Healthy Travel Media, publishers of ’Patients Beyond Borders’ have released an up dated and expanded third edition of the consumer guide to medical tourism and international health travel. This print and ebook offers health travellers information to help make decisions about traveling abroad for healthcare. The publisher claims that more than a million US patients will cross borders for medical care in 2014; nearly double the number in 2011. Both figures have to be questioned due to the lack of supporting data; there were no published figures for outbound US medical travel in 2011, there are none now, and analysts suggest that both figures are a huge exaggeration. The risk is that these figures will be used and re-used in future years by commentators and the media as “internet facts”. Patients Beyond Borders author Josef Woodman says, "Worldwide, millions of patients young and old are without access to quality, affordable medical care, often one diagnosis away from financial ruin." Patients Beyond Borders lists hundreds of international hospitals and clinics, providing healthcare consumers a wide range of affordable medical tourism options for quality care that did not exist just ten years ago. The book claims that overseas costs savings of 40% to 85% compared to US medical costs are common in more than 20 leading medical destinations around the world. But the publishers do not state where this information comes from. Patients Beyond Borders is available in print and fully searchable ebook format. Jeremy Abbate, publishing director of Scientific American Worldview, comments, ’The seeking of health solutions beyond one’s own national boundaries can be seen as part of the broader patient empowerment movement, in which the locus of control begins to shift from provider to health seeker.”

With Europeans being a target market for medical tourism it is important to note that most are actually content with their local healthcare providers, but while some countries are very happy, others are not at all content. The latest Eurobarometer survey ’Patient safety and quality of care’ on patient quality of care was conducted in all 28 EU countries. Overall, Europeans are happy with the quality of their healthcare, although with big differences between countries. 70% are satisfied with the overall quality of the healthcare in their home country. While almost all in Belgium (97%), Austria (96%), Malta and Finland (both 94%) say that the overall healthcare quality in their country is good, only 25% in Romania and 26 % in Greece say the same. The eurozone debt crisis has forced some governments to drastically cut public health budgets in an effort to contain deficits, with Greece being one of the countries taking the toughest measures. But despite the crisis, in some countries, citizens are becoming happier about the quality of healthcare they receive. Since the last Eurobarometer survey in 2009, there have been some big shifts in opinions, including in Lithuania, where 40% said the overall quality of healthcare in their country was good compared to 65% now. In Hungary, Portugal and Malta they are now considerably more likely to be positive about the overall quality of healthcare in their respective countries. When asked to name up to three criteria that they associated with high quality healthcare, the top three are well-trained staff (53%) and treatment that works (40%) and modern medical equipment (25%). Surprisingly, people said that cleanliness is as important as no waiting lists and proximity of hospital and doctor (24%). That waiting list length is of quite low concern is important for hospitals and countries targeting Europe on the basis that this is a factor that could encourage people to become medical tourists.

Research by WhatClinic says that butt implants, also called buttock augmentation, rose by 484% in the past two years, and involves silicon implants similar to breast implants being inserted into each buttock to give a fuller, rounder posterior. Women want to look like Jennifer Lopez, Kylie Minogue, Cheryl Cole, Kim Kardashian or Pippa Middleton. This procedure is not cheap at a price tag of £4,229 in the UK. So Central and Eastern Europe see patients travelling to these destinations to pay half what they would in the UK. On WhatClinic, Turkey has seen the most enquiries for butt lifts, implants and reductions, followed by Poland and the Czech Republic. Short flights and cheap air travel make these destinations popular with the British. In Turkey, a butt lift will cost £2,118, while butt implants cost £2,393. Poland is the cheapest destination for butt lifts at £2,103 and the Czech Republic for butt implants at £2,117. 2013 cosmetic surgery statistics just from clinic comparison site WhatClinic users says arm lifts increased by 473% as women waved goodbye to bingo wings. Prices in the UK average £3,872. One of the more unusual procedures trending in 2013 was buffalo hump removal that had no interest in 2012, but saw a 350% increase in 2013.This surgery removes the fatty build –up at the base of the neck caused by excessive weight gain. Although still not widely available in the UK, demand from British patients is up. Male breast reduction enquiries more than doubled but one in three went overseas to countries such as Poland, the Czech Republic and Belgium, where surgeries are considerably cheaper than in the UK. Some treatments such as tummy tuck and abdominal etching are less popular as many patients opt for alternatives including fat transforming. Facelifts fell dramatically as people move to less invasive treatments, such as non-surgical facelifts and dermal fillers. WhatClinic also reveals popular trends in where people go and for what treatment- •Dentures in Thailand. •Turkey for butt implants. •Czech Republic for rhinoplasty. Overall, the most popular cosmetic surgery and fertility treatment destinations for Brits are Spain, Greece, Czech Republic, Thailand, Turkey, Hungary, Bulgaria and Poland. Caelen King of WhatClinic comments: “The biggest draw of medical and cosmetic tourism is price as Brits going abroad can look to make considerable savings even after the travel costs. There are fantastic cosmetic surgeons all over the world but some countries are less regulated, so standards can vary dramatically.” While price is a factor, the range of prices within the UK for any treatment can be huge- •Avon is the most expensive city for a dental consultation (£67); Bradford is the cheapest (£15). •Dental implants in Plymouth cost £2733, but in Oxford can be £1200. WhatClinic looked at fees charged by 11,000 private dentists across the UK for some of the most common treatments. Surprisingly, the cheapest areas for treatment were all in the south of England and not the North or rural areas as may be expected. The reason for this is that there is more competition in the South.

Ensuring Ontario’s health system remains strong means Ontario’s Liberal government must immediately ban medical tourism says the province’s top professional nursing association in an open letter. The Registered Nurses’ Association of Ontario (RNAO) condemns the increasing practice of Toronto hospitals attracting medical tourists from abroad. The Registered Nurses’ Association of Ontario is the professional association representing registered nurses, nurse practitioners, and students in Ontario In an open letter the RNAO argues that it is now is the perfect time to reaffirm that Ontario’s publicly funded health system needs to be protected and strengthened: “Our treasured health system is under attack by those who seek profit making opportunities from the provision of health services. The tragedy is that now, the enemy is from within. Experiments with medical tourism are underway by hospitals in Toronto that are soliciting pay-for-treatment patients from abroad. These experiments are eroding the quality and accessibility of health services for all Ontarians.” There has always been a strong health lobby in Canada that opposes both inbound and outbound medical tourism, but this is the first time that an entire professional body has asked for a complete and immediate ban.

Medical tourism agencies are crucial connectors between foreign patients and host countries. They help patients navigate countries, doctors and specialties. But little attention has been paid to the authenticity of information displayed on their websites and whether they follow ethical guidelines and standards. Agents must be educated about the ethical aspects of patient care, prevented from exploiting patients or clients, and made to respect their privacy and confidentiality. They must be subject to regulation at the international level by an organisation that has the power to enforce its decisions. It is equally important to assess consumers’ perceptions and educate them on the information displayed on web portals and its implications. Ethical guidelines must also be established and followed if these companies are to build the trust and reliance of patients. These are the conclusions of Suchitra Wagle, a research scholar at the Indian Institute of Technology, Bombay, who analyzed the websites of 200 medical tourism agents and published the results in an Indian Journal of Medical Ethics report “Web-based medical facilitators in medical tourism: the third party in decision-making” The emergence of web-based medical tourism agents has added a new dimension to the phenomenon of cross-border travel. They help patients navigate countries, doctors and specialties. However, little attention has been paid to the authenticity of information displayed on the facilitators’ web portals, and whether they follow ethical guidelines and standards. The research analyses the available information on 208 agency websites across 47 countries for the services offered. India was the most common destination country linked to 81 agents. The five countries with the most agents were USA, UK, India, Canada and Poland. The paper identifies concerns regarding the information displayed about patients’ safety, and the maintenance of confidentiality. There is a need to develop ethical standards. Extracts from the full paper: “There is no control over the type of information displayed on websites. A study based on framing theory shows that positively framed information – such as when web portals carry photographs of accredited hospitals equipped with the latest technology, or success stories of foreign patients – can influence consumers’ decisions. However, while doing this, the websites may ignore important issues such as information about the risks associated with surgeries, or about post- operative care. There are also questions about the accuracy of the information transmitted to patients. Additionally, when patients provide personal medical information, ethical questions arise regarding privacy and confidentiality. These portals may not always provide information about the healthcare laws and regulations in the host country. Studies have shown that limited information is displayed on the web portals, specifically about legal aspects and patients’ rights. There do not seem to be any regulatory boundaries within which facilitators should function. Cost is considered to be the major pull factor for medical tourists and web portals are cashing in on this aspect. Out of 120 agencies displaying information about prices, 36 provided a price comparison between the prices in the host country with various destination countries. For example, prices for various medical procedures such as bypass surgery or knee replacement were compared across the USA, the UK, India, Singapore and Thailand. Patients’ testimonials usually appeared on the side columns and described good experiences of medical tourists with the hospital or the doctor. Web portals providing cosmetic service information carried before and after photographs of patients. The most common services were medical and cosmetic procedures, followed by ophthalmic and dental services. Specialized surgical procedures covered heart surgeries including bypass and angiography, hip replacement procedures. Cosmetic procedures included weight loss techniques, breast augmentation surgeries and body sculpting procedures. Some portals were dedicated to dental and eye procedures. Ophthalmic procedures were chiefly LASIK operations. Most of the portals providing cosmetic services were also linked to dental services. The websites studied displayed patient information in the form of testimonials and photographs, along with the type of treatment taken, and other details. Such information could be very sensitive and patients may not want to disclose it. It is not clear whether patients gave consent for these details to be made public. Aftercare was given the least importance by the portals, usually described in a one-line reply as part of the frequently asked questions. Patients may be attracted by price comparisons and perceived quality of care. However, important issues such as confidentiality of information, aftercare and patient’s rights are not prominently discussed on these sites. Privacy and data protection are important subjects when technology allows information to be easily stored, retrieved, accessed and exchanged. When medical information is posted without any data protection, the confidentiality of patients’ personal information is compromised. Further, medical tourists return to their home country after the treatment, so providing information about aftercare is very important. The fact that none of the websites mentions patients’ rights should be taken into consideration at the time of formulating guidelines. The proliferation of agencies raises ethical concerns that highlight the need for regulatory measures. Recommendations ·Portals can be evaluated and rated by health professionals to enable patients to better determine the quality of information. ·They should also receive accreditation by international bodies. ·Information about the health provider is a decisive factor while choosing a hospital. Agents should ensure that they provide correct information about the education, qualification and years of experience along with the registration details of the provider. ·They must ensure information shared by patients on these sites is kept confidential. ·Patients should receive information on the potential risks of a procedure, as well as any risk associated with their travel and stay, before they make a decision to use medical tourism. ·The medical tourist must be informed of relevant health regulations and ethical guidelines in the country where s/he is going for treatment.

When there are a substantial number of people from one country or group of countries, rather than them going overseas to get treatment, dentists and others have been setting up clinics in the UK to target that market. This has happened to Hungarian dental clinics, and all types of clinics for Poles. These clinics may start off as targeting one nationality but soon their fame as low cost but efficient and friendly clinics means they get people of all nationalities. Some Hungarian dentists and businessmen realized that patients are reluctant to travel for medical treatment, especially if they had not yet met their dentist. Rather than waiting for patients to come to them they decided to go to the patients and set up clinics in the UK. Vital Europe were one of the first clinics to offer treatment in the UK and Hungary and say that people are a lot more likely to travel if they can have a consultation carried out at home. These clinics give patients the option to have treatment in the UK, in Hungary or a combination of both. Since 2007, private Polish medical clinics have sprung up all over the UK; there are at least 20 in London, they exist in Manchester, Reading, Bristol and Glasgow. Wherever there is a Polish community, there is a private clinic. My Medyk was launched in 2008 and has doctors split across the sites at Ealing Broadway and Hanger Lane. Of its 30,000 patients, 70% are Polish speaking. Some prefer to see Polish-speaking doctors, although many who use the private clinics speak excellent English. More simply want better customer service than British GPs tend to provide, with their brief consultations and frustrating systems for booking appointments. In Poland, as in much of continental Europe, GPs do not act as gatekeepers. Patients book appointments directly with specialists, who also perform procedures that would be classed as outpatient services in the UK. The clinics charge fixed fees, which are published on their websites, for consultations and treatments. This means that they rely on regular customers for revenue, and need to treat them well if they are to retain them. Green Surgery in London and Manchester has Slovaks, Hungarians, and Portuguese on its books. Whereas the Green Surgery caters mainly to professionals, My Medyk’s patients come from a broader range of backgrounds. Clinics tend to open longer than most private clinics and offer a far wider range of services than GPs. My Medyk in April 2014 began offering specialist eye care, in co-operation with a specialist eye clinic in Poland– Oftalmika. Instead of sending patients to Poland, the specialists fly regularly from Poland to London to treat patients in the UK.

Sandy Beach Medical Center and US hospital group AMERIMED have joined forces to build a full service medical tourism hospital in Puerto Peñasc. Puerto Peñasco is a city in the Northwest of the Mexican state of Sonora, 100 km from the border with the US state of Arizona. The location joins the peninsula of Baja with the rest of Mexico. The area is part of the Altar Desert and since the 1990s there has been a push to develop the area for tourism, as it is heavily visited by people from Arizona and California. Puerto Peñasco is often called Rocky Point in English, and has been nicknamed “Arizona’s beach” as it is the coast closest to the major cities of Phoenix, Tucson and Yuma, and many Arizonans spend weekends there. In 2009 Dr. Jesús González-Gaytán opened his clinic in Rocky Point. Sandy Beach Medical Center offers services to locals, expatriates and medical tourists from the USA. Dr. González sees the potential of Puerto Peñasco for tourism. He is now medical director of the new Hospital AMERIMED Puerto Peñasco. With four hospitals located in Cabo San Lucas, Cancun, Puerto Vallarta and San José del Cabo AMERIMED is used to running medical tourism hospitals with bi-lingual staffs, U.S. trained, certified and/or educated and licensed doctors and nurses, state of the art diagnostics equipment and a corporate core commitment to the medical tourism industry.

A Taipei-based healthcare company has launched a partnership with Aerospace Industrial Development in Taiwan, to offer new medical tourism services that include aerial tours in a small seven-seat plane. Show 101 Royal Health Care, part of the Show Chwan Health Care System, has developed the tour package for international travellers, business travellers and retirees who can enjoy relaxing trips provided by AIDC’s flight service after they have used Show 101 facilities for a physical check-up or cosmetic beauty treatment. It is not suitable for people who have had medical, dental or serious cosmetic surgery. The company is targeting customers from Japan, South Korea, Indonesia, Vietnam and Thailand. Show Chwan Health Care System has several hospitals in Taiwan. A healthcare coordinator accompanies passengers to ensure they are in good enough physical condition to fly safely. AIDC pilots provide guided tours either in Chinese or English and customers have three options to choose from: north line, south line and round-island line, it said. The tours allow passengers to view landmark buildings and popular tourist attractions from on high with breathtaking aerial views of Taiwan.