled our state’s health care and bioscience industry, and their enhanced investment is another sign that this industry is thriving,’ commented Arizona Governor, Doug Ducey.

‘Not only will those of us in Arizona be served by expanded services at Mayo Clinic, but it will further secure Arizona as a global destination for excellence in healthcare.’

The project will include a new six-storey patient tower, a three-floor addition to the existing four-story Mayo Clinic Building; a new three-story building to house an expanded Emergency and other departments; expanded patient and infrastructure space; and additional parking.

The campus has undergone essential growth over the last five years to support those with complex healthcare conditions, leading to boost in number of specialisms, such as cardiovascular diseases and neurosurgery, as well as new technologies which have been bought to the fore.

The organisation’s investments have been the development of its cancer centre, as well as the launch of the first proton beam therapy programme in the region. It is also responsible for housing one of the largest organ transplant programmes across the US.

Dr Ali Parsa, founder and chief executive, babylon health

Artist’s impression of the Arizona Forward Project


South Africa’s life healthcare sells Max Healthcare stake

According to Business Day, South Africa’s third-biggest private hospital group, Life Healthcare, is exiting its Indian business after almost a year’s talks. It will sell its stake in Max Health-care to global investment firm Kohl-berg Kravis Roberts for about R4.3bn (US$412m).

Life Healthcare took a 26% stake in Max Healthcare, one of India’s biggest private hospital chains, in 2012. It increased its shareholding to 49.7% in two further transactions, investing R2.9bn (US$206m) in the joint venture. As India’s public health system is chronically underfunded, many patients use private health care, but it proved a tough market and Life Healthcare failed to get the returns investors had hoped for.

Life Healthcare CEO Shrey Viranna said exiting the Indian business will enable the

company to focus on its core operations in SA, the UK, Poland and Western Europe.

‘This is not in any way to detract from Max Healthcare as a group or India as a long-term market. For other investors it is still an exciting environment to be in,’ he said.

‘In the last year, we have taken the view that our long-term growth will be in building a more integrated portfolio in SA, expanding from acute care into complementary care and diagnostics, and focusing more on the investments we have made in diagnostics and imaging in Europe,’ he said.

Life Healthcare has invested R2.2bn (US$156m) in the Polish hospital chain Scanmed, and R13.9bn (US$988m) in the UK-based diagnostic group Alliance Medical, according to its 2017 annual report.

W I N T E R 2 0 1 8

Canadian telehealth; Arizona; South Africa; Singapore; Thailand

TM

Thailand hospital added to Asian platform

Major SE Asian online healthcare platform Book-Doc signs agreement with Bumrungrad International Hospital to offer medical travel services to local and international patients.

BookDoc has announced its latest healthcare partner in Thailand, Bumrungrad International Hospital. BookDoc has established an integrated online ecosystem for local and overseas health

travellers. The ecosystem allows users to search and book healthcare professionals, and integrates seamlessly with navigation (Google Map, Waze), transport (Grab, Uber, AirAsia), accommodation (Agoda and Airbnb) and recommended restaurants & attractions (TripAdvisor). BookDoc’s goal is to enhance the access to healthcare in the Asia region.

Shrey Viranna, CEO, Life Healthcare

NMC Health has completed its first UK acquisition with the £10m capture of Aspen Healthcare as it bids to grow its IVF services.

The United Arab Emirates based private healthcare operator said Aspen’s existing footprint offered a ‘solid foundation’ for its IVF services but said it would not be making other UK purchases outside of the fertility market.

Aspen, which was bought by US healthcare group Tenet Healthcare for around £142m three years ago, has a network of nine facilities across the UK, including four hospitals

with three based in Greater London.

As well as being a ‘cost-effective’ means of introducing its fertility services to the UK, NMC said Aspen’s orthopedics and oncology services, which represent half of the operator’s revenue, are ‘highly underserved’ in the UAE.

This offers the potential for patient referral to NMC’s own international facilities when medical treatment is unavailable in the UK, the company said.

NMC health buys Aspen Healthcare to grow IVF


INBUSINESS

Oman insurance may cut outbound medical travel

More Irish access cross-border healthcare

Oman’s Council of Ministers issued a decision to imple-ment a national insurance policy in 2017. It will be compulsory for companies to provide their employ-ees and their families with health insurance from January 2019. This will in the long term reduce the number of Omanis going overseas for medical treat-ment.

Implementation of the na-tional insurance programme is expected to take place in phases. The initial phase at the beginning of 2019 will be all companies with more than 100 employees and all consul-tancy firms. From May 2019, it will extend to companies with more than 50 employees. All other employers will comply later in 2019, with the imple-mentation of the final phase. The dates and categories are still provisional.

Work is in progress to include the linking of insur-ance companies to hospitals and an electronic system for medicines and treatments to prevent manipulation and price increases. Much work has to be done to develop basic policies, systems and

controls.Oman’s Chamber of

Commerce previously stated that health insurance cover should be provided to all pri-vate sector workers by 2018. Tough market conditions and government austerity meas-ures have made providing insurance to workers less of a priority for some businesses. This reform comes in the wake of statistics showing how few employees in the private sector, both nationals, and expatriates, are provided with health insurance.

To work properly, the local health sector needs consid-erable improvement. The compulsory medical insurance aims to curb the pressures placed on government-run

medical facilities, as the increasing population takes its toll on the resources.

Many Omanis in the private sector do not have health insurance, so the introduction of compulsory insurance will almost certainly reduce the number seeking treatment overseas.

It will be a huge surprise however if everything is ready for January 2019, mid to late 2019 or even 2020 is more probable, as no legislation has yet been tabled, yet alone passed.

IMTJ estimates over 70,000 Omanis travel abroad for med-ical treatment.

HSE numbers show a significant increase in Irish patients accessing health-care services in Northern Ireland, other parts of the UK and mainland Europe.

The Health Service Executive (HSE) provides public health and social care services to everyone living in Ireland. It has a national cross-border healthcare office staffed by 11 people, dealing

with a surge in demand over the last four years for surgery abroad.

HSE figures show that the number of Irish citizens accessing healthcare services overseas has risen from 157 in 2014 to 2,011 in 2017. The predicted number for 2018 is 4,200.

Irish residents are reim-bursed for using healthcare services abroad that they

would have been entitled to access locally. Patients in border counties who can get treatment more quickly in Northern Ireland because of shorter waiting lists regularly use the scheme.

There has also been a rise in people throughout the Republic of Ireland using the option to access operations and procedures in the UK or mainland European countries.

Oman’s Chamber of Commerce

For detailed analysis, visit the IMTJ Country Profile

TM

Chinese safetyCtrip, the largest online travel agent in Asia, has joined an alliance to launch an initiative to promote safe and re-sponsible global travel. The formation of this travel safety alliance sets to highlight sustainable travel, enhance security support, develop travel industry protocols for emergency situations and minimise travel risks for all travellers.

Airbnb expands for patients in needAirbnb has expanded its Open Homes programme, to help those traveling for medical reasons in the US to stay for free. It is now working with the Fisher House Foundation to help provide alternative accom-modation for military and veterans’ families traveling for medical treatment.As part of this expansion, Airbnb will be working with the Fisher House Founda-tion to support military and veterans’ families and the Make-A-Wish® foundation to support children with critical illnesses

UnitedHealth global partnership signedThe London Clinic (TLC) has partnered with US-based insurance giant UnitedHealth Global, to give policyholders access to its cancer care hospi-tal in central London. Members will be able to get treatment at the Duchess of Devonshire Wing in Marylebone, and use its physiotherapy, di-gestive diseases facilities and endoscopy service.

Inbrief


WeDoctor and Singa-pore-based Fullerton Healthcare form a strategic partnership, to both target China’s medical tourists going abroad, and expand clinics in China.

Chinese online healthcare solutions platform WeDoctor, has sealed a strategic part-nership with Singapore-based healthcare service provider Fullerton Healthcare Corporation Limited to provide an integration of online and

offline healthcare services in Asia.

The deal will create a new platform, Health Management Organisation (HMO), to pro-vide WeDoctor’s 160 million or so Chinese registered users with access to Fullerton Health’s network of more than 500 healthcare facilities and over 8,000 network healthcare providers across Asia Pacific, said Fullerton Health in a statement.

‘In line with WeDoctor’s

international growth strategy, the alliance with Fullerton Health will extend our reach and facilitate our development in Asia,’ said Jeff Chen, chief strategy officer of WeDoctor, in the same statement.

The new platform will utilise the opportunities arising from China’s rapidly growing outbound medical tourism, he added.

In terms of Fullerton Health, the partnership will support the company to launch business plans in the Chinese market, said David Sin, co-founder and executive deputy chairman of Fullerton Health in the same statement. Earlier this year, the company announced that it will open over 100 clinics in China over the next few years.

Founded in 2010, Hangzhou-based WeDoctor is an online healthcare provider

that aims to tackle the prob-lem of China’s overstretched and underfunded hospitals. According to the company’s website, it provides healthcare support services to more than 2,700 hospitals, 220,000 doc-tors and 27 million monthly active users in China.

The company aims to list on the Hong Kong stock exchange in late 2018 and it is currently valued at US$5.5 billion. In May, the company secured a US$500 million pre-IPO fundraising. Tencent-backed WeDoctor has long been eyeing markets outside China as well. The company had teamed up with Hong Kong-listed financial servic-es company Mason Group and Asian investment firm Aldworth Management to acquire Australian fertility treatment firm Genea in late August.

WeDoctor expands in Asia

Hospital Rwanda

In an interview with The New Times, Dr Joaquin Bielsa, the CEO of Oshen-King Faisal Hospital talked about his five year plan to become a leading medical centre in Africa and receive more referred patients than any other hospital in East Africa. It already receives private patients from the Democratic Republic of Congo, Burundi, and Uganda.

DabaDoc, the Moroc-co-based healthtech disrupt-er, has raised money from AXA Insurance Morocco to move into new countries.

DabaDoc, the Morocco-based healthtech disrupter, has raised an undisclosed amount from AXA Insurance Morocco to improve the service and move into new countries. The service is currently available in Morocco, Algeria, Tunisia, Nigeria and South Africa.

DabaDoc offers a platform to find and book doctor appointments online, and ask health questions using video conferencing with doctors.

Launched in 2014, DabaDoc helps thousands of patients to connect with doctors through its platform each month.

The investment means AXA

becomes the first institutional investor in DabaDoc, which sets out to democratise access to healthcare with its practice management solution and disruptive online booking technology. It has seen over two million appointments booked through its platform since its launch.

Says founder, Zineb Drissi-Kaitouni: ‘We are at

the inception of a disrup-tion in the way healthcare is delivered. Having AXA as a shareholder adds an impor-tant dimension to our mission of democratising access to healthcare. We are excited about further growth pros-pects with this partnership and the expertise provided by AXA in our existing and future markets.’

DabaDoc moves into new countries

W I N T E R 2 0 1 8

Oman; Ireland; China; Morocco; Rwanda

TM

52 | MAY 2018 | IMTJ - LaingBuisson

INBUSINESS


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In Vitro Fertilisation


The global fertility services sector is seeing an emergence of serial acquirers and an increased pace of consolidation, according to Alantra, an investment banking and asset management firm.

Alantra data shows that by the end of Q3 2018 there were 53 acquisitions made in com-parison with 47 in the same period last year. By deal type, there was a 40% increase in M&A deals and a 42% increase in trade deals, by the end of the third quarter of 2018 compared with the same period in 2017. The remainder were attributed to private placement or cross border transactions.

Justin Crowther, a Partner in the UK advisory business of Alantra identifies the following market drivers that are driving acquisition activity in the fertility services sector:

Growing demand for IVF services is being driven by the continuing decline in fertili-ty rates, growing public awareness of and increased accessibility to treatment, and tech-nological advancements which are improving success rates.

The UK is a favourable fertility tourism hotspot due to its international healthcare reputation, well-regulated market and ability to implement the most advanced treatments.

Several international private hospital groups and specialist fertility treatment providers have emerged as the leading consolidators as they look to take advantage of the fragmented

provider landscape.Instituto Valenciano De Infertilidad (IVI) is

particularly active, acquiring five operators in the last two years. The acquisition of UK-based Midland Fertility enhances IVI’s international capability and capacity by leveraging the latest research and developments in fertility care and treatment technologies.

Valuation multiples remain strong as corpo-rate and private equity-backed trade players look to deploy capital to capture incremental market share and scale platforms.

Key fertility services transactions over the last 12 months include: IVI’s acquisition of Reproductive Medicine Associates of Philadelphia, P.C; Virtus Health’s acquisition of Complete Fertility and FutureLife AS’s acquisi-tion of Galway Fertility through its Irish vehicle Reprome.

The proportion of NHS funded hip and knee re-placement procedures being carried out by independent providers has grown steadi-ly over the last five years.

According to data from NHS Digital, the independent sector performed almost one in five (19.7%) NHS-funded hip replacements last year, and nearly one in three knee replacements.

Private hospitals carried out 28,700 knee replacements, representing 29.4% of all NHS

knee replacements in 2016/17 compared to 16,688 proce-dures in 2012/13.

During the same year, 22,872 NHS hip replacements were performed by independ-ent providers compared to 14,427 in 2012/13.

The figures were published in response to a parliamenta-ry health question posed by former health minister Lord Hunt.

NHS Partners Network chief executive David Hare said: ‘

‘What matters most to NHS

patients is the quality of care they and their families receive. On this the evidence is clear that independent hospitals deliver overwhelmingly safe and effective care, with 19 of the top 20 hospital operators for patient outcomes in hip and knee surgery being inde-pendent hospitals.’

Professor Derek Alderson, president of the Royal College of Surgeons, said private hospitals provide much-need-ed extra capacity for routine operations.

Increasing global fertility acquisitions and consolidations in 2018

W I N T E R 2 0 1 8

Global IVF; UK private sector; Asia; Russia; Switzerland

TM

AirAsia & MHTCAirAsia Indonesia has signed an MoU with Ma-laysia Healthcare Travel Council (MHTC) to jointly promote Penang as Ma-laysia’s top healthcare tourism destination.

MHTC will arrange medical tourism trips including doctor and hospital appointments, as well as airport pick-up services, for Indonesian passengers of AirAsia vis-iting Penang for medical treatment, according to TTGAsia.

AirAsia will provide exclusive flight discounts to MHTC customers, Surabaya.

MD Medical postsRussian healthcare pro-vider MD Medical Group (MDMG) has posted an 8% increase in revenue as it ramped up operations at its existing sites and opened a new facility in Samsara, the Volga region. Year-on-year revenue climbed to RUB 7.1bn (ap-proximately £77.7m) in the first half of 2018 against RUB 6.6bn (approximately £72.2m) in the same peri-od last year.

Swiss growthMediclinic, one of South Africa’s three biggest private hospital groups grows its Swiss footprint with clinic acquisition. According to Business Day, Mediclinic is to com-bine its Geneva-based Clinique La Colline with privately held Clinique des Grangettes as it moves to grow its Swiss footprint.

Inbrief

Third of all hip and knee ops carried out by private sector


INBUSINESS

Health City Cayman Islands launched in 2014 with an ambitious medical tourist target. It is making steady progress with expansion plans for 2019, but with far lower numbers than predicted.

Health City Cayman Islands, a JCI accredited tertiary care hospital on Grand Cayman, launched with high am-bitions to attract a significant number of American medical tourists.

While the predicted volume has not materialised, it has made steady pro-gress by expanding services gradually and targeting nearby countries and islands. Much business is from local residents.

The hospital is a tertiary care, super specialty medical resource for cardiol-ogy, cardiac surgery, anaesthesiology, orthopaedic surgery, pulmonology,

paediatric endocrinology, neurology, neurosurgery, medical oncology, urolo-gy, critical care services, spinal surgery, bariatric surgery, colorectal surgery, cos-metic surgery and diagnostic services.

2019 will see a new cancer treatment centre and the completion of residential units adjacent to the hospital.

A new law on human tissue trans-plants now allows the hospital to offer this procedure as long as it is a vol-untary donation locally by consent of family members, whose loved ones had agreed to donation before their death.

Health City Cayman Islands was the idea of top Indian heart surgeon Devi Shetty, and was run and owned by his Indian hospital group Narayana Health and the US-based Ascension, a large faith-based and non-profit health systems. Narayana Health offers

treatment at a bundled rate, but do not release annual patient and medical tourism numbers.

Ascension pulled out of its partner-ship with Health City Cayman Islands in 2017.

Health City Cayman Islands’ steady progress

According to the Yucatán Times, progress with the ‘Health City’ project will boost medical tourism in Cancún. The ultimate aim is to create the largest health complex if its kind in the Yucatan Peninsula, targeting the multimil-lion-dollar medical tourism market, mainly from the US. A high-profile medical tourism construction project announced in 2014 has failed to take off however.

The article quotes Jabib Chapur, vice president of Food and Beverage of the Grupo Palace hotel chain, confirming that the first hotel of the City Exprés chain will be inaugurat-ed this month, while a second lodging centre of the NH Hoteles firm is also in the final phase of construction.

‘It is a complex where the arrival of large firms of private hospitals and specialised services for retirees from the United States, Canada and

Europe is expected’, Jabib Chapur said. He said the project will be developed almost entirely by third-party investors, but on land owned by Grupo Palace, and although there will be hotels and spe-cialised lodging services, most of these establishments will be operated by other compa-nies and not by Grupo Palace.

Miguel Ángel Lemus, vice president of the Business Coordinating Council said that it is a long-term project, since in addition to specialised clin-ics, the complex will feature shopping centres, convention centres, spas, housing areas, luxury condominiums, office buildings, entertainment areas, as well as spaces for scientific research. He claims it will ultimately be the largest complex if its kind in the Yucatan Peninsula, seeking to attract the multimillion-dollar medical tourism market, main-ly from the US.

The article states that

an ambitious medical tourism project in 2014 called Wisdoms Gardens , pro-moted by the Medical Tourism Association of Quintana Roo and involving the construction of six hospitals, failed due to lack of available land.

The Yucatan Peninsula is

one of many popular destina-tions in Mexico for inbound medical tourism. Almost all medical tourists are from the US, with a few from Belize and the Caribbean Islands, Australia, Canada and Europe, although the latter two are probably mostly tourists and expatriates. Mexico receives a high number of medical tourists as a result of their low comparative prices.

Grupo Palace chain kicks of ‘Health City’ project

Expansion for UDG

Dublin-based UDG Healthcare has acquired two healthcare focused businesses in New York through its global division Ashfield Healthcare. Advertising agency Create NYC and SmartAnalyst, a consulting company focused on the pharmaceutical and biotech sectors, have been bought by the healthcare service provider for a total of around $82.4m.

For an independent assessment of the number of inbound medical

tourists to Mexico, visit the IMTJ Country Profile

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