Light at the end of the medical tourism tunnel?

Following my outpourings on the “Outlook for Medical Tourism in 2010”, I am pleased to say that I’ve received some positive feedback (always a good thing.... I’ll keep on blogging!). And some reassurance that I am not alone in my view of the medical tourism world.

In particular, one of the long established medical tourism facilitators told me “how it was” in 2009 and how they think it might be in 2010. It’s refreshing to hear someone be open and upfront about their business experiences in medical tourism and the challenges that are facing people in the business.

I’d like to share some of these comments with others in the medical tourism world. Here is what it was really like in 2009 for one medical tourism business, a business that is well established, well run, and isn’t a “one man and his dog” outfit. I’m going to respect their confidentiality and not name the company concerned.

The view from the marketplace

Here’s what our medical tourism facilitator had to say about 2009:

“We have dabbled in the elective surgery market and have come to the same conclusions as you.... that to continue in this sector we would need to consolidate and concentrate on niche or rather more specialist sectors. Otherwise, we are finding ourselves becoming a "Jack of all trades and Master of none".

Last year was a really bad year. We were very busy with enquiries, but our conversion rate was disappointing and for those that did convert, the average spend was down. We have put the conversion problems down to a 50/50 mix of:

1. Recession - people not spending, or when they are travelling for treatment, they are spending less.
2. Competition - it seems in the last 18 months that every person in Europe, with a spare room and who knows a dentist, has jumped on the medical tourism bandwagon.

Another factor that has not helped is the pound sterling rate against other currencies, especially the Euro; this has meant a 20% increase in costs and prices. This does not only apply to the treatment cost but the patient stay while they are away. (Hotel rates are more expensive, eating out is more expensive etc.) The effect has been significant. Our patient numbers fell by 30% in 2009 and the average spend per patient dropped by 25%.”

So, a difficult time for this medical tourism business. But it is not unique. Some dental clinics in Europe have been relating similar experiences. One major implant centre in Budapest has reported overseas patient numbers down by more than 20% and a similar 25% fall in average spend per patient.

Do these experiences reflect the reality of the medical tourism business in recession?

Lies, damned lies and statistics?
The UK is one country where we count stuff. We have an Office for National Statistics and they employ around 4,000 civil servants who count stuff...including medical travellers. At Treatment Abroad, we do our bit to keep the civil servants in jobs by buying the data that they produce – specifically, the International Passenger Survey (IPS), a survey of a random sample of passengers entering and leaving the UK by air, sea or the Channel Tunnel. The IPS attempts to identify the number of people both travelling into the UK and out of the UK where the prime reason for travel is medical treatment (as opposed to business or a holiday).

Now.... you need to take these statistics with a very large pinch of salt. Statistics contain statistical errors and the smaller the sample, the bigger the risk of the error.

Here is a graph of IPS data showing outbound medical travellers from the UK from 2002 to 2009 (projected from 3rd quarter statistics). The sample size in this data is small - the number of actual travellers interviewed in each quarter who stated that their prime reason for travel was medical is around 50 to 100. So, there is room for wide variations in the data!

But, it may well be a reflection of the actual trends in UK medical tourism and for 2009 may indeed reflect the experiences of many in the marketplace who have seen the number of medical tourists in decline over the last 18 months or so, since the credit crunch hit.

Light at the end of the tunnel?
Our medical tourism facilitator quoted above has a more positive outlook for the future:

"We have already seen an increase in booking numbers for dentistry in 2010. January is already 100% up on January 2009 (and nearly the same number as in 2008, so something is starting to change.”

With some good news on the economic horizon in the UK, we may be seeing an increase in consumer confidence. House prices are increasing, and we have seen a return to economic growth, albeit not as good as many would have hoped. We wait to see what the effect may be on unemployment. But, like many industries, medical tourism follows the trends in the economy as a whole. Medical tourism is not immune to recession and certainly is not flourishing in it.

The way forward.. focus and think niche
Back to our medical tourism facilitator, who is planning the strategy for 2010:

“Our progress for 2010 will be to expand the dentistry further and concentrate more on the cosmetic surgery. We had taken a step back on cosmetic surgery in 2009, due to the difficult climate and similar to your (Keith Pollard’s) points about offering too much, we have recognised that rather than be a "Jack of all trades.....", we need to have a separate department. Having the same staff switching between the two products (dentistry and cosmetic surgery) does not really work.”

And our medical tourism facilitator concludes with a message for all in the industry:

“I totally concur with the conclusions of your article, and recognise that this medical tourism industry is not as simple and as great as people have made out. Only the companies that keep adapting and recognise the importance of focusing and having the correct resources to manage a particular sector of this industry will survive or be commercially viable.”

Practice makes perfect...a message for medical tourism providers and patients

In the largest ever study of hospital mortality rates published in the UK,"death rates for emergency patients jump 6 per cent when newly qualified doctors start work. The Health Services Journal reports that "the traditional first day for NHS doctors is the first Wednesday in August. Researchers found that patients brought into hospital the week before were more likely to survive.....Researchers could not find a definite reason for the higher mortality rate, but said early August was known as an “unsafe period” in hospitals due to the influx of new doctors"

Now, what can we conclude from this?

Might I suggest that doctors with more experience are better than those with less experience? It goes without saying, really.

So, how does this help the medical tourist who is trying to make a decision about which doctor or specialist overseas to choose for their operation? The problem of patient choice in healthcare whether it is a choice of an overseas surgeon or a domestic surgeon is the "how do I know that he's any good?"issue. In the UK, we're probably ahead of the game in enabling patients to make informed choices about treatment. The NHS web site is has been renamed "NHS Choices" and in recent years there's been a drive to expose data on clinical outcomes and surgeon and hospital performance, and make this freely available to patients.

One of the strengths of the UK healthcare system (and one of its shortcomings!) is that the vast proportion of healthcare is delivered by one healthcare provider - the NHS. This means that data on processes, outcomes, performance and patient satisfaction is fairly standardised, thus enabling valid comparisons to be made between one hospital and another, between one specialist and another.

Let's imagine that I need a knee replacement. Under the NHS, I can choose to go to any hospital in the UK, not just my local hospital. But let's assume that I want to stay fairly local. Here's some of the data I can access about my local hospitals through NHS Choices. For each "quality factor", I have highlighted the best result.

Impressed? Which hospital would you choose? Or which hospital would you rule out of consideration? The above table only scratches the surface of the data that is now being made available to patients. I could also compare the quality of the food, levels of service and so on. And I can also begin to make comparisons between individual surgeons.

Where does this leave the medical tourist? The reality is that there are few countries where this kind of comparative information would be made available to the patient. And the reality is that different healthcare systems often measure things in different ways, so that comparing outcome data from a hospital in Thailand with outcome data from a hospital in India might be very difficult.

So, the medical tourist probably needs to ask some very basic questions about the hospital and specialist. One of which is a fundamental measure of "how do I know that he's any good?” It's "how many times have you done this operation before?" "Practice makes perfect" as the recent study demonstrates. Choose a surgeon with experience in exactly what you require. If you're looking for a knee replacement, choose an orthopaedic surgeon who does knee replacements and virtually nothing else. Don't choose a "general" orthopaedic surgeon who does “everything under the sun" - knees, shoulders, feet, hips etc.

And ask the guy "how many have you done this year?"

Dental tourism...Let's work together

The Irish Dental Association is the most recent medical professionals body to publish a "survey" raising doubts about medical tourism.
In a recent press release from the Irish Dental Association, they state that "3 out of every 4 Irish dentists are treating patients for problems arising from treatment abroad. Let's take a look at the background to the survey, and examine some of the real concerns that are raised.
The Consumers’ Association of Ireland has published research about the high costs of dental treatment in Ireland. The Irish Dental Association accepts that Irish dentists are not immune from the wider economy and the bottom line is that Ireland is a high-cost economy. As a result, significant numbers of Irish dental patients travel for treatment to minimise treatment costs. Some of these are cross border dental tourists. Many services carried out in Northern Ireland are between 25% and 45% cheaper than the same services in the Republic, according to the study published in the Consumers’ Association of Ireland’s magazine Consumer Choice. And of course, many Irish patients take advantage of low cost treatment in countries such as Hungary and Poland. Several Budapest dental treatment providers have offices or representatives in the Republic of Ireland.
According to the Irish Dental Association survey, 76% of Irish dentists in private practice [more than 3 out of 4] have had to treat patients for problems linked to the dental treatment they received abroad.
First, we need to examine the basis of this claim.

• There are approximately 1,700 dentists in private practice in Ireland at present.
• 440 Irish dentists responded to the survey.
• 334 said that they are treating problems arising from treatment overseas.
• So.... in fact 334 out of 1,700 said that they were seeing problems which is 20%. Obviously, this assumes that those who didn't bother are not seeing problems.

When reviewing such surveys conducted by on or on behalf of professional associations, we have to bear the following in mind:

• Inbuilt sample bias: People who see a problem are more likely to respond to a survey on that issue, than those who don't. We've seen similar bias built into surveys conducted by a PR agency in behalf of the British Association of Plastic Surgeons.
• Motivation: We always need to remember that professional associations represent the interests of their members. Losing patients to Belfast or Budapest hits the pockets of private dentists.

Nevertheless..... the Irish Dental Association has made some valid points. Are there concerns for dental patients who travel for treatment? Yes. Are the problems as big as the Irish Dental Association suggests. No.

At the end of the day, the Irish Dental Association also has the best interests of Irish dental patients at heart. Dr Donal Blackwell of the Irish Dental Association says that that one of the problems is that when considering travelling abroad for dental treatment, patients tended to focus on short term, aesthetic results rather than the long term quality of the care they receive and suggests that people travelling abroad for dental treatment actually don't know what they need when they enquire about costs. He's certainly right in some cases.

So, what's the solution and what's in the best interests of dentists and patients?

I'd like to see the following:

1. The Irish Dental Association issuing guidance for dentists and patients when considering dental tourism. See the UK General Dental Council's Dental Tourism Checklist on Treatment Abroad.
2. Irish dentists providing assessment and follow up of patients who travel abroad for treatment.
3. Irish dentists visiting some overseas dentists to get an understanding of how they work and their clinical skills and quality.
4. Irish dentists forming partnerships with overseas dentists, so that patients who need extensive treatment but can't afford Irish treatment have access to the treatment they need under the supervision of their own dentist.
5. Overseas dentists communicating with the patient's Irish dentist when a patient turns up in Budapest or Krakow - informing the patient's Irish dentist what work is to be undertaken, and providing post treatment reports on the work that has been carried out.

Common sense really. So, let's work together!

A word of warning for medical tourism companies

A woman from Wales who underwent cosmetic surgery in Belgium is bringing a test case against the Belgian clinic in the UK courts.The patient is suing the clinic after undergoing a face-lift and upper and lower eye surgery in 2005. She claims that she has been left with scarring around the eyes and the ears and has experienced numbness of the face.

It is a significant case because it could set a precedent for other patients who wish to sue a clinic or medical tourism company after going abroad for treatment. Rather than sue in Belgium, the legal firm involved have decided to sue the clinic in the UK courts where they might expect higher payouts if they win the case. Laurence Vick, the solicitor who is representing the patient, is a medico-legal expert and specialises in clinical negligence claims. (Coincidentally, he and I were undergraduate students at the same college, many years ago!)

• See the Independent news story: Woman sues in UK over Belgian face-lift

The question of who to sue in medical tourism cases is one that faces any patient where surgery abroad doesn't work out as it should. Is surgery abroad any riskier than surgery in the UK? No one knows.... because there is no comparative data. But the answer is probably not. Nevertheless, any surgery carries a risk. Cosmetic surgery is not risk free, so there are going to be cases of alleged clinical negligence where the patient will pursue a legal action. Medical tourism companies need to be aware of this test case, particularly those that have a UK presence. Rather than sue the surgeon or the hospital in the destination country, the patient may opt to sue the medical tourism company in the UK.