Last year, many thought the plans by McKinsey & Company to research and present a definitive study on medical travel would end all the arguments about how many medical travellers there are in the world. It has now been published.
The report has, by and large, been met with a stunned silence by the medical travel industry. Most people seem to be so bewitched by the McKinsey name that they refrain from commenting or disagreeing, yet as I am sure McKinsey would be the first to agree, it is far from infallible, and there are many instances where its predictions have proved incorrect, most notably their prediction that banks would dominate the insurance world. Having seen the report, there are very serious concerns with its methods, logic and figures. More seriously, suggesting that an industry where there are at least five million medical tourists equates to at most 85,000 inpatients worldwide is likely to restrict investment, and damage both businesses and economies relying on medical travel.
This article is written by Ian Youngman, a specialist researcher and publisher of detailed research reports on insurance and medical tourism.
Like McKinsey, I have no time for agencies, experts, politicians and hospitals that make ludicrous estimates of actual or potential numbers. A typical example last year was an Asian country, where one week one minister stood up and said his country had 100,000 medical tourists, while the next week saw another minister claiming it was 200,000. A particular problem is the ever-quoted “150,000 Americans go overseas every year”, which is nonsense with no statistical base. On the other hand, I see no need for some general agreement over a figure so that commentators on medical tourism present a united front. I am not a doctor and have no connections with any agency, hospital, government, tourist board or medical tourism group. As well as writing news stories and features for IMTJ, I research and publish my own management reports on medical tourism worldwide, and so the figures I present are from my own research. They may be wrong, but they are defendable, I believe.
As a researcher who has tried to come up with my own figures for medical tourism, I have some sympathy for McKinsey. Accurate figures are not easy to come by. There are official figures, but you have to be able to translate what they do and do not include. Other independent professional research organisations have produced reports on the subject where they interpret figures. Although none agree on exact figures, they are all in the same direction on various countries and way above the McKinsey figures. These reports are compiled by people who spend all day every day ploughing through official and other statistics. As a co-founder of a national research association, an economist by education, author of hundreds of management reports, and with years in marketing and development, I too am used to trawling through the garbage to find and analyse hidden gems.
By definition, almost every official figure is flawed. They are often badly collected, imperfectly collated and spun to infinity. Some hospitals inflate figures by counting the number of patient visits rather than number of patients. Nevertheless, McKinsey has made a number of fundamental errors in the report.
McKinsey’s research on why people go into foreign hospitals conflicts with all other reports and the experience of people in this business. The clue here is that “Nearly every provider [McKinsey] visited has received this form of [JCI] accreditation”. This is a basic sampling error. Simply researching JCI hospitals does not represent a fair or accurate sample in any country. The vast majority of medical travellers use clinics, surgeries and hospitals that are not and have no need nor inclination to be part of the JCI system.
McKinsey interviewed patients in 50 hospitals, almost all of JCI status. It then assumes that these hospitals account for 60 to 80 percent of the total world market. Even if it meant that the 200-plus JCI hospitals accounted for 60 - 80 percent of the worldwide market, this a dangerous assumption.
There are hundreds of non-JCI hospitals in the world who are in the medical travel business, plus thousands of clinics and surgeries. While some JCI hospitals are major players in the business, many have other reasons for being accredited and have little or no medical travel business.
Equally, many other hospitals, including those with other international accreditations from JCI rivals, have substantial numbers of medical travel patients. McKinsey’s assumption that its sample hospitals account for most of the world market is a cavalier one with no statistical basis. The grossing up on the basis of a non-representative sample of medical travel hospitals goes a long way to explaining why their figures are way too low.
There is a much bigger statistical error, which McKinsey themselves own up to. As we all know, almost all dental and cosmetic surgery is not on an inpatient basis. If you look at the records for hospitals that are heavily involved in medical tourism, a large amount of their business is day-surgery or outpatient treatment.
The trend in modern medicine is to keep people out of hospital beds.
In the 2006 figures for UK residents going overseas for treatment, the most common types of elective surgery were hip replacement, knee replacement, laser eye surgery and cataract removal, which are all done on an outpatient basis.
McKinsey claims that 40 percent of all worldwide medical tourists seek the world’s most advanced technologies, and most of them travel to the US. As the notes tell us, “the number of patients come from providers that participated in the research”, which in this case means a total of just under 50,000 patients. Since this is estimated as 60 to 85 percent of the total market size, it means of a total of 85,000, 32,000 go to the US and so only 53,000 go to all the other countries in the world. Contrast this with the figures from the respected Singapore Medicine whose figures in 2006 are 410,000 visits specifically for healthcare. According to Exim Bank, India had 500,000 medical tourists in 2006. Admittedly the number of people visiting the US for medical treatment has often been played down by those wanting to show that the only important market is Americans going overseas, but McKinsey has gone too far the other way. There are huge numbers travelling from one country to another outside the US. For instance, 65 to 70 percent of foreign patients going into Malaysia are from Indonesia, 5 to 6 percent from Japan, 5 percent from Europe and 3 percent from India. The numbers from the US are tiny. In Singapore, half the patients come from neighbouring Indonesia, the other main countries being Malaysia and Brunei. The US is about number 20
as a source.
In Europe, Treatment Abroad's Medical Tourism Survey 2007 reveals that India, Hungary and Turkey are the most popular medical tourism destinations for UK patients. The full list includes most European and Asian countries. The US is on a par with Tunisia, South Africa and Brazil, where only tiny numbers go.
Official government figures from the Polish Information and Foreign Investment Agency show over half a million medical tourists visit Poland every year. That figure does not include spas and wellness trips. Almost all are from within the EU; the number of Americans can be counted in tens.
The main sources of medical tourists to the US are; Canada, Mexico and Central and South America.The Middle East is low on the list, and Europeans lower still. Their reasons for visiting vary hugely. Canadians are driven by long waiting times. Those coming from the Middle East or Europe are the very well off who often seek specialist treatment; they are completely unaffected by any waiting lists at home as they use private medicine, not state health.
Type of treatment
McKinsey only counts people travelling for inpatient surgery. Dental tourism and cosmetic surgery tourism are serious medical treatments and to ignore them puts huge distortions on the figures. For example, according to the latest official International Passenger Survey (IPS) (www.statistics.gov.uk), 100,000 UK residents travelled abroad for dental and other medical treatment in 2007. If you take out dental and cosmetic treatment, this falls to below 15,000, and if you then ignore outpatient surgery, you are then below 1,000, less than 1 percent of the real figure. If you take out border hopping, it goes down even more.
If this seems too inclusive, consider that most medical tourism figures do not include the millions of people who travel abroad for health and wellness holidays to hotels, spas and wellness centres. You could argue that such health treatments are not medical. But what are all doctors and governments telling us to do and trying to encourage us to do to reduce the strain on their hospitals – lead healthier lives and have regular health checks. So using McKinsey’s theories, if I go to Taiwan for a heart operation I am a medical tourist, but if I go there for a day or more for a series of health checks, I am not. And to argue that Western medicine is medical treatment, but non-Western treatments of Chinese, Filipino or Korean medicine or Ayurveda, is simply not sustainable.
Official tourist figures
I agree with McKinsey that official tourist figures are not always accurate, but this does not mean that they should be ignored. When hospital associations, medical tourism bodies and the like go to great trouble to collect reliable statistics from their members, why should we discount them in favour of government ones on inbound tourism? Many countries do not collect detailed statistics. Some countries argue that it is an infringement of civil liberties to even ask people why they are entering or leaving a country.
But the real problem is more fundamental. The vast majority of people, who are going overseas for any type of medical treatment, if asked for reason for trip, will say “holiday”. In some countries this is because they do not want to risk being sent back on the plane. In others it is to avoid long questioning about what their medical problem is, so the authorities can check it is not contagious. Most countries only want to know if you are entering their country for business or pleasure; the former can get you into detailed questions of how long for, what work you are doing there and have you got a work visa.
Medical tourism figures
When governments, hospital associations and medical tourism bodies go to great trouble to collect reliable statistics from their members, why should we discount them? Why are they any less valid than government ones on tourism? The former often use real figures, while the latter are frequently on a sampling basis. The real reason McKinsey ignored all available figures is that those figures include all medical tourists, and these do not fit the analysts skewed and limited views of who medical tourists are.
McKinsey does not count as medical tourists any holiday or business traveller who receives treatment on an emergency basis. This is a rare area where I agree with them.
They also exclude all expatriates, ie people of one country who are either temporarily or permanently living abroad.
There are millions of expatriates in Spain, South America and the Gulf States. They are not medical travellers in the true sense. But they are often counted as international patients by hospitals. There is a dilemma here. Their purpose for travelling is not medical treatment. But when they need medical treatment, the trend is not for them to be covered by the state health system where they live. But they do have a choice – firstly of which hospital to go to in that country or to go back to their country of origin for treatment. They are a legitimate market for hospitals that also seek medical tourists, but are not home nationals or travellers.
Excluded by implication
McKinsey argues that anyone who does not put the main purpose of their travel as “medical treatment“ is not a medical tourist. But there are huge communities of first-, second- or third-generation immigrants who combine medical treatment with a trip to see the extended family in their country of origin. The classic examples are Britons going to India, the millions of Chinese and Koreans in the US and Filipinos from almost anywhere going to the Philippines.
These are markets targeted by countries and individual hospitals, which will always put the prime purpose as visiting the family. For some of these groups, the ties are so strong that every year they spend weeks or months “back home”, so having paid the airfare, increasingly they also have medical treatment, particularly as these groups are least likely to be able to afford private treatment or insurance in their county of residence.
As far as McKinsey is concerned, anyone who travels in “contiguous geographies to the closest available care” is excluded. This excludes all cross-border US to Mexico, Mexico to US and Canada to US trips. The total of these three alone would exceed McKinsey’s estimate of the world market. It also excludes most African countries where people travel to South Africa, a whole host of local Asian travel, China to Hongkong, China to Taiwan and many more. A lot of cross-border travel is the inpatient and outpatient medical treatment, while in some areas there is also dental and cosmetic treatment too; these people are not travelling as there are no facilities at home.
If you look at Europe, millions of Europeans travel across borders, a few for medical treatment, but a lot more for dental work. A million Germans travel every year to Hungary for dental treatment.
McKinsey argues that these patients have not been included because “they don’t consider other medical-travel destinations and the financial burden is minimal”, which is a strange argument, and also implies a fair
amount of mind-reading.
According to McKinsey, the worldwide total of medical tourists, using their definition, is between 60,000 and 85,000 people annually, or between 30,000 and 55,000 people who go to countries outside the US.
I compared their findings to another report that came out the same week, to which I have no connection. Independent analysts Koncept Analytics (www.konceptanalytics.com) has a short overview report on medical tourism in the four top Asian countries. The report’s author Vikas Gupta accepts that not all figures are reliable, and is very sceptical about ones for India. He has been conservative in using 2006 figures rather than higher 2007 estimates, as this gives a better like-for-like comparison. Gupta told IMTJ: “The medical tourism data was specifically sourced from government statistics.” The report has avoided the wilder claims of health groups and medical tourism promoters. The author is a specialist in economic data, so is used to navigating the world of official figures, and has no reason to inflate or deflate figures.
The individual 2006 country figures, which Gupta believes are as reliable as any government figures can be; Thailand 1,280,000, Malaysia 300,000 and Singapore 448,000.The report does not believe figures that suggest India already has over a million medical tourists a year. Taking the lowest Indian figure of 200,000, adding that to the figures above show that just the top four medical tourism countries in Asia account for over two million medical tourists every year. A recent Exim Bank survey was also dubious of Indian claims of millions of medical tourists, so used a cautious figure for 2006 of 500,000. Looking at these reports, the figures look reasonable and not hyped. Few could argue that these are the four top Asian destinations, or that the enormous amount of private and government activity will see 2008 figures much higher than 2006.It is justifiable to suggest that in 2008, three million people will visit these four for medical tourism.
Meanwhile, statistics for UK residents going overseas for medical treatment is just over 100,000, higher than McKinsey’s total world figures. It is apparent that McKinsey fell for the myth that most medical tourism is connected to the US. European countries make a lot less noise than other areas about medical tourism, but Hungary and Poland each get as many medical tourists as top Asian countries, and that is without counting health and wellness travellers.
It is my belief that if you include as medical tourists all those people who should rightly be included, and exclude emergencies, expatriates and internal country travel, my most conservative estimate for the number of medical tourists is five million. This would exclude the millions that travel for wellness, spas and health checks.
This figure is arrived at by taking the lowest possible official figures from countries and ignoring scores of countries that are active but have no figures. This includes the American continent 600,000, Europe 1.75 million and Asia 2.25 million. Almost every country shows increases in 2007 and 2008, so a realistic but very cautious figure for 2008 would be five million. If you believe that India has one million medical tourists rather than 200,000, the annual figure exceeds six million.
Earnings through medical tourism would go up to US$2 billion by 2012, said Healthcare in India: The Road Ahead, produced by the Confederation of Indian Industry, written and researched by none other than McKinsey
According to a 2006 study by global accounting and consulting firm Ernst and Young and the Federation of Indian Chambers of Commerce and Industry, 100,000 medical tourists went to India in 2004. It agreed with McKinsey that the Indian medical tourism industry could be worth US$2 billion in 2012, annual growth of 20 percent.
McKinsey may have had good intent, but the new figures could possibly damage the medical travel industry. If they do so, it would be a great shame.