Cover StoryFrom OSN Europe

Medical tourism expands opportunities for ophthalmology market

In the era of globalization, medical tourism has become a significant phenomenon and developed into a national industry in more than 50 countries. Driven by marketplace forces, it involves a constantly growing number of patients who seek non-emergency medical treatment and surgery outside their country of residence, often in collaboration with the tourism industry.

Medical travelers are driven by the lower costs, favorable exchange rates and shorter waiting lists offered by destination countries, in combination with high-quality hospital services and the added allure of resting during and after the treatment in attractive holiday resorts. Mainly limited to cosmetic surgery and dental procedures in earlier decades, the medical tourism industry has gradually expanded to nearly all medical specialties, including ophthalmology.

Health is the biggest value of all developed societies and the largest individual economic sector of the most developed Western countries, Ante Barisic, MD, clinical ophthalmologist at the University Eye Hospital Svjetlost in Zagreb, Croatia, said.

Efekan Coskunseven, MD

Efekan Coskunseven, MD, said that there is enormous potential in medical tourism for countries that offer touristic attractions as well as high-quality medical services at competitive prices.

Image: Coskunseven E

“Technologically, the health industry is the most advanced industry in the world, especially in ophthalmology. It is supported by a great amount of investigations and by huge investments, which are ethical because they are aimed at reducing suffering and disability and at prolonging life expectancy,” he said.

Medical tourism offers “enormous opportunities and great perspectives because the demand for health is unlimited and is growing with the longer life expectancy,” Barisic said.

Good quality at affordable prices

In ophthalmology, the highest demand is for refractive procedures, including corneal laser surgery, phakic IOLs and lens surgery with implantation of premium IOLs. Oculofacial plastic surgery is also popular.

“Patients don’t come to us just for elective procedures, however,” Efekan Coskunseven, MD, director of the Refractive Surgery Department at Dünyagöz Eye Hospital, Istanbul, Turkey, said. “We have foreign patients also for vitreoretinal surgery, keratoplasty and glaucoma surgery. We offer the most updated technology, highly experienced surgeons and the highest-quality eye care services. All this at a more affordable price than in their home countries.”

Dünyagöz Eye Hospital is the only hospital certified by the Joint Commission International in Turkey. It is part of one of the world’s largest hospital chains, with clinics in 18 locations in Turkey and Europe.

Offers for medical tourism packages on the Dünyagöz website include airport transfer, full board hotel accommodation and leisure activities in addition to specific surgical procedures with preoperative assessment and postoperative follow-up. Prices vary from 1,255 for bilateral LASEK to 1,905 for LASIK with a femtosecond laser. Femtosecond laser-assisted cataract surgery with implantation of a premium IOL is offered for an average of 2,500. Insurance options are also offered.

Ante Barisic

“The reception was wonderful. Instead of being treated like confused tourists we were treated like family members. It gave me a sense of comfort and [we] didn’t have to think about any practical things. We were in Turkey to relax and feel good,” according to one testimonial on the website.

“Dünyagöz plays an important role in increasing Turkey’s medical tourism revenues. Currently, 30,000 foreign patients from 107 different countries choose Dünyagöz for their treatments. In 2013, we expect this number to grow up to 50,000,” Coskunseven said.

The Svjetlost eye clinic currently receives 24% of its patients from neighboring countries, such as Slovenia, Bosnia-Herzegovina and Serbia. Strictly speaking, this is not medical tourism, Barisic said, because patients come just for the treatment, attracted by the quality of services, the short-distance destination and the lack of language barriers.

“But we have ambitious projects for the future,” Barisic said. “Croatia is a favorite summer holiday destination for European tourists. We are planning to set up a cluster including travel agents, marketing agencies, media, local authorities, airlines and insurances. We need people who are willing to invest in the business.”

New market opportunities will be created when Croatia joins the European Union in July.

“We need to show our credentials also in ophthalmology. We have developed tremendous quality with the newest technology in all procedures but need some form of accreditation. There is also a negative image of this part of the world that we have to remove related to the political upheaval, recession and conflicts we suffered in the 1990s,” he said.

The Svjetlost eye clinic offers discount prices for LASIK and PRK at 800 per eye. Refractive cataract surgery varies between 1,100 and 1,850, depending on the lens implanted.

“RLE with implantation of a trifocal lens, which is my IOL of choice, is 1,700,” Barisic said.

International reputation

Spain also has a growing medical tourism industry, with affluent patients coming from the U.K., Scandinavia, North Africa and the Middle East. Mediterranean Health Care, based in Alicante, groups together eight of the most prestigious private hospitals and health clinics in the province and offers medical tourism services for all specialties.

“Eye care is currently 15% of our demand. We believe that there is a future trend for medical tourism in ophthalmology related to the technological advances in cataract surgery and the unmet demand for premium procedures in national health care-regulated systems. The cutting-edge developments in laser eye surgery have also created a large market, and we offer cost-saving opportunities and shorter waiting times,” Sandra Ruiz Salinas, manager of Mediterranean Health Care, said.

Sandra Ruiz Salinas

Vissum Corporacion Oftalmologica is one of the founders of the association but also receives foreign patients independently, thanks to a long-standing international reputation.

“About 90% of foreign patients come to us because we have an image abroad. This made us expand with new clinics in other countries, like the Balkans and in the Gulf area,” Jorge L. Alió, MD, PhD, founder and medical director of Vissum and an OSN Europe Edition Board Member, said.

Alió said there are two categories of medical travelers. The first is made up of those who come from other European countries, are entitled to reimbursement by their national health service and create their own contacts with specific medical centers and surgeons. The long waiting lists for cataract surgery and other procedures in their home country is often the reason for traveling to Spain for surgery. Patients in the other group follow the tourism route, which is aimed at combining medical procedures and holidays, and rely on medical tourism agencies for their choices.

Jorge L. Alió

“We also have patients from abroad who are referred to us by their own doctors. Among these, also a few patients from the U.S. for procedures and treatments that are not yet performed there due to [U.S. Food and Drug Administration] limitations,” he said.

The international reputation of Zoltan Z. Nagy, MD, PhD,DSc, at Semmelweis University in Budapest, Hungary, drives patients to seek treatment from him. Nagy, an OSN Europe Edition Board Member, was the first surgeon in the world to perform femtosecond laser-assisted cataract surgery.

“Patients come from all over Europe and also from the U.S. because I have the longest experience in this field. They also come for other procedures, like oculoplasty and refractive surgery, including the correction of residual refractive error following cataract operations. About 10% of my patients now come from abroad,” Nagy said.

Since the launch of various budget airlines, such as Wizz Air and Jet2, Hungary has become a popular destination for dentistry, orthopedics and cosmetic surgery. Private practices in ophthalmology are now joining the medical tourism field, offering highly competitive prices, up to 70% less than the average in the U.K., Germany and Austria.

“If we can offer foreign patients a high level of professionalism and premium services, at least as good as they would find in their own countries, then medical tourism makes sense. If it is driven by purely financial reasons, problems are bound to arise,” Nagy said.

Coordinating care and aftercare

Coordinating appropriate aftercare once the patient returns home is one of the challenges of medical tourism. Some agencies provide resources for follow-up care upon the patient’s return.

“A full medical report is given to the patient at the time of discharge to be used for any medical appointments back home. Should patients require consultations with our doctors, they can be arranged at any time by telephone or over the Internet,” Ruiz Salinas said.

“Patients who come here for surgery can be seen in one of our other clinics in Turkey or in Europe during the follow-up,” Coskunseven said.

Keeping in touch with the referring doctor is another option, Alió suggested.

India is a leading country for medical tourism, with an annual growth rate of 30%. The Confederation of Indian Industry reported that 150,000 medical tourists came to India in 2005, which grew to 200,000 by 2008. A study by the Associated Chambers of Commerce and Industry of India reported that there were 850,000 medical tourists in India in 2011 and projected an increase to 3.2 million by 2015.

Amar Agarwal

Chennai has been called India’s health capital, attracting an estimated 150 international patients every day. Among specialty hospitals that offer a wide range of services for foreign patients, Dr. Agarwal’s Eye Hospital is a leader in ophthalmology.

“We have patients coming from neighboring countries like Pakistan, Bangladesh and Sri Lanka, but also from the Middle East, namely Oman, Iraq and Iran. These patients are coming for corneal transplantation, high-tech retinal surgery or glued intraocular lens surgery. They get quality at an affordable price, and we directly take care of all the needs they have in terms of transfer and accommodation,” Amar Agarwal, MS, FRCS, FRCOphth, an OSN APAO Edition Board Member, said.

Agarwal’s clinic has special contracts with various hotels in the vicinity where patients can stay. Patients are picked up from the airport and have immediate access to a preoperative evaluation and surgery. The clinic has a separate department for international patients, with international patient coordinators who speak different languages and take care of patients’ needs in and outside of the hospital.

Since 2006, the hospital has embarked on a major expansion program, building 60 hospitals in the Indian subcontinent and other locations in six countries abroad, with a total of 2,500 people working in the group.

“Most of our ‘foreign’ patients are referred to us from these other clinics whenever there is a complicated case to treat,” Agarwal said. “Then they are sent back to the local hospital for the follow-up, and I keep constantly in touch with the doctors there.”

Opening branch centers and eventually developing large hospital chains seem to be successful strategies in medical tourism.

“We have clinics in several locations in Turkey, but also in Germany, the Netherlands and in England. In the next 5 years, we are planning to open five new hospitals in Europe, the Middle East and [Commonwealth of Independent States] countries, and every year, three new eye hospitals in Turkey,” Coskunseven said.

“Networking has allowed us to become leaders in medical tourism, offering a wide range of coordinated services, including case management upon return of the patients in their own country. Routine aftercare and potential postoperative complications can be dealt with at any of our branches abroad,” he explained.

“In June, Svjetlost is opening two new clinics in Istria, along the Adriatic coast, in Pula and Rovinj,” Barisic said.

Ensuring quality, protecting consumers

Establishing regulatory frameworks and quality standards and protecting consumers from unreliable, disreputable health care providers are key issues in medical tourism. Several international hospitals and large practices today undergo accreditation by one or more of the international health care accreditation organizations, such as the Joint Commission International, QHA Trent Accreditation and Accreditation Canada. However, it is not rare for patients to be pulled in by practices that have inadequate services and doctors with poor credentials who may charge substantial additional payments for needless examinations or surgeries, Alió said.

“This is a main limitation in medical tourism. Patients are often unaware of the criteria for a making a good choice and might be attracted by the appearance of online advertising,” he said.

The Medical Tourism Association (MTA) is a global nonprofit association for the medical tourism industry that works with health care providers, governments, insurance companies, employers and other buyers of health care, focusing on transparency and quality. It was started in 2007 and currently has 300 members from 100 countries.

“We are the only international trade association in the world in the medical tourism industry. Among our members there are many who offer excellent eye care in different countries in the world,” Cristina Cardona, executive global program manager of the MTA, said.

Cristina Cardona

The MTA offers educational training, certification and other brand-development programs to hospitals, health care providers and governments that actively work toward developing a sustainable medical tourism program and increasing patient volume.

“Research shows that a medical tourist spends approximately three times more than a regular patient and stays in a destination for 2 to 3 weeks traveling with a companion. This translates into increased revenues for the destination and internal economic growth,” Cardona said.

The MTA’s mission also extends to raising consumer awareness of international health care options.

“We recommend patients do their research before they travel. It is important to choose the right provider for the specific procedure they need. Patients should look for hospitals that are accredited, doctors that have a solid experience and high success rates, among other aspects that will impact their experience. We offer consumers our support in making choices,” Cardona said.

An opportunity for growth

Expectations for future developments and scope of medical tourism are great.

“Combining medical care and vacations is an option that is going to be available more and more in the future. In our area it is just beginning to take off, and we expect a considerable growth in the next 3 to 5 years,” Alió said. “It widens patients’ opportunities and creates a new global market to the benefit of all. As doctors, we must be aware of the needs and ready to provide an adequate response.”

“It is an opportunity we should not miss — not just for the individual benefit, but to the advantage of the entire country. Medical tourism is a source of economic growth and creates employment opportunities,” Barisic said.

Medical tourism is a fast growing market, Coskunseven said.

“It expands patients’ choice, opening up a worldwide range of opportunities for treatment. As physicians, it is rewarding to work for an international clientele. It is a great incentive to continuous improvement, and we are proud to take care of the eyes of the world,” he said.

In many developing countries, medical tourism has been actively promoted by the government. India’s National Health Policy, for example, says: “To capitalize on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings.”

In Turkey, medical tourism has become part of the development and investment plans of the State Planning Organization. In the draft report of the National Tourism 2023 Strategy prepared by the Ministry of Tourism, health tourism has been examined as a high-priority area.

In other countries, medical tourism has not yet been actively promoted by the government and still relies on private initiative.

“During the national forum ‘Health inWest’ held in Zagreb, medical tourism gathered a lot of interest as a topic. We pointed out that it will play an important role in the future of the domestic health care system. But we have no state support at present,” Barisic said.

He emphasized, however, that the business side of medicine should never turn physicians away from the primary goal of providing all people, rich and poor, with the best possible care.

“Countries with a mature public health system don’t run the risk of creating significant quality differential by expanding the private sector through medical tourism. In our country, for instance, the public health system still covers 85% of the demand and delivers excellent services, mostly not so highly differentiated from what the private sector can provide. The strive for quality of private medicine can in fact be a stimulating factor for the progress of health care in general,” Barisic said. – by Michela Cimberle

Disclosure: No products or companies are mentioned that would require financial disclosure.

POINTCOUNTER

Could medical tourism reduce health care resources for local populations and exacerbate inequalities in destination countries?

POINT

Negative effect on equitable development and provision of health systems

Medical tourism is thought to amplify health equity concerns inherent in the private provision of health care by greatly increasing the size of the potential market of privately paying patients.

Firstly, medical tourism usually takes place in private health care facilities located in urban settings with ready access to the international patient market. As such, there are concerns that the increasing popularity of medical tourism will further incentivize care providers to practice in private urban health facilities, reducing the available supply of workers in the public health care system and/or in smaller, less-central cities and rural locations. This may especially be the case for better-trained and more-experienced health workers who can command higher prices for their services, leaving less-experienced workers to practice in the public system.

Rory Johnston

Secondly, countries seeking to build a medical tourism sector often give public subsidies to assist the development of private health care facilities. These subsidies may take the form of land grants, tax breaks, state-guaranteed loans or publicly supported guiding committees that benefit the private health sector instead of bolstering public health programs or care provision. These subsidies divert resources from the public to private sector and may not be recouped by the public. Less directly, the state is usually a heavy investor in the education of a country’s health workers, thereby subsidizing the private medical tourism sector if health workers choose to limit or entirely opt out of participating in public sector practice.

Finally, there are worries that medical tourism incentivizes investment into equipment and training that favors expensive curative treatments over more cost-effective primary health care and preventive health measures that are not as readily commodified. It is for these reasons that medical tourism can negatively affect the equitable development and provision of health systems worldwide.

Rory Johnston is a PhD student in the department of geography at Simon Fraser University, British Columbia, Canada. Disclosure: Johnston has no relevant financial disclosures.

COUNTER

Many positive sides to medical tourism

In my opinion, medical tourism cannot be held responsible for inequalities and reduced access to health care by the general population. To have this effect, it would have to be significant enough to represent a large proportion of the internal market and demand for health care. This is not the case, even in countries where it is well developed. In many of these countries there is a general problem with the health care system, due to underfunding, poor management, corruption and lack of insurance coverage, public or private. These issues can create inequalities, not medical tourism.

There are many positive sides of the medical tourism business. First of all, it can stimulate innovation and increase quality standards. The high level of technology and updated training required by health facilities catering to foreign visitors could have an overall positive effect on domestic standards.

Rupa Chanda

Secondly, it can counteract the “brain drain,” encouraging local doctors to stay or those who have trained abroad to come back. The more the industry grows, the more it will create opportunities for those who would otherwise migrate to pursue improved and better financially rewarded careers. The increased number of hospitals providing advanced, super-specialized treatment with updated technology will affect the demand for highly qualified human resources. In India, this has already happened. Doctors come back and bring in new patients, which increases the demand for doctors. It creates a nice, virtuous circle.

Last but not least, a well-managed two-tier system can create incentives for hospitals to cross-subsidize from superior to basic service users. The extra revenue brought in by high-income patients can be used to subsidize health care-related projects and services for lower-income groups. Medical tourism can become an added bonus. It is a matter of how governments use, or misuse, this extra source of money.

It is also up to governments to monitor private health care facilities to ensure that conditions that have been placed on them regarding subsidies and other incentives are met and the local population is served. Regulatory failure and mismanagement are often the main reasons why medical tourism may not serve public interests, but this does not mean that medical tourism is the root cause of these inequities.

Rupa Chanda is a professor of economics and social sciences at Indian Institute of Management, Bangalore, India. Disclosure: Chanda has no relevant financial disclosures.

In the era of globalization, medical tourism has become a significant phenomenon and developed into a national industry in more than 50 countries. Driven by marketplace forces, it involves a constantly growing number of patients who seek non-emergency medical treatment and surgery outside their country of residence, often in collaboration with the tourism industry.

Medical travelers are driven by the lower costs, favorable exchange rates and shorter waiting lists offered by destination countries, in combination with high-quality hospital services and the added allure of resting during and after the treatment in attractive holiday resorts. Mainly limited to cosmetic surgery and dental procedures in earlier decades, the medical tourism industry has gradually expanded to nearly all medical specialties, including ophthalmology.

Health is the biggest value of all developed societies and the largest individual economic sector of the most developed Western countries, Ante Barisic, MD, clinical ophthalmologist at the University Eye Hospital Svjetlost in Zagreb, Croatia, said.

Efekan Coskunseven, MD

Efekan Coskunseven, MD, said that there is enormous potential in medical tourism for countries that offer touristic attractions as well as high-quality medical services at competitive prices.

Image: Coskunseven E

“Technologically, the health industry is the most advanced industry in the world, especially in ophthalmology. It is supported by a great amount of investigations and by huge investments, which are ethical because they are aimed at reducing suffering and disability and at prolonging life expectancy,” he said.

Medical tourism offers “enormous opportunities and great perspectives because the demand for health is unlimited and is growing with the longer life expectancy,” Barisic said.

Good quality at affordable prices

In ophthalmology, the highest demand is for refractive procedures, including corneal laser surgery, phakic IOLs and lens surgery with implantation of premium IOLs. Oculofacial plastic surgery is also popular.

“Patients don’t come to us just for elective procedures, however,” Efekan Coskunseven, MD, director of the Refractive Surgery Department at Dünyagöz Eye Hospital, Istanbul, Turkey, said. “We have foreign patients also for vitreoretinal surgery, keratoplasty and glaucoma surgery. We offer the most updated technology, highly experienced surgeons and the highest-quality eye care services. All this at a more affordable price than in their home countries.”

Dünyagöz Eye Hospital is the only hospital certified by the Joint Commission International in Turkey. It is part of one of the world’s largest hospital chains, with clinics in 18 locations in Turkey and Europe.

Offers for medical tourism packages on the Dünyagöz website include airport transfer, full board hotel accommodation and leisure activities in addition to specific surgical procedures with preoperative assessment and postoperative follow-up. Prices vary from 1,255 for bilateral LASEK to 1,905 for LASIK with a femtosecond laser. Femtosecond laser-assisted cataract surgery with implantation of a premium IOL is offered for an average of 2,500. Insurance options are also offered.

Ante Barisic

“The reception was wonderful. Instead of being treated like confused tourists we were treated like family members. It gave me a sense of comfort and [we] didn’t have to think about any practical things. We were in Turkey to relax and feel good,” according to one testimonial on the website.

“Dünyagöz plays an important role in increasing Turkey’s medical tourism revenues. Currently, 30,000 foreign patients from 107 different countries choose Dünyagöz for their treatments. In 2013, we expect this number to grow up to 50,000,” Coskunseven said.

The Svjetlost eye clinic currently receives 24% of its patients from neighboring countries, such as Slovenia, Bosnia-Herzegovina and Serbia. Strictly speaking, this is not medical tourism, Barisic said, because patients come just for the treatment, attracted by the quality of services, the short-distance destination and the lack of language barriers.

“But we have ambitious projects for the future,” Barisic said. “Croatia is a favorite summer holiday destination for European tourists. We are planning to set up a cluster including travel agents, marketing agencies, media, local authorities, airlines and insurances. We need people who are willing to invest in the business.”

PAGE BREAK

New market opportunities will be created when Croatia joins the European Union in July.

“We need to show our credentials also in ophthalmology. We have developed tremendous quality with the newest technology in all procedures but need some form of accreditation. There is also a negative image of this part of the world that we have to remove related to the political upheaval, recession and conflicts we suffered in the 1990s,” he said.

The Svjetlost eye clinic offers discount prices for LASIK and PRK at 800 per eye. Refractive cataract surgery varies between 1,100 and 1,850, depending on the lens implanted.

“RLE with implantation of a trifocal lens, which is my IOL of choice, is 1,700,” Barisic said.

International reputation

Spain also has a growing medical tourism industry, with affluent patients coming from the U.K., Scandinavia, North Africa and the Middle East. Mediterranean Health Care, based in Alicante, groups together eight of the most prestigious private hospitals and health clinics in the province and offers medical tourism services for all specialties.

“Eye care is currently 15% of our demand. We believe that there is a future trend for medical tourism in ophthalmology related to the technological advances in cataract surgery and the unmet demand for premium procedures in national health care-regulated systems. The cutting-edge developments in laser eye surgery have also created a large market, and we offer cost-saving opportunities and shorter waiting times,” Sandra Ruiz Salinas, manager of Mediterranean Health Care, said.

Sandra Ruiz Salinas

Vissum Corporacion Oftalmologica is one of the founders of the association but also receives foreign patients independently, thanks to a long-standing international reputation.

“About 90% of foreign patients come to us because we have an image abroad. This made us expand with new clinics in other countries, like the Balkans and in the Gulf area,” Jorge L. Alió, MD, PhD, founder and medical director of Vissum and an OSN Europe Edition Board Member, said.

Alió said there are two categories of medical travelers. The first is made up of those who come from other European countries, are entitled to reimbursement by their national health service and create their own contacts with specific medical centers and surgeons. The long waiting lists for cataract surgery and other procedures in their home country is often the reason for traveling to Spain for surgery. Patients in the other group follow the tourism route, which is aimed at combining medical procedures and holidays, and rely on medical tourism agencies for their choices.

Jorge L. Alió

“We also have patients from abroad who are referred to us by their own doctors. Among these, also a few patients from the U.S. for procedures and treatments that are not yet performed there due to [U.S. Food and Drug Administration] limitations,” he said.

The international reputation of Zoltan Z. Nagy, MD, PhD,DSc, at Semmelweis University in Budapest, Hungary, drives patients to seek treatment from him. Nagy, an OSN Europe Edition Board Member, was the first surgeon in the world to perform femtosecond laser-assisted cataract surgery.

“Patients come from all over Europe and also from the U.S. because I have the longest experience in this field. They also come for other procedures, like oculoplasty and refractive surgery, including the correction of residual refractive error following cataract operations. About 10% of my patients now come from abroad,” Nagy said.

Since the launch of various budget airlines, such as Wizz Air and Jet2, Hungary has become a popular destination for dentistry, orthopedics and cosmetic surgery. Private practices in ophthalmology are now joining the medical tourism field, offering highly competitive prices, up to 70% less than the average in the U.K., Germany and Austria.

“If we can offer foreign patients a high level of professionalism and premium services, at least as good as they would find in their own countries, then medical tourism makes sense. If it is driven by purely financial reasons, problems are bound to arise,” Nagy said.

PAGE BREAK

Coordinating care and aftercare

Coordinating appropriate aftercare once the patient returns home is one of the challenges of medical tourism. Some agencies provide resources for follow-up care upon the patient’s return.

“A full medical report is given to the patient at the time of discharge to be used for any medical appointments back home. Should patients require consultations with our doctors, they can be arranged at any time by telephone or over the Internet,” Ruiz Salinas said.

“Patients who come here for surgery can be seen in one of our other clinics in Turkey or in Europe during the follow-up,” Coskunseven said.

Keeping in touch with the referring doctor is another option, Alió suggested.

India is a leading country for medical tourism, with an annual growth rate of 30%. The Confederation of Indian Industry reported that 150,000 medical tourists came to India in 2005, which grew to 200,000 by 2008. A study by the Associated Chambers of Commerce and Industry of India reported that there were 850,000 medical tourists in India in 2011 and projected an increase to 3.2 million by 2015.

Amar Agarwal

Chennai has been called India’s health capital, attracting an estimated 150 international patients every day. Among specialty hospitals that offer a wide range of services for foreign patients, Dr. Agarwal’s Eye Hospital is a leader in ophthalmology.

“We have patients coming from neighboring countries like Pakistan, Bangladesh and Sri Lanka, but also from the Middle East, namely Oman, Iraq and Iran. These patients are coming for corneal transplantation, high-tech retinal surgery or glued intraocular lens surgery. They get quality at an affordable price, and we directly take care of all the needs they have in terms of transfer and accommodation,” Amar Agarwal, MS, FRCS, FRCOphth, an OSN APAO Edition Board Member, said.

Agarwal’s clinic has special contracts with various hotels in the vicinity where patients can stay. Patients are picked up from the airport and have immediate access to a preoperative evaluation and surgery. The clinic has a separate department for international patients, with international patient coordinators who speak different languages and take care of patients’ needs in and outside of the hospital.

Since 2006, the hospital has embarked on a major expansion program, building 60 hospitals in the Indian subcontinent and other locations in six countries abroad, with a total of 2,500 people working in the group.

“Most of our ‘foreign’ patients are referred to us from these other clinics whenever there is a complicated case to treat,” Agarwal said. “Then they are sent back to the local hospital for the follow-up, and I keep constantly in touch with the doctors there.”

Opening branch centers and eventually developing large hospital chains seem to be successful strategies in medical tourism.

“We have clinics in several locations in Turkey, but also in Germany, the Netherlands and in England. In the next 5 years, we are planning to open five new hospitals in Europe, the Middle East and [Commonwealth of Independent States] countries, and every year, three new eye hospitals in Turkey,” Coskunseven said.

“Networking has allowed us to become leaders in medical tourism, offering a wide range of coordinated services, including case management upon return of the patients in their own country. Routine aftercare and potential postoperative complications can be dealt with at any of our branches abroad,” he explained.

“In June, Svjetlost is opening two new clinics in Istria, along the Adriatic coast, in Pula and Rovinj,” Barisic said.

Ensuring quality, protecting consumers

Establishing regulatory frameworks and quality standards and protecting consumers from unreliable, disreputable health care providers are key issues in medical tourism. Several international hospitals and large practices today undergo accreditation by one or more of the international health care accreditation organizations, such as the Joint Commission International, QHA Trent Accreditation and Accreditation Canada. However, it is not rare for patients to be pulled in by practices that have inadequate services and doctors with poor credentials who may charge substantial additional payments for needless examinations or surgeries, Alió said.

PAGE BREAK

“This is a main limitation in medical tourism. Patients are often unaware of the criteria for a making a good choice and might be attracted by the appearance of online advertising,” he said.

The Medical Tourism Association (MTA) is a global nonprofit association for the medical tourism industry that works with health care providers, governments, insurance companies, employers and other buyers of health care, focusing on transparency and quality. It was started in 2007 and currently has 300 members from 100 countries.

“We are the only international trade association in the world in the medical tourism industry. Among our members there are many who offer excellent eye care in different countries in the world,” Cristina Cardona, executive global program manager of the MTA, said.

Cristina Cardona

The MTA offers educational training, certification and other brand-development programs to hospitals, health care providers and governments that actively work toward developing a sustainable medical tourism program and increasing patient volume.

“Research shows that a medical tourist spends approximately three times more than a regular patient and stays in a destination for 2 to 3 weeks traveling with a companion. This translates into increased revenues for the destination and internal economic growth,” Cardona said.

The MTA’s mission also extends to raising consumer awareness of international health care options.

“We recommend patients do their research before they travel. It is important to choose the right provider for the specific procedure they need. Patients should look for hospitals that are accredited, doctors that have a solid experience and high success rates, among other aspects that will impact their experience. We offer consumers our support in making choices,” Cardona said.

An opportunity for growth

Expectations for future developments and scope of medical tourism are great.

“Combining medical care and vacations is an option that is going to be available more and more in the future. In our area it is just beginning to take off, and we expect a considerable growth in the next 3 to 5 years,” Alió said. “It widens patients’ opportunities and creates a new global market to the benefit of all. As doctors, we must be aware of the needs and ready to provide an adequate response.”

“It is an opportunity we should not miss — not just for the individual benefit, but to the advantage of the entire country. Medical tourism is a source of economic growth and creates employment opportunities,” Barisic said.

Medical tourism is a fast growing market, Coskunseven said.

“It expands patients’ choice, opening up a worldwide range of opportunities for treatment. As physicians, it is rewarding to work for an international clientele. It is a great incentive to continuous improvement, and we are proud to take care of the eyes of the world,” he said.

In many developing countries, medical tourism has been actively promoted by the government. India’s National Health Policy, for example, says: “To capitalize on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings.”

In Turkey, medical tourism has become part of the development and investment plans of the State Planning Organization. In the draft report of the National Tourism 2023 Strategy prepared by the Ministry of Tourism, health tourism has been examined as a high-priority area.

In other countries, medical tourism has not yet been actively promoted by the government and still relies on private initiative.

“During the national forum ‘Health inWest’ held in Zagreb, medical tourism gathered a lot of interest as a topic. We pointed out that it will play an important role in the future of the domestic health care system. But we have no state support at present,” Barisic said.

He emphasized, however, that the business side of medicine should never turn physicians away from the primary goal of providing all people, rich and poor, with the best possible care.

“Countries with a mature public health system don’t run the risk of creating significant quality differential by expanding the private sector through medical tourism. In our country, for instance, the public health system still covers 85% of the demand and delivers excellent services, mostly not so highly differentiated from what the private sector can provide. The strive for quality of private medicine can in fact be a stimulating factor for the progress of health care in general,” Barisic said. – by Michela Cimberle

Disclosure: No products or companies are mentioned that would require financial disclosure.

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POINTCOUNTER

Could medical tourism reduce health care resources for local populations and exacerbate inequalities in destination countries?

POINT

Negative effect on equitable development and provision of health systems

Medical tourism is thought to amplify health equity concerns inherent in the private provision of health care by greatly increasing the size of the potential market of privately paying patients.

Firstly, medical tourism usually takes place in private health care facilities located in urban settings with ready access to the international patient market. As such, there are concerns that the increasing popularity of medical tourism will further incentivize care providers to practice in private urban health facilities, reducing the available supply of workers in the public health care system and/or in smaller, less-central cities and rural locations. This may especially be the case for better-trained and more-experienced health workers who can command higher prices for their services, leaving less-experienced workers to practice in the public system.

Rory Johnston

Secondly, countries seeking to build a medical tourism sector often give public subsidies to assist the development of private health care facilities. These subsidies may take the form of land grants, tax breaks, state-guaranteed loans or publicly supported guiding committees that benefit the private health sector instead of bolstering public health programs or care provision. These subsidies divert resources from the public to private sector and may not be recouped by the public. Less directly, the state is usually a heavy investor in the education of a country’s health workers, thereby subsidizing the private medical tourism sector if health workers choose to limit or entirely opt out of participating in public sector practice.

Finally, there are worries that medical tourism incentivizes investment into equipment and training that favors expensive curative treatments over more cost-effective primary health care and preventive health measures that are not as readily commodified. It is for these reasons that medical tourism can negatively affect the equitable development and provision of health systems worldwide.

Rory Johnston is a PhD student in the department of geography at Simon Fraser University, British Columbia, Canada. Disclosure: Johnston has no relevant financial disclosures.

COUNTER

Many positive sides to medical tourism

In my opinion, medical tourism cannot be held responsible for inequalities and reduced access to health care by the general population. To have this effect, it would have to be significant enough to represent a large proportion of the internal market and demand for health care. This is not the case, even in countries where it is well developed. In many of these countries there is a general problem with the health care system, due to underfunding, poor management, corruption and lack of insurance coverage, public or private. These issues can create inequalities, not medical tourism.

There are many positive sides of the medical tourism business. First of all, it can stimulate innovation and increase quality standards. The high level of technology and updated training required by health facilities catering to foreign visitors could have an overall positive effect on domestic standards.

Rupa Chanda

Secondly, it can counteract the “brain drain,” encouraging local doctors to stay or those who have trained abroad to come back. The more the industry grows, the more it will create opportunities for those who would otherwise migrate to pursue improved and better financially rewarded careers. The increased number of hospitals providing advanced, super-specialized treatment with updated technology will affect the demand for highly qualified human resources. In India, this has already happened. Doctors come back and bring in new patients, which increases the demand for doctors. It creates a nice, virtuous circle.

Last but not least, a well-managed two-tier system can create incentives for hospitals to cross-subsidize from superior to basic service users. The extra revenue brought in by high-income patients can be used to subsidize health care-related projects and services for lower-income groups. Medical tourism can become an added bonus. It is a matter of how governments use, or misuse, this extra source of money.

It is also up to governments to monitor private health care facilities to ensure that conditions that have been placed on them regarding subsidies and other incentives are met and the local population is served. Regulatory failure and mismanagement are often the main reasons why medical tourism may not serve public interests, but this does not mean that medical tourism is the root cause of these inequities.

Rupa Chanda is a professor of economics and social sciences at Indian Institute of Management, Bangalore, India. Disclosure: Chanda has no relevant financial disclosures.