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.

“There is enormous potential in medical tourism for countries that offer touristic attractions as well as high-quality medical services at competitive prices,” Efekan Coskunseven, MD, director of the Refractive Surgery Department at Dünyagöz Eye Hospital, Istanbul, Turkey, said.

Image: Coskunseven E

“The demand will continue to grow as people become more educated about their international options for medical treatment and as air travel becomes more convenient and less expensive,” Kah Guan Au Eong, MD, medical director and senior consultant, Singapore International Eye Cataract Retina Centre, said.

The health industry is the most technologically advanced industry in the world, especially in ophthalmology. It is supported by many investigations and large investments, which are ethical because they aim to reduce suffering and disability while extending life expectancy, Ante Barisic, MD, clinical ophthalmologist at the University Eye Hospital Svjetlost in Zagreb, Croatia, said.

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

At the crossroads of Europe and Asia, Turkey enjoys a strategic location for medical tourism. 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 US$1,600 for bilateral LASEK to US$2,500 for LASIK with a femtosecond laser. Femtosecond laser-assisted cataract surgery with implantation of a premium IOL is offered for an average of US$3,300. Insurance options are offered.

“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 US$1,000 per eye. Refractive cataract surgery varies between US$1,500 and US$2,400, depending on the lens implanted.

“RLE with implantation of a trifocal lens, which is my IOL of choice, is US$2,200,” Barisic said.

The World Health Organization ranked Singapore’s health care system sixth best in the world and highest in Asia. Singapore is a dynamic and multicultural country with excellent infrastructure and great attractions. With well-respected specialists trained in the best centers around the world and internationally accredited hospitals, Singapore has established itself as Asia’s leading medical hub, serving medical travelers from around the world. A range of medical care is offered, from basic health screening and wellness services to high-end specialist care and surgical procedures. In 2011, revenue from medical travelers reached US$761 million, increasing by US$162 million from the year before, Au Eong said.

“Ultimately, medical travelers seek peace of mind. Singapore is one destination where they can receive medical care of the highest quality in an environment that is safe and welcoming, with no uncertainties of wars and bombs, social unrest or natural disasters, and no worries about blood safety. It is here that patients can focus on recovering well without other concerns,” Au Eong said.

Foreign patients represent 50% of his surgery volume. Most come from Indonesia and Bangladesh, and others travel from Myanmar, Vietnam, Cambodia, China and India. Word-of-mouth is still the best recruitment vehicle.

“Most of my new international patients are referred by their friends and relatives who have previously been treated in our clinic,” he said.

Cataract surgery and vitreoretinal surgery are the most commonly performed procedures.

“Cost is an important consideration for many international patients. While list prices appear higher in Singapore than in other Asian countries, final bills are often comparable due to shorter hospital stays. On top of the value for money, patients in Singapore are assured of quality treatment and excellent clinical outcomes, similar to those in the United States and Europe,” Au Eong said.

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.

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.

Expanding to hospital chains

Since 2006, Agarwal’s 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.

Magrabi Hospitals & Centers has expanded from a single eye hospital in Jeddah, Saudi Arabia, to a network of 24 hospitals and centers in nine countries in the Middle East and Africa.

“In the past 20 years, the number of medical travelers has increased, particularly in touristic locations like Egypt and holy places like in Saudi. They come for our good reputation for surgery, though our prices are not the lowest,” Abdulrahman Debis, PhD, regional director of Magrabi Hospitals & Centers, said.

Bilateral LASIK is performed there for US$2,700, and cataract surgery with standard IOL implantation is US$2,800, while premium IOLs are implanted at higher prices.

“Follow-up visits can be performed at any of our Magrabi eye clinics. In other cases, we provide patients with detailed medical reports to be seen by their own doctors,” Debis said.

“We are planning to open more hospitals in Africa and also in Cambodia and Malaysia. In the next 2 years, we’ll have 100 eye hospitals all over the world,” Agarwal said.

“Building up a chain in health care is difficult; you have to train doctors, but we do and send them out. Also, the local doctors spend a training period in Chennai to learn our techniques and approaches,” he said. “We like to have a combination of Indian and local workforce in our branches abroad. Indian staff knows our system and train the local staff.”

In June, the Svjetlost clinic is opening two new branches 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.

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.

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.

“It is a fast growing market. 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,” Coskunseven said.

“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.

Governments are noticeably playing a strong marketing and promotional role in the emerging medical tourism industry in Asian countries.

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.”

Singapore’s government strongly supports medical tourism. Exploiting the country’s economic value as a regional medical hub is a priority of the Ministry of Health. Supported by three government agencies involved in tourism and economic development, the Ministry of Health launched in 2003 SingaporeMedicine, a multi-agency government-industry partnership committed to strengthening Singapore’s position as Asia’s leading medical hub and promoting Singapore as a world-class destination for advanced patient care. Via cross-subsidization mechanisms, medical tourism revenue contributes to support public hospitals.

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 some areas, medical tourism has not yet been actively promoted by governments 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

References:

The Associated Chambers of Commerce and Industry of India website. www.assocham.org/events/recent/recentevents.php.

Düniagöz website. en.dunyagoz.com.

Gahlinger PM. The Medical Tourism Travel Guide. North Branch, Minn: Sunrise River Press; 2008.

Hadi A. Globalization, medical tourism and health equity. Paper presented at: Symposium on Implications of Medical Tourism for Canadian Health and Health Policy; Nov. 13, 2009; Ottawa, Canada. www.globalhealthequity.ca/electronic%20library/Globalization%20medical%20tourism%20and%20health%20equity.pdf.

Hamid Z. The medical capital’s place in history. The Hindu. Aug. 20, 2012. www.thehindu.com/news/cities/chennai/the-medical-capitals-place-in-history/article3796305.ece.

Hazarika I. Health Policy Plan. 2010;doi:10.1093/heapol/czp050.

Indian medical tourism to touch Rs 9,500 cr by 2015: Assocham. The Economic Times. Jan. 6, 2009. economictimes.indiatimes.com/indian-medical-tourism-to-touch-rs-9500-cr-by-2015-assocham/articleshow/3943611.cms.

Johnston R, et al. Int J Equity Health. 2010;doi:10.1186/1475-9276-9-24.

Medical Tourism Association website. www.medicaltourismassociation.com.

Medical tourism services in Turkey. cubukalternatifturizm.com/Medical_Tourism_Services_in_Turkey.htm. 2012.

Singapore Medicine website. www.singaporemedicine.com/index.asp.

Smith R, et al. Health Policy. 2011;doi:10.1016/j.healthpol.2011.06.009.

Tata S. Medical travel in Asia and the Pacific: Challenges and Opportunities, United National Economic and Social Commission for Asia and the Pacific; 2007.

Wagle S. Indian J Med Ethics. 2013;10(1):28-33.

For more information:

Amar Agarwal, MS, FRCS, FRCOphth, can be reached at Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai, India 600086; +91-44-28116233; fax: +91-44-28115871; email: dragarwal@vsnl.com.

Kah Guan Au Eong, MD, can be reached at Singapore International Eye Cataract Retina Centre, 3 Mount Elizabeth 07-04, Mount Elizabeth Medical Centre, Singapore 228510; +65-6887-2020; fax +65-6887-2021; email: aekg@eyecataractretina.com.

Ante Barisic, MD, can be reached at Svjetlost Eye Clinic, Heinzelova ulica 39, 10000 Zagreb, Croatia; +385-1-7775-656; email: ante.barisic@svjetlost.hr.

Cristina Cardona can be reached at Medical Tourism Association, 4371 Northlake Blvd., Suite 304, Palm Beach Gardens, FL 33410, U.S.A.; +1-561-792-6676 ext. 806; fax +1-866-756-0811; email: cristina@medicaltourismcongress.com.

Efekan Coskunseven, MD, can be reached at Dünyagöz Eye Hospital, Istanbul, Turkey; +90-212-3623232; fax +90-212-2750580; email: efekan.coskunseven@dunyagoz.com.

Abdulrahman Debis, PhD, can be reached at Magrabi Hospitals & Centers, P.O. Box 7344, Jeddah 21462, Saudi Arabia; +966-2-6365000, ext. 550; email: abdulrahman.debis@magrabi.com.sa.

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

 

 

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

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.

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.

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.

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.