In April last year, 19 Singaporeans flew to Taiwan for a six-day group tour. Two of their destinations--Taipei 101, the tallest building in the world, and the scenic eastern coast--figure prominently in most tourist itineraries in Taiwan. But their third destination, the newly retrofitted dialysis center at Ren Chi Hospital in Taipei, was a bit off the beaten tourist path. This stop was added to the Singaporeans' itinerary by a local travel agency because seven of the tour members required dialysis every three days.
The tour was covered by Taiwanese as well as Singaporean media. Back in Singapore, David Lim, who has long lived with kidney problems, saw the coverage of the tour and started making his own plans to visit Taiwan. "It's great to combine medical services and tourism because it enables the patient to kill two birds with one stone," says Lim, who traveled to Taiwan with his wife for sightseeing six months later.
Outsourced by Ren Chi to Asia Renal Care, a Singapore-based provider of dialysis services in Asia, the dialysis center is a showcase for the hospital because of the high standard of hygiene and comfortable environment. For Lim, it was also impressive because of the affordability of its services, with each round of treatment costing less than NT$5,000 (US$150), compared with S$250 (US$170) in his own country. "And the medical staff was professional and cheerful," says the Singaporean, who has also had dialysis in London, Sydney and in Ipoh, Malaysia. Lim says he enjoyed his trip and plans to return to Taiwan.
"If this center can change and reach a new level with limited resources, then there is much more to expect when more medical facilities in Taiwan focus on medical tourism," says Mark Lee, the director of Ren Chi's dialysis center.
Last October, 17 tourists from Palau came to Taiwan for a five-day tour organized by Shin Kong Wu Ho-Su Memorial Hospital in Taipei. On this third health checkup tour for Palauans since last August, the visitors spent half a day in the hospital for routine physical examinations that cost US$240. Many of the visitors also elected to spend an additional US$1,100 on a positron emission tomography screening for cancer. When the checkups were finished, the Palauans traveled by rail to a tourist farm on the east coast owned by the Shin Kong Group. "We gave them a unique travel experience by putting the east coast on the itinerary and getting them there on a train. You know, there are no railways in Palau," says Vivianna Chen, a section chief at Shin Kong who is primarily responsible for medical tourism development. "We have Japanese clients too. But for them we arrange hot spring tours in Taipei."
Medical tourism is booming due to the development of inexpensive yet high-quality medical services around the world. In Asia, medical tourism is becoming a significant factor in the economies of India and Thailand. According to Chiu Wen-ta, superintendent of Wan Fang Hospital in Taipei and chairman of the Taiwan Nongovernmental Hospitals and Clinics Association (TNHCA), Singapore began to develop medical tourism around 2000 and saw 500,000 visitors come from around the world last year to seek medical services, including surgical and non-invasive procedures. "The success story of Singapore is very inspiring for Taiwan," he says.
Revenue Streams
Taiwan's hospitals are seeking new sources of revenue in part because their profit margins have dropped since the 1998 implementation of the National Health Insurance system's global budgeting program. The insurance system has benefited the public, but it has also caused financial woes for hospitals and created fears that the quality of services they offer could decline. "In this regard, Singapore's experience is significant. Singapore is now using the money earned from foreigners to sustain the level of medical services provided to locals," says Hsueh Jui-yuan, secretary-general of the Department of Health's bureau of medical affairs.
Palauan Vice President Camsek Chin and his wife received health checkups last year at Taipei's Shin Kong Hospital. (Courtesy of Shin Kong Hospital)
In the past, the vast majority of people overseas learned about Taiwan's medical services through personal connections or government-supported medical missions to Taiwan's allies such as Palau, where both Wan Fang and Shin Kong are known for the medical aid they provide. But Shin Kong began to focus on medical tourism in a more systematic manner last April by establishing an eight-person team responsible for introducing its services abroad. "We are recruiting people proficient in English and other foreign languages for the new service," says Chen, who is fluent in Japanese.
Wan Fang was accredited by Joint Commission International (JCI) in 2006, becoming the second hospital in Taiwan to win certification from the US non-profit organization. An international healthcare center exclusively devoted to taking care of foreign patients and a call center operating around the clock for patient referrals from abroad were set up by the end of last year. "We also offer training programs for foreign doctors, and nearly 600 foreign groups have been invited to the hospital. We hope they will recommend our hospital when they go back to their own countries," Chiu Wen-ta says.
The government approved the International Medical Services Project last July, earmarking NT$44 million (US$1.3 million) for the initiative. The launch of the project's management center was announced last November. It is operated by a team consisting of TNHCA, Chung Hua Institution for Economic Research (CIER) and Taiwan External Trade Development Council (TAITRA), along with 20 prestigious hospitals around Taiwan. "In Taiwan the best Taiwanese students tend to choose medicine as their major in university, which means this field has the best chance of all service sectors to shine on the international stage," says Ko Chen-en, chairman of CIER, which is responsible for researching the sector's economic impact.
To promote Taiwan's strength in medicine abroad, the project has chosen five areas where Taiwan is competitive on a global basis--liver transplantation, joint replacement, assisted reproduction and craniofacial and cardiovascular surgeries. However, despite exceptional cases in which foreign patients are referred to well-known doctors in Taiwan for treatment, the vast majority of medical tourists come to Taiwan only for a physical examination combined with sightseeing. On average, Wan Fang sees only about five patients from abroad per month for surgeries.
Positioned for Success
Boasting quality medical treatment and advanced facilities but comparatively inexpensive fees, Taiwan is positioned to develop a healthy medical tourism industry. Knee joint replacement surgery, for example, costs NT$180,000 (US$5,600) in Taiwan, compared with NT$420,000 (US$13,000) in the United States and NT$300,000 (US$9,300) in both Singapore and Thailand. Assisted reproduction costs NT$88,000 (US$2,600) in Taiwan, about one fifth of the fee for the same treatment in the United States.
"The doctor visits, hospital costs and procedures are far more affordable here than in America," Kelly Manske of the United States says of the fertility treatment she began at Chung Shan Hospital in Taipei about two years ago. Her treatment included the removal of a uterine fibroid tumor and the use of in vitro fertilization (IVF), an assisted reproduction technique. "I spent about US$5,000 on the fibroid surgery and the subsequent five-day hospitalization; in the States it would cost three times that at least," Manske says.
But lower prices are not the only reason the 40-year-old American thinks highly of her treatment in Taiwan. Suspecting that her fibroid tumor might be the cause of her infertility, Manske began to pursue fertility treatment at the age of 33 when she still lived in the United States. But her doctor told her that the benign tumor was somewhat difficult to remove and likely had little effect on her ability to get pregnant. She tried several types of fertility treatments in vain.
Wan Fang Hospital set up its International Liaison Center to enhance services for foreign patients late last year. Nearly 600 foreign groups have visited the hospital to learn about its operations. (Photo by Huang Chung-hsin)
Manske moved to Taiwan with her husband for work five years ago, and this provided an opportunity to reassess her condition. Her local doctor advised her to have the tumor removed in order to improve her chances of becoming pregnant. After the operation, Manske began IVF last May and became pregnant on her first attempt. "The treatment and care are better in Taiwan than what I experienced in the United States," she says. "I've heard that many overseas Taiwanese women come back just to receive fertility treatment."
Work to Do
However, before Taiwan becomes a major player in medical tourism, much work remains to be done in terms of branding and marketing. "If you ask around on the street whether Thailand is more reliable than Taiwan in terms of medical treatment, most people would say no, but international patients may give a different answer," Ren Chi's Mark Lee says.
The nephrologist believes that international patients tend to choose Thailand over Taiwan not on the basis of medical treatment quality, but because Thailand, already a top destination for international tourists, is better at presenting its services to foreign patients.
For now, Taiwan's marketing strategy is focused on creating a positive collective image of the country as a great environment for medical tourists. "We're actively participating in medical tourism exhibitions around the world to build this image," says Wang Jiann-chyuan, director of CIER's Division of Taiwan Economy, who attended a medical tourism exhibition in Hong Kong last October. That is why TAITRA, with a network of offices around the world promoting Taiwan's merchandise and services, is playing a role in promoting medical tourism. TAITRA will provide information and help arrange trips to Dubai, Singapore and Japan for exhibitions, forums and seminars on medical services in the first half of this year.
Marketing aside, groups involved in the project are starting to establish supplementary measures for medical tourism development. A taskforce for regulations and malpractice litigation is working on laws pertaining to foreign patients. A standard operating procedure must also be established, starting from the first contact between the patient and the hospital and ending with post-treatment follow-up. All of the steps must be conducted in English or other foreign languages if the patient does not speak Mandarin. "Compared with domestic health care, it's much more complex to offer services to international patients," CIER's Ko says. "A foreign patient has a long way to go before actually seeing a Taiwanese doctor."
In line with government policy, the Ministry of Foreign Affairs began to issue visitor visas for medical reasons last May, a significant development for people from countries such as Myanmar and Sri Lanka. In the past, visa applications from citizens of these countries were strictly examined. Today, if medical visitors are able to prove they have relevant medical records, sufficient financial resources and previous contacts with hospitals in Taiwan, they qualify for a visitor visa that allows them to stay in Taiwan for up to 180 days.
Visitors from China who seek treatment of diseases that cannot be appropriately treated there, or who require treatment in the five aforementioned areas where Taiwan is competitive, have been able to visit Taiwan more easily since last August. In September, a woman suffering a recurrence of cervical cancer flew from Nanjing to receive treatment at Taipei Medical University Hospital, becoming the first patient to cross the Taiwan Strait in the name of medical tourism. Chinese patients were previously allowed to come to Taiwan for treatment on a case-by-case basis, but bureaucratic hurdles limited the number that actually made it across the strait.
Kelly Manske praises Taiwan's assisted reproduction services both for their quality and comparatively low prices. (Photo by Huang Chung-hsin)
A taskforce for assessing performance is responsible for reviewing the project's economic benefits as well as the performance of the participating hospitals. "We need to make sure hospitals are serious about quality control and don't get into a price war," says Wan Fang's Chiu Wen-ta. This group will investigate whether the development of medical tourism will encroach on the right of Taiwanese citizens to receive medical care. Indeed, in order to attract foreign patients, hospitals might shift medical resources and sacrifice services for locals.
"Only when a hospital has extra capacity should it look to foreign patients; the services for foreigners should complement rather than substitute for those for locals," CIER's Wang says.
Stronger Incentives
Meanwhile, Taiwan is working with foreign insurance companies to provide stronger financial incentives for international patients to come to Taiwan. In November, a Taiwanese delegation including representatives from four major Taiwanese hospitals went to the United States for 10 days to introduce Taiwan's advanced medical services to overseas Taiwanese in the hope of encouraging them to have their health problems treated in Taiwan. Members of the delegation also talked with several major American insurance companies about their policies regarding treatment their clients receive abroad. "It'll be great if the talks can lead to solid results within a year. Once we reach agreements with these insurance companies, the number of American patients coming to Taiwan for medical treatment will increase considerably," says Wu Ming-yen, the secretary-general of TNHCA.
US insurance companies like the fact that their clients can find less expensive services in Taiwan. However, they are worried that poor medical services provided overseas could require costly subsequent follow-up treatment, which could offset any savings. According to Wu, US insurance companies are more willing to cooperate with a hospital if it is accredited by JCI. Wu has also sought to educate US insurance companies about the reliability of Taiwan's hospital appraisal system in an effort to persuade them to sign contracts with hospitals that perform well by Taiwanese standards, but that have yet to be accredited by JCI.
The availability of officially endorsed quality medical services is significant for the 30 million US citizens who are underinsured, according to Wu. For those who have insufficient insurance coverage, medical expenses can present a big burden in the United States, making Taiwan an ideal place for them to seek medical treatment. "We especially expect to attract the underinsured. They may find medical expenses that are too high at home are still affordable abroad," he says.
Taiwan is racing against time to build an infrastructure for medical tourism and explore overseas markets. "Compared with our neighbors, Taiwan is very late in developing medical tourism," Wan Fang's Chiu Wen-ta says. All 15 major hospitals in Singapore have been accredited by JCI, he notes, while Bumrungrad International Hospital in Bangkok, known for its welcoming attitude toward patients and multilingual services, has become an acknowledged model around the world in this emerging sector.
"However, the pie, which is still relatively small, is getting bigger," Wang Jiann-chyuan says. "No single country can take care of all international patients, and each has its own strengths in this field." CIER hopes that the accumulated revenue from medical services provided by Taiwan's hospitals to foreigners can reach NT$7 billion (US$215 million) within three years. Whether Taiwan's ambition to reach this goal will be realized remains unclear, but as experiences such as David Lim's and Kelly Manske's become more widely known, the country's reputation for offering quality medical services at a reasonable price will undoubtedly grow.
Write to Oscar Chung at oscar@mail.gio.gov.tw