First published in ITIJ 115, August 2010

The recent political turmoil in Thailand has left the country’s tourism industry barely registering a pulse. Arrival figures have plummeted and hotels are struggling to attract guests, yet one sector remains fighting fit – international medical care. Mick Shippen reports from Bangkok

Medical tourism in Thailand is a remarkable success story. A little over a decade ago, a handful of Bangkok’s hospitals turned their attentions to the international market and quickly established a reputation for medical excellence, state-of-the-art technology, outstanding care, and value for money. It is testament to Thailand’s international standing for medical care that in recent years it has managed to weather SARS and bird flu epidemics, a military coup, and a period of prolonged and violent civil unrest. In fact, last year alone the country welcomed 1.6 million medical tourists, a figure that has increased every year since 2002 when arrivals were just 600,000.

Despite Thailand’s uncertain political climate, Matthew Bleach, vice president of corporate marketing for Bangkok Dusit Medical Services PCL (BDMS), believes the outlook for the country’s medical tourism sector is positive. “In 2009, approximately 40 per cent of the revenue from our hospitals was derived from foreign patients – that is, expatriates living in Thailand, plus those travelling here specifically to receive medical treatments. Although the present political situation is an issue, this year has been very encouraging for us. People requiring medical care tend to be less concerned about local issues than holidaymakers.”

Currently, 60 per cent of international patients arriving in the country reportedly check into a BDMS hospital – a group that encompasses 16 medical facilities in Thailand, including Samitivej Hospitals, BNH Hospital, and Bangkok Hospital, the latter of which is located in the heart of the city and treats 3,000 patients every day, 30 per cent of which are foreigners. Having identified a niche in the international market, the group has ambitious plans to expand in Thailand, where a 60-bed hospital is due to open next year in the royal resort town of Hua Hin, as well as overseas.

Standards of care

Although patients often talk about the opulence of Thailand’s private hospitals and the fact that there is likely to be a Starbucks or even a sushi restaurant in the lobby, what actually wows them is the five-star service and highly skilled internationally trained specialists. Many of Thailand's private hospitals now offer some of the finest healthcare available anywhere in the world and have been accredited by leading international institutions such as Joint Commission International (JCI).

last year alone the country welcomed 1.6 million medical tourists

“As of 1 June 2010, 11 hospitals in Thailand have received JCI accreditation but many others continue to be interested,” says Singapore-based Dr Paul Chang, managing director of JCI for the Asia Pacific region, an affiliate of US-based The Joint Commission. The oldest accreditation body in the world, JCI first developed its hospital accreditation standards specifically for the international market in 1999. Preparation for JCI accreditation generally takes about 18 to 24 months to complete, with the cost of an accreditation survey varying depending on the size of the establishment and the complexity of the services delivered. “The survey duration and the cost would typically be higher for a large, tertiary level hospital than a small general hospital. The median survey cost for hospitals in 2009 was approximately US$46,000 for a three-year accreditation,” explained Dr Chang. Although the process is lengthy, the benefits to the hospital are substantial.

Patients seek treatment in Thailand for a variety of reasons; those from the UK are attracted by the lack of waiting lists, while annually some 750,000 Americans travel abroad to avoid the astronomical fees of their own healthcare system. But what all medical tourists have in common is a need for confidence that the treatment they seek is of a high standard. “JCI standards are developed with an international expert panel and tested in the five major regions in the world. In terms of the number of organisations accredited worldwide, JCI is the undisputed market leader with 346 organisations accredited or certified in 41 countries as of June 2010,” says Paul. This, he asserts, makes JCI not only attractive to hospitals and patients but also to insurers. “They understand that our standards are extremely rigorous and our survey process is comprehensive, objective and data-driven. For organisations focused on serving patients from the US, JCI's standards have similar expectations as The Joint Commission’s standards for US-based healthcare organisations.”

Thus, insurers have the benefit of knowing that they are working with a quality-focused organisation that is maintaining compliance with internationally developed and accepted standards in 13 important hospital functional areas such as assessment of patients, care of patients, patient and family rights, infection prevention and control, medication management and use and facility management and safety. Compliance with these standards is externally validated by a team of highly experienced healthcare professionals. “JCI accredited hospitals must also ensure that they do not make false or inaccurate claims about the services they provide to patients,” says Dr Chang. “They must also inform patients of their rights and must also provide patients with an avenue for complaints in the event of any disagreement or dispute.”

Furthermore, in 2009, JCI signed a memorandum of agreement with the Faculty of Medicine Ramathibodi Hospital at Mahidol University to jointly provide education and training on JCI accreditation standards, quality improvement and patient safety to Thai hospitals through its Thai International Healthcare Standards Training Centre (TITC). “This is a new initiative that will help JCI provide education and training on its accreditation standards to more hospitals in Thailand,” says Dr Chang. “As a result, we are confident that we will see more hospitals and other healthcare facilities in Thailand becoming JCI accredited over the next decade as greater awareness and understanding of our accreditation standards occurs.”

Call to insurers

The savings for overseas patients seeking treatment in Thailand should not be underestimated. They are substantial and particularly attractive to the middle class and self-employed who may not have health insurance. The competitive pricing of groups such as BDMS draws in patients from 180 countries.

“Price-wise we are cheaper than the US and Singapore,” says Matthew Bleach of BDMS. “In Europe, particularly the UK, governments are struggling to maintain antiquated health systems and the huge financial burden that entails. This is our target market; organic growth as more people look elsewhere for quality medical care.”

Figures provided by the American Medical Association give the cost of a heart bypass in the US at $130,000, but the same procedure costs just $11,000 in Thailand. Similarly, a hip replacement priced at $43,000 in the US comes in at $12,000 in Thailand. In real terms, this means that a patient from the US or Europe can schedule an operation without a waiting list, fly to Thailand with a member of their family, enjoy a week or so post-operative rest and relaxation in an agreeable climate and still benefit from a 50 per cent saving on treatments in their home country. Bleach believes that insurance companies are missing out on huge opportunities within the medical tourism sector. "It is apparent that many insurers do not provide the flexibility for their customers that would enable them to seek quality treatment in places other than their home country,” he says, “approximately 32 per cent of our international patients are 'self payers'. Although we are not aware if any file a claim with their insurers when they return home, it is evident that many are sidetracking insurance based upon the availability of quality care at a reasonable cost coupled with a pleasant location.”

Many of Thailand's private hospitals now offer some of the finest healthcare available anywhere in the world

Another major player in Thailand’s international medical care market is Bumrungrad International Hospital, one of the country’s remarkable success stories. When it opened 25 years ago as a 200-bed hospital, it basically served the local Sukhumvit community; but today, Bumrungrad International has positioned itself as a world leader. “Medical facilities at [the hospital] include 538 inpatient beds and suites, 19 operating rooms, intensive care and coronary care units,” says director of marketing at the hospital, Kenneth Mays.

However, the hospital witnesses a very different payment spread to Bangkok Hospital, with approximately 70 per cent registered as self payers, 17 per cent who pay through insurance, and 13 per cent who receive corporate care. Despite the low volume of patients seeking treatment with insurance, Kenneth Mays believes that Bumrungrad International Hospital is an attractive choice for insurers: “I would encourage insurers to visit and understand our healthcare framework. We charge local, international, insured and uninsured patients the same. We do not build in margins to offer discounts later. Hence, we are sensitive about requests for discounts or referral fees,” he says.

There are also newcomers to the market such as Vejthani Hospital in Bangkok’s Lad Prao district. Managing director Charkrit Soucksakit says that, at the moment, most of the hospital’s patients are self-payers but he is keen to engage with insurers and build a strong mutually beneficial relationship. “We are only just starting to liaise with the insurance world, so we envisage an increase in claimants over the next few years.” Currently 55 per cent of the patients at Vejthani Hospital are Thai. The rest are international, including a number of expatriates and employees of UNICEF and UNESCO. The recently established international department has also bee attracting Middle Eastern patients. “Last year, we treated over 50,000 international patients. Many come for treatments at our renowned Total Joint Replacement facility,” says Soucksakit. “Recently, we had our first insured patient for a total knee replacement. We believe there is huge potential within the insurance market to increase our share of elective surgery.”

With a total joint replacement priced at $13,500 and private room rates starting at just $175 per night, it easy to see why self-payers and insurance companies may both find Vejthani Hospital an attractive proposition. The 500-bed establishment boasts JCI accreditation and provides international-standard, quality care at rates that are 40 to 60-per-cent cheaper than costs in the US and around 20-per-cent cheaper than nearby Singapore. Patients enjoy plush surroundings, attentive care throughout the whole process, even a traditional Thai foot massage while they await test results.

Essentially, BDMS’s Bleach believes that an increased awareness of the high standard of medical care overseas, the ease of travel with cheap and regular flights, and no waiting lists means that patients will demand greater flexibility and freedom of choice from insurers. “Insurance companies will be increasingly pushed to evaluate alternative locations and procedural bulk purchasing to further improve their own attractiveness, competitiveness and profitability,” says Bleach. “The implementation of US healthcare reform may just be the catalyst to a major paradigm shift in the thinking and actions of both domestic and international medical and travel insurers.” As such, he – and others like him – are keen to establish a relationship with insurers that he describes as a ‘win-win scenario’.

Although hospitals within the BDMS group operate a cashless system for insured patients through a direct guarantee of payment from the insurer or via a local third party medical assistance company, Bleach believes the system could be improved by better co-operation between the insurer and provider. “Offering a cashless service is one thing, but ensuring that it is timely, effective and in line with clearly understood policy terms and conditions for the consumer is another,” he says. “Often, consumers appear to have been misled by a sales process that involves a third party, and misinterpret or simply don’t understand the level and extent of their coverage.”

The sheer amount of different types of insurance policies available is what he describes as an ‘age-old problem’ that seriously needs to be addressed. “Quite frankly, consumers get confused and frustrated. The claims experience is a stressful time for all involved. Other industries and businesses are moving forward with technology and listening to the wishes of consumers and providers – why shouldn't the medical insurance industry also step into the 21^st century?” he asks.

It is apparent that many insurers do not provide the flexibility for their customers that would enable them to seek quality treatment in places other than their home country,”

Indeed, Bleach is currently talking to several insurance companies that are looking at how they can achieve cost savings by pushing business from the US and Europe to Thailand. At the moment, they are identifying specific ailments and surgeries where the risk is relatively low and patients can endure a long flight, such as orthopedic treatments, hip replacements and longer term cancer care. In effect, Bleach believes there is still a level of immaturity in terms of insurers’ understanding of the relatively new and fast-changing medical tourism sector. He believes a little entrepreneurial spirit is essential to bring about positive change and would like to see insurers create more innovative products. With a huge increase in people flying directly to Thailand for medical care, insurance companies are clearly missing out on the growth. “They need to open up accessibility through international coverage and provide more freedom of choice. In their Healthcare 2020 Predictions, PricewaterhouseCoopers stated that in 2002, the cumulative health spend of 24 OECD countries was US$2.7 trillion, but estimate that this will triple to US$10 trillion by 2020. Clearly, closer co-operation between insurers and providers will be essential to successfully tapping this market,” says Bleach.

Room for growth

Perfectly placed to build on its already established medical tourism industry, Thailand looks set to lead the way in future negotiations with regards to accommodating foreign patients. But despite having the passion to grow this sector, there are, of course, neighbouring countries also vying to win business from international self-pay patients and insurers alike. Dr Chang believes that Thailand’s medical market as a whole is facing clear and increasing competition. “In Southeast Asia, countries like Singapore, Malaysia and the Philippines are certainly challenging Thailand in the medical tourism sector. Korea and Taiwan are also strong competitors for Thailand in the North Asia market,” he says.

But despite the current political climate and the rising challenges from other Asia countries, Matthew Bleach says the outlook for Thailand’s medical tourism remains positive: “I believe that over the next three to five years there will be a significant shift in the awareness and understanding of Thailand’s medical capabilities. The future looks healthy.”