Medical tourism was once seemed as growing industry globally; however, recently it is said that the numbers of medical tourists are static or falling which indicates that Korea should find ways to revitalize the industry. With the support of the Korean government, they are trying to market themselves as a medical-hub to the other countries. Since the medical treatment costs more than what they offer in nearby medical tourism destinations it is not simple to remain competitive. Thus it is important for the Korean medical tourism industry to find the fields where they can stand above the other destinations then try to develop and provide what tourists are expecting to obtain internationally. Also the Korean medical tourism industry should distinguish what areas the factors influencing medical tourism destination choice to attract tourists by extending the medical tourism industry to Lao People’s Democratic Republic.
Medical Tourism
Medical tourism, defined as travel with the express purpose of obtaining health services abroad, is not a new activity strategy (Guy et. Al, 2015). While Burns 2015 defines medical tourism as the process of traveling to a distant location to obtain general medical, dental, or cosmetic surgery at a higher value (quality divided by cost) than is commonly available in one’s own local system. For decades, wealthy citizens of developed countries have traveled abroad to obtain services such as cosmetic surgery, specialized medical treatments, and ‘wellness services’ at spas and resorts. Additionally, patients from lesser developed countries came to the U.S. and Western Europe for better quality care or advanced treatments not available in their home countries. These typically were persons who could afford the higher cost care and the associated costs of travel. As a result of trends impacting healthcare options for consumers worldwide, the scale and scope of medical tourism has shifted dramatically, as has the profile of who seeks healthcare services abroad and for what reasons. Generally and from a scholarly perspective, medical tourism has been poorly researched and most of it has been merely conceptual. Among notable gaps are demand aspects including patient/ consumer characteristics and profiles, investigation of decision models, what types of information are used to evaluate medical tourism options, where that information is sourced, what factors are most valued, and the role of the internet and medical tourism brokers on consumer search strategies (Guy et. Al, 2015).
Medical tourism is an international medical practice where patients travel across national borders with the intention of receiving private medical care. As opposed to state sponsored cross border care arrangements, medical tourists initiate their travel abroad and typically pay for it out of pocket. This practice is gaining attention by policy-makers and health system administrators in high income countries as their citizens are often perceived to be increasingly traveling to low-to-middle income countries for more affordable and accessible care to avoid the high cost of care at home and/or long wait lists for procedures. Medical tourism is not a new practice; however, citizens of low-to-middle income countries have long traveled abroad both regionally and globally to access care not available in their home countries (Snyder et al, 2015). This results the opportunity to place the South Korea medical technology to the strategic location in Lao People’s Democratic Republic by building a medical school and international hospital.
As international trade in services has become increasingly desirable, health services have been identified as a promising export sector by many national governments and business consultancies worldwide. Medical tourism is one form of health services export that has recently attracted considerable attention, often reported as a sector that is quickly growing and immensely valuable. Most generally, medical tourism describes the temporary movement of a patient outside the health system of their habitual country of residence for the purpose of purchasing medical care (Johnston et al, 2015).
Southeast Asia provides what is perhaps the best documented regional example of medical tourism development and promotion, with numerous hospitals and national and provincial governments strategically targeting the sector for investment. Private hospitals in Singapore, Thailand, and Malaysia are all known to be attracting significant numbers of medical tourists from both within and outside the region. These countries’ national governments have been very supportive of medical tourism, creating policies and organizations to increase the export of medical services. The policies and strategies adopted among these countries commonly include the creation of visas specifically for medical tourists, the reduction or elimination of taxation on imported medical equipment and supplies, incentives and/or requirements for international hospital accreditation, and international marketing efforts that advertise the high quality of medical care available. When taken together, these initiatives demonstrate a regional concentration of similar promotional and development initiatives among proximate health care markets competing for international privately paying patients (Johnston et al, 2015). It is important that the government of Lao People’s Democratic Republic support the accreditation process and business implementation as national-wide.
Types of Medical Tourism
Medical tourism can be sub-divided into domestic and international. Domestic medical tourism refers to patients traveling within their own country to receive care at a ‘center of excellence’ (COE) – e.g., institutions with large patient volumes and documented quality outcomes (e.g., University of Pittsburgh Medical Center for transplantation), or those that enjoy this status via common public recognition (e.g., Mayo Clinic, Cleveland Clinic). International medical tourism refers to traveling outside of one’s country (sometimes to an international COE) to obtain care at significantly reduced cost or (for those traveling to more modern countries) increased quality. Owing to the rising cost of healthcare and health insurance to access that healthcare, such cost savings have become more attractive to the healthcare consumer (Burns, 2015).
Outbound medical tourism offers patients the opportunity to access procedures not available or affordable in their home countries, thereby potentially relieving patients of suffering and saving lives (Snyder et al, 2015).
According to Moreira 2013, medical tourism, or health tourism, includes a combination of the new trends on patient mobility, which is in itself constituted by three patient categories: international temporary visitors, long-term international residents, and outsourced patients.
Today, medical tourism includes (www.capetown.gov.za): Spa tourism (spas, Day Spa etc.); Holistic tourism (nursing homes, yoga centers); Medical tourism (surgery, aesthetics, dentistry, fertilization etc.); Professional wellness tourism (life coaching, stress management) (Patrichi and Dodu, 2014).
Patients Go Overseas
Over the past two decades the number of individuals traveling abroad for the purpose of obtaining health care has increased. There are multiple reasons why they decide to travel far distances. The most common reasons are lack of health insurance, not enough health insurance, high costs, inaccessibility, and unfamiliar language and culture. These individuals have diverse backgrounds; the common denominator is their belief that they can obtain health care in another country that is more affordable, more accessible, and/or comparable or better quality (Tseng, 2013).
In recent year’s access to health care, cost, safety, and efficiency have been contentiously debated in the political realm. Even though the Supreme Court up held the Patient Protection and Affordable Care Act, commonly referred to as the Affordable Care Act or ACA, politicians and political pundits continue to argue about every aspect about health care. Many others point to the gaping health disparities among groups based on race, ethnicity, gender, age, socioeconomic status, and geographical location to urge the government to do more in regards to health care for the people. Some authorities speculate the current health care conundrum will worsen because supply will not keep up with demand. Although it is too early to assess what effect the ACA will have on the state of health care and the American people, there is no question that there are millions of people who do not have access to healthcare, have inadequate healthcare, cannot afford costs related to health care, or are fed up with the inefficiencies found in our current healthcare system. Many individuals have become proactive in seeking health care by means of medical tourism with the assistance of medical tourism agencies or brokers, family, friends, or on their own (Tseng, 2013).
For individuals who are uninsured or are underinsured, traveling to a foreign country may be their only option for health care besides the local hospital or clinic. According to the U.S. Census Bureau, 15.1% of United States residents are uninsured and 11.4% of New York state residents are uninsured (2011). The Commonwealth Fund reports that 16% of adults ages 19–64, or 29 million adults, are underinsured in 2010 (September 8, 2011). Underinsured adults are those who have insurance all year but have medical expenses equaled to 10% or more of their income, or 5% or more of their income if low-income, or deductibles that are 5% or more of their income. The exact number of uninsured or underinsured individuals who travel out of the country for health care is unknown since limited research has been conducted on the demographics of medical tourists from the United States. Despite this fact, it can be inferred that one’s health insurance status plays a role in his or her decision to become a medical tourist based on the out-of-pocket costs for healthcare in the United States (Tseng, 2013).
‘Affordability is a major factor influencing American travelers’. The average annual insurance premiums for 2012 are $5615 for single coverage and $15 745 for family coverage. 8 Surgical procedures conducted in the Unites States are some of the most expensive in the world. Many surgical procedures conducted overseas cost a fraction of what it costs in the United States. For example, cardiac bypass surgery would cost approximately $144 000 in the United States but would cost $25 000 in Costa Rica and $5200 in India. Knee replacement surgery in the United States costs $50 000 but would cost $10 000 in Thailand or $7000 in India. A magnetic resonance imaging in the United States costs on average $1080 but in India the same procedure would cost $138. Other reasons for traveling internationally for healthcare are because of eliminated long waits for elective surgery, privacy, undergoing a procedure that is illegal in the country of residence, or for a procedure not approved at home. Individuals who were originally from another country but currently resided in the United States may prefer to travel back to their home country for health care. Some immigrants decide to travel abroad because they want to return home to their countries of origin and receive care within health care systems that share their language and culture (Tseng, 2013).
Consumers in developed markets, especially the United States, with discretionary health needs, are seeking for lower cost (Ehrbeck, Guevara Mango, 2008). The price difference for various medical procedures and wish to take advantage of cost is the primary motivation in choosing a destination for medical tourism. Table 4 provides a comparison of costs for some procedures in different countries. Practicing lower cost is driven by relatively low wages granted medical staff, reduced insurance premiums in case of medical malpractice, cost-related tourism infrastructure etc. For example, doctors from India, are receiving 40% of the salary of U.S. physicians, nurses receive from 1/5 to 1/20, while wage differences among unskilled and semiskilled workers are even higher. While American doctors pay for liability insurance in case of malpractice over $ 100,000 / year, a doctor in Thailand pay about $ 5,000/ year (Herrick D. M., 2007, p. 11) (Iordache et. al, 2013).
Cost factor is very important especially for the uninsured (U.S. Census Bureau puts the figure at 46 million in 2009) or for those who cannot afford minor surgical procedures, even in developed countries, due to the limited scope of the policy compulsory health insurance (eg., U.S.) (Iordache et. al, 2013).
McKinsey and Company report claims that 40% of medical tourists search this type of tourism for advanced technology from other countries (Patrichi and Dodu, 2014).
These tourists take their search for high-quality medical care global, giving little attention to the proximity of potential destinations or the cost of care. Most such patients – originating in Latin America (38%), the Middle East (35%), Europe (16%), and Canada (7%) – travel to the United States (Ehrbeck, Guevara C. and Mango P, 2008). 32% of them are looking for better medical services (better healthcare) which they mostly find in developed countries (Patrichi and Dodu, 2014).
Other 15% are looking for faster medical services, with smaller calling to certain interventions, and 90% take into consideration lower costs (Patrichi and Dodu, 2014).
Given that building the entire medical services is very difficult in Lao People’s Democratic Republic, collaboration of South Korea medical school and hospital can provide the specific medical services like dermatology and cosmetic surgery to build the industry in order to bring the other medical services. It is important to use the branding power of South Korea’s medical platform and technique for the implementation of industry building in Lao People’s Democratic Republic.
Demand for Medical Tourism
Healthcare spending in the U.S. is projected to exceed $4.1 million by 2016.6 By 2020, healthcare spending is expected to consume 21% of U.S. GDP compared with 16% of GDP in other developed countries.7 While the U.S. accounts for over $1.7 trillion of $3.3 trillion spent annually for worldwide healthcare, it ranks as low as 37th in certain quality of care measures.8 Lower quality at higher costs will be a driver for increased medical tourism among U.S. citizens. Additionally, increased demand as a result of more people receiving health coverage via the Affordable Care Act, coupled with a shortage of doctors to meet that increase, may mean longer waiting times, less quality time available with doctors, and packed Emergency Rooms. This is an additional factor likely to spur people to consider traveling out-of-country to obtain affordable medical services of high quality, without extended waiting. As many as 23 million Americans could be spending nearly $79 billion per year for medical and surgical care abroad (Guy et al., 2015).
Garcia-Altés 2015, states in his study that the increase in disposable income, the changes in lifestyle, the availability of services, and the specificities of the different treatments are factors that may contribute to the growth of health tourism in general and of thermalism in particular (Rocha and Brandao, 2014).
When people invest their time in the promotion of ‘more’ and ‘better’ health, the cost to the individual is the value of disregarded leisure. The value of the improvement of health is measured in both the consumption and production. The intrinsic value of being healthy is, ultimately, the value we attach to life. The value of health in the production of other goods is reflected not only through lower rates of absenteeism but also in terms of production per employed worker. For both the consumption and production sides, the health product sector is a significant contribution to the economy (Rocha and Brandao, 2014).
Moreover, it is thought that the demand for treatment abroad has the potential to create pressure for improved domestic health systems as patients often return from abroad having received and become accustomed to high quality care. However, increased access to medical services abroad through improved travel networks and expansion of the medical tourism sector in many countries has the potential for significant negative economic impacts on patients and their friends and families at home. As lifesaving procedures become within reach through the practice of medical tourism, these patients and their loved ones may lose their savings and incur substantial debt in the pursuit of care that may fail, require expensive follow-up care, or achieve limited success. While it has been speculated that the outflow of private patients from these low-to-middle income countries may have ripple effects for their wider economies as well, slowing economic growth and delaying the development of expanded care locally, such implications have yet to be fully examined through on-the-ground empirical research. In this article we address this knowledge gap through considering the ways in which health systems, health policy makers, and clinicians are responding to the practice of outbound medical tourism from Mongolia based on a thematic analysis of 15 face-to-face interviews conducted with stakeholders (Snyder et al, 2015).
Like many other low-to-middle income countries, Mongolia is seeing a significant outflow of patients to countries such as China, Japan, South Korea, and Thailand for medical care. The reported motivations for Mongolians seeking care abroad include a lack of faith in the domestic health system combined with the hope for treatment afforded by seemingly limitless options abroad. This is consistent with research examining the outflows of patients from other countries, including Yemen and Canada. These perceptions are reinforced by the lack of high-technology interventions and reliable diagnostic services of all types in Mongolian health centers. Mongolian patients and their families regularly deplete their savings and impoverish themselves through the purchase of relatively expensive or lengthy treatments abroad, driven by the cultural premium placed on attempting to overcome poor health despite unfavorable odds. As a result, medical tourism from Mongolia has a considerable impact on the Mongolian economy and health system, creating a need to better understand the scope of this practice and practical steps for addressing demand for it. Further to this, there is concern in Mongolia that this practice is having negative economic impacts on the domestic economy and individual finances. Expanding on these worries, here we examine the concerns and proposed responses that are developing due to observations or growing awareness of the outflow of patients from Mongolia and their consequent economic effects. While these proposed responses focus on the Mongolian context, they also provide warnings and lessons for other low-to-middle income countries experiencing similar outflows of patients (Snyder et al, 2015).
Consumers
A Deloitte study of medical tourism found that as people age, their willingness to consider medical tourism declines, with 51.1% of Generation Y being willing, compared to 41.9% of Generation X, 36.7% of Boomers, and 29.1% of seniors. In one study, medical tourists, the majority of whom went to India, China, and Jordan were over age 46, but in UAE, most were between ages 36 and 45 years.10 Gan and Frederick expected the young and early middle aged to be more motivated or willing than the late middle or elderly, and found the two younger groups were more motivated to participate by economic variables than those 51 and over, but both the younger and older were more motivated by travel factors than those middle aged. Conversely, Lunt and Carrera found middle agers were more likely to need and consider medical tourism for elective medical procedures. 4 Distinguishing between genders, the only empirical data found was from the Deloitte study which indicated that males were significantly more willing to consider medical tourism (44.5%) than females (33.3%) (Guy et al., 2015).
Generally those more educated enjoy better overall health and have higher frequency of doctor visits. Those moderately educated are more sensitive to travel factors – like safety and communication issues – than the less educated or highly educated.4 Low income persons may receive assistance through government and charitable sources but lower health is correlated with lower socioeconomic status, and poor health may prevent extensive travel. Therefore, those with lower income may be less likely to seek care abroad than those in the middle. Higher income persons may have less need due to insurance or higher ability to pay, but those with higher income may have more opportunity to travel abroad and be less dissuaded by cultural concerns or stereotypes. Gan and Frederick found lower and middle income groups were more sensitive to economic incentives than upper income groups (which certainly could be true about a variety of products and expenditures) (Guy et al., 2015).
Growth of Medical Tourism
Medical tourism, marrying medical services (including medical checkups, robot surgery, and plastic surgery) with tourism and leisure, has grown mostly in developing countries. The global medical tourism industry has grown 12.1 percent a year, with a total market of $40 billion in 2004 forecast to be $100 billion in 2012. The number of medical tourists soared at an annual rate of 16.1 percent from 19 million in 2005 to 40 million in 2010.
Thailand and Singapore in particular have succeeded in developing unique products by harnessing their resources as a popular tourist destination (Thailand) and as an international hub for commerce (Singapore). Korea with its outstanding clinical medicine and medical systems is well positioned for strong growth in this industry. Medical tourism inflows have grown from 7,900 in 2007 to 60,210 in 2009.12 to further develop this industry, Lao People’s Democratic Republic will need to benchmark Singapore’s strategy of high quality medical services and competitive medical R&D.
Medical Tourism Boom
A medical tourism boom has been evolving in Asia in recent years as patients seek alternative healthcare options owing to surging healthcare costs in their home countries and the availability of a higher quality of care elsewhere. Healthcare tourism in countries such as Thailand, Singapore, India and Malaysia has been growing from strength to strength.
South Korea appears to be finally jumping onto the medical tourism bandwagon, with the government keen to make this subsector a key growth driver of not just the tourism industry but the broader economy. A number of initiatives, such as devising a compensation system for foreign patients on malpractice, allowing foreign medical staff to participate in patients’ treatments and training more medical translators, are in place to help the government achieve its target of 300,000 foreign patients by 2015.
While we note that South Korea’s medical tourism industry is some way off this target, with only 81,000 patients registered in 2010, a number of factors suggest to us that the nascent industry is well placed to ride along with the region’s healthcare tourism boom. The nation already has well-developed medical infrastructure and technology in place. Additionally, according to L. Casey Chosewood, a director of the US Centers for Disease Control and Prevention, South Korea’s healthcare industry is considered to be very safe, which further enhances its prospects as a choice destination for medical tourists.
South Korea also has a well-regarded reputation for cosmetic and aesthetic surgeries, many of which require a high degree of specialization backed by advanced medical technology. The healthcare tourism industry will thus be able to leverage on this and further promote other aspects of medical tourism.
Medical Tourism in Asian Countries
The State of Medical Tourism in Korea
In January 2009, a promotional law pertaining to medical tourism was enacted. The Korean medical brand names “Medical Korea” and “Smart Care” were introduced to enhance the image of medical tourism and promote it overseas. Korea attracted 81,789 foreign medical tourists in 2010, who accounted for 0.9% of all foreign tourists in Korea. These medical tourists spent US$100 million on medical care services, equivalent to an expenditure of US$1,300 per foreign patient (Newswire, 2011). The number of foreign medical tourists in 2010 increased by 36% over the number in 2009 (Seongseop Kim et al., 2013).
In June 2011, the Korean Ministry of Culture, Sports and Tourism and the Ministry of Health and Welfare announced various measures to stimulate the medical industry. These measures included insurance compensation for wrongful surgery or side effects following surgery, the integration of related laws, cooperation between related public agencies, the establishment of Korean medical schools, improvements in the visa system, regular evaluations of hospitals, quality assurance systems, education of professionals in medical tourism, and the establishment of a cooperative medical tourism website (D. Kim, 2011; M. Kim, 2011a, 2011b). The Korean government seeks to become a center of Asian medical tourism by attracting 110,000 medical tourists by 2013 and 300,000 medical tourists by 2015 (Ministry of Health and Welfare, 2011a). Approximately 62% of these tourists receive medical care in Seoul, followed by Gyeonggi Province (13.3%), Daegu City (5.4%) and Busan (5%). As of September 2011, 1,814 hospitals were registered with the Korean government to treat medical tourism clients (Kim et al., 2013).
As mentioned above, the average medical expense per foreign medical tourist in Korea is US$1,300, and inpatients spend more than outpatients do (Ministry of Health and Welfare, 2011b). 9.2% indicates that patient care consists of outpatient treatment, health examinations (14.2%), and inpatient treatment (6.6%). Approximately 43.3% of all patients and 53.4% of health examination patients select upper-class hospitals (Ministry of Health and Welfare, 2011b) (Kim et al., 2013).
Medical tourists are separated by nationality; the nation contributing the highest percentage of foreign patients was the USA (32.4%), followed by China (19.4%), Japan (16.8%), Russia (7.7%), and Mongolia (2.8%). For health examinations, the highest percentage of foreign patients by nationality came from the USA, followed by China, Russia, Japan, and Canada. Foreign medical tourists most frequently sought treatment in dermatology and plastic surgery (14.0%), internal medical care (e.g. digestive system, circulatory system) (13.5%), health-examination centers (13.1%), family medical care (9.8%), obstetrics/gynecology (5.6%), and orthopedics (4.9%) (Ministry of Health and Welfare, 2011b) (Kim et al., 2013).
The Korean government divided the healthcare market into three categories in a strategic market and competitiveness study. The first market category includes short-distance markets, such as Japan, China, and Koreans living overseas. These tourists tend to have minor symptoms that require short-term treatment. The second market category includes medical tourists who reside in countries in the Russian Far East, Southeast Asia, and Middle Asia, where medical services are underdeveloped. Potential patients in this market segment expect to receive more advanced medical care because the medical services in their countries are relatively poor. The third market category comprises potential medical tourists who live in economically advanced countries. Because medical costs are high or medical care is difficult to obtain in these nations, medical tourists visit Korea for less-expensive medical services. Given that most of these medical tourists have serious medical conditions, they require advanced medical treatment and incur large medical expenses (Kim et al., 2013).