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Should medical tourism facilitators be regulated?

Regulator signing off a clipboard

Zahid Hamid from the UK facilitator, Euromedical Tours, puts forward his view on the need for regulation of medical tourism facilitators and agencies in the growing medical tourism market. Do we need regulation... and who should be the regulator?

“Would you like to be regulated as a facilitator, Zahid?” was the question put to me as I sat in the breakfast Q&A session at the European Medical Travel Congress 2012 in Berlin.  Here’s my view for the benefit of a wider audience.

Let us make the distinction between the two types of facilitators that sit between the patient and the service provider; those facilitators who reside in the destination country, and; those who are based in the country of origin of the patients. There can be little doubt that the former are provider-centric and the latter patient-centric. This distinction comes by way of the proximity of the facilitator to provider or patient. To whom they owe their allegiance determines the attitudes that they bring to the patients’ journey, the services provided and the value added to the patient journey and experience.

Coming back to the question put to me, let me ask a counter-question; how many facilitators have adopted the Treatment Abroad Code of Practice?  It is very obvious that the adoption of a code of practice brings credibility to the activities of the compliant companies and helps them raise their heads above the rest.

The answer is instructive and reveals the true dimensions and nature of medical travel model in existence. There are a dozen facilitators who are currently compliant and all have a singular focus; to win the custom of UK patients. There is a 50:50 split between the compliant companies being clinics or facilitators. And, only one of the twelve is a facilitator and is based in the UK. But, compliance stops short of regulation. Compliance is about talking the talk and regulation is about having to walk it while you are watched!

Why do we need regulation?

So when asked the question, if I would like to be regulated as a facilitator, my answer was unequivocally in the affirmative.  To borrow from Shakespeare, ‘some facilitators have the onus thrust upon them’. Sitting in the UK, it is inescapable to:

(a)   make credible the pre-treatment, diagnostic processes

(b)   render complete visibility to pricing

(c)    translate post-operative care into reality with support in the country of origin

(d)   provide for a return to the destination for revision or corrective treatment and,

(e)   have a plausible and tangible answer to the ‘what-if’ scenarios that can and do arise.


Facilitators based in the destination countries, just like hospitals and clinics, do not wish to reach out to the patients in the country of origin, but bury their heads in the sand to wish the problems away, when they arise. The problem is that they can get away with it! That is why regulation must be hastened to oversee the healthcare travel model.  In this state of healthcare tourism that exists around us today, one is reminded of George Orwell’s Animal Farm and the fact that ‘some facilitators are more equal than others’. 

This is not an exercise in self-gratification but simply an illustration that the healthcare travel industry is hamstrung by the lack of outreach in the diagnostic and post-operative care dimensions, which accompany, of necessity, local presence and proximity to the patient. The facilitator in a destination country is no more than a glorified concierge; the middle man that allows the service provider to distance itself from the patient, when they need it the most. In my response at the Q&A session, I had remarked about the need to breed trust between the players, the processes and the patients that they serve. This element of trust will only come with that outreach, to begin with.

Who should regulate facilitators?

The next key point is... who should regulate the facilitators? There is an analogy with every other association of tradespeople that espouses a code of conduct to serve the industry and further its members’ interests.  In my view, the US based Medical Tourism Association is not such a body and its certification programme is the exception that proves the rule. For the record, the MTA Certification program, launched in Nov 2008, has a total of four certified facilitators; two based in Canada and another two in the US.

If outreach and the accompanying trust that it must harbour, do not supplement the healthcare travel model to render it complete, medical tourism will remain a cottage industry. One heard of the European Medical Travel Alliance in Budapest in 2009 but little progress was made. The European Cross Border Healthcare Organisation (ECHO) met for the first and only time in Barcelona at the 3rd EMTC in 2011, however, the name did not echo in Berlin at the Fourth. Will it surface in Monaco at the IMTEC 2013? Only time will tell. Time is one commodity we have plenty of in the world of Medical Tourism – it’s not going anywhere without us!


Comment


Profile of the author

Zahid Hamid

Zahid Hamid is a Management Consultant with over thirty years of experience in the public and private sectors. He managed two software houses listed on the London Stock Exchange before committing himself to the healthcare sector in 2004. He presently heads an outbound facilitation service to Europe and South Asia - Euromedical Tours - and an inbound and intra bound service to the UK - Right Choice UK.  He is a regular speaker on issues of topical import at healthcare travel industry events.


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I am so glad to have opened Pandora 's Box in broaching the subject of Facilitator regulation and am grateful for all contributions that illustrate the extent of the problem and emphasise the need to rein in this beast!

Julie,
- Your reminder of the reminder of the MTQuA is welcome and I remain grateful for your invitation to have granted me the certification/membership. However, I referred to the EuMTA which was floated by Mr Balazs in Hungary in 2009.
- I insist that travelling for health is a regional phenomenon and, therefore any legislation/regulation must be in the context of the market dynamics and the environment.
- Call 'travelling for healthcare' by any other name, it remains the delivery of healthcare away from home with its distinctive requirements as opposed to healthcare at home.

Constantine,
- Despite all the respect that I have for the enthusiasm that goes into promoting Turkey as a destination, I do have my reservations about the direction, substance and emphasis. Casting travel agents in the mould of facilitators, whether or not to the exclusion of all others, is driven by the misnomer 'tourism' that accompanies the term medical or health and a grave error.
- Quite apart from causing a conflict of interest in serving two masters, a facilitator would, to their own peril, display the spineless and extraordinary anatomical ability of bending backwards and forwards with equal aplomb.

Laurence,
Thank you for a very valid point about 'facilitator-patient' engagement and the consequent liability issue. A very difficult one to underwrite, indeed!

You will hear more on this in my next contribution that looks beyond the facilitator.

Zahid Hamid (01/08/2012 12:01:43)

Ian, I understand your point clearly. The UK is not the only country that has highly regulated the travel industry.

If an agent has run off with someone's money, the patient has a legal recourse. Problem is the agent probably doesn't have the funds to return to the patient if instructed by the courts.

There are straightforward solutions to the problem of payment transfers without having to resort to more regulation. Patients can make their own travel purchase of transportation and accommodation directly or through a licensed travel agent. Patients can pay hospitals directly and not the agent, or the agent may set up a separate escrow account for payments. Patients can pay the agency its fee.

Simple. At Cosmetic Surgery Travel, we have been operating this way for many years. We also have had people pay very large amounts directly into our bank account, and I am always amazed that they do, mostly without question.

Running off with people's deposits or transfers may be a bigger problem with smaller amounts of money than larger, i.e. dental treatments, genetic testing, etc. It's much easier for a naïve medical tourist to fork over a couple thousand dollars or pounds to an agent than 15,000 or 20,000.

A major reason a straightforward solution for payment transfers is not a standard practice in this industry is that too many agents – good and bad – prefer to hide their fees and their profits in so-called medical tourism packages or dental tourism packages, etc. Let's not kid ourselves. Packages make money for the hospital and for the agent.

“A la carte” services, on the other hand, are often offered at discounted rates and an agency has to transparently add on its fees. A la carte has not become standard operating procedure because tourists do not value the services that an agency provides and when they see a separate service fee, they balk and do not want to pay it.

And that's the catch-22. Agencies that provide quality care management services find it to be a hard sell to have patients buy in to the notion that they will be much better served and have better outcomes by hiring one of them. What they must charge for their services is usually much less than the value of these services to the patient.

Selling medical packages can be done by just about anyone, especially someone with a travel industry or hospitality background. The patient doesn't expect much, other than a car and driver, local-language guide, a cell phone – all easily provided by ground services and destination travel agencies at the medical destination.

The patient understands “packages” and will put up the money for a “medical holiday” more readily. After all, this is a “tourism” industry, is it not?

So you can see I don't see the absconding with funds as the major problem others do, as I believe there is an easy fix to this problem.

This out of the way, I prefer to focus on the more important matters in medical tourism, good clinical outcomes, safety and security for the patients. This is what Medical Travel Quality Alliance certification means.

Anyone who studies the certification process that MTQUA offers will see the certification is not at all merely a "declaration" and "impressive-looking emblem." It is earned and demands a commitment on the part of the provider or service business. Even membership in MTQUA has to be earned.

If you don't think I'm very serious about quality and safety for medical tourists, you don't know me very well.

Constantine, true that trust is not built by brands. It has to be earned through proven track records and meaningful care management protocols.

Julie Munro (31/07/2012 14:14:10)

Julie

I appreciate you are not familiar with UK travel regulation so see why you may have misunderstoof me on patient protection.

No quaity seal or list of approved agencies will actually protect the patient as ABTA does for travellers.

If a tour operator or travel agent goes bust -then the bond system gets that person back home at no extra cost to them,the protection also applies to journeys part way .

Taking into account the number of medical tourism agenices that have gone bust in recent years
no '' quality seal;' or' certification ; will allow a patient and companion to both complete their journey, get hospital care, and get home if the agent has run of with the money they have paid him/her.

Without this real protection and regulatory teeth that can put a bad agency out of business-no certfiicate is worth the paper it is written on..

We have seen the effect of voluntary regulation on banking and finance !

The Turkish position may look extreme but would you go to a hospital or doctor who had no formal qualification, use an accountant with no qualifications.Here you have to be trained and certified to do any electrical work, cut trees, install or service boliers, etc

why should medical travel agents be any different ?

If they get advice wrong they can get people killed or badly hurt or badly out of pocket.

If they really do think they are a profession-then they should have both qualifications and registration and part of a system where customer money is protectedl


Ian

Ian Youngman (30/07/2012 16:16:08)

This issue is covered well here by the experts.
A separate but related point - should facilitators offer complications insurance for their clients?
The flip side - the more informed the facilitator and the more he or she demonstrates in-depth knowledge of the foreign clinic, the greater the risk of being held liable in his and his patient's home court. The involvement of a facilitator or agent of the clinic also helps the patient's lawyer secure jurisdiction in the patient's home jurisdiction. Is insurance available for facilitators to cover this? A difficult one to underwrite?

Laurence Vick (30/07/2012 12:24:25)

I personally know, like and respect Zahid and felt the urge to pile in with some observations and comments.
Some will have read my writtings and rants both on the subject of Regulation and Facilitators.
Whereas in most instances - when it comes to health - we tend to have "over-regulation", in the case of the Medical Facilitation Profession, we currently have no Regulation - although we are aware of a number of Certification Schemes.
We know that one country, Turkey, is intent on regulating the Profession. Of course, it can only regulate those based in Turkey. And even then, Turkey has a problem (I know because I have been present and participated in somne of the debates). The very powerful Travel Agents Association is
vigorously lobbying to have the services associated with Medical Facilitation handled exclusively by Travel Agents (who happen to be both Regulated and Certified). They want the existing Facilitators "outlawed".
As to where the facilitator's allegiance lies (destination - source - and provider-centric - patient-centric) - in my view - and in practice - location makes no difference. Inevitably the facilitator serves two masters - and I am prepared to be challenged on this view. Conventionally, the Facilitator
earns revenue from the Provider.
I will not enter into the discussion and argument of who should regulate.
But I do want to question why the demand for regulation only comes from the Industry (and not also from the Market).
And as to the need for Regulation, why do we not ask the Market, directly?
Is the Market voiceless?
And when does the Industry, once again, remember to raise the issue of Facilitator Regulation?
It seems to happen when business is not so good.

In conclusion, as in all industries, if the consumer does not trust the provider or agent, no amount of regulation will help.
Trust is not gained by declerations and the appending of impressive-looking emblems / logos to websites and documents.
It is won the hard way, for example, by having a proven track record.
It is like a brand - which is all about reputation.
Can a "Certificate and Logo" replace and trump "reputation and track record?"

Constantine Constantinides (29/07/2012 03:57:03)

Zahid, Thank you for the shout out to the Medical Travel Quality Alliance. This is the organization you refer to that was first mooted in Budapest in 2009. MTQUA is alive and well, and very busy.

Its website mtqua.org has news and analysis of medical tourism markets, Inside Medical Travel blog, best practices in medical tourism, world's best hospitals for medical tourists, a bill of rights for medical travelers, and much more. Care and Management of Traveling International Patients is the most downloaded publication in medical tourism.

Your discourse here on regulation for medical tourisms facilitators is admirable, and your sentiments about wanting to be regulated understandable.

When Ian makes the statement that “the chances of a proper international system are almost nil - as those who offer ' certification' do so just to make money,” he is not aware that newly revised certification programs from MTQUA are in the process of being launched. They are offered to promote quality in medical tourism and safety for the medical tourist. Even membership in MTQUA asks of its members that they play an active part in promoting quality and safety for medical tourists.

Ian says there is “no protection to the consumer.” In fact, for almost a year MTQUA has been providing a free “Medical Travel Patient Registry” specifically designed to help patients be safer as medical tourists.

Ian is absolutely on the mark in his review of some medical tourism companies who sell travel in their packages – medical tourists are taking a huge risk buying flights as part of a medical tourism package.

Zahid, I disagree with your reasons for wanting regulation. You and Ian paint a picture of medical tourism that is so different from the one that I have experienced for the past decade as a medical travel facilitator.

I straddle both worlds as you describe them, soliciting patients for cross-border treatment, and providing care management of these same patients at the medical destination. I know many other companies that do exactly the same thing.

I know and work with many medical travel facilitators based all over the world, in “feeder” countries and in medical destinations. They provide full patient care management from acquiring patients and managing the initial planning to providing after care and following up at home.

Why are these medical travel facilitators not as well known or given more attention?

The medical tourism industry would be very well served to continue this debate but with a better understanding of just what is a medical travel facilitator, a medical traveler, a medical tourist, etc. Steve Green recently started a discussion on the QHA Trent Accreditation Discussion Group on LinkedIn. He asked, What is a medical tourist? Guess how popular this discussion was and how many comments it received from its 800 members …

Julie Munro (28/07/2012 09:22:48)

I totally agree. Most facilitators sign up client heathcare organizations and then promote them without a real check on not only their medical competence, but also no check on whether or not the HC organization's staff can provide language access and cultural appropriateness to the various patient populations they are marketing to. I find Medical Tourism to be even less regulated than US hospitals were in treating patients from other cultures and language backgrounds when I started writing and training US healthcare in these skills 20 years ago. Now, in the US, at least, the Joint Commision and Federal and State laws require on-going training of physicians and staff. JCI, (and I would imagine other accrediting agencies)on the other hand, only checks on the physical environment and staff credentials and does not seem to care about patient/physician communication.
Facilitators, unfortunately have even less of a stake in investigating either the quality of care that is offered by their member hospitals and clinics. They earn their commission simply by getting their members patients.

Suzanne Salimbene (27/07/2012 20:15:49)

Zahid

Totally agree

It should be up to the country where the agent is based.

The chances of a proper international system are almost nil - as those who offer ' certification' do so just to make money and offer no protection to the consumer.

I feel that an agent is more like a tour operator -because they arrange travel, accomodation, activities when there etc-rather than a travel agent just arranging the travel.

What i never understand is how any UK medical travel agent can escape complying with the law;

The Package Travel, Package Holidays and Package Tour Regulations 1992 require organisers of package holidays to provide protection for customers money and to bring them home if necessary.

A package holiday is a holiday that consists of two or more elements, e.g. transport and accommodation, that are sold as a package at an inclusive price.( transport plus medical treatment is a package by law )

If people book a package holiday that includes a flight, then money must be protected under the ATOL scheme. This is operated by the Civil Aviation Authority (CAA). If they book a package holiday that doesn't include a flight, then money will be protected either by way of a bond held by a trade association, such as ABTA, or by way of an insurance policy, or by placing money into a trust account.

Flight-Only Arrangements

The Civil Aviation (Air Travel Organisers' Licensing) Regulations 1995 require tour operators who sell flight-only arrangements to provide protection for money and to bring people home if necessary.

This protection doesn't apply to flights that are bought directly from an airline.


Flight-Plus Arrangements

The Civil Aviation (Air Travel Organisers' Licensing) Regulations 2012 are new and require travel companies who sell Flight-Plus arrangements to provide protection for yoney and to bring people home if necessary.

Flight-Plus arrangements are holidays composed of a flight and accommodation or car hire bought together (i.e. within 2 successive days).

This protection doesn't apply to flights and other services that are bought directly from an airline.


Some travel companies offer protection for money voluntarily. For example, accommodation-only providers may offer protection although there's no legal requirement for them to do so.

If protection is offered it may be by way of a bond held by a trade association, such as ABTA, or by way of an insurance policy or by placing customer money into a trust account.

ABTA also offers a code of practice and complaints procedure


The law that recently caught up with those selling flight plus holidays icontains provisions allowing the government to -without new legislation - extend the protection to other classes of customers not currently protected.

It would be a simple measure to force all UK medical tourism agencies who fly people overseas to be a new category under the CAA - with an exclusion for any ABTA members .

So they would have to decide whether to join ABTA or pay for a new licence.

The current protections are done by a fee added to every booking.

My problem is that is suspect that many who sell packages are not complying with the existing law and would ignore any new law

ABTA has special guidelines on sustainable tourism , so there is also a precedent for adding special guidelines on medical and health tourism of all types.

I will leave it up to others to suggest solutions for other countries


ian



Ian Youngman (27/07/2012 16:35:31)