Medical Tourism and Taiwan

Sign in an elevator: watch out for pickpockets.

I spent this week touring hospitals on behalf of the government of Taiwan. It's been quite educational.

Prior to the 2008 election medical tourism had been identified as a growth area by outsiders looking for places to expand Taiwan's economy in the future. Local initiatives in this area actually date back a few years, to the early 2000s. Time magazine recently articled:

And why not? Taiwan has long been popular with its expatriate population as a medical-travel destination. At Taipei's abundant health care facilities, the equipment is modern and sophisticated, and most importantly, prices are considered a steal. Some of the biggest savings are in liver-transplant surgery, which runs to around $91,000, compared with some $300,000 in the U.S.

Price tags like that have built a small but devoted following for Taiwan's niche medical-tourism market, and it's about to get a lot more customers.

Taiwan's neighbors across the strait have been making their way to the island for a nip or a tuck since travel restrictions for Chinese tourists were lifted in mid-2008. Now, in the latest of a series of agreements and concessions between China and Taiwan, Taipei announced last week that Chinese tourists will soon be allowed to travel individually to
the island — a development that many medical-tourism proponents are hoping will be a boon to their industry.

Taiwan's current policy only permits controlled tour groups from the mainland, which limits options for Chinese who seek varied medical services. "Under group-travel restrictions, tourists are told where they can go and when. They can't deviate from the set itinerary," says David Wang, a plastic surgeon and chairman of the Taiwan Medical Tourism Development Association. "I've heard of a few people who will secretly come [for plastic surgery], perhaps under a fake name or by claiming they are here on business." Now, Chinese patients seeking operations can plan ahead and book Botox treatments and eye-bag or double-eyelid surgery at Wang's offices on their own schedule.

Compared to those of its regional neighbors, Taiwan's medical-tourism industry is only in its infancy. Its output last year narrowly missed the $20 million mark, whereas revenue in more established Asian medical-travel industries, Singapore and Thailand, reached billions of dollars.

In Taiwan medical tourism is promoted by an industry association, the TMTDA, and by a government task force, the Taiwan Task Force for Medical Travel. With that unerring accuracy found throughout Taiwan government English coinage, the government Task Force selected the little-used term medical travel rather than the usual medical tourism.

Medical tourism in Taiwan is one of the island's encounters with the shaping forces of globalization. In Taiwan internationalization is often synonymous with Englishicization -- it is international if we use more English. But in some of the local hospitals I visited a form of true globalization is sought -- importation of best practices for sale to international markets. In the medical tourism business this means obtaining accreditation from an accreditation body of one of the world's major western industrial nations, as well as having doctors trained overseas, and development of and/or acquisition of the latest medical technology. Languages other than English were offered; at one major hospital I visited signs were in English, Chinese, and Japanese. Another offered translation services in more than twenty languages, including Arabic. Another sign of internationalization is non-denominational prayer halls, found in all hospitals, missionary or otherwise.

Some hospitals appeared to be pursuing the opposite goal, hiding behind the walls erected by Department of Health regs to resist incorporation into global health networks. English can serve that function as well -- as a buffer against the outside world rather than a conduit for its entrance. The medical tourism policy may be loved by bureaucrats and private hospital owners but it is often opposed by staff and administrators. The issues are complex.

One administrator observed that in Thailand and Singapore, two popular medical tourism destinations, doctors are selling "excess capacity" in the medical system -- extra beds and extra doctors. In Taiwan neither exists. Because the Department of Health regulates the bed-to-population ratio, doctor-patient ratios, and so forth, capacity is nearly always right at its limits. Thus to handle medical tourists, a VIP population with special demands for attention, doctors must find time within their 65-80 patient a day workloads to squeeze in foreign patients, and administrators must similarly adjust workloads and facilities. Moreover, the nurse-patient ratio in Taiwan is low since family members are expected to attend at the bedsides of the ill and perform many simple activities nurses often do in western nations with higher nurse-patient ratios. The introduction of foreign patients without local families thus puts strain on the system, especially since they require nurses trained in a foreign language (the locals solve the problem of a lack of family by hiring people who hang out by hospitals just to fulfill that role).

Another issue bound up with medical tourism is tourism itself. One reason Thailand and Singapore have so many medical tourists is that they have so many tourists, period. This not only produces more opportunities for expenditures on medical needs but also creates the familiarity and word of mouth that support the growth of a medical tourism industry. I had to laugh when I heard administrators at several hospitals echoing my own appraisals of the Tourism Bureau's ineptitude: "They always promote the same things: Taipei 101, Taroko..." A key component of medical tourism is an active tourism industry separate from medical tourism that brings foreigners into the country. Taiwan is already visited by numerous Japanese and increasingly, Chinese, tourists; naturally, those two countries lead the list of medical tourists in Taiwan.

Yet another issue is regulations that ban advertising by hospitals. A Taipei Times report from January noted:

But local hospitals are lagging behind in terms of international marketing and resources to develop the industry, Mark Lee said. This, combined with tight regulations, poses a hurdle to the medical tourism sector, he said.

As the medical services sector is considered non-profit, government regulations bar hospitals from advertising their prices to attract foreign clients.

To appeal to potential medical tourists abroad, authorities need to loosen restrictions on advertising, Mark Lee said, adding that Taiwan must also simplify the visa application process for medical tourists.

Some hospitals are already attempting to build products using their brand name. For example, one hospital we visited has launched a line of ready-made main dishes for meals. However, it can't advertise to build brand recognition. Because of these laws hospitals are also leery about putting information online about prices for specific procedures, instead simply posting the public NHI fee requirements.

In addition to the demands on staff, foreign patients frequently require separate luxury facilities. One hospital had erected a set of international patient suites that were each the size of large hotel rooms, so family members of patients could stay there. Several offered separate offices or departments where foreigners were served separately and rapidly. With the large number of doctors trained overseas, it was never a problem to find a near-fluent speaker of English to chat with about the hospital. Of course, we had a lot of fun with the numerous English-speaking volunteers, invariably older women with plenty of Taiwan-style sass.

As with so many other Taiwan government policies, medical tourism is something that seems obvious on the surface -- many articles present it simply as a problem of marketing the "unknown" greatness of Taiwan -- but marketing the product is just the surface of the issue. To wit:

Ben Tsao of Kaohsiung Aesthetic Medical Tourism Promotion Association cites a report from Taiwan Institute of Economic Research (TIER) showing that foreign patients accounted for less than 1 percent of total medical service users in 2008. He points out that the most popular services among foreign patients are health examinations and cosmetic surgery; and not the five physical surgeries promoted by the government of joint replacement, cardiovascular operations, in-vitro fertilization, facial rejuvenation and liver transplants, “Those surgeries normally have to be performed at large teaching hospitals, which may use resources that should be reserved for citizens. It is difficult for the patients to travel after the surgery.

Tsao goes on to suggest that smaller clinics handle such functions, and indeed several are in the government task force. But several individuals I spoke to opined that the Task Force is not the right place for their organization to achieve its medical tourism goals.

Indeed, going by the website alone, that would appear to be true. The Task Force website is a good example of bad government internalization at work: it appears that no international marketing consultant was hired to help construct it. The search function is clunky, the "tourism information" is nonexistent, the English is well-groomed Chinglish etc. Individuals familiar with Taiwan's government websites will know the drill. It may be cheap, but it's a marketer's nightmare. Taiwan's doctors may be world class, but until the government reaches their level, the market will continue to grow at a snail's pace.

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