The tipping point: When Locals Resent Medical Tourism Visitors

At many medical tourism destinations, local residents are beginning to speak out in resentment to the "invasion" of their local healthcare assets. Many view the new health private healthcare facilities situated in or near their communities to be a commodity reserved for affluent foreigners who come and go without investing time, attention, or money on the local community.

The majority of medical tourists don't really go sightseeing as you may be led to believe in many propagandized advertorials and medical tourism facilitator and referral agency websites. There's a logical explanation for this:

Returning Diaspora

If the medical travel patients are returning Diaspora, as are many at destinations such as Israel, Turkey, and parts of Central and South America, or Caribbean Islands, they don't want to go sightseeing. They go to the destination, visit with friends and family, get the healthcare they want or need, and go back to where they came from. These are prudent buyers. They are attracted by the logical argument of price arbitrage for commodity health services such as dental care, checkups, and minor procedures that are more expensive where they usually reside. They trust the local healthcare suppliers, feel comfortable among familiar cultural norms, language, food, and have people who support them in close proximity. This group of medical travelers also rarely uses the services of a medical tourism facilitator or travel agent. But by definition, they are medical tourism patients because they don't live locally. and they came specifically for healthcare as their primary reason to travel to the destination and they spent one or more nights at the destination but less than a year.

The primary attractant for these medical travelers is the family and friendship re-connection; not the health facility or some high-profile, branded practitioner with world renown or a chance to relax at a 5 star/5 diamond resort or spa. And it certainly isn't amusement parks, historic attractions and sightseeing. So locals don't view them as community economic development potential.

And if they are traveling on a resident passport (as dual citizens) or as resident aliens from their current home destination, they may not even be "counted" among medical tourists. They simply blend in. This anomaly of statistical data gathering is due to the fact that many destinations have arbitrarily decided to count only foreigners with foreign passports - not people who traveled to the destination from within the country or people who returned for healthcare but who now live elsewhere as their usual place of residence.

The out of town local nationals

These medical travel visitors engage in domestic medical tourism. They drive in, fly in, use ferries, or take a train or a bus. However they arrive, they are non-resident nationals. These medical travelers are people who reside in rural areas with healthcare manpower shortages. While they may have access to local primary medical or dental care, access to consulting specialists is scarce. So they must travel or do without. Their local area tourism satellite spend is accommodation and meals. Not much else. This group of medical travelers also rarely uses the services of a medical tourism facilitator or travel agent. So, they too, may not be counted among the medical traveler statistics being reported. Nevertheless, they come, spend the night, spend less than a year, obtain their healthcare and return home directly. But by definition, they are medical tourism patients because they don't live locally. and they came specifically for healthcare as their primary reason to travel to the destination. The appointment times they fill push back access to private care for local residents willing to pay extra to source healthcare services from their usually bleak, single payer national health system.

Spain is an exception to this because the public health system in Spain is actually quote good, it just isn't "pretty" or laden with creature comfort amenities. Most Spanish public health and academic medical center facilities are well-equipped with technology but they generally don't spend money on furniture, fixtures, or other equipment ("FF&E") that have no medical value and that depreciate substantially in short order. They also tend to be short-staffed because the culture in Spain is that no one expects a patient to be in a hospital alone. They also expect family members and friends to help out with keeping the patient occupied, helping them eat, ambulate in the hallways with assistance, and provide toileting assistance. Private health facilities in Spain tend to be a bit prettier, at least to my eye. I tend to appreciate the clean modernism lines, use of white tile, natural wood surfaces and white ceramics, and stainless steel design elements which are popular in many Spanish private clinics. They also have higher nurse-to-patient ratios than their public health counterparts. But many times, the private clinics (what private hospitals are called in Spain) lack the fancy medical technologies that the public hospitals have at their disposal. So a local national medical travel patient entitled to use the public system for complicated diagnostics and scarce therapies or specialist consultations and willing to pay for the private health system amenities, could possibly end up taking appointment times in both settings. In this case, local residents again are displaced but the local tourism satellite spend on sightseeing and incidentals is often very low. This group of medical travelers also rarely uses the services of a medical tourism facilitator or travel agent.

Foreign patients

Foreign patients are people who have no other resident connection to the country at which they've arrived to purchase health care services. They may be viewed as affluent by the locals but not in their own country. Or they may truly be affluent and could have chosen anywhere in the world to source specialist consultation and treatment and they intentionally chose a Center of Excellence at the destination for reasons other than low price.

A bed-day is a bed-day. These medical travelers they take up a set number of available bed days and medical diagnostic technology appontments at a destination that the locals may have been willing to utilize but cannot access because a foreigner is in the bed instead of them.

Health tourism's dirty little secret

Many private health facilities and practitioners have been beguiled by the reports of affluent foreigners coming to less expensive destinations for healthcare. As such, I encounter more and more medical tourism destinations with what I call the industry's "dirty little secret": The same identical healthcare services rendered to foreigners with discriminatory prices as much as 200% higher than charges invoiced to local patients. I have a word for this that is translated to any language you please: GREED. It happens in Philadelphia, Tel Aviv, Korea, Turkey, Thailand, Singapore, Colombia, Mexico, Germany, Hungary, Ukraine, and many other places. In other destinations, these private health facilities don't just single out foreigners, they just raise the prices up across the board. And in still other facilities, they set up special wards with VIP level accommodations. I've even encountered whole facilities strategically built to serve foreigners and choose not to target even affluent locals. I've encountered these in special economic zones (SEZ) and foreign trade zones (FTZ) in Dubai, Colombia, and other locations. That's because under the SEZ/FTZ rules, the medical services are set up as exports and under export rules, the investment benefit bundles there are tied to tax holidays, etc., but not permitted to be sold to locals under any circumstances.

How and why local resentment for medical travelers occurs

So the locals resent these medical visitors as interlopers who've come to take up what existing capacity exists, get special treatment, drive up prices for services, and which delay or impede rapid local access to care. This is especially true if the local private hospital is running a 90% or higher average daily census. At that high a local utilization, I often wonder what they would do with the foreign or Diaspora medical tourists they attract if they are successful in converting them from prospects to appointments.

Branding is one way a health facility explains to the public the reason why a business exists. It demystifies this reason for being and who is viewed as the target clientele for the consumers, the medical staff, and the employees and the local community. It's as if the branding message and tag line for the private facility seeking to attract medical tourism patients is "Come, we're great, we're internationally accredited, we have the specialists, the medical technologies and the amenities ... but not if you are a local."

When I am hired by governments or investors and stakeholders planning a health tourism clusters/hubs to carry out a situation assessment of the medical travel destination, I am in surveillance mode for assets and risks that affect the likelihood of success for their health and wellness tourism business development. I examine foreign policy, medical tourism public policy and sentiment, visa and immigration policies, ease of wire transfers and bank transactions, airport and rail access and hub connections, hotel and alternative accommodation readiness, and destination attractiveness. Things like branding messages that offend locals, rigid SEZ and FTZ rules that deny access to locals, greedy unsubstantiated foreigner surcharges, and already high utilization, high risk for terrorism attacks, political unrest, high levels of local poverty, and disproportionate incidences of international kidnap and ransom raise my eyebrows and trigger built-in alarms that have been established over the years from my professional experience after 35+ years in the business of health tourism business development.

But the access and cost issues, or the sign that essentially translates to "locals not welcome" aren't the only things that influence the tipping point and drive up resentment. Locals can get hurt in a kidnap and ransom or terrorist attack as collateral damage. Locals experience the higher prices if the hospital or clinic moves to higher prices across the board. Local value chain stakeholeders don't get the opportunity to benefit from tourism satellite spend as the propaganda advertorials often claim if the volumes are coming from Diaspora and domestic travelers not interested in sightseeing.

What about "bleisure" travel and medical tourism?

Bleisure travel is a term that has received recent attention in medical tourism because on its face, it has potential.

From our own corporate experience working with bleisure travel and medical tourism since 2003 at Mercury Health Travel, while the trend is a spike (as seen in the chart on the right) over the past 14 years, it has a long way to grow. And, in medical tourism while the potential for "bleisure"/medical travel and tourism exists, few destinations have created a strategy to attract "bleisure" tourists with a medical or dental care dimension. In fact, it is very rare to find hospitals, clinics and hotels that want to attract that business. When I start to discuss this with potential network partners for Mercury Health Travel, our medical tourism case management service for employers and corporate clients, very often, I get intense push back from the hotels.

For example, in Las Vegas, Marbella, Spain, and in Thessaloniki, Greece, I've met with hoteliers of 5-diamond accommodations who "have the chops for" doing bleisure travel extremely well. And the hospitals (and I) have approached them to partner for medical tourism and they aren't interested. The reason for this is that their 5-diamond/5-star business and luxury travel brand vision and strategy doesn't include people in wheelchairs, facial bandaging, the odors of catheter bags of full of urine, or post op orthopedic patients stuck in the depths of their $11,000 Mies van der Rohe replica sofas in the lobby needing help to get up. They don't want that as the image they want to portray for the rest of their guests. Not at any price. So the restaurant, spa and golf caddy tips, extra shifts, and added heads in beds and REVPAR and room night taxes don't materialize by intention even though its true that the potential is there to grow the medical tourism/bleisure hybrid market.

And if some of those patients do make it into the hotel unannounced, the management secretly resents their presence. That's because a) they are concerned about the comfort and impression of their targeted clientele, and b) they are caught off guard and worried about risks that could materialize with these guests with a fall, an allergic reaction, nausea and vomiting in the hotel beds and carpets, or a hotel emergency that requires evacuation, or some other peril they were not permitted the opportunity to plan for.

This is also the primary reason why I am mercilessly disdainful of most propaganda "data" offered to by the media and many medical tourism industry conference organizers who encourage new, naive medical tourism advertisers to sponsor events, rent exhibit stands, and buy published reports about medical tourism market size, revenue potential and other investment opportunities in the sector. Most of that data and opportunity hyperbole is pure buncombe and sets new medical tourism startups on a quest for the impossible dream. They invest prematurely thinking they've hit the jackpot in connections and employers who can't wait to meet them, realize no benefit in return, feel cheated or gullible, become angry, and then decide against future attendance or investment in other events at any location, by any organizer in the future.

When planning a strategy to develop medical tourism market potential, hired consultants, health facilities, practitioners, investors and government authorities must take into account the local community impact in a way that is similar to other environmental impact assessments undertaken for large community impact projects. This must occur before the strategy and tactical plan, branding, pricing, and revenue estimates can be finalized.

Many of the materials I've reviewed by other consultants that preceded me in several destinations focused only on "fairy tale marketing" strategies. I call them fairy tale because they delivered a fairy tale marketing plan for a not yet developed product and went straight to advertising to the world instead of doing the necessary pre-work to define the customer, identify target source markets and pull the other affiliated value chain actors into the product design.

Conclusion

Just because a destination has hotel rooms, an airport, taxis, and a health facility and doctors does not mean it is an ideal or even viable candidate for medical tourism and health travel services industry development. The social, health, economic and cumulative benefit potentials and receptiveness must be examined without bias to build the medical tourism hub or destination with total disregard for what the data indicates.