First published in ITIJ 96, January 2009
Thailand boasts world-class private medical facilities, together with a comprehensive system of state healthcare provision, all at an enviable cost. The country’s assistance industry is also in a healthy condition, as Dr Michael Moreton reveals
Thailand is a popular destination for the international patient seeking medical care, and boasts some of the world’s most renowned hospitals. Foreign holidaymakers who find themselves in need of emergency medical treatment also have access to this expert medical attention, and it is a policy of the Thai government to be supportive of the work of Thai hospitals in providing medical care to visitors from abroad. At the same time, the country provides a system of universal healthcare for its citizens, who pay just 30 baht (0.60p) for each outpatient visit or hospital admission in designated district-based networks of providers (consisting of health centres, district hospitals and co-operating provincial hospitals). And although the standard of care varies between the state hospitals and clinics throughout the country, the overall quality is good.
The assistance industry, meanwhile, has grown with Thailand’s tourism industry. Many major international assistance providers, including International SOS, AXA Assistance, Europ Assistance and Mondial Assistance, have representative offices in the country, and the number of Thai-owned assistance companies has also flourished in recent years, with leading providers including Asian Assistance and Asia Assistance Partners.
Healthcare for all
Thailand has a population of 64 million, with two thirds living in rural areas. Not surprisingly, however, public and private hospital beds, as well as doctors, are concentrated in Bangkok, although comprehensive healthcare coverage had been achieved through developing infrastructure in rural areas: successive governments have built up health centres, staffed by nurses, that dispense primary care in all sub-districts; and community hospitals (with between 10 and 120 beds), that provide primary and some secondary care in more than 90 per cent of districts. Like government hospitals throughout the world, these are often busy, crowded and short of staff, but they provide a good level of care. Furthermore, each province has provincial hospitals that provide secondary and some tertiary care. The standard of care in these hospitals is quite acceptable and while the technology is less advanced than in university or private hospitals, it is very adequate. Young doctors, as part of their national obligation, are required to spend two to three years providing care in these hospitals. In the major cities, state hospitals provide primary, secondary and tertiary care to local patients and those referred to them. Like health services throughout the world, they have budgetary problems, but Thailand is extremely proud of the standard of care it offers to both citizens and visitors alike.
A country's ability to provide care for non-residents is necessarily built on the structure created to treat its own people
Thailand spends just three per cent of GDP on healthcare, but a growing economy means this could change in the near future. In the meantime, the government provides universal healthcare for eligible citizens – i.e. those who do not belong to the Social Security health insurance scheme (SSO scheme) or the Civil Servants’ Medical Benefit Scheme (CSMBS) – who must simply register with a hospital network and obtain a free insurance card in order to subscribe to the 30-baht scheme. Medications, with some limitations, are also provided without cost.
A country’s ability to provide care for non-residents is necessarily built on the structure created to treat its own people. Only a country with well-trained professionals working in a system that is well organized and that embraces excellence can hope to offer a suitable standard of care to visitors coming to that country for medical care. The leading Thai hospitals have worked hard to create a medical system that places an emphasis on quality and which also provides a warm welcome to visiting patients and their families. However, foreign patients seeking care in provincial hospitals are usually assessed and stabilized and, if possible, are transferred to a private international hospital for further treatment, where standards of care are higher, international administration departments can co-ordinate efficiently with any involved assistance parties, and doctors speak a variety of different languages. Although foreigners who are travelling in rural areas often seek care in provincial hospitals, these medical establishments generally only have a very limited ability to communicate in English, or a language other than Thai, and so the patient is usually moved following initial treatment. That said, most foreign patients who have been treated at a provincial hospital have been nothing but complimentary about the care they received.
For the Thai people, private health insurance is readily available, and companies with over five employees are required to offer health insurance as a benefit, enabling policyholders to access private hospitals. Overall, approximately 15 per cent of the Thai population is covered by private medical insurance. For the most part, this is used to obtain care in private hospitals but it is also used to obtain better accommodation and cover added expenses in government tertiary care hospitals.
The public and private systems exist together in a cooperative manner, sharing programmes and expertise, senior doctors customarily working in both the public and private systems. The Ministry of Health audits the work of both the public and private hospitals and is meticulous in its licensing and inspection procedures.
Unique in Asia
Thailand’s place in Asia is unique; as the only country in Southeast Asia not to suffer the indignity of colonisation, it has been a self-confident, outward looking, internationally minded country. Many companies and international agencies thus choose Bangkok to be their Asia headquarters. At the same time, the country’s climate and positive attitude towards foreigners has also made it a popular destination for retirees either as permanent or occasional residents. The country has responded by providing world-class medical care for these visitors. BNH Hospital (previously known as the Bangkok Nursing Home) was established in 1898 as the first hospital to offer care to foreign residents. Other hospitals soon followed suit, and now the country has a series of private International hospitals dedicated to providing a high standard of medical care to Thai people, expatriate residents, tourists and those coming to Thailand specifically for medical treatment. In fact, the medical tourism industry in Thailand has boomed in recent years, with many foreigners taking advantage of the affordable treatment and state-of-the-art facilities.
Success has also been achieved in the country’s medical system by combining the indigenous population’s inherent sense of warmth and hospitality with a well-educated medical community. For over a century, Thai doctors have trained in the West and then returned home to use their skills in the local healthcare system, but in recent years, the number of Thai doctors who have received training abroad, particularly in the UK and the US, has grown rapidly. Many such doctors now hold American Board or Royal College certification, and their English language skills are excellent. As Dr Somarch Wongkhomthong, director of Bangkok International Hospital explains: “We understand that respecting people’s traditions, tastes and faith, enabling them to communicate in their own language, and enjoy their own food has a positive effect on medical outcomes.”
The public and private systems exist together in a co-operative manner, sharing programmes and expertise
As with most other international hospitals, Thai medical staff understand that patients coming from other countries may be apprehensive, and so the private hospitals all run elaborate concierge services, meeting patients at the airport and bringing them either to their hotel or to the hospital. Furthermore, arrangements have been made with local hotels regarding the accommodation of outpatients and their families, while in some hospitals serviced apartments are available on site. Immigration and other formalities are also taken care of in order to make the patient’s arrival as seamless as possible. The hospital’s concierge department can help patients and families with Visa problems, for example if they should they outstay their Visa, or re-book airline tickets when necessary. Needless to say, these International hospitals have all sought and obtained accreditation from either, or both, the American JCI or other, European authorities.
Independent establishments with such accreditation are most commonly located in the capital city of Bangkok, but are also found in the major tourist cities, such as Samui, Phuket, Pattaya, and Chiangmai. John Duke, the Australian C.O.O. of BMC comments: "The measurable improvement of hospital care in Thai Hospitals as demonstrated by JCI accreditation combined with the Thai service model and latest technology, all at an efficient cost, will create more and more opportunities. The more international patients that are directly exposed to Thailand’s leading private hospitals the more demand there will be for our tertiary level services.”
So, who are some of the main private medical providers in Thailand? Bangkok Dusit Hospital Medical Services is the largest hospital group in the country, and the second biggest in Asia. It has 18 hospitals in the group; the flagship hospital being the 600-bed Bangkok Hospital Medical Center (BMC) in Bangkok. Sixty per cent of its patients are Thai nationals and the other forty per cent are from other countries. This second group can be categorized into visitors, both tourists and business people, expatriates resident in Thailand or neighboring countries, and medical tourists who come to Bangkok specifically for medical care. In this last category, the biggest groups come from the Islamic countries in the Persian Gulf: the United Arab Emirates, Oman, Qatar and Kuwait. The governments of these countries have contractual relationships with several hospitals in Bangkok, which results in several thousand patients come to Thailand each year for care. Furthermore, in recent years, more patients from Europe, Australia, New Zealand, North America and, more recently, East Africa have been coming to Thailand for care.
Another large group comes from the neighboring countries of Cambodia, Laos, Vietnam, Myanmar and Bangladesh, where the quality of medical care is generally not as advanced as in Thailand. Both the citizens of these countries and the large expatriate communities living there often come to Thailand for care. As Europ Assistance told ITIJ: “Generally, we find the standard of healthcare in Thailand excellent, particularly in Bangkok. We often move patients into Bangkok from other countries in Asia because of their excellence.” In fact, in 2007, Europ Assistance audited hospitals throughout the country in the areas most frequented by tourists, and rated 56 per cent as excellent, and 30 per cent as satisfactory.
Other hospital groups include the Samitivej Hospitals, which have a long-standing reputation for the excellence of their women’s and children’s healthcare programmes, and Bumrungrad Hospital, which is well respected for its services for International patients.
These well known hospitals commonly have areas of special expertise. BNH Hospital, for example, has a well deserved reputation in the area of spinal surgery, and BMC has an international reputation for its cardiac, neurological and cancer centres. The larger medical establishments also often have aviation medicine departments that can facilitate the transfer of patients, and also arrange repatriations, accompanied by doctors and nurses, if necessary. BMC, for example, has a dedicated Eurami-certified medical evacuation team and is able to send either a ground ambulance, fixed-wing or HEMS craft to retrieve patients from all over Thailand, Laos, Cambodia and Vietnam.
Real value for money
Over the years, assistance companies working in Thailand and the local hospitals have developed a cooperative attitude and patient transfers, and the general handling of international patients, are achieved very smoothly. BMC, for example, has developed some special relationships notably with CFE, the French agency that pays for care for French nationals outside of France and has direct billing agreements with over ninety international insurance and assistance companies, fifty of them in Europe. Separately, Jerome Kelly, managing director of Lawton Asia Insurance, a major healthcare broker in South East Asia, told ITIJ: “Over the past decade, we have built up an excellent relationship with doctors and hospitals in Thailand. Their standards of care, skill levels, medical facilities and claims processing procedures are equal to the very best in the world.” High praise indeed.
Private Thai hospitals often have international departments dealing with third party payers. As in other countries, they obtain approval for admission and treatment plans, obtain guarantee of payment for patients admitted in emergency situations, and are able to obtain pre-authorization for elective admissions.
Over the last ten years in particular, the assistance industry in Thailand has grown steadily, reflecting the growth in tourism to the region. Susanne Morch of Asian Assistance says of the industry: “The neighboring countries of Cambodia, Laos and Vietnam are also experiencing an increase in tourism and assistance companies are being called upon to transfer patients to Bangkok. Our networks, knowledge of the languages, logistics and concern for cost-control makes local assistance companies very significant.”
Another local provider, Asia Assistance Partners (AAP), has its 24/7 alarm centre in Bangkok, with offices all over the region, including in Cambodia, Singapore and Australia. It provides full medical assistance to travellers, as well as evacuation and repatriation, technical assistance and concierge services. The company’s international operations director Siriporn Wongurai told ITIJ AAP’s strong relationship with its hospital network in Thailand means it can efficiently obtain medical reports, cover medical expenses, and arrange patient admission and discharge. The company also monitors medical bills to ensure they matches the treatment received. “Assistance providers have to work with both public and private hospitals,” commented Wongurai, “but local assistance providers help the hospitals to communicate with overseas assistance and insurance companies regarding medical coverage and billing procedures.”
The problem of the uninsured foreign patients is one that causes great concern, but hospitals act as ethically as they can in these situations, and patients are not denied care because of their inability to pay. Patients and families often appeal to their Embassies for help in such situations, but this is rarely successful.
local assistance providers help the hospitals to communicate with overseas assistance and insurance companies regarding medical coverage and billing procedures
Going forward, the assistance industry looks set to continue its steady expansion in Thailand. But cost is an important factor, and although hospitals in Thailand are able to offer care at a lower cost than hospitals in other countries, pricing is something that assistance companies are keeping an eye on. Europ Assistance handles over 1,400 cases in Thailand each year, and its assistance expenses will exceed €2 million this year. A company spokesperson comments: “With the level of medical expenditure increasing steadily in Thailand year after year, we are working on local cost containment solutions.”