In an unusual research project, dental systems research group, Software Advice, asked Americans what issues would persuade those considering overseas dental care to cancel and get treatment at home. US dentists are frustrated that Americans go overseas for dental care, and some dentists suggest that this may be because they are unaware of the range of dental treatment and the range of prices available in the USA, and that once travel and accommodation costs are taken into account, the saving may not be significant. US dentists feel they can offer better care. So dental systems research group Software Advice surveyed a random sample of 1,155 U.S. patients to identify what issues might persuade those most likely to travel for dental care to reconsider their travel plans. Only among those that said that they could perhaps be persuaded to cancel their travel plans, 39% would reconsider more expensive care in the U.S. if they were educated on the health risks associated with dental care abroad. Overseas countries and dentists may dispute this allegation, but some US dentists argue that risks could be substantial, including the potential for additional damage following a botched procedure. As a result, a course of action that patients hope will help them save time and money could actually result in worse outcomes and higher costs. American dentists hope that if they take the time to explain this to patients, they may be able to retain patients’ business while keeping them protected from health-related, financial, and legal consequences. The survey makes the flawed assumption that there are health risks involved for all potential dental tourists. It asked patients how they would like to be informed of these risks. The results showed that the majority of patients (43%) would prefer to have an in-office conversation with their dentist. In-person communication is one of the most effective ways to decrease anxieties and remind patients of the benefits and value of local certified dental care, followed by a poster or brochure, website, and new patient packet. The survey asked people about their primary concerns before undergoing dental care, and cost was the most prevalent answer at 41%, followed by no concerns at 35%, time for treatment recovery at 16%, and pain/fear at 9%. The survey suggests that those who live in the Western states are the most eager to seek a bargain overseas, with 25.5% of respondents living in the western part of the U.S. This is followed by the South at 10.1%, Midwest at 9.9%, and Northeast at 8.2%. Bearing in mind the many millions who get treated in the USA, dental tourism is a mere pinprick when it comes to numbers, and is never going to challenge the livelihood of American dentists. The survey suggests that dental tourism is growing, although there are no figures on the number of Americans actually going overseas for dental treatment. The survey does point out that web based information on dental treatment and prices in the USA and globally is becoming more easily available, and that while patients educate themselves about their choices, dentists need to have an honest conversation with their patients about the advantages of staying in the country for their dental care, not the least of which is patient familiarity with the dental team, U.S. regulated care, and immediate access to care if they have any problems. Perhaps the most interesting thing about this survey is as a reminder that educated informed patients have more control, and a threat of dental tourism can bring about improvements in how dentists treat their customers.

The government in South Korea has changed the law to allow clinics and hospitals to own and operate hotels, to help promote medical tourism. There are several hotels that have partnerships with hospitals and clinics, but the new rules will allow organisations targeting medical tourists to build and run hotels for medical tourists and partners, in their grounds or nearby. The change removes the anomaly where it was legal for hotels to own and operate clinics, but not the other way round. The stem cell clinic at the Imperial Palace Seoul hotel in Gangnam gets one in three patients from overseas, up from one in five in 2013. It has brochures in Chinese and has hired a Chinese interpreter to help Chinese patients, who account for a significant portion of foreign customers. Anti-aging treatments using stem cells are the most popular services at the clinic, and patients stay three days and two nights on average at the hotel. The clinic says that the proximity of the clinic to the rooms is an important selling point. The hotel has been running various clinics since 2009 and these now include a dental clinic, dermatology clinic, and a cosmetic clinic Other hotels partner with a nearby clinic. The Lotte Hotel in Seoul partners with the Samsung Medical Center and Korea University Hospital, who both send their patients to the hotel, where they benefit from discounted rooms and an interpretation service. The Plaza has similar partnerships with local cosmetic surgery clinics. The Grand Hyatt Incheon accommodates patients from the Inha International Medical Center, operated by Inha University’s medical school and located near Incheon International Airport. Korean Air owns both the hotel and Inha University. The Ritz-Carlton in Seoul houses the May Clinic, which has one dermatology clinic and two cosmetic surgery clinics. While local patients make up a majority of their clientele, these hotel medical clinics are now targeting foreign tourists. One reason why the government is tweaking and improving the medical tourism offering is that Korea’s currency has been strengthening—the won recently reached a six-year high against the US dollar—and unfavourable exchange rates may keep Chinese tourists, who accounted for 35.5% of the country’s visitors last year, away. Whether this will affect medical tourists is not known. Rising political tension between Korea and Japan has already reduced tourism numbers from Japan, by 22% in 2013.

The southern Chinese tourist resort of Hainan offers tourists the chance to live longer. The International Expert Committee on Population Aging and Longevity (ISCPAL) has declared the island province as a World Longevity Island. The only other island in the world names as a longevity island is South Korea’s Jeju Island. ISCPAL conducted field research in 17 places in 2013. Hainan has 1.2 million residents above the age of 60, 13.36 % of its total population. By 2015, the number of octogenarians is expected to reach 170,000. The tropical island has high-quality air and water, an outstanding natural environment and strong social welfare system. It. A study by the ISCPAL showed that the hair of Hainan’s centenarians has ample trace elements, which are beneficial to human health. The soil and produce in Chengmai county in western Hainan are rich in selenium. Two places in Hainan were previously branded as "Longevity Cities" by ISCAL, Chengmai and Wanning. Wenchang City is also famed as one of the country’s top longevity spots. China hopes that this latest accolade will help Hainan attract health and wellness tourists. Longevity tourism is a peculiarity of China with thousands of Chinese travelling to Bama County in South China’s Guangxi Zhuang Autonomous Region to seek the recipe for a long life. The county’s longevity pilgrims can be seen crawling around on four-legs and are even known to drink urine, believing the practices help keep illness at bay. IMTJ’s editor has been volunteered to test whether it works for Europeans. Longevity tourists even have their own name "houniaoren," or "migratory people," who fly south in winter and stay in Bama for several months. Government statistics show 180,000 migratory people visit Bama each year. Bama and Hainan are seeing increasing numbers and want to attract people from other countries, although this may be limited to Chinese speakers for long stays, as local language ability is very limited. The Hainan Boao Lecheng International Medical Tourism Pilot Zone, the only national pilot program in medical tourism granted by the State Council, is now under construction, featuring healthcare and longevity-related services.

A recent magazine feature suggests that the business of “assisted suicide” is now attracting people who are not terminally ill. In Switzerland, the numbers of people travelling from abroad to die are growing dramatically. Even more disturbing is the fact that the reasons they cite in seeking suicide are growing beyond inevitably terminal illness to include traditionally manageable conditions. For years, the Swiss government has adopted a hands-off attitude to the business. Assisting suicide in Switzerland is technically illegal, but the law punishes only those with selfish motives–which has turned out to be nearly impossible to prove in Swiss courts. This has, in practice, led to a system where anyone can assist in a suicide with essentially no restriction on whose suicides they facilitate. Assisting suicide is legal in only a handful of jurisdictions in the USA and Europe. The New Scientist magazine article, ’Non-fatal diseases increasingly drive assisted suicide’ reports “An ongoing study of assisted suicide in the Zurich area has found that the number of foreign people coming to the country for the purpose is rising. 123 people came in 2008 and 172 in 2012. In total 611 people came over that period from 31 countries, with most coming from Germany or the UK, with 44% and 21% of the total respectively. " “Neurological diseases, only some of which are fatal, were given as the reason for 47% of assisted suicides for 2008 to 2012, up from 12% between 1990 and 2000. Rheumatic or connective tissue diseases, generally considered non-fatal, such as rheumatoid arthritis and osteoporosis, accounted for 25% of cases in the new study. Between 1990 and 2000, they were cited in only 10% of cases. There was also a tiny rise in the number of people coming to Switzerland because of mental health problems – 3.4% in the latest study, up from 2.7%. Cancer was cited in 37% of cases between 2008 and 2012, a decrease of 10%.” According to the Swiss government, “Assisted suicide is resorted to when life no longer appears worth living for the person concerned, in particular due to a serious physical illness.” This legal vagueness has made Switzerland attractive to outside groups who promote suicide. The leading promoter of suicide tourism is Dignitas, but an increasing number of other businesses arrange trips for potential suicide victims. The New Scientist article quotes UK suicide advocate Michael Charouneau “We know that many of those who travel do so earlier than they would wish, whilst they are still physically well enough to make the journey.” The UK laws on assisted suicide are complex, and in most US states it is illegal. But doctor prescribed suicide is legal in Washington State — where there was a 43 percent rise in doctor-prescribed suicides in 2013. In a trend similar to that in Switzerland, other concerns, not pain from a terminal illness, are motivating the requests for suicide. It is also legal in Oregon and Vermont.

While medical tourism linked insurance has not yet happened, and shows few signs of being important to health insurance in the future, an increasing number of international health plans accept that in certain parts of the world it is important to offer cross-border healthcare. This cross border healthcare is aimed at situations where a hospital or clinic in a nearby clinic may offer the best solution for a patient. These insurances are not blazing a trail for overseas treatment, as they are following where people already go. They are not aimed at covering planned overseas treatment, as many of these procedures such as cosmetic and dental surgery are outside the cover, AXA PPP International has a new international plan for Kenya and Tanzania as part of the strategy to expand into African countries using local partners. The Pan Africa Plan is distributed by Nairobi based insurance broker J W Seagon, and covers treatment and care in facilities across the African continent, as well as offering the added flexibility of having treatment in India and Pakistan when needed. Pan Africa Plan offers five levels of cover to meet people’s healthcare needs and budgets. Bronze cover provides benefit for in-patient and day-patient treatment and includes the option to add outpatient cover for those wanting extra protection. Silver and Gold provide additional benefits to those of Bronze, including outpatient drugs and dressings and, for Gold, an annual health check. Platinum, the top-of-the-range option, includes cover for routine dental care and Chinese herbal medicines as well as palliative care for all diagnoses. Emergency evacuation or repatriation comes as standard across all five cover levels. An increasing number of New Zealand health insurance providers, allow customers to go to Australia for treatment. Like all health insurance, the products do not cover existing health problems. In most of these policies, it is the insurer who decided where the customer is treated; the customer cannot on a whim decide to go to an overseas hospital. Insurers have their own global network of hospitals and doctors, mostly with agreement on prices drastically below the list price that a direct patient would pay; which is why agents and hospitals targeting insurers by comparing prices in their country with where the customer lives, are wasting their efforts.

IMTJ has published several reports on plans for medical tourism to the Bahamas, but these plans have yet to bear fruit. A local surgeon has put forward his view on the lack of progress. Bahamas surgeon Duane Sands says, “The Bahamas must knock down all the barriers that threaten the viability of a medical tourism industry, as there is a disconnect between rhetoric and reality. The Bahamas needs to embrace medical tourism and push it aggressively to potential overseas clients/healthcare providers, if it is to establish itself as a major player in the sector. The supporting infrastructure, with a timely and efficient approvals process, requires implementation. Time is money, and various approvals committees described in legislation are yet to be appointed. So potential investors will head elsewhere rather than suffer inordinate delays in the Bahamas." A new law on the still controversial use of stem cell therapy is aimed at making the Bahamas a global pacesetter in stem cell therapy and related practices But Sands points out that the new law is useless unless the infrastructure is in place so that people can get treatment. “It is all well and good to talk about it and strategise about it. The difficulty is when you convert that into action. I am not holding my breath. We need implementation, whether it is one, two or three new medical tourism programmes by the Government, or the private sector with the support of government, to make anything happen. I am not optimistic that anything will ever be done. It threatens the viability of the industry if you create projects and business plans on a basis that assumes certain things will happen. Then they do not happen, and you have got to go back and revise it and revise it again. It is then that people start to look at other jurisdictions. Investors will not wait for a two or three year delay in a multi-million dollar project." The Bahamas has a history of medical tourism projects that have been slow to materialise. Doctors Hospital has suffered licensing and permit delays associated with its medical tourism programme. Approvals delays meant its Bahamas Medical Centre hit just 53% of its projected $2.64 million revenue target for the year to end-January 2014. The frustration of Doctors Hospital is expressed by chairman, Joseph Krukowski: “Delays in receiving the appropriate approvals for the projects to proceed continue to frustrate our intentions. Further delays could result in loss of these enterprises to other destinations, which appear more receptive to accommodating the operation. If this were to occur, it would be detrimental to the patient community, the medical profession, the hospitality industry and the country’s reputation in general.” Building and other planning regulations are not the only barriers to progress. Fiscal incentives for clinics buying imported medical equipment have either not happened or have been difficult for clinics to access and gain approval from the government. The development of the Princess Margaret Hospital’s critical care block has also suffered delays. The unfinished building is already 18 months behind schedule. Duane Sands concludes, “It is one thing to say you are committed to medical tourism, it is another thing entirely to allow it to happen. The government’s approach to-date had been a lot of hyperbole, a bit of rhetoric and business as usual. The Bahamas needs to dedicate resources to make it happen, with the Ministry of Tourism, Ministry of Health and Ministry of Finance working in concert.” The Bahamas is not the only country where politicians have made numerous promises of support for medical tourism, until it comes to the point of committing time, money and resources.

International tourist arrivals grew by 4.6% in the first half of 2014 according to the latest UNWTO World Tourism Barometer. Destinations worldwide received 517 million international tourists between January and June 2014, 22 million more than in the same period of 2013. Growth was strongest in the Americas (+6%) followed by Asia and the Pacific and Europe (both at +5%). By sub region, South Asia and Northern Europe (both +8%) were the best performers, together with North-East Asia and Southern Mediterranean Europe (both +7%). For the full year 2014, international tourist arrivals are expected to increase by 4% to 4.5% worldwide, above UNWTO’s long-term forecast of 3.8% per year for the period 2010 to 2020. Growth picked up significantly in the Americas (+6%). All four sub regions benefited, with North America, boosted by Mexico, Central and South America all increasing by 6%, and the Caribbean by 5%. In South America (+6%), the hosting of the Football World Cup in Brazil contributed to the positive results in the sub region – receipts from international tourism in Brazil grew by 10% in the first seven months of the year with a 60% increase in June and July. Asia and the Pacific (+5%) consolidated the trend of recent years, with South Asia (+8%) and North-East Asia (+7%) in the lead and major destinations such as Japan, the Republic of Korea and Malaysia posting double-digit growth rates. The region has been benefiting from economic growth, continuous investment in infrastructure and simpler visas. Europe (+5%), the most visited region in the world, continued the strong pace of growth of 2013, driven so far this year by Northern Europe (+8%) and Southern Mediterranean Europe (+7%). These results reflect improved consumer confidence in Europe and the rebound of important traditional European source markets. Africa’s international tourist numbers grew by 3% as the recovery consolidated in North Africa (+4%). The Ebola virus outbreak might affect tourism to the region due to misperceptions about the transmission of the virus. The World Health Organization does not recommend any ban on international travel. Putting a halt on flights or imposing unnecessary travel restrictions will not help contain the virus. International tourist arrivals in the Middle East are down by 4%, though this figure should be taken with caution as it is based on limited available data for the region. In terms of source markets, data for the first half of 2014 shows a consolidation of the rebound in spending in travel abroad in 2013 in some advanced economies. Expenditure out of the Italian and Australian markets was up 8% and 7%, respectively, while the US market was up by 5%. Data for France and Canada indicates a 3% increase. Demand generated by emerging markets continues to be strong, though decelerating as compared to 2013. Chinese outbound expenditure was up 16% in the first half of the year as compared to 26% in the whole of 2013, while expenditure out of the Russian Federation was up by 4% as compared to 25% last year.