It takes 90 days or less for medical tourists to make their buying decision, according to Placidway’s latest report ’Medical Tourism Global Consumer Demand Survey’. In the last decade, medical tourism has been transformed from a niche marketplace to a highly competitive environment with more and more medical providers seeking customers for their hospital, clinic or specialist service. As customers find it almost impossible to differentiate between competing claims on knowledge, technology, specialisms and medical skills, people are putting a heavy emphasis on the price, the country’s overall reputation in healthcare services, and peer reviews. When it comes to choosing the healthcare provider, consumers look first at countries with advanced economies that have long offered advanced medical care such as Germany. But high costs in those countries drives individuals to look for alternatives in emerging countries, such as Mexico and Latin America (for people in USA and Canada), India (for African consumers), Turkey or Poland (Middle Easterners & Europeans). According to survey author Pramod Goel, "Medical travellers take their time to ensure the decision they make is the right one, so if we are talking about the best hospital in the world, or the top specialists for a particular treatment, it all comes down to price, country reputation and peer reviews. Even if the exact same services are available in their home country they will first look up the prices for the treatment in hospitals abroad." The 90 days to make a decision has to do with the way that people make the hard decisions in life. There are factors that influence decision-making processes: age, socioeconomic status, and cognitive abilities. As the survey analysis shows, younger adults will request more information when compared to older adults and, depending upon the education level - the decision making process can be faster in lower educated health travellers while it becomes slower in higher educated individuals. 34% need about one month or more to make a decision from the time of inquiry to board the flight for medical travel. 32% will make a decision in 3 months, while 23% will know what they have to do in 6 months. Some of them would need more time, so 6% will make a decision in a year and 4% in more than one year. 66% can make a decision within 90-days starting from the day of their inquiry. Pramod Goel explains, “The majority said that the average duration from research start to boarding the plane for treatment would be 3 months. We have concluded, after analysing all the factors and age groups, that if the individuals will not make the buying decision within 3 months from the first inquiry, the chances of buying medical travel treatment goes down to less than 10%". All three factors are important - cost, location and peer reviews, provided that the information on technology availability, specialists, and/or advanced treatment options is then easy to find by the consumer. As medical providers have been trying to tap into the potential of the demand for medical tourism services, the first concept that is key is the consumer’s behaviour. The consumer process has several main steps and the key one for providers is the ability of the consumer to ensure that the hospital or clinic is a reliable option or, better yet, the optimal solution for the problem identified. How communications can speed up the buying process will mainly depend upon the medical provider’s ability to reach the future customer - whether it is with the best price, location advantage, or favourable peer reviews.

Australian health insurer NIB has launched a national campaign to promote cheap dental treatment in Thailand. NIB is acting as a medical tourism agent. NIB is offering offshore cosmetic surgery and dental packages that give patients a 12-month guarantee on overseas surgery, provided they use approved hospitals with luxury accommodation in Thailand under a new business that is not restricted to its health fund members and does not involve health insurance. The NIB Options package includes treatment, airfare and accommodation, covering both dental and medical procedures. It also offers aftercare in Australia and the option of treatment within Australia. Since the launch of the pilot in early 2014 NIB has been getting between 30 and 40 inquiries a day for its offshore package, with about half of that for dental work. So far, the most popular procedures have been for crowns and implants, with full or partial mouth reconstructions also in demand. Australians are being driven overseas by the high costs of local dental treatment and are attracted to fixed price packages as many Australian dentists refuse to tell people or guarantee what costs will be for any treatment. Dental care is excluded from the Medicare health plan.

The on-going row between medical bodies and hospitals in Canada over medical tourism is escalating. Ontario could be vulnerable to legal challenge because of medical tourism. Allowing international patients to pay for health care sets Ontario up for a challenge by Canadians who want to do the same. Doris Grinspun of the Registered Nurses’ Association of Ontario, says the practice of some hospitals accepting foreign patients for profit may lead to demands by Canadians to be allowed to pay for private medical care. If Ontario fails to order all hospitals to cease accepting any medical tourists immediately -the nursing union threatens a court challenge over the right to pay out-of-pocket for health care. Inbound medical tourism in Canada is particularly sensitive in certain provinces that do not allow either private healthcare or private health insurance. Medical tourism is a threat to public healthcare because it creates a double standard that could see well heeled Canadians demand to pay out-of-pocket to jump the queue and get quick treatment. The court threat is not as idle as it may sound. In September, British Columbia is headed to court on a legal challenge over patient access to private surgery centres. The union threat is that the legal costs to hospitals and government will more than offset any income they make from a small number of medical tourists. Health Minister Eric Hoskins says international patients can be treated in Ontario hospitals only if zero public dollars are used, domestic patients are not displaced, and any monies made are reinvested into improving care for Ontarians. Hoskins promises a ministry review to look at ways to strengthen the current rules of the universal public health care system. So far in 2014 Sunnybrook Hospital has treated three foreign patients for cancer, two from the Caribbean and one from Europe. At the University Health Network, 75 international patients have been treated; 31 from Libya and the rest from the Caribbean, Middle East and Africa. Dr. Nizar Mahomed of UHN International has defended medical tourism on the basis that what the University Health Network is doing is not medical tourism, but providing care to people who cannot get it at home. Patients from Libya were wounded in that country’s civil war and that their care at UHN is paid for by the Libyan government. The nurses are far from convinced by the statements of politicians or hospitals and argue that treating people from overseas is medical tourism, wherever they come from or why. A head to head clash between the three is now inevitable.

The recent high profile case of British child, Ashya King, has sparked a war of words in the media and on social media between the parents on one side and the police and NHS on the other. Hampshire Police tweets said that the parents had broken the law by removing their son from hospital care and taking him abroad to raise funds for proton beam therapy. The hospital claimed never to have had any objection to the parents taking their child and paying for treatment in the Czech Republic. If the parents had not been so social media aware and pro-active, the story may have had a different ending. People in the UK seek private proton therapy treatment in the USA and Europe. France, the USA, Germany and Switzerland have had proton cancer treatment centres for some years. Two centres are under development in the UK. The NHS funds proton beam treatment for NHS patients in the USA, when the clinical team believe it is the appropriate treatment option. Proton beam therapy is a highly targeted type of radiotherapy that can treat hard-to-reach cancers, such as spinal or brain tumours. It has a lower risk of damaging the surrounding tissue and causing side effects than other treatments. Like regular radiotherapy, proton beam therapy kills cancer cells. But unlike X-ray beams, proton beams stop once they hit their target instead of carrying on through the body, which cuts the chances of damaging the surrounding tissues. Patients are often treated as outpatients, so they do not even have to be admitted to hospital. The number of sessions depends on the type of the cancer. There are two types of proton beam therapy- the low energy type used for eye surgery, where there are NHS and private clinics in the UK, and the high-energy type used to treat cancer, where the UK will not have any centres until 2018 - one in London and one in Manchester. Some doctors argue against them as each one costs over £100 million to build, and they are only suitable for less than 1% of cancer patients. Other doctors argue that the cost does not need to be that high and a much higher percentage of patients can be treated. The therapy is not available in the UK so British patients may travel to the US or Europe for treatment. The NHS pays for around 100 patients and families a year to be sent to the USA or Switzerland, at a cost of £100,000 each. From April 2018, the treatment will be offered to up to 1,500 cancer patients at hospitals in London and Manchester, and a future centre is planned for Birmingham. Most British patients seeking proton cancer therapy from the estimated 40 centres for themselves or their children, do so at their own cost. Most centres are in the USA and a few in Europe. The Prague Proton Therapy Centre is one of the newest in Europe and uses an ultra-modern application of proton therapy - pencil beam scanning. It accepts British patients for outpatient treatment. It is just a 2 hour flight from London, and has a UK office in Basildon, Essex. It claims to offer treatment at least as good as in the USA, for around a third of the US price and lower travel costs. The case is seen as a spark to light the debate about what cancer treatment the NHS offers in the UK and what the NHS should offer to patients for overseas treatment. Recent cross border cancer studies show that the UK lags behind many EU countries on various measures of cancer care, including survival rate.

Medical tourism packages on treatment in Dubai for residents and visitors will be launched in late October. Dr Ramadan Ibrahim of Dubai Health Authority explains, "Medical tourism packages will be rolled out for tourists and residents alike in Dubai. We have collaborated with Emirates Holidays, Dubai Immigration, the Department of Tourism and other stakeholders to roll-out several medical tourism packages. For tourists the package will include hotel stay and flight tickets. For residents, it will offer discounted rates for certain medical services. The packages are comprehensive and convenient." The packages will cover seven areas of treatment including dermatology, weight loss, dentistry, preventive health check-ups, cosmetic surgery, orthopaedics and ophthalmology. Only packages for wellness and health-check-ups will be launched in October. These will range from basic checks to executive ones offering comprehensive health services. Packages for men and women will include specialist consultation, laboratory tests and other diagnostic tests. A women’s health package will include consultation with a gynaecologist, several investigations including but not limited to blood tests and breast cancer screening and mammogram. There will also be a weight-loss package that includes consultation with a dietician and diet plans based on the person’s medical history. This package offers discounts ranging from 10 to 40 % at various health facilities in Dubai. 40 hospitals and clinics in Dubai have signed up to the packages and been designated as health tourism centres. Other hospitals and clinics will offer packages but are not health tourism centres. Packages offered to Dubai residents will vary from those offered to medical tourists. For residents in the country, it depends on what package they choose, the insurance they have, and the amenities that they are willing to get treated at. If a patient chooses a facility not covered by their insurance provider, then they will not be able to use that particular package. Packages are also being planned targeting different social groups and will be similar to airline bookings in that the earlier people book, the better deal they get. Several packages are being negotiated and may or may not be ready to add to those at the October launch. Some packages are being negotiated with government hospitals, but if launched they are unlikely to be ready by October. Packages aimed at medicals tourists are for short-term treatment only as two weeks is the maximum time any patient will be able to stay in Dubai for treatment. The initiative aims to attract tourism through short procedures only. The packages are part of the first phase of a DHA initiative, which will run until 2016, and will see the launch of a dedicated portal for medical tourism. A second phase to 2020 will aim to further develop facilities and branding for Dubai medical tourism.

The Gran Canaria Spa Wellness & Health Association has identified the top six most popular medical treatments. Most customers come from the United Kingdom, Germany and Scandinavia. The most popular treatments are: • Botox or similar treatment to remove wrinkles between the eyebrows, crow’s feet and forehead. • Hyaluronic acid to diminish wrinkles and plumps areas like lips or cheekbones. • Lifting with micro cannulas: a non-invasive procedure that corrects wrinkles and lost volume. • Bio stimulation facial rejuvenation treatment through the application of autologous plasma (blood fraction containing the patient’s own regenerative factors). • Radiofrequency and mesotherapy to restore skin hydration and lost elasticity caused through ageing. • Personalised cosmetic treatment on skin to reduce the impact of aging. A popular destination is the Hospitales San Roque in Gran Canaria, where they can combine a healthy rejuvenating break with medical aesthetic treatments that include cosmetic surgery, health checks, and cardiologic checks .They can also have a range of natural spa treatments at Gran Canaria Wellness. The Canary Islands are a tourism hotspot with 12 million tourists visiting each year. The Gran Canaria Spa, Wellness and Health Association consists of 12 hotels and a private medical group.

In a survey of medical professionals in Dubai Healthcare City, the most popular reported treatment for medical tourists is for infertility. The survey was commissioned by Dubai Healthcare City using respondents from its 120 medical facilities. The data collected represents a six-month period, beginning January 2014. The sample size was weighted for facilities that offer clinical services so that it was representative of the medical tourism profile. DHCC surveyed doctors on their views, observations and expectations of medical tourism in Dubai. 48 % of medical tourists come primarily from the GCC; 32 % cent from the wider Arab World; 26 % from Eastern and Western Europe; and 23 % from Asia. For those travelling from Saudi Arabia or Oman, Lebanon or Egypt, the UAE is a natural choice: it is close to home, and there are linguistic and cultural similarities that help foster better understanding between them and their doctors. The three most popular procedures are: first, infertility treatments, second, cosmetic treatments, and third, dental. Doctors say that 89% of medical tourists go to Dubai for quality of care; 62% for the city’s experienced doctors, while 48% go for the availability of specialist treatments, and 36% because Dubai is nearby; the figures combined show that there are often several reasons not just one. Care has to be taken with these results as this is the doctor view of what they think the reasons for going to Dubai are, not what the medical tourists actually say themselves- and accounts for the weight put on experienced doctors. Doctors think that the key concerns of medical tourists are cost (32%), post treatment care (23%) and accommodation/ travel (16%). Marwan Abedin of DHCC comments: “As a strategic priority for DHCC, we are committed to increasing the flow of medical tourists visiting Dubai. We can achieve this with regular feedback and cooperation among our partner clinics and hospitals as well as medical tourism agencies.” The Dubai Health Authority aims to attract 500,000 medical tourists a year by 2020 in an ambitious strategy that will include building 22 new hospitals and the employment of more than 3,800 private-sector healthcare staff in the next few years. In 2012, 107,000 medical tourists visited the emirate, generating Dh652 million. By 2016, the authority expects that number to increase to 170,000, with revenues of about Dh1.1billion.

Houston becoming a medical tourism destination. Once best known as the Texas home of America’s space programme, Houston is now attracting an estimated 20,000 medical tourists a year. The Texas Medical Center recently initiated a study of how much medical tourism business currently comes to Houston, to help it a plan to further build its name recognition abroad. A few years ago it had many national and international medical tourists, but recession, poor marketing and competition from nearby Mexico hit numbers hard. For the last two years it has been rebuilding the business, particularly as the drugs war on the borders that has claimed 40,000 lives is frightening people off Mexico. The plan for Texas Medical Center is to be a global healthcare destination. It wants to increase the number of affiliations around the world with foreign hospitals, medical schools and private companies, It is also setting up offices abroad to build name recognition and attract patients. Texas always claims to have the biggest of everything, so it is no surprise to find The Texas Medical Center (TMC) claiming to be the largest medical complex in the world. TMC includes 21 hospitals, 13 support organizations, eight academic and research institutions, six nursing programmes, three public health organizations, three medical schools, two universities, two pharmacy schools, and a dental school. It attracts a staggering 7.4 million people every year; more than the combined populations of Los Angeles, Houston, and San Francisco. There are 7000 patient beds and 171,000 annual surgeries. It performed the first successful heart transplant in the USA and has performed the most heart surgeries globally. At present there is no unified advertising or marketing campaign, but after recent decisions for joint efforts on many topics, this will change. Many of the hospitals currently market individually, having created international patient centres and hotel-like luxury hospital suites to attract international patients. While common for websites to be in English and Hispanic, some hospitals have gone further and offer other languages such as Arabic. International patients sometimes bring their families, lease apartments and hotel rooms and stay in the Houston area several months for surgery, treatment and follow-up care. Most are cash customers so provide $ millions to hospitals and the local economy, Hospitals like them as they pay more than Medicare, Medicaid or private insurers. With 17 international airlines flying to Houston, TMC is a convenient destination for patients too ill to wait hours for layovers, and one hospital even has its own fleet of six medical helicopters. It is estimated that for every $1 a Houston medical tourist spends on medical care, accommodation, travel, food, entertainment and the like has at least a $2 effect on the economy by generating business and jobs. 3,000 international patients seek treatment at Houston Methodist annually. Half have international insurance coverage. The rest pay cash or have cover through their embassies. The hospitals’ international centres assist with medical appointments, travel arrangements and hotel and apartment leasing. M.D. Anderson gets 1800 international patients annually seeking second opinions and treatment options. Half pay cash. 25% are insured. The rest carry embassy- or employer-sponsored coverage. M.D. Anderson’s reputation for groundbreaking treatments and research has spread mainly because of the cancer centre’s relationships with facilities in Turkey, Spain and Brazil. Citizens of Mexico and Saudi Arabia make up the majority of international patients. In part, this is because of medical and business connections established by Houston Methodist Hospital, University of Texas M.D. Anderson Cancer Center and Memorial Hermann Health System in those countries. Medical care may be much cheaper in Mexico but TMC argues that it has no intention of getting into a price war, and says it will maintain an edge because of its international reputation for innovative, quality care provided by leading doctors.