Beauty from Afar

Chapter 3 Page 5 | The Media Imprimatur

The media in the United States did not really discover medical tourism until 2004-05, and it was found in the Far East rather than in central and South America. It was Bumrungrad Hospital in Thailand and the Apollo Hospital Group in India and Penang Adventist Hospital in Malaysia that made 60 Minutes and the front pages of the Wall Street Journal and The New York Times, not the plucky surgeons and dentists of Costa Rica, Mexico, and Brazil — even though far more U.S. citizens were heading South for inexpensive medical and dental care and surgery than were heading to the Far East. There are a few good reasons for that, which I offer not as an apology for the media but as explanation:

1. The story wasn’t about cosmetic surgery, which, despite its popularity and the professionalism of its practitioners, doesn’t get the same treatment in the news as does “real” medicine. Cosmetic surgery news is fluffier, more frivolous, than open-heart surgery news. The international hospitals of the Far East, wisely, didn’t play up cosmetic surgery — though they do a lot of it. They played up cardiothoracic surgery, and their state-of-the-art technology and facilities, and thus were taken more seriously. For the first time, much was made of the fact that there is an estimated 42 million people in the United States who lack adequate medical insurance who could go out of the country to get treatment they could not otherwise afford.

2. The story was delivered in part as a business story with big dollar signs, the kind that gets attention from the media. India put a $2 billion sticker on medical tourism. As previously noted, Bumrungrad sees more than 350,000 patients a year.

3. The story was generated by big multipurpose hospitals, and supported by the tourism and economic development officials of their respective countries. This is the way countries in the Far East go after markets, and there is nothing in Central or South America to compare as yet.

As we move through the first decade of the 21st century, medical tourism is still both newly discovered and in transition. The tip of the iceberg remains elective medical care, mostly cosmetic surgery and dentistry; beneath the surface is the larger consumer health-care market of North America and Europe.

And the media is paying attention. In February 2006 a West Virginia state legislator introduced the first bill in the country providing for the outsourcing of medical care to foreign countries. In Chicago, Blue Cross/Blue Shield investigated and then approved payment for an insured child’s heart surgery in India. And when President Bush visited India for the first time in March 2006, the two countries released a statement pledging American support for Indian efforts to support medical tourism, saying there is “enormous potential for collaboration” in health tourism.

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Chapter 3 Page 3 | Build It, and They Will Come …

Arnoldo Fournier, M.D., a cosmetic surgeon in San Jose, Costa Rica, was one of the pioneers in marketing his services abroad. He came to Costa Rica in the early 1980s, fresh from his residency at St. Luke’s Hospital in New York, and was told that there was no demand for aesthetic procedures in Costa Rica.

Stubbornly, he stayed and went after the U.S. market. He placed his first ad in the Tico Times, the Central American country’s English-language daily; later, he turned to the flight magazines of the international airlines: LACSA, Eastern, Skyward and Passages among them.

By the 1990s,  Dr. Fournier and other Costa Rican cosmetic surgeons, dentists, and doctors thought they had a pretty good thing going. Costa Rica was beginning to prosper as a tourist destination and U.S. retirees were making the country their home in increasing numbers; the number of Americans desiring cosmetic surgery was starting to rachet up.

Prices for cosmetic surgery in Costa Rica then, as now, were much lower than in the United States. I received an e-mail in December of 2004 from a woman in Florida who had read what I had written about my own trip for dental work; she affectionately recalled going to see my dentist, “Dr. Telma,” in 1986. She wrote:

In 1986, Dr. Telma installed 13 crowns in my mouth for $1,200. At that time, if I had this work performed in the U.S., it would have cost about $4,000 to $6,000 … As she worked, Dr. Telma and I also had incredible intellectual discussions on the anthropology of Central American Indians, their bone structure and diet, and where they came from. Both she and her husband are very well educated in many other areas, and not just dentistry … I came across your article as I was searching the ‘Net for her services again. I need two crowns and some teeth bleaching, and a minor face lift, which I am going to coordinate and schedule this summer if possible.

So what was to become known later as medical tourism was already growing in Costa Rica in the 1980s and into the 1990s. In what was to prove to be a prescient report, the World Bank in September 1995 published a 52-page study on Prospects for Health Tourism Exports for the English-Speaking Caribbean. (2) It noted:

Direct patient care is the major health service exported by Costa Rica. In addition to plastic surgery, a full range of pediatric and adult services including high technology dependent procedures such as open heart surgery are exported. Costa Rica’s target markets for the export of health services are the United States, other Central American countries, Puerto Rico, Barbados, and other Caribbean nations, Colombia, Venezuela, Canada, and Spain.

The prescient part of the study identified the reasons why potential for further substantial growth existed in the Caribbean countries:

• Demographics in target markets (for example, aging post-war baby boomers who are concerned about physical appearance, semiretirement, full retirement and relaxation) will mean marked increases in demand for cosmetic surgery, spas, and retirement communities.
• The growing affluent class of baby boomers may be less price sensitive and more sensitive to other aspects of the marketing mix (for example, location and confidentiality.)
• Lifestyles in Europe and North America increase the demand for services such as spas, fitness centers, cosmetic work, or addiction treatment centers.
• Waiting time for procedures in the United Kingdom and, to a lesser extent, in Canada encourages the search for outside health services.
• A large portion of the U.S. population is uninsured or underinsured.
• Private insurance does not cover selected treatments.
• Operations in Caribbean regions appeal to doctors from target markets that enjoy visiting the region, which could facilitate strategic alliances and capital investment.
• Lifestyle health-related problems in the target markets are similar to those among people in the Caribbean, and quality health and social marketing materials could be exported to these markets.

“The U.S .market is most apt to offer opportunities to the Caribbean because it has a large uninsured and underinsured population, it has very high prices, and it is geographically close to the Caribbean,” the report stated. “Moreover, the U.S. system is more fragmented and less controlled than health sectors in other industrialized countries. As a result, the U.S. market has multiple avenues of entry.”

The report also summed up the challenges facing countries going after the health tourism market as well, among them that:

• U.S. medical doctors act as “gatekeepers” for the U.S. health-care system and would not want to lose patients to the Caribbean market.
• Questions about quality of care in the Caribbean will exist in consumers minds and will be difficult to overcome.
• Neighboring countries in Latin America could provide care at lower cost, as could countries in Eastern Europe.

Other than leaving out the entry of Asian, Middle Eastern or African nations into the market, the World Bank study was a blueprint for medical tourism for the next decade for anyone who cared to follow it. However, it made no particular impact then that I can discover now. What it stated was already obvious to pioneers in Costa Rica and elsewhere, but it took years for much of the world to begin to notice. The third and final precondition for medical tourism to become a globe-straddling business was that people had to know about it; it had to be marketed to a broader audience, somehow. The Internet came along at just about the right time.

(2) Prospects for Health Tourism Exports for the English-Speaking  Caribbean by Maggie Huff-Rousselle, Carol S. Shepherd, Robert Cushman, John Imrie, Stanley Lalta. World Bank, Washington, D.C.; Social Sectors Development Strategies, Inc. September 1995.

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