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h e a lt h   c a r e    m ay   2008




          Mapping the market for
          medical travel
          The market is smaller than conventional wisdom suggests, and most of today’s medical
          travelers seek high quality and faster service, not lower costs. However, the potential for growth
          is significant.


          Tilman Ehrbeck, Ceani Guevara, and Paul D. Mango



Article   Medical travel has captured the world’s attention and imagination, but a new McKinsey
at a      study suggests that the market isn’t as large as reported and that most medical travelers seek
glance    high quality and faster service instead of lower costs.

          McKinsey places the current market at 60,000 to 85,000 inpatients a year, but these
          numbers could grow substantially if certain barriers, such as noncoverage from payors, were
          removed. Payors and providers looking to benefit from this nascent market have a
          substantial opportunity.
2




Introduction
The idea of traveling around the world for medical treatment has captured much
attention and imagination. As the debate on health care reform heats up in the
United States, few weeks go by without a story about an under- or uninsured patient
going to India or Thailand for heart surgery or hip replacement. Although medical
travelers have many motives, lower-cost procedures and discretionary cosmetic
operations represent only small segments. Most of these people seek the world’s most
advanced technology, better quality, or quicker access to medical care.

To create a rigorous and credible fact base about the nascent medical-travel market,
McKinsey studied more than 20 medical-travel destinations; analyzed primary
data on the number, type, and origin of medical travelers; and conducted interviews
with providers, patients, and intermediaries in 20 countries. We place the current
market at 60,000 to 85,000 inpatient1 medical travelers a year—numbers far
smaller than others have reported.

These smaller numbers hinge in part on our strict definition of medical travelers:
people whose primary and explicit purpose in traveling is medical treatment
in a foreign country. We excluded from our study patients who receive care on an
emergency basis (such as ordinary tourists who become sick), “wellness tourists”
(for example, people traveling for massages or acupuncture), and expatriates seeking
care in their country of residence. We also excluded patients who travel in largely
contiguous geographies to the closest available care, for they don’t consider other
medical-travel destinations and the financial burden is minimal.

Our examination of the motives and behavior of these patients reveals that this
market has great potential for growth, though current volumes are modest. The
benefits to providers attracting international patients are big—in addition to filling
beds and increasing revenues per bed, such patients may boost an institution’s
domestic prestige. But fewer than half of the international inpatients at the providers
we visited were true medical travelers. Furthermore, several global forces and a
number of important structural barriers may prevent or inhibit the market’s growth.

1	
  Outpatients were not included in this analysis, because providers don’t collect detailed data about them. We recognize,
	 however, that some providers do have substantial numbers of international outpatients. Our survey showed that at one location,
	 a significant number of these patients reported traveling primarily to receive outpatient care.
Web 2008
                      Medical tourism                              3
                      Exhibit 1 of 6
                      Glance: Only a fraction of today’s international inpatients are medical travelers.
                      Exhibit title: A market that’s smaller than it seems

Exhibit 1
A market                                                                    All international inpatients1
                                                                            receiving care
that’s smaller than
it seems                                                                               100%



                                     Subtract expatriates seeking care in          –25 to –30%
                                     their country of current residence


                                                                                   –30 to –35%
                                     Subtract emergency cases



                                                                                      35–45%


                                                                                Medical travelers


                      1Outpatientsare excluded from analysis, because providers don’t collect detailed outpatient data; a few providers, however,
                      have substantial numbers of international outpatients.
                      Source: Interviews with providers and patient-level data; McKinsey analysis




                      The fate of the medical-travel market has important implications for the financers
                      of health services (governments, health insurers, and employers), the uninsured,
                      providers trying to attract medical travelers from other countries, and providers
                      in countries where medical travel originates. Removing barriers to it—such as
                      the reluctance of large US insurers to include medical-travel destinations in their
                      networks, the absence of transparency in quality and outcomes, the lack of clarity on
                      malpractice jurisdiction, and the difficulty of obtaining travel authorization to some
                      destinations—could increase and accelerate the flow of patients into the market.
                      Health providers, payors, and third-party brokers have a substantial opportunity.
4




                 Five discrete segments
                 The largest segment, with 40 percent of all medical travelers, seeks the world’s most
                 advanced technologies. These men and women 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 percent),
                 Web 2008
                 Medical travel
                 the Middle East (35 percent), Europe (16 percent), and Canada (7 percent)—travel to
                 Exhibit 2 of 6 States.
                 the United
                 Glance: The two largest segments of medical travelers seek higher-quality care.
                 Exhibit title: Quality drives most of today’s market


Exhibit 2
Quality drives   Relative size of medical-traveler segments

most of          100% = 49,980 patients1

today’s market
                                                                                  Lower-cost care
                                                  Lower-cost care for             for discretionary procedures
                                                  medically necessary
                                                  procedures                      4
                                                                             9
                                           Quicker access for
                                                                                                        Most advanced
                                           medically necessary      15                          40      technology
                                           procedures



                                                                             32

                                                   Better-quality care for
                                                   medically necessary
                                                   procedures


                 1Number  of patients come from providers that participated in research; total market size assumes that participating providers
                 represent 60–80% of market.
                 Source: Interviews with providers and patient-level data; McKinsey analysis




                 With 32 percent of all medical travelers, the second-largest segment comprises
                 patients who seek better care than they could find in their home countries, which are
                 often in the developing world. When selecting a destination, such patients generally
                 trade off perceived quality against burdens such as costs, distance, and unfamiliar
                 cultures. Some of these people disregard costs to some degree; others are looking for
                 higher quality at the best available price. Patients in this segment seek care in several
                 different specialties, particularly cardiology.

                 The third-largest segment comprises people who want quicker access to medically
                 necessary procedures delayed by long wait times at home for orthopedics, general
                 surgery, or cardiology. Its numbers depend on capacity in the home countries, so
                 health investments there can reduce the need to seek care abroad. Recent and
                 ongoing infrastructure investments in the United Kingdom, for example, have
                 focused on cutting wait times. Those for knee and hip replacements, which used to
                 be especially long, have fallen by about 40 percent in the past six years.
5




                    While only 9 percent of the travelers seek lower costs for medically necessary
                    procedures, this segment has the greatest potential for growth. Since the price of
                    treatment varies greatly around the world, patients can save significant amounts,
                    depending on the procedure. An aortic valve replacement costs more than $100,000
                    in the United States, for instance, but about $38,000 at a provider in Latin America,
                    and only $12,000 at a provider in Asia. US patients make up 99 percent of the people
                    in this group. In 30 percent of all cases, patients are traveling for orthopedic care,
                    and in 16 percent, for general surgery.

                    Patients seeking lower costs for discretionary procedures, such as breast
                    augmentation and reduction, abdominoplasty/liposuction, or rhinoplasty, come
                    mostly from developed markets, particularly the United States. This segment, whose
                    expansion correlates with growth in GDP and discretionary incomes, is the most
                    fragmented: patients travel to many smaller, specialized providers rather than to
                    large, multispecialty hospitals.2

                    Medical travelers are highly satisfied with care
                    Medical travel is a truly global phenomenon: the patients, evenly split between
                    people in high- and low- GDP countries,3 come from and receive treatment in every
                    continent. In our sample, patients from Africa, Asia, Europe, the Middle East, and
                    North America sought care abroad in at least three continents.
                    Web 2008
                     Medical travel
                   2	Exhibit 3 of 6
                     Our research focused on institutions, so this segment may be larger than our study indicates.
                   3	
                     Glance: Medical travel is a global phenomenon .
                     We defined the threshold between low- and high- GDP countries at a GDP of $25,000 (purchasing-power-parity) per capita.

                     Exhibit title: Across the globe


Exhibit 3
Across the globe    Medical travelers by point of origin

                        Africa        Europe               Middle East           Oceania
                        Asia          Latin America        North America




                                                                                           10%
                                                45%                            33%
                                                                                             39%                  6%
                                   27%
                                          North America                                Europe             1%
                                                            2%       5%                        13%
                                               26%                                                    32%         Asia   93%
                                                                                           8%
                                                                                                Middle East
                                                     87%
                                                                                                 58%
                                                                                                             2%
                                                                                       4%
                                         12%                                                 Africa                                   >99%
                                                     Latin America                                     95%
                                                                         1%                1%
                                                                                                                                     Oceania
                                                                                                                               <1%




                    Source: Interviews with providers and patient-level data; McKinsey analysis
6




We interviewed patients who had traveled to the emerging world for medical
treatment and found them largely satisfied with the care they received. Accreditation
from the Joint Commission International ( JCI), a not-for-profit, US -based
organization that establishes standards and inspects providers who voluntarily agree
to be assessed, appears to serve as an effective proxy of quality for providers. The
providers themselves, however, are divided about whether the JCI accreditation
process made their patients more confident about the quality of their services. Nearly
every provider we visited had received this form of accreditation.

Much potential for growth
The medical-travel market is significantly smaller now than it could be in the longer
term. Major barriers include the inability of providers in medical-travel destinations
to enter the networks of the developed markets’ payors, a lack of transparent
worldwide data on the quality of health care, the inconvenience of travel, and the
desire to undergo medical procedures in familiar settings.

Given the price differences between procedures in the United States and in
developing markets, it might seem that US payors stand to gain substantially by
including treatment abroad in their coverage. But the US market and competitive
dynamics are not so simple. Continuity of care is a major consideration for patients
suffering from chronic disease, and it’s not clear how well a multinational approach
to the delivery of care could address this issue. Besides, many procedures require
follow-up treatment or additional operations, which should optimally be performed
by the original surgeon. Furthermore, the unit cost of hospital care in the United
States depends highly on the volume and overall capacity utilization of a facility. If
10 percent of the eligible procedures in a hospital were performed abroad, the fixed
costs of delivering its services might be absorbed by the remaining procedures—and
therefore by the same payors that actually seek to lower their overall costs.

What’s more, though medical travel may offer superior value for elective surgical
admissions—20 percent, or 8 million cases, of US inpatient admissions in 2007—the
actual market will be significantly smaller, since payors and patients probably
won’t pursue overseas options in break-even or minimally profitable situations. The
required savings for patients are likely to be more than $10,000 a case, the threshold
reported by today’s uninsured US medical travelers. If payors covered medical travel,
the potential US market would probably range from 500,000 to 700,000 patients a
year, compared with 5,000 to 10,000 today. The savings might be on the order of
$20 billion.
Exhibit 4 of 6
                                                               7
                    Glance: The potential US market if payers cover medical travel is in the range of hundreds of
                    thousands of patients.
                    Exhibit title: Size of the prize


Exhibit 4
                                                                     Potential savings for payors from US contestable
Size of the prize   US inpatient admissions
                                                                     medical-travel market, %
                    100% = 40 million                                                                 Current US medical travelers report a $10,000
                                                                                                      threshold. A market of 500,000–700,000
                                        Procedures for which                                          medical travelers is realistic, since payor
                                        medical travel may well      100% (total savings2) = $51      coverage will require additional savings
                                        represent superior value1                            billion per case.

                                                                                 Commercial                 $40
                                                                                                   30       billion
                                                                                Other public,
                             80              20                          including Medicaid3       16         35
                                                                                                                       $33
                                                                                                              15       billion
                                                                                                                                      $19
                                                                                   Medicare        54                    38           billion   $13
                                                                                                              50                 14             billion
                                                                                                                                        49 7            6
                    Procedures for which                                                                                 48                       58
                                                                                                                                        44              36
                    domestically supplied value
                    will remain superior (eg,                         Minimum savings           Break even ≥$5,000    ≥$10,000 ≥$15,000 ≥$20,000
                    emergent, unpredictable,                         threshold per case         or above
                    low-cost procedures)
                                                                     Millions of medical           8.0       3.0         2.0           0.71      0.36
                                                                            travel cases

                                                                    US provider revenue            190      100         75            35        20
                                                                          today, $ billion


                    1Based on DRG-level analyses (DRG = diagnosis-related group).
                    2Aftercosts for travel and lodging; estimated at $7,700 per case based on travel costs for patient and companion and
                     two-bedroom suite in five-star hotel for average length of stay (7 days) plus 7 days for recuperation.
                    3Assumes Medicaid pricing is ~90% of Medicare fees.

                    Source: Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample; Kaiser Family Foundation; Milliman
                    payor claims data; Zuckerman et al, “Trends: Changes in Medicaid Physician Fees 1998–2003: Implications for Physician
                    Participation,” Health Affairs, June 23, 2004; McKinsey analysis




                    Other issues include the willingness to travel abroad, as well as how to give patients
                    an incentive for doing so and to increase their awareness of medical travel in the
                    first place. These problems would have to be addressed in parallel for this market to
                    realize its full potential.

                    The medical travelers we interviewed were uniformly quite satisfied with their
                    experience. They wouldn’t hesitate to go abroad for care should they need it again
                    and would strongly recommend that friends and family members do so as well.
                    Some patients and family members were so pleased with what they perceived as the
                    quality of care that they said they would seriously consider traveling abroad to get
                    better care even if care were accessible and quickly available in their developed home
                    countries.

                    Geopolitical events can quickly impact patient flows
                    The providers we studied recognize that events driving the global economy at large
                    (such as changing currency values) can affect their value proposition and flows of
                    medical travel. This market is also particularly susceptible to geopolitical events
                    and acts of nature that could influence the willingness of patients to visit a given
                    country—or their ability to do so.
8




                    The events of September 11, 2001, for example, drastically reduced the number of
                    Middle Eastern patients admitted to US facilities for care. In 2001, 44 percent of
                    the medical travelers from one country in the Middle East went to the United States
                    for care; by 2003, only 8 percent did so, because many travelers and their com-
                    panions had difficulty obtaining US visas. Although the numbers have since bounced
                    Web 2008
                    back to their pre-9/11 levels, the market took six years to adjust. In another major
                    Medical travel
                    medical provider we studied, political instability led to a 33 percent decrease in
                    Exhibit 5 of 6
                    medical travel.
                    Glance: Geopolitical events can influence a patient’s willingness to travel to certain countries.
                    Exhibit title: Shocks can shift patterns quickly


Exhibit 5
Shocks can shift    Effect of 9/111 on patient flows from one                    Effect of political instability on medical travel: inflows to one
                    Middle Eastern country,2 share of patients by               destination country, % change from average for 3 months prior to
patterns quickly    destination country                                         political unrest

                                                                                                    Political unrest began
                                                                                    20                                           Political instability
                                                                       100%                                                      intensified
                                                        8        8
                                                16                                  10
                      United States     44
                                                                                      0

                                                                                   –10
                                                84     92       92
                            All other                                              –20
                                        56
                           countries
                                                                                   –30

                                        2001   2002   2003     2004                –40
                                                                                Month     –3 –2 –1 1        2    3    4      5   6   7    8    9



                   1Sept11, 2001, attacks on World Trade Center and Pentagon; patients and companions seeking care in United States faced increased
                    processing tme for approval to enter country.
                   2From 2001 to 2004, Germany’s share grew to 34%, from 17%; reports indicate that number of patients going to United States in
                    2007 has returned to pre-9/11 levels.
                   Source: Interviews with providers and patient-level data; McKinsey analysis




                    Changes in national health care policy—such as investments in health care
                    infrastructure or insurance coverage levels—in the major originator nations can also
                    change the medical-travel market significantly. Spending on health service capacity
                    or quality, for example, may make it less necessary for patients to travel abroad in
                    search of higher-quality care or reduced wait times. In Oman, government-funded
                    medical travel for oncology fell by 92 percent from 2004 to 2005 after an oncology
                    center opened. In Abu Dhabi, government-funded medical travel for cardiology
                    decreased by 55 percent from 2004 to 2006 after a cardiac-surgery team with
                    significant international experience set up shop in the emirate.
9




Successful providers have clear strategies
Top provider destinations can offer treatment at a cost compatible with its perceived
value, focusing on one or more patient segments, regionally or globally. Providers
should consider and shape the quality of the variables they largely control, such
as their local and international reputation, the credentials of their physicians, the
outcome of treatment, and even the maintenance of infrastructure. Nonetheless,
they must recognize that the perceptions of patients are heavily influenced by the
provider’s location—for example, the country’s economic-development level, which
can affect perceptions of safety and ease of transportation, and its reputation in a
patient’s country of origin. Providers in any country should also assess its general
relationship with foreigners, its attractiveness as a tourist destination, and its
cultural affinity with the home countries of potential patients.

Medical travelers either approach providers directly for information on physicians,
the price of procedures, and logistics, or they work with intermediaries. As a liaison
between a potential patient and providers, intermediaries typically collect from
them a percentage (up to 20 percent) of the price of the treatment. Patients often find
providers and intermediaries on the Internet after seeing news reports on medical
travel or hearing about it by word of mouth. The phrase that patients type into the
initial search field often influences which provider or intermediary they choose.

Successful providers offer services, such as translators and airport pickups, to ease
patient worries, from travel hassles to cultural disconnects. In particular, successful
providers reassure patients by giving them access to physicians ahead of time. Many
medical travelers know more about their doctors overseas than about their doctors
at home: they have the physician’s CV in hand, have spoken with the physician, and
receive assurances that during their stay they’ll have 24-hour access to personal care
from the physician.
Web 2008
                  Medical travel                              10
                  Exhibit 6 of 6
                  Glance: Successful providers can provide treatment costs compatible with their perceived value.
                  Exhibit title: The right price

Exhibit 6
The right price   Impact of patients’ goals in seeking medical care on acceptance of cost and characteristics of provider countries


                                  World class
                                                                                                                          ‘I need to be sure I am
                                                                                                                           getting the best quality
                                                                                                                           possible’
                                                                                                                           High GDP per capita
                                                                                     ‘Destination country                  Highly industrialized
                                                                                      matters to me. I simply              Strong tourist and
                                                                                      won’t go to certain                  immigration destination
                                                                                      countries’                           Well-branded medical-
                                                  ‘I want good clinical
                                                                                      Midrange GDP per capita              research leaders catering to
                  Perceived value                  quality at the lowest cost’
                                                                                      Moderately industrialized            medical-travel market
                  of medical care1                 Low GDP per capita
                                                   Primarily rural                    Moderate-to-strong country
                                                   Country perceived to have low      attractiveness
                                                   attractiveness                     Clinically focused hospitals
                                                   Low costs for health-care labor    catering to medical-
                                                   Major source of immigration to     travel market
                                                   developed markets
                                                   Clinically focused hospitals
                                      Lowest       catering to medical-travel
                              acceptable level     market
                                                 Low                                                                                                High
                                                                                          Treatment cost


                  1Includes   patient's perception of both country and clinical-quality metrics.
                  Source: Interviews with providers and patient-level data; McKinsey analysis




                   The more advanced providers have systems and processes to accommodate the
                   special demands and idiosyncrasies of medical travelers. Some patients seeking
                   quality care abroad, for example, arrive ready to pay in cash. The normal delays
                   associated with billing won’t do for these travelers—the provider must be able to
                   expedite billing and track its progress so that patients can pay before leaving.

                   To some extent, the services of intermediaries and providers overlap, but providers
                   have already shown that they can build reputations and generate traffic by
                   themselves. Intermediaries must therefore specialize and define a value proposition
                   to avoid the fate of traditional travel agencies.

                   Implications for players in the medical-travel market
                   Commercial and government payors in developed markets stand to capture
                   significant cost savings by offshoring elective surgical care. Rising US health
                   care costs could translate into substantial payoffs for commercial payors that
                   accommodate medical travel and for the federal Medicare program.

                   To establish the feasibility of medical-travel products, however, payors must first
                   answer some basic questions. These include how to evaluate foreign medical
                   providers, to encourage beneficiaries to choose them, to control the potential
                   community backlash, and to manage medical-travel malpractice exposure and
                   follow-up treatment.
11




                           Established providers need to determine what steps they would take to capture the
 Related articles
                           potentially large upside of medical travel sponsored by third parties. These providers
“Innovation in health      should, for example, evaluate how much to invest now to prove conclusively that
 care: An interview        they provide adequate clinical quality, to pursue relationships with payors, to
 with the CEO of the       establish new facilities, and to accept malpractice exposure in originator countries.
 Cleveland Clinic”

“A better hospital
                           Providers aiming to capture this market should develop strategies to counter each
 experience”               of the barriers limiting their penetration of contestable procedures in originator
                           markets. Established providers cover the market fairly well, so the entry of new ones
“Universal principals      probably won’t expand it substantially unless the barriers to growth fall. Entrants
 for health care reform”
                           will therefore compete with established players largely within the current market
                           framework.

                           Given the limited size of the medical-travel market, domestic providers are
                           concerned about it now primarily in the form of exposure to medical liability if they
                           provide follow-up care. However, they could face serious competition if the payors’
                           networks open up to foreign institutions.

                           Medical travel is a highly relevant market worthy of further observation. The
                           acceleration of unsustainable health care costs in many developed economies,
                           the advent of advanced technologies in just a few locations, and the increasing
                           concentration of wealth in developing economies are only a few of the factors
                           fueling it. Over the next couple of decades, these trends may largely dispel the idea
                           that health care is a purely local service.             Q




                           The authors wish to thank Elissa Chalouhi, Imad Hammad, Sarra Karzai, Simrat Randhawa, Ali Ustun, and Caroline
                           Xu for their contributions to this research. We are also grateful for the insights we received from Chinta Bhagat,
                           Jean Drouin, Viktor Hediger, Nicolaus Henke, Claudia Süssmuth-Dyckerhoff, Reinhard Wichels, and numerous
                           other McKinsey colleagues around the world. Thanks as well to the providers, payors, policy makers, patients, and
                           intermediaries who participated in our research.



                           Tilman Ehrbeck is a principal in McKinsey’s New Delhi office, Ceani Guevara is a consultant in the Dubai office,
                           and Paul Mango is a director in the Pittsburgh office. Copyright © 2008 McKinsey & Company. All rights reserved.

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Medical travel

  • 1. h e a lt h c a r e m ay 2008 Mapping the market for medical travel The market is smaller than conventional wisdom suggests, and most of today’s medical travelers seek high quality and faster service, not lower costs. However, the potential for growth is significant. Tilman Ehrbeck, Ceani Guevara, and Paul D. Mango Article Medical travel has captured the world’s attention and imagination, but a new McKinsey at a study suggests that the market isn’t as large as reported and that most medical travelers seek glance high quality and faster service instead of lower costs. McKinsey places the current market at 60,000 to 85,000 inpatients a year, but these numbers could grow substantially if certain barriers, such as noncoverage from payors, were removed. Payors and providers looking to benefit from this nascent market have a substantial opportunity.
  • 2. 2 Introduction The idea of traveling around the world for medical treatment has captured much attention and imagination. As the debate on health care reform heats up in the United States, few weeks go by without a story about an under- or uninsured patient going to India or Thailand for heart surgery or hip replacement. Although medical travelers have many motives, lower-cost procedures and discretionary cosmetic operations represent only small segments. Most of these people seek the world’s most advanced technology, better quality, or quicker access to medical care. To create a rigorous and credible fact base about the nascent medical-travel market, McKinsey studied more than 20 medical-travel destinations; analyzed primary data on the number, type, and origin of medical travelers; and conducted interviews with providers, patients, and intermediaries in 20 countries. We place the current market at 60,000 to 85,000 inpatient1 medical travelers a year—numbers far smaller than others have reported. These smaller numbers hinge in part on our strict definition of medical travelers: people whose primary and explicit purpose in traveling is medical treatment in a foreign country. We excluded from our study patients who receive care on an emergency basis (such as ordinary tourists who become sick), “wellness tourists” (for example, people traveling for massages or acupuncture), and expatriates seeking care in their country of residence. We also excluded patients who travel in largely contiguous geographies to the closest available care, for they don’t consider other medical-travel destinations and the financial burden is minimal. Our examination of the motives and behavior of these patients reveals that this market has great potential for growth, though current volumes are modest. The benefits to providers attracting international patients are big—in addition to filling beds and increasing revenues per bed, such patients may boost an institution’s domestic prestige. But fewer than half of the international inpatients at the providers we visited were true medical travelers. Furthermore, several global forces and a number of important structural barriers may prevent or inhibit the market’s growth. 1 Outpatients were not included in this analysis, because providers don’t collect detailed data about them. We recognize, however, that some providers do have substantial numbers of international outpatients. Our survey showed that at one location, a significant number of these patients reported traveling primarily to receive outpatient care.
  • 3. Web 2008 Medical tourism 3 Exhibit 1 of 6 Glance: Only a fraction of today’s international inpatients are medical travelers. Exhibit title: A market that’s smaller than it seems Exhibit 1 A market All international inpatients1 receiving care that’s smaller than it seems 100% Subtract expatriates seeking care in –25 to –30% their country of current residence –30 to –35% Subtract emergency cases 35–45% Medical travelers 1Outpatientsare excluded from analysis, because providers don’t collect detailed outpatient data; a few providers, however, have substantial numbers of international outpatients. Source: Interviews with providers and patient-level data; McKinsey analysis The fate of the medical-travel market has important implications for the financers of health services (governments, health insurers, and employers), the uninsured, providers trying to attract medical travelers from other countries, and providers in countries where medical travel originates. Removing barriers to it—such as the reluctance of large US insurers to include medical-travel destinations in their networks, the absence of transparency in quality and outcomes, the lack of clarity on malpractice jurisdiction, and the difficulty of obtaining travel authorization to some destinations—could increase and accelerate the flow of patients into the market. Health providers, payors, and third-party brokers have a substantial opportunity.
  • 4. 4 Five discrete segments The largest segment, with 40 percent of all medical travelers, seeks the world’s most advanced technologies. These men and women 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 percent), Web 2008 Medical travel the Middle East (35 percent), Europe (16 percent), and Canada (7 percent)—travel to Exhibit 2 of 6 States. the United Glance: The two largest segments of medical travelers seek higher-quality care. Exhibit title: Quality drives most of today’s market Exhibit 2 Quality drives Relative size of medical-traveler segments most of 100% = 49,980 patients1 today’s market Lower-cost care Lower-cost care for for discretionary procedures medically necessary procedures 4 9 Quicker access for Most advanced medically necessary 15 40 technology procedures 32 Better-quality care for medically necessary procedures 1Number of patients come from providers that participated in research; total market size assumes that participating providers represent 60–80% of market. Source: Interviews with providers and patient-level data; McKinsey analysis With 32 percent of all medical travelers, the second-largest segment comprises patients who seek better care than they could find in their home countries, which are often in the developing world. When selecting a destination, such patients generally trade off perceived quality against burdens such as costs, distance, and unfamiliar cultures. Some of these people disregard costs to some degree; others are looking for higher quality at the best available price. Patients in this segment seek care in several different specialties, particularly cardiology. The third-largest segment comprises people who want quicker access to medically necessary procedures delayed by long wait times at home for orthopedics, general surgery, or cardiology. Its numbers depend on capacity in the home countries, so health investments there can reduce the need to seek care abroad. Recent and ongoing infrastructure investments in the United Kingdom, for example, have focused on cutting wait times. Those for knee and hip replacements, which used to be especially long, have fallen by about 40 percent in the past six years.
  • 5. 5 While only 9 percent of the travelers seek lower costs for medically necessary procedures, this segment has the greatest potential for growth. Since the price of treatment varies greatly around the world, patients can save significant amounts, depending on the procedure. An aortic valve replacement costs more than $100,000 in the United States, for instance, but about $38,000 at a provider in Latin America, and only $12,000 at a provider in Asia. US patients make up 99 percent of the people in this group. In 30 percent of all cases, patients are traveling for orthopedic care, and in 16 percent, for general surgery. Patients seeking lower costs for discretionary procedures, such as breast augmentation and reduction, abdominoplasty/liposuction, or rhinoplasty, come mostly from developed markets, particularly the United States. This segment, whose expansion correlates with growth in GDP and discretionary incomes, is the most fragmented: patients travel to many smaller, specialized providers rather than to large, multispecialty hospitals.2 Medical travelers are highly satisfied with care Medical travel is a truly global phenomenon: the patients, evenly split between people in high- and low- GDP countries,3 come from and receive treatment in every continent. In our sample, patients from Africa, Asia, Europe, the Middle East, and North America sought care abroad in at least three continents. Web 2008 Medical travel 2 Exhibit 3 of 6 Our research focused on institutions, so this segment may be larger than our study indicates. 3 Glance: Medical travel is a global phenomenon . We defined the threshold between low- and high- GDP countries at a GDP of $25,000 (purchasing-power-parity) per capita. Exhibit title: Across the globe Exhibit 3 Across the globe Medical travelers by point of origin Africa Europe Middle East Oceania Asia Latin America North America 10% 45% 33% 39% 6% 27% North America Europe 1% 2% 5% 13% 26% 32% Asia 93% 8% Middle East 87% 58% 2% 4% 12% Africa >99% Latin America 95% 1% 1% Oceania <1% Source: Interviews with providers and patient-level data; McKinsey analysis
  • 6. 6 We interviewed patients who had traveled to the emerging world for medical treatment and found them largely satisfied with the care they received. Accreditation from the Joint Commission International ( JCI), a not-for-profit, US -based organization that establishes standards and inspects providers who voluntarily agree to be assessed, appears to serve as an effective proxy of quality for providers. The providers themselves, however, are divided about whether the JCI accreditation process made their patients more confident about the quality of their services. Nearly every provider we visited had received this form of accreditation. Much potential for growth The medical-travel market is significantly smaller now than it could be in the longer term. Major barriers include the inability of providers in medical-travel destinations to enter the networks of the developed markets’ payors, a lack of transparent worldwide data on the quality of health care, the inconvenience of travel, and the desire to undergo medical procedures in familiar settings. Given the price differences between procedures in the United States and in developing markets, it might seem that US payors stand to gain substantially by including treatment abroad in their coverage. But the US market and competitive dynamics are not so simple. Continuity of care is a major consideration for patients suffering from chronic disease, and it’s not clear how well a multinational approach to the delivery of care could address this issue. Besides, many procedures require follow-up treatment or additional operations, which should optimally be performed by the original surgeon. Furthermore, the unit cost of hospital care in the United States depends highly on the volume and overall capacity utilization of a facility. If 10 percent of the eligible procedures in a hospital were performed abroad, the fixed costs of delivering its services might be absorbed by the remaining procedures—and therefore by the same payors that actually seek to lower their overall costs. What’s more, though medical travel may offer superior value for elective surgical admissions—20 percent, or 8 million cases, of US inpatient admissions in 2007—the actual market will be significantly smaller, since payors and patients probably won’t pursue overseas options in break-even or minimally profitable situations. The required savings for patients are likely to be more than $10,000 a case, the threshold reported by today’s uninsured US medical travelers. If payors covered medical travel, the potential US market would probably range from 500,000 to 700,000 patients a year, compared with 5,000 to 10,000 today. The savings might be on the order of $20 billion.
  • 7. Exhibit 4 of 6 7 Glance: The potential US market if payers cover medical travel is in the range of hundreds of thousands of patients. Exhibit title: Size of the prize Exhibit 4 Potential savings for payors from US contestable Size of the prize US inpatient admissions medical-travel market, % 100% = 40 million Current US medical travelers report a $10,000 threshold. A market of 500,000–700,000 Procedures for which medical travelers is realistic, since payor medical travel may well 100% (total savings2) = $51 coverage will require additional savings represent superior value1 billion per case. Commercial $40 30 billion Other public, 80 20 including Medicaid3 16 35 $33 15 billion $19 Medicare 54 38 billion $13 50 14 billion 49 7 6 Procedures for which 48 58 44 36 domestically supplied value will remain superior (eg, Minimum savings Break even ≥$5,000 ≥$10,000 ≥$15,000 ≥$20,000 emergent, unpredictable, threshold per case or above low-cost procedures) Millions of medical 8.0 3.0 2.0 0.71 0.36 travel cases US provider revenue 190 100 75 35 20 today, $ billion 1Based on DRG-level analyses (DRG = diagnosis-related group). 2Aftercosts for travel and lodging; estimated at $7,700 per case based on travel costs for patient and companion and two-bedroom suite in five-star hotel for average length of stay (7 days) plus 7 days for recuperation. 3Assumes Medicaid pricing is ~90% of Medicare fees. Source: Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample; Kaiser Family Foundation; Milliman payor claims data; Zuckerman et al, “Trends: Changes in Medicaid Physician Fees 1998–2003: Implications for Physician Participation,” Health Affairs, June 23, 2004; McKinsey analysis Other issues include the willingness to travel abroad, as well as how to give patients an incentive for doing so and to increase their awareness of medical travel in the first place. These problems would have to be addressed in parallel for this market to realize its full potential. The medical travelers we interviewed were uniformly quite satisfied with their experience. They wouldn’t hesitate to go abroad for care should they need it again and would strongly recommend that friends and family members do so as well. Some patients and family members were so pleased with what they perceived as the quality of care that they said they would seriously consider traveling abroad to get better care even if care were accessible and quickly available in their developed home countries. Geopolitical events can quickly impact patient flows The providers we studied recognize that events driving the global economy at large (such as changing currency values) can affect their value proposition and flows of medical travel. This market is also particularly susceptible to geopolitical events and acts of nature that could influence the willingness of patients to visit a given country—or their ability to do so.
  • 8. 8 The events of September 11, 2001, for example, drastically reduced the number of Middle Eastern patients admitted to US facilities for care. In 2001, 44 percent of the medical travelers from one country in the Middle East went to the United States for care; by 2003, only 8 percent did so, because many travelers and their com- panions had difficulty obtaining US visas. Although the numbers have since bounced Web 2008 back to their pre-9/11 levels, the market took six years to adjust. In another major Medical travel medical provider we studied, political instability led to a 33 percent decrease in Exhibit 5 of 6 medical travel. Glance: Geopolitical events can influence a patient’s willingness to travel to certain countries. Exhibit title: Shocks can shift patterns quickly Exhibit 5 Shocks can shift Effect of 9/111 on patient flows from one Effect of political instability on medical travel: inflows to one Middle Eastern country,2 share of patients by destination country, % change from average for 3 months prior to patterns quickly destination country political unrest Political unrest began 20 Political instability 100% intensified 8 8 16 10 United States 44 0 –10 84 92 92 All other –20 56 countries –30 2001 2002 2003 2004 –40 Month –3 –2 –1 1 2 3 4 5 6 7 8 9 1Sept11, 2001, attacks on World Trade Center and Pentagon; patients and companions seeking care in United States faced increased processing tme for approval to enter country. 2From 2001 to 2004, Germany’s share grew to 34%, from 17%; reports indicate that number of patients going to United States in 2007 has returned to pre-9/11 levels. Source: Interviews with providers and patient-level data; McKinsey analysis Changes in national health care policy—such as investments in health care infrastructure or insurance coverage levels—in the major originator nations can also change the medical-travel market significantly. Spending on health service capacity or quality, for example, may make it less necessary for patients to travel abroad in search of higher-quality care or reduced wait times. In Oman, government-funded medical travel for oncology fell by 92 percent from 2004 to 2005 after an oncology center opened. In Abu Dhabi, government-funded medical travel for cardiology decreased by 55 percent from 2004 to 2006 after a cardiac-surgery team with significant international experience set up shop in the emirate.
  • 9. 9 Successful providers have clear strategies Top provider destinations can offer treatment at a cost compatible with its perceived value, focusing on one or more patient segments, regionally or globally. Providers should consider and shape the quality of the variables they largely control, such as their local and international reputation, the credentials of their physicians, the outcome of treatment, and even the maintenance of infrastructure. Nonetheless, they must recognize that the perceptions of patients are heavily influenced by the provider’s location—for example, the country’s economic-development level, which can affect perceptions of safety and ease of transportation, and its reputation in a patient’s country of origin. Providers in any country should also assess its general relationship with foreigners, its attractiveness as a tourist destination, and its cultural affinity with the home countries of potential patients. Medical travelers either approach providers directly for information on physicians, the price of procedures, and logistics, or they work with intermediaries. As a liaison between a potential patient and providers, intermediaries typically collect from them a percentage (up to 20 percent) of the price of the treatment. Patients often find providers and intermediaries on the Internet after seeing news reports on medical travel or hearing about it by word of mouth. The phrase that patients type into the initial search field often influences which provider or intermediary they choose. Successful providers offer services, such as translators and airport pickups, to ease patient worries, from travel hassles to cultural disconnects. In particular, successful providers reassure patients by giving them access to physicians ahead of time. Many medical travelers know more about their doctors overseas than about their doctors at home: they have the physician’s CV in hand, have spoken with the physician, and receive assurances that during their stay they’ll have 24-hour access to personal care from the physician.
  • 10. Web 2008 Medical travel 10 Exhibit 6 of 6 Glance: Successful providers can provide treatment costs compatible with their perceived value. Exhibit title: The right price Exhibit 6 The right price Impact of patients’ goals in seeking medical care on acceptance of cost and characteristics of provider countries World class ‘I need to be sure I am getting the best quality possible’ High GDP per capita ‘Destination country Highly industrialized matters to me. I simply Strong tourist and won’t go to certain immigration destination countries’ Well-branded medical- ‘I want good clinical Midrange GDP per capita research leaders catering to Perceived value quality at the lowest cost’ Moderately industrialized medical-travel market of medical care1 Low GDP per capita Primarily rural Moderate-to-strong country Country perceived to have low attractiveness attractiveness Clinically focused hospitals Low costs for health-care labor catering to medical- Major source of immigration to travel market developed markets Clinically focused hospitals Lowest catering to medical-travel acceptable level market Low High Treatment cost 1Includes patient's perception of both country and clinical-quality metrics. Source: Interviews with providers and patient-level data; McKinsey analysis The more advanced providers have systems and processes to accommodate the special demands and idiosyncrasies of medical travelers. Some patients seeking quality care abroad, for example, arrive ready to pay in cash. The normal delays associated with billing won’t do for these travelers—the provider must be able to expedite billing and track its progress so that patients can pay before leaving. To some extent, the services of intermediaries and providers overlap, but providers have already shown that they can build reputations and generate traffic by themselves. Intermediaries must therefore specialize and define a value proposition to avoid the fate of traditional travel agencies. Implications for players in the medical-travel market Commercial and government payors in developed markets stand to capture significant cost savings by offshoring elective surgical care. Rising US health care costs could translate into substantial payoffs for commercial payors that accommodate medical travel and for the federal Medicare program. To establish the feasibility of medical-travel products, however, payors must first answer some basic questions. These include how to evaluate foreign medical providers, to encourage beneficiaries to choose them, to control the potential community backlash, and to manage medical-travel malpractice exposure and follow-up treatment.
  • 11. 11 Established providers need to determine what steps they would take to capture the Related articles potentially large upside of medical travel sponsored by third parties. These providers “Innovation in health should, for example, evaluate how much to invest now to prove conclusively that care: An interview they provide adequate clinical quality, to pursue relationships with payors, to with the CEO of the establish new facilities, and to accept malpractice exposure in originator countries. Cleveland Clinic” “A better hospital Providers aiming to capture this market should develop strategies to counter each experience” of the barriers limiting their penetration of contestable procedures in originator markets. Established providers cover the market fairly well, so the entry of new ones “Universal principals probably won’t expand it substantially unless the barriers to growth fall. Entrants for health care reform” will therefore compete with established players largely within the current market framework. Given the limited size of the medical-travel market, domestic providers are concerned about it now primarily in the form of exposure to medical liability if they provide follow-up care. However, they could face serious competition if the payors’ networks open up to foreign institutions. Medical travel is a highly relevant market worthy of further observation. The acceleration of unsustainable health care costs in many developed economies, the advent of advanced technologies in just a few locations, and the increasing concentration of wealth in developing economies are only a few of the factors fueling it. Over the next couple of decades, these trends may largely dispel the idea that health care is a purely local service.  Q The authors wish to thank Elissa Chalouhi, Imad Hammad, Sarra Karzai, Simrat Randhawa, Ali Ustun, and Caroline Xu for their contributions to this research. We are also grateful for the insights we received from Chinta Bhagat, Jean Drouin, Viktor Hediger, Nicolaus Henke, Claudia Süssmuth-Dyckerhoff, Reinhard Wichels, and numerous other McKinsey colleagues around the world. Thanks as well to the providers, payors, policy makers, patients, and intermediaries who participated in our research. Tilman Ehrbeck is a principal in McKinsey’s New Delhi office, Ceani Guevara is a consultant in the Dubai office, and Paul Mango is a director in the Pittsburgh office. Copyright © 2008 McKinsey & Company. All rights reserved.