Effect of Rising Insurance Coverage in USA on Indian medical Tourism

Introduction

Medical Tourism industry, that is tourists visiting for medical reasons, in India has been growing at a fast pace. But there are other countries like Thailand, Indonesia etc. that have been giving tough competition to India. Though Indian government has brought out many policies to help the development of this industry, India still lacks in terms of infrastructure required for this industry.

The research paper intends to establish a relation between the rising costs of insurance, the rising unemployment and the Number of uninsured people in USA. It also intends to draw a relation between the rising number of uninsured people and the number of Americans opting for medical travels. Literature on medical tourism has repeatedly stated that rising insurance cost in USA is one of the main reasons why Americans opt for medical tourism. So the paper will try to bring out the fact that more the number of uninsured, due to high insurance cost, more will be the number of people opting for medical travel. And hence a bigger market to be captured by India.

Their have been studies on how India and other medical tourism destinations have been progressing and how they offer better services than the host countries. A number of reasons have been stated for people opting for medical travel. The paper will tell exactly which factor, out of the many stated in literature, effects medical travel decisions the most.

It is important to understand what factors, out of the many stated, are most important when people take up a decision to travel for medical reasons. Indian medical tourism providers can make use of these reasons to enhance the experience of medical tourists, and in turn do better than their competitors.

Literature review

Medical tourism, also referred to as medical travel, has been defined as the act of travelling to different destinations for medical reasons. This travel takes place because medical services provided in the host country are not feasible due to cost or non-availability of certain medical services.

Medical tourism is a very new industry but it gained significance at a very fast rate. The growth of this industry is really commendable. A RNCOS report of 2010 evaluated the value of the industry to be of $60 Billion and forecasted its growth to $ 100 Billion by the year 2012.

Major destinations for medical tourism are Thailand, India, Singapore and Malaysia (Grail Research) out of which India ranks second with 0.45 million medical travelers (2007 data). This ranking is in terms of FTA for medical reasons. A CII – McKinsey research states that 1,50,000 foreigners visited India in 2005 for medical reasons and the figure is expected to grow at a rate of 15% annually. Another report by IBEF calculated the growth rate for India to be 29% and reach $2.4 Billion by 2012. Indian tourism statistics has calculated that in 2009 FTA in India for medical reasons was 1,12,388, which was 2.2% of the total FTA in India. The same statistics for 2010 was 1,55,942, which was 2.7% of the total FTA. India has medical tourists coming in from developed nations like USA, UK, Canada, etc. as well as from the neighboring countries like Bangladesh, Sri Lanks, Nepal, etc. (Shanmugam) India’s major competitors in the medical tourism sector are Malaysia, Singapore and Thailand which give tough competition not only on cost but also on the infrastructure.

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Healthcare costs have been rising significantly across the developed nations like USA, Canada, England, etc. Healthcare in USA is the most expensive in the world (Piazolo and Zanca) and hence USA is one of the largest contributors as well to the industry with its outbound medical tourism growing at a rate of 35% (Figure 1: Underwood and Keckley) .

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A research conducted by Gallup states that if costs are low, then medical tourists from USA opt for the following medical procedures:

  • 40% Americans opted for major medical problems
  • 37% Americans opted for cancer diagnostics/treatment
  • 27% Americans opted for hip or knee replacement
  • 27% Americans opted for heart bypass surgery
  • 20% Americans opted for cosmetic surgery

People with no health insurance in USA had a slightly different story to tell:

  • 51% Americans opted for major medical problems
  • 46% Americans opted for cancer diagnostics/treatment
  • 41% Americans opted for hip or knee replacement
  • 36% Americans opted for heart bypass surgery
  • 30% Americans opted for cosmetic surgery

Research has stated a number of reasons for Americans taking up medical travels. They are as below:

1. Rising rate of health insurance premiums (National Coalition on Healthcare)

Health insurance premium has seen an exponential growth in USA since the last 12 years (Figure 2). Insurance premium has risen much more than the salaries of workers.

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Employers have been passing the rising insurance cost to employees, which have become unaffordable for employees. The share of insurance premium paid by the employee has increased from 36.8% in 2005 to 39.7% in 2011 (Mayne, Girod, Weltz) . Between 2000 and 2006, employee contribution in paying insurance premiums has increased by almost 143% (National Coalition on healthcare).

These rising costs of insurance premiums have also increased the uninsured population in USA over a period of 12 years (Figure 3). Though the American government has been bringing out plans to help the uninsured (Patient Protection and Affordable Care Act, informally called as Obamacare), but it was not enough to get over the insurance woes of Americans. Majority of this uninsured population takes up a decision for medical travel. Even the employers encourage their employees to take up medical travel as it reduces costs for them too.

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2. High cost of treatment (Underwood and Makadon)

Medical treatments are very expensive in USA as compared to India. With recession coming in, companies closing business and more people getting unemployed, it seems quite natural that Americans would look out for cheaper options for medical care. The money saved is big enough to compensate for time taken for travel. Even the cost of drugs is very high in America. Many health plan providers are also in negotiation with healthcare service providers in medical tourist destinations to provide suitable health plans for medical travelers. (Jeffrey C. Bauer). Figure 4 shows a comparison of some of the treatment costs. The prices are approximate prices, which also include an estimate of airfare for the patient and the companion. The prices will differ on certain factors like hospital, doctor’s experience, accreditation, currency exchange rates, etc. (Detailed price comparison data in Appendix A)

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3. No referral from doctors required (Underwood and Makadon)

Patients and healthcare providers can be in contact directly without any mediation or referral from doctors in the host country. This has made the procedure more flexible and easy to access.

4. Long waiting times for treatment (Yap, Chen Nones)

Americans do not find it easy to access the healthcare services in their host country. They have to deal with long waiting times to see a doctor for any consultation or procedure. Even though the physician – patient ratio is high in some of the major cities, still the waiting time has seen an average increase of 8.6 days from 2004 to 2009 (Meritt Hawkins). Figure 5 gives waiting times for some of the procedures.

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5. Treatments not accepted by American medical speciality societies (Jeffrey C. Bauer)

There are some non – economic reasons as well for people opting for Medical Tourism. One such reason is that there are certain treatments that are not accepted by American medical agencies but are available outside the country. For example, shark cartilage is not an accepted cancer treatment in USA but it is available in some countries (Jeffrey C. Bauer). People who believe in the treatment travel for it.

6. Treatments not accepted in USA due to administrative reasons (Jeffrey C. Bauer)

Another non – economic reason cited for medical travel is getting treatment for procedures that are not available is USA due to political and administrative reasons. For example, therapies for stem cell research (Jeffrey C. Bauer) are yet not available in USA due to some administrative decisions but they are acceptable in other countries, where Americans chose to go for medical travel.

7. Eastern system of medicine (RNCOS)

Eastern system of medicine like Yoga, Homeopathy, Ayurveda, Naturopathy has become very attractive for the western world. Americans have started showing preference to these systems of medicines. Many Americans visit Kerela for Panchkarma treatment for rejuvenation and orthopedic treatments. Other East Asian countries are also well known for these ancient medicine systems. People from all over the world are travelling to make best use of treatments offered by these medicines.

Customers consider various factors when deciding on the place to choose for medical tourism. These factors can be organized to form the value chain of medical tourism.

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Pre Procedure Stage:

1. Quality of Treatment
  • Competence of doctors and paramedical staff
  • Quality of medical procedure
  • Quality of medical infrastructure
  • Quality of non clinical infrastructure
2. Connectivity
  • Destination well connected to home country
3. Cost of Treatment
  • Low cost of medical procedure
  • Overall cost of travel and treatment
4. Ease of Access
  • Less wait time for treatment
  • Availability of Visa
  • Pre procedure documentation
5. Ease of Purchase
  • Help to finalise travel itinerary
  • Terms of payment
  • Availability of medical insurance
  • Affordable cost of medical insurance

Procedure Stage

1. Professionalism in management of hospitals
  • Swift admission process
  • Attention to customers’ needs
  • Coordination between different wards and departments
  • Enthusiastic and proactive staff
  • Pickup facility on arrival
2. Competence of staff
  • Assurance of confidentiality
  • Helpful and cheerful daily care staff
  • Daily care staff sensitive to customers’ needs
  • Knowledgeable and skilful nursing staff
  • Quick and responsive nursing care staff
  • Nursing staff demonstrates concern
3. Competence of doctors
  • Doctors available when required
  • Doctors willing to share information
  • Qualified and skilful doctors
4. Facilitation and care
  • Linguistic abilities of doctors and nurses
  • Linguistic abilities of non medical staff
  • Empathetic doctors and nurses
  • Comfortable and affordable accommodation
  • Good food
  • Privacy
  • Proper arrangements for accomplice

Post Procedure Stage

  • Simple and swift discharge procedure
  • Discharge instructions clear and understandable
  • Self explanatory billing free from any surprise hidden charges
  • Swift and error free billing
  • Quality of recuperative stay
  • Post procedure monitoring by hospital/doctor
  • Recovery monitoring and facilities for physical and alternative therapy
  • Follow up care and instructions for medicine regime
  • Post treatment vacationing
  • Availability of prescribed medicines in home country
  • Opportunity for consultation after getting back home
  • Hospital to be in touch with hospitals/doctors in home country

India has been one of the most favoured destinations for medical tourism. A number of reasons have been cited for this:

  • A high quality medical service is available at reasonable cost (SINET)
  • Availability of highly qualified doctors (SINET)
  • High success rate in advanced healthcare services (SINET)
  • Good hospitals with latest state of art medical equipments (Begde)
  • Ancient medical system centres like Yoga, Ayurveda, Homeopathy, Unani and Naturopathy are well developed in India
  • India has a rich and vibrant culture that attracts the western world
  • India offers various tourist destinations, hence people can combine medical travel with vacation

Apart from so many advantages, India also lacks at some points:

  • Poor coordination among players of the medical tourism value chain. that is, between hospitals, airlines and hotels (SINET)
  • Poor infrastructure like roads and power supply (Zafar)
  • Non uniform pricing structure across hospitals (SINET)
  • Government aided hospitals are badly managed due to their bureaucratic style of management (Zafar)
  • Industry players complain of poor government support in terms of land reforms and funding facility

Medical Tourism industry can turn out to be as successful a story as the Indian IT sector once did. Indian government has understood the potential of medical tourism and has taken several steps to support the industry.

  • The medical tourism activity in India is mainly driven by private sector, and the Indian Ministry of Tourism functions as a facilitator in terms of marketing and promoting the sector.
  • The Indian Ministry of Tourism has promoted medical tourism at several international platforms such as World Travel Mart London, ITB Berlin, etc.
  • The government has extended the medical visa limit to 1 year, from 3 months, and this is also extendable by another 1 year (Zafar)
  • Visa processing has also been expedited.
  • Government has also exempted the medical tourists from taking a gap of two months for re-entry (KPMG).
  • India’s National Health Policy has declared that treatment of foreign nationals is an export activity and hence also eligible for fiscal incentives extended to export earnings.
  • The Ministry of Tourism as a step to promote the medical tourism sector has produced brochure, CDs and other such publicity materials
  • The “Incredible India Campaign” of the Ministry of Tourism has been promoting the alternate medicine system in India namely Yoga, Ayurveda, Wellness and Unani.
  • Brochures and CDs on Body, Mind and Soul covering the traditional system of medicine have been extensively produced and circulated by the Ministry of Tourism.
  • Road shows focusing on medical tourism were organized in many places like Dubai, Riyadh, Kuwait and Doha.
  • A study was commissioned by the Ministry of Tourism to understand the problems and challenges faced by medical tourists visiting India. The study was conducted through Indian Institute of Tourism and Travel Management, Gwalior.
  • Under the scheme of Market Development Assistance, the Ministry of Tourism Extends financial support to Medical Tourism Service providers, i.e. Representatives of Hospitals accredited by Joint Commission for International Accredited Hospitals (JCI) and National Accreditation Board of Hospitals (NBAH) and Medical Tourism Facilitators, e.g. Travel Operators and Travel Agents, approved by the Ministry of Tourism and also engaged in Medical Tourism.
  • The Ministry of Tourism also provides assistance to the above mentioned operators and facilitators for participation in approved Medical/Tourism Fairs/Medical Conferences/ Wellness Conferences/ Wellness Fairs and its allied Road shows.
  • A major government initiative is coming in the form of Medi City in Gurgaon. the projects entails 900 bed hospital with 17 super specialties , a medical and paramedical college. The Medi City will have allopathic care clubbed with Unani, Ayurvedic and Homeopathic medicinal treatments as well.

Some state governments have also been making efforts to leverage on the charm of medical tourism:

  • Kerela has used its expertise in Ayurveda to promote medical tourism in the state.
  • An International Health City Corporation is in the process of being setup in Karnataka
  • Industry status has been granted to this sector by Maharashtra government so that all incentives given to other industries can be received by the medical tourism sector.

The players in the Indian medical tourism industry have also been making efforts to promote the industry. Hospitals have been developing state of art medical infrastructure like blood banks, imaging services, comprehensive diagnostic services, etc. so as to capture more and more cross border patients. Hospitals have also been tying up with tour operators to provide comprehensive medical tourism experience to international patients. In the recent past a big name in hospitals - Apollo hospitals has come into contract with big name in hospitality like Taj Group, to provide quality medical tourism experience. Similar deals are being planned between ITC and Jupiter Hospitals.
Hospitals in India have been rigorously trying to get accreditation by international bodies and presently there are 16 hospitals that have been approved by Joint Commission for International Accredited Hospitals. There are about 3000 hospitals and 7,26,000 registered medical practitioners in India that serve the needs of people. Some well-known hospitals are Apollo, Fortis, Sahara, Workhardt, etc. These hospitals also provide facilities for translators, private chefs, etc during the stay of foreign patients.

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Methodology

The sample data for the analysis has been drawn from various secondary sources. There has been usage of two data analysis tools – multiple regression and correlation.

Multiple Regression has been done to find out what was the effect of number of unemployed people in USA and the rising cost of insurance premiums on the number of uninsured people in USA. The data has been taken for 12 years from 2000 to 2011. The data for number of uninsured people was extracted from US Census Bureau statistics. The data for number of unemployed people has been taken from US Department of Labor. Milliman Medical index reports from 2005 to 2011 were used to find the insurance rates in USA. The insurance cost is the average insurance premium for a family of four.

Simple Correlation has been done to find out the strength of relation between the number of people uninsured in USA and the number of Americans opting for medical travel. The data for American outbound medical travel is available only from the year 2007. Before 2007, medical tourism was not considered as an important industry worldwide and hence no proper data has been recorded. In fact, before 2007, people from across the world visited America for medical reasons due to the advanced medical technology that they possessed. Hence correlation has been done only for the data of 5 years from 2007 to 2011.

Results and discussions

The statistical tests indicated that 96.6% of variation in the number of uninsured people (UNINS) in USA could be explained by the rising cost of insurance (ICOST) and the rising unemployed population (UEMP) in USA.
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Further ANOVA table confirmed that the regression model was useful in predicting the rising number of uninsured people in USA. F statistic was significant enough to validate the model.
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Out of the two predictors, the effect of insurance cost on the rising number of uninsured people was more than the effect of rising unemployed population in USA.
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This means that with recession phasing out and new policies being rolled out by the government, employment condition have been improving, but the wages are still not high enough to afford insurance plans.

A correlation test run between the number of uninsured in USA and the outbound medical travel (OUTBOUND) showed a moderately high correlation of 0.625.
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The data available for outbound medical travel was only for 5 years and hence the correlation result is just moderately high. Other reason for this could be that the people who are uninsured do not have resources to opt for medical travel as well. They might come under the unemployed segment of population.

The data for waiting time for treatments would have also been useful to predict its effect on outbound travels, but its non-availability restricted the analysis on this particular aspect.

It is clear from the results that more the number of uninsured people in USA, more is the number of Americans opting for medical travel. Even though American government has brought out policies to help the uninsured, there was no help from the rising cost of medical treatment in USA. People who have insurance coverage also try not to take medical service in USA due to the high cost of medical treatment and drugs.

Literature has shown that India ranks second among the top best medical tourism destinations, in terms of number of medical FTA in India. India has the potential to be the market leader; all it needs is some support from the government and also a robust medical tourism value chain. Internet has made communication easy. Medical tourism providers can directly contact the patients and market their services to them. If they try to capture more and more of this uninsured population of USA by designing packages specially suited to them, they can do well.

The problems of Indian medical tourism can be categorized in two segments:

  1. Problems due to poor government administration
  2. Problems due to poor medical tourist management by the medical tourism operators

As stated earlier, the Indian government has realized the importance of the medical tourism sector and is working towards the promotion of the sector. Government issues range from policies to poor infrastructure. Government has planned many policies to promote the sector but the implementation process of these policies has been very slow, giving an edge to the nations competing with India in Medical Tourism Sector. As for the infrastructure part, not much has been done yet. The political instability that has captured the country makes it difficult for the development of proper infrastructure. Western world already has an impression that India scores very low when it comes to safety, hygiene and infrastructure.

Apart from the customers, the industry players also face certain problems. Industry players complain that the land reforms are very poor in the country and funding facility is also very less, which prohibits them from stimulating growth in the industry. The bureaucratic form of management in most of the places is an imperative for most of the industry players.

The government is making efforts to improve road connectivity between cities and major airports of the country are also being renovated to suit international standards. 45 private sector hospitals have been promoted by the government as Centers of Excellence. The government has also recognized medical tourism as a service export so that the sector is able to get tax benefits.

Good power supply is very important for hospitals and hotels to function well. But absence of proper power supply shoots up the operating costs of hospitals. And hence they might have to compromise on the quality of services they offer.

India has a rich heritage of tourist spots. Indian Tourism Industry is a big market with a contribution of 6.2% to the GDP. The graphs below show India’s FTA (Foreign Tourist Arrival) and FEE (Foreign Exchange Earnings from Tourism) for a period of 23 years. It is quite evident that the tourism market has also been growing gradually and contributing well to country’s income.
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There is a good chance to promote tourism along with medical tourism and vice versa. Medical tourists can utilize their visits for vacation as well, which in turn will boost tourism of different states. The graph below shows that USA has been the top most country in terms of tourists arriving in India. This is a direct indication that India is a favorite tourist destination among US citizens. A report by Stark Tourism Associates, states that from 2011 to 2013, India has seen the highest growth of 23% in terms of US outbound tourism destination.
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But lack of proper road, bus and rail infrastructure can forbid the tourist from doing so. Also in recent times the innumerable cases of violence and molestation against women, has been scaring off the tourists. These incidents have spoiled the image of India and foreign tourists see it as a very unsafe place, especially for women. Government along with the private tourism providers and medical tourism providers should work towards improving the infrastructure as well as removing the fears of the tourists regarding their security. The tourists need to be ensured of excellent quality medical service as well as good security conditions.

The government aided hospitals lack proper infrastructure and a hygienic atmosphere in India. They suffer form inadequacy of funds as well. Though these hospitals are far cheaper in terms of cost still there is no proper regulatory body to look into the quality of these hospitals. They still follow a bureaucratic form of management with political interference in recruitment and promotion, which gives way to poor quality health service. The government-aided hospitals also have problems like unhealthy work culture, inefficiency of staff and trade unions calling strikes every now and then. The standard requirements of bed and nursing care are also not met in these hospitals. Another issue that comes out of this is that there is no uniformity in terms of cost across hospitals in India, and this confuses the medical tourists a little. A research states that public sector doctors had a very detached and low involvement attitude towards medical tourism. Government should look into improving these hospitals as well, apart from launching various policies for medical tourism.

The ancient systems of medicine like Ayurveda, Yoga, etc. need to be promoted more and more. These systems are cheaper also when compared to modern medical techniques. Medical practitioners in western countries are also prescribing to these ancient systems of medicines. For example, Ayurveda has been accepted officially as a reliable healthcare system in Hungary.

There are not many good quality medical tourist operators in India. Medical tourists often complain on lack of coordination between the service providers starting from the airlines to the hotels and the hospitals. An ideal medical tourism service provider is expected to specialize in offering services like making travel bookings, assisting with selection of hospitals and doctors, and also lending a helping hand in completion of paper work to medical tourists. There are very few names in the sector like Advent Medical Services, Indicure Limited, Erco Travels, etc. but they provide very limited services. In the recent past, some new names have been coming up like Mediscapes India Limited and Sahara Medical Tourism that provide complete medical tour facility to the tourists. The facilities are providing a International Patient Care Coordinator, providing special phones to patients, etc. But the problem is that these facilities require a large infrastructure, which is not available with most of the service providers.

What is required is more of such operators who coordinate every activity from selecting a hospital, to fixing an appointment with the doctor, stays in hotels, air tickets, and also helping them in sight seeing as well as discovering ancient systems of medicine. These providers also need to have a uniform price of treatments all over the country to reduce the confusions and concerns of medical tourists.

Medical Tourism sector can also utilize the growing reach on Internet. Medical Tourism providers can market their services to a wider range of customers. It will also be a benefit to customers as they can have customized healthcare services. The process will be more streamlined and the concern of the customers regarding low coordination among players of the medical tourism sector will die down.

An insurance company WellPoint in USA had announced a program that allowed employees of a Wisconsin company to get coverage for non-emergency surgeries in India. Many insurance companies of USA were worried of losing customers as uninsured people could get treatment at low cost abroad. Hence some of them have started including treatment in foreign land as part of their insurance coverage. This initiative by insurance companies can be utilized by medical tourism sector of India to boost their business and capture more and more customers. A collaboration with insurance companies can be helpful in this.

A robust model of medical tourism value chain needs to be developed, which can kill the concerns of the tourists as well as the operators and service providers. Lack of communication creates misconceptions as well as cost over runs for medical tourist as well the medical tourist operators. Even though the tourists are opting medical tourism due to cost considerations, they are also worried about the time they spend outside their home. If there is an efficient value chain with proper communication channels, then time for treatments will also come down, giving an edge on the global arena to the operators in India.

Conclusion

Healthcare has become an expensive and painful service in USA. Insurance coverage rates, drug costs, treatment costs, and waiting time for treatment – all have been on a rise. Rising insurance cost is more serious a problem for the population of USA but it is a boon for the Indian medical tourism industry. All that India needs to do is capture this opportunity and further develop this industry.

This research tried to bring out the relation among rising insurance costs and rising number of uninsured in USA, so as to understand the nature of medical travels and also explain the growth of industry. But the research had one major problem and that was the non-availability of data. Medical tourism was not a full-fledged industry before 2007;hence not enough data is available. Even in India there has not been much research done in this area. Forecasted data had to be used at some points to bring out the trends.

Further research can be done to understand decision-making factors that medical tourists’ take into concern. The issues can be categorized under three sections: Push factors (things that drove patients away from care at home); Pull factors (things that drew patients to other countries); Information sources consulted. This can help in capturing more and more of the untapped medical tourism market. It would also be helpful in improving the present status of the medical tourism industry.

Research can also be done to understand how the opinion of companion of medical tourists affects their decision to take a journey for medical reasons. A research states that companions require time, attention and resources, companions can disrupt the provision of quality care and companions can also be exposed to risks. These factors can be further researched to reach out in a better way to the medical tourists.

Research can be carried out to find ways of improving government aided hospitals and also the attitude of healthcare professionals in these hospitals. These hospitals can play a major role in providing low cost healthcare service to medical tourists.

References

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Appendix A

Cost comparison of medical procedures across few countries
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