Medical tourism is what kind of activity

The health business

I Table of Contents

II List of Figures

III List of tables

IV Preliminary remarks

1 Introduction
1.1 Problem
1.2 Objective
1.3 Structure of the thesis

2 Medical tourism in the jungle of health tourism terms
2.1 Definition of medical tourism
2.2 Classification and delimitation of medical tourism

3 The global medical tourism market
3.1 Historical development of medical tourism
3.2 Current importance of medical tourism
3.2.1 The market for medical tourism in Germany
3.2.2 Extent of medical tourism from Germany
3.2.3 Causes for medical tourism from Germany
3.2.4 Forecast for medical tourism from Germany

4 The medical tourism offer for the source market Germany
4.1 Infrastructure
4.2 Product
4.2.1 Type and scope of travel
4.2.2 Quality
4.3 Branding
4.4 Distribution channels
4.4.1 The medical facility
4.4.2 Patient mediators
4.4.3 Internet databases
4.5 channels of communication
4.6 Target market
4.7 Benefits
4.7.1 Economic benefits
4.7.2 Reduction of waiting times
4.7.3 Medical benefits
4.7.4 Quality advantages
4.7.5 Service benefits
4.7.6 Travel options
4.7.7 Social benefits
4.7.8 Personal benefits
4.8 Legal structure
4.9 Social and economic aspects

5 Financing medical trips
5.1 Price analysis
5.1.1 Preliminary remark
5.1.2 Procedure
5.1.3 Implementation
5.1.4 Results
5.1.5 Reason
5.2 Benefits from statutory health insurances
5.2.1 Within the EEA or Switzerland
5.2.2 Outside the EEA or Switzerland
5.2.3 General principles

6 Summary

7 Conclusion

8 Outlook

V Bibliography and sources

VI Appendix

Statutory declaration

II List of Figures

Figure 1: The segments of medical tourism at a glance

Figure 2: Characteristics of voluntary patient tourism

Figure 3: The segments of health tourism at a glance

Figure 4: Medical tourism destinations

Figure 5: Description of the medical tourism market

Figure 6: The medical tourism offer for Germany

Figure 7: Service chain of a medical trip

Figure 8: Space-time differentiation of the medical tourism offer

Figure 9: Distribution channels of medical tourism

III List of tables

Table 1: Examples of primary offers for the source market Germany

Table 2: Specialization of medical services in different destinations

Table 3: Price analysis for cosmetic and plastic surgery

Table 4: Analysis of savings in cosmetic and plastic surgery

Table 5: Price analysis in dentistry, orthopedics, cardiology and ophthalmology

Table 6: Analysis of savings in dentistry, orthopedics, cardiology and ophthalmology

Table 7: Countries with the possibility of using medical services (EEA countries)

IV Preliminary remarks

The various medical institutions and patient placement agencies that were used to analyze this work have not been personally visited by the author. Apart from four expert interviews with employees of patient placement agencies (see Appendix 3 to Appendix 6), there was also no further personal exchange with the agencies and medical institutions. The reader should understand that such an effort is not possible in the context of a thesis, which is subject to time constraints. The results of the study are therefore based on the evaluation of secondary literature and the information available to everyone on the websites of various medical tourism providers. An evaluation of the service providers by the author does not take place and is also not the purpose of this work, since it is primarily about the description of the medical tourism offer for the source market Germany and not about its assessment. Potential medical tourists should therefore, in spite of the extensive information in this work, also inform themselves about all important services and qualifications of the medical tourism providers. Too often there are changes and corrections in the advancing development of this industry than the content of this work could make a binding statement about the medical tourism offer of tomorrow.

1 Introduction

Health tourism is booming. It has positioned itself as a very promising market at the interface between health and tourism and has long been practiced in many EU countries, but also worldwide. There are many reasons for the continuously increasing demand for health tourism offers. One of the most important is probably people's increasing willingness to invest in their health, because this is becoming more and more important in society and people are becoming more aware of their own responsibility for health. Along with this development, numerous health tourism trends and currents emerge, so that the market currently offers an almost unmanageable range of health services and goods. In the course of this flooding of the market, the term medical tourism appears more and more frequently. Most experts agree that this is more than a "fad" and that it is on the rise in the health tourism market. The market development and forecasts are consistently positive and underline the increasing importance of the role of medical tourism in the tourism industry.

1.1 Problem

But what exactly is medical tourism? The interviews conducted for the present work have shown that even the experts do not yet fully agree on this. Many tourists are also overwhelmed and helpless. Most of them can no longer find their way around the current jungle of health tourism terms. Wellness, cures, therapeutic baths, rehabilitation, relaxation holidays; the list seems endless. Many of these terms are mistakenly equated. But with the development of the last few years and the increasing differentiation of the individual health tourism market segments, this is no longer tenable.

The advancing privatization of medical costs in Germany as well as the increasing deductibles are causing the costs for medical services and medication to explode and are only two of many reasons for the continuous development of the medical tourism market. The media are also doing their part by reporting more and more often about medical treatments abroad, where up to a tenth of the cost savings are possible. German patients are becoming active and are increasingly looking for inexpensive treatments abroad in order to achieve the best price-performance ratio and thus reduce their health expenditure. It is therefore not surprising that the medical tourism offer for the source market Germany is becoming more and more diverse and the number of providers is increasing in number. But how exactly can the market and the offer be characterized? Who arranges medical trips and what do the services of the providers look like in detail? Which destinations and medical services are offered? How cheap are the operations abroad really and how can they be financed? Patients still often feel in the dark, as there is so far only little literature and studies on this topic and many questions therefore remain unanswered.

1.2 Objective

The aim of this work is the analysis and structural processing of the medical tourism offer for the source market Germany. Medical tourism is to be defined as a new form of tourism and classified in the health tourism market. The previous development, the current importance and the potential of this market are to be analyzed, discussed and clearly presented together with all aspects of the variety of medical tourism offers.

1.3 Structure of the thesis

The medical tourism offer is examined on the basis of the evaluation of secondary literature and expert interviews (see Appendix 3 to Appendix 6) that were carried out with patient placement agencies for medical trips. The present work has been divided into seven chapters. The introductory chapter should lead to the topic and explain the chosen approach. In order to then be able to start analyzing the medical tourism offer for the German market, it is necessary in advance to clearly delimit the term medical tourism in order to bring order to the chaos of health tourism terms. Therefore, in the second chapter, a generally understandable definition of medical tourism is first derived in order to then be able to delimit and classify this segment in the health tourism market. The third chapter describes the emergence and market development of medical tourism and its dimensions in Germany. The attempt is made to give the reader an idea of ​​how strongly this market has developed in Germany in recent years, what causes were decisive and what future prospects it has in store. In the course of these first chapters, the theoretical foundations for the present work are also clarified, which are necessary for understanding and narrowing the investigation. Based on the market components, the medical tourism offer on the German health market is analyzed and characterized in the fourth chapter. The main focus is on the investigation and description of the product medical tourism and the presentation of the range of providers, destinations and services. The fifth chapter of the present work is devoted to the financial aspects of a medical journey. Here, the uncertainties of potential medical tourists with regard to prices and possible cost savings are resolved and patients' questions about the assumption of benefits by statutory health insurances are answered. Finally, there is a summary of the results, followed by their interpretation combined with a conclusion and an outlook.

2 Medical tourism in the jungle of health tourism terms

Medical tourism is often mistakenly equated with the term health tourism. Not only in the everyday language of tourists, but also in the media and in literature, these two terms are now incorrectly used interchangeably. This problem also applies to the various other forms of health tourism. Both wellness tourism and spa, spas and recreational tourism etc. are faced with increasing uncertainty and disorientation among consumers with regard to the classification and delimitation of the health tourism segments. The main reasons for this confusing diversity are the fluid boundaries of the individual market segments and the failure of health tourism providers to remedy the ignorance on the demand side. As a result, there is a need to specify the product medical tourism. For this reason, the following is an attempt to find a generally understandable definition for medical tourism in order to remove any problems of understanding the term and to clarify the subject of the present analysis of the medical tourism offer for the source market Germany. However, it is equally important to clarify how medical tourism integrates into the health tourism market. For this purpose, the definition of the health tourism market is presented in its individual forms in order to be able to make a necessary delimitation of medical tourism.

2.1 Definition of medical tourism

The term medical tourism is apparently made up of the two words "medicine" and "tourism". Accordingly, it describes a trend that has both tourist properties and medicinal characteristics. It therefore makes sense to find a definition that takes these two characters into account. It is also noticeable that the term medical tourism, through the lively use of the word in the media, provides tons of synonyms. The words “patient tourism”, “clinic tourism” and “surgery tourism” are used interchangeably for medical tourism in literature and the media and are therefore used accordingly in this work. The definition should therefore try to include these synonymous words in its explanation.

Barth and Werner describe hospital tourism as a movement of patients "... in search of a country in which the quality and price of medical services are the best match" (Barth / Werner 2005, p.55f.). Rulle, on the other hand, pays much more attention to details and proposes a definition that explains patient tourism as "... the cross-border traffic of patients who use medical services abroad for various reasons" (Rulle 2004, p. 40). These two definitions are very useful as an approach, as they identify both the tourist aspect and the medical characteristic. However, they fail to explain both aspects in more detail and ignore the fact that patient flows within a country are also included in medical tourism. Böhm recognized this mistake and, in its definition of hospital tourism, includes not only the treatment of German patients abroad and the travel of foreign patients to Germany, but also the demand for medical services from Germans away from home within Germany (see Böhm 2007, p.5). This view is also supported by the tourism definition of the World Tourism Organization (WTO), according to which tourists are those people “... who travel to places outside their usual environment and stay there for no more than a year for leisure or business reasons that do not associated with the exercise of a paid activity at the place visited ”(WTO, quoted from Uherek 2008). Accordingly, medical tourism also includes those patients who request medical services in clinics within their own country that are outside their usual place of residence and residence.

A comprehensive definition of terms that takes into account all the aspects discussed here is unfortunately not yet found in the German literature, which is why it is essential to draw up this. As such and as a basis for the present work, the author suggests the following definition:

Medical tourism is a synonym for the terms patient, clinic and surgical tourism and describes the movement of patients who, for various reasons, make use of medical services in places outside their usual environment, whereby the stay does not exceed the duration of a vacation and often with the Demand of tourist activities is combined.

The further examination of this definition and the different reasons for a medical trip leads to the realization that medical tourism can be divided into two segments. Based on Rulle, these two patient flows are referred to as "voluntary patient tourism" and "state surgery tourism" and can be characterized as follows (see Rulle 2005, p.133f.): Der Voluntary patient tourism is based on the patient's main motivation to pay a lower price for treatment at home or abroad. This must justify the effort of moving the patient despite the travel costs. Representative examples of this are all medical interventions, the costs of which the patient has to bear in full or in large part, such as cosmetic surgery or dental treatment. The State operational tourism arises from national supply bottlenecks that force patients to seek medical services abroad. A typical example of this are Norwegian patients whose health insurances refer them for orthopedic interventions in clinics in northern Germany because the waiting lists for such treatments in their home country are too long. The costs of the trip will of course be covered by the responsible health insurance companies.

In a second publication, Rulle makes the same subdivision of medical tourism, but adds a few more distinguishing features (see Rulle 2005, pp. 40f.). According to this, the consumers of voluntary patient tourism only partially use the clinics they visit as a place to sleep and are mainly accommodated in spa accommodations or hotels, while those involved in state surgery tourism mostly spend the night in hospitals. Another important differentiating criterion is that the choice of the destination is not left to the participants in the state surgical tourism themselves, as these, unlike the voluntary patient tourists, are sent abroad by the state and the patient movement is not based on self-motivation.

In contrast to state surgery tourism, voluntary patient tourism can be broken down into two different forms of travel (see Fox 2006, p. 5): medical travel, the main motivation of which is the demand for a medical service away from home, and patient travel, which includes medical treatment with a vacation and tourist travel Combine activities. The distinction between these two forms of travel is elementary, as it can have an impact on the choice of clinic and destination as well as on the travel distance and duration. In order to differentiate the two types of voluntary patient tourism described, they are used in this thesis Tourist patient trip and Medical patient journey called. This subdivision does not apply to state surgery tourism, as the patient's travel decision is not their own, but rather is determined by the referring health insurances. As a result, no other tourist services are requested besides the arrival and departure, because it is only about the use of the medical service. The following figure illustrates the individual segments of medical tourism once again (see Figure 1).

Figure not included in this excerpt

Figure 1: The segments of medical tourism at a glance

The subject of the analysis of the medical tourism offer for the source market Germany will only be the segment of voluntary patient tourism in the present work, since little or no importance is attached to the state surgical tourism in the German health system. The investigation of the individual factors and components of the offer will relate to both the tourist and the medical patient journey.

It should also be noted that these two forms of travel can again be divided into sub-categories, according to which the character of the respective trip results. The voluntary patient journey must be differentiated into: Disease-oriented to travel that serve to eliminate a disease state through interventions such as dental treatments or transplants, and in Non-disease mindedto travel in which, for example, medical check-ups or cosmetic interventions are requested. Within these two categories, a distinction is again made between two forms: The Outpatient medical trip , whereby the guest inquires about the medical service in a practice or clinic, but does not stay there due to his medically stable condition, but chooses his own place to sleep. And the Stationary Medicine trip , with which the patient stays in the clinic because he needs further medical treatment or observation. The following figure illustrates the characteristics of the voluntary patient journey again (see Figure 2).

Figure not included in this excerpt

Figure 2: Characteristics of voluntary patient tourism

This subdivision does not apply to state surgery tourism, as it is always disease-oriented and has an inpatient character because it only relates to illness-related, necessary operations that require an inpatient stay.

2.2 Classification and delimitation of medical tourism

Classifying medical tourism and differentiating it from other forms of tourism is not easy. Since this form of tourism is a relatively new phenomenon on the German tourism and health market, there is little literature to be found about it. However, some experts have already dealt with this topic and tried to classify and delimit medical tourism. Unfortunately, there is still a great deal of diversity of opinion on this issue. However, all experiments have one thing in common: the hypothesis that medical tourism is to be viewed as a segment of health tourism. It stands to reason that this theory is correct, since health tourism includes health-oriented tourist activities according to the wording, which accordingly also includes the medical tourism use of medical treatments. The most comprehensive definition of health tourism, which supports this theory, can be found in Kaspar, who describes health tourism as the “... totality of relationships and phenomena that result from the change of location and the stay of people to promote, stabilize and, if necessary, restore the physical, mental and social well-being with the use of health services for which the place of residence is neither the main nor permanent place of residence or work ”(Kaspar 1996/1, p.53).

However, the experts are still finding it difficult to uniformly segment the health tourism market. The authors' understanding of the various areas and how they are differentiated from medical tourism differ considerably. While spa and rehabilitation tourism are often viewed as branches of health tourism, there are great differences of opinion as to which other subspecies exist (see Müller and Lanz 1998, p.486 and Rulle 2002, p.75). Barth and Werner, for example, subdivide the market into clinic, spa and wellness tourism. (see Barth / Werner 2005, p.14f.). Böhm also divides health tourism into these three segments, but renames health tourism to prevention / rehabilitation tourism (see Böhm 2007, page 5). Albaner and Grozea-Helmenstein are of a similar opinion, but differentiate between spa and rehabilitation tourism and add the branch of fitness tourism (cf. Albaner / Grozea-Helmenstein 2002, p. 29). In the opinion of the author, however, the most up-to-date and appropriate subdivision can be found in Scholz. He sees health tourism as a generic term for two different areas: the medical health trip, which includes all forms of health tourism offers that serve to cure a pathological condition, such as spa, rehabilitation or clinic tourism, and the health vacation, which includes all forms of health tourism Health-preserving tourism includes, such as the fitness or wellness vacation (see Scholz 2001, p.63).

Taking into account the opinions of the experts presented here and based on Scholz's differentiation, the author suggests differentiating health tourism as follows (see Figure 3).

Figure not included in this excerpt

Figure 3: The segments of health tourism at a glance

The criterion used for the subdivision and delimitation is based on a determination by Rulle, according to which the gradual differences within health tourism "... mainly result from the extent to which conventional medical procedures are used" (Rulle 2005, p.131) Divide health tourism into two major categories: The Preventive health trip whose sub-forms include all offers that serve to prevent disease and thus maintain health. And the Medical health trip which, in addition to medical tourism, includes all trips whose scope of application of conventional medical procedures is much higher than for preventive health trips, since the main destination here is the elimination of pathological conditions and thus the restoration of health. (The only exception here are medical trips that are not disease-oriented, e.g. due to the performance of cosmetic operations or medical check-ups). What should not be forgotten is that the boundaries from one segment to the next are often fluid.

According to Lanz Kaufmann, wellness tourism can be characterized as the "... totality of relationships and phenomena that result from the journey and stay of people with the main motive of maintaining or promoting their health" (see Lanz Kaufmann 1999, p.11) . Wellness offers aim to create a holistic well-being for body, mind and soul during the vacation stay through an extensive bundle of services consisting of physical fitness, healthy nutrition, relaxation and mental activity (see Lanz Kaufmann 1999, page 11). This form of travel is thus clearly differentiated from medical tourism, as it focuses less on the medical and is not geared towards individual goals of restoring health.

The other forms of preventive health travel also show their differentiating criteria to medical tourism. Both recreational tourism, which aims at "... spontaneous, primarily non-medically controlled recovery and regeneration of performance ..." (Rulle 2004, p.33), as well as beauty tourism and fitness tourism or sports tourism that does not require medical Procedure, have a far lower application of conventional medical procedures than medical tourism does.

Another segment of preventive health tourism that is often mentioned in the literature is health-oriented holidays. This is sometimes also described with the terms “fitness vacation or sports vacation”, “leisure-oriented health tourism”, “active vacation” or “health tourist vacation”. However, the offers that are hidden under these terms are almost identical. Therefore, the health-oriented vacation cannot be seen as a separate market segment of the preventive health trip and therefore does not appear separately in the above description, but falls under the segment of fitness / sports tourism.

The delimitation of medical tourism from the forms of medical health travel can also be made according to the degree of conventional medical applications. According to the German Spa Association (DHV), spa and medicinal bath tourism is understood to mean "... the special therapeutic process of therapeutic treatment with special means, methods and tasks in spas and health resorts with characteristic structural features" (DHV 2005, p.22). The cure is a medical measure prescribed by a doctor that serves to maintain and improve health or to alleviate chronic diseases with the help of natural remedies (see Albaner / Grozea-Helmenstein 2002, p. 30). This makes it clear that spa and spa tourism takes place on the basis of medical applications, but cannot demonstrate the same intensity of conventional medical measures as medical tourism due to the use of medicinal products.

Rehabilitation tourism also lags behind medical tourism in this regard, since its main goal, the restoration of restricted or lost functional capabilities, is achieved with the help of medical procedures, but this should not be brought about by medical interventions. Rather, it is used to help the patient to regain his pre-illness state of health after an operation through alternative medical methods and exercise training.

In addition to the intensity of the medical application, the delimitation of the individual segments of health tourism is based on another aspect: the degree of health restoration. This is a factor associated with the intensity of the medical application. The greater the degree of application, the more the journey is aimed at eliminating a pathological condition.

3 The global medical tourism market

Although medical tourism is relatively small compared to normal tourism, it cannot be dismissed as temporary or insignificant. According to the World Health Organization (WHO), medical tourism is a “megatrend” of continuously growing size with enormous economic importance (see Bookman / Bookman 2007, p.2). Many also refer to it as "... one of the hottest niche markets in the hospitality industry" (Demicco / Cetron 2006, p.527). It is characteristic that it does not yet attract masses of tourists, but is already significant enough to generate sufficient business (see Bookman / Bookman 2007, p.41). In this chapter, the extent of this global growth market is to be analyzed. A description of the historical development of medical tourism is provided at the beginning. Subsequently, its current importance on a global level will be examined and explained which dimensions and potentials medical tourism from Germany has and which causes exist for the development there.

3.1 Historical development of medical tourism

Medical tourism is a new term, but not a new idea. Since human existence has existed, people have traveled to see doctors or healers. In ancient Greece, the sick came from all over the Mediterranean to Epidaurus, to the holy place of the Greek god Asklepius, to be released from their suffering with the help of thermal water (see Siva 2006, p.10). The city of Bath in England also attracted people from all over the world for over two thousand years because of its holy water (see Siva 2006, p.10). At the beginning of the 18th century, many people from different parts of Europe traveled to bathing resorts in Germany and to Egypt on the Nile in order to undergo treatment for their pathological complaints (see Siva 2006, p.10). Many wealthy German patients were also among them (see CBC News 2004).

Nowadays, it is mostly the wealthy people who initially embarked on a medical journey and went from industrialized countries to other industrialized nations in order to take advantage of high-quality medical services (see Herrick 2007, p. 1). According to Berg, this form of medical tourism bears the designation "quality and (prestige) oriented patient tourism" (see Berg 2008, p.171). Over the years, however, the number of medical trips for less wealthy people looking for cheap medical help in emerging or developing countries increased. This form of medical tourism is called “cost-oriented patient tourism” (see Berg 2008, p.171). Initially, medical tourism was mainly limited to the Anglo-American region, but later it was also given increasing importance in the European area. So the situation today has not changed much compared to before. Patients are still ready to go long distances to be freed from their ailments. What is new in the 21st century, however, is that people are traveling even longer distances, traveling to poorer countries, using modern, advanced medicine and in many cases even combining treatment with a vacation (see Bookman / Bookman 2007, p. 5). The nature and spread of the trip have changed, but the goal has remained the same. Probably the most important consequences of this are that the economic importance of this type of travel has increased significantly both for the destinations and for the source markets and that the phenomenon of medical tourism now has a name as a result (see Bookman / Bookman 2007, p .5). The economic importance of medical tourism was first recognized and named by the International Union of Travel Officials in 1973 (see Bookman / Bookman 2007, page 5).

It has been around ten years since the first patients from industrialized countries flew abroad for medical treatment called medical tourism. (see Imedo 2008). In the course of this development, the term medical tourism has also become increasingly popular in Germany in recent years. While initially only cheap cosmetic and plastic surgeries were in demand, more and more patients with serious health problems joined in for interventions such as hip operations or cancer treatments.

3.2 Current importance of medical tourism

In 2005, around 19 million patients worldwide traveled from industrialized countries to less developed countries to receive medical services (see Jeffery 2006). It is assumed that this number will increase to 40 million by 2010 (see Jeffery 2006). With the growing number of tourists, the medical tourism industry generated over 60 billion dollars worldwide in 2006 (see Althaus 2007). McKinsey Company estimate that this amount will increase to 100 billion dollars by 2012 (see Herrick 2007, p. 1). According to the National Coalition on Health Care, around 500,000 Americans traveled abroad in 2005 to seek treatment (see nTelagent 2008). This makes them the largest group of international patients, followed by the British with 219 million medical tourism trips carried out by the end of 2005 and £ 10 trillion spent on them (see Herrick 2007, p. 2).

Due to the increasing international demand for medical trips, foreign hospitals, doctors, health companies and patient placement agencies are flooding the global medical tourism market with offers and price reductions (see European Medical Tourist 2008). The Internet plays a decisive role here, as it is the quickest and easiest way to address potential customers, even over long distances. While a year ago the keyword "medical tourism" only yielded around 777,000 hits on the Internet search engine Google (see Horowitz / Rosensweig 2007, p.32), on August 20, 2008, around 1.3 million Internet pages can be found there ( see Google 2008).Another indication of the growing interest in medical tourism is the observation that more and more magazine and newspaper articles are appearing on this topic and that more and more books are entering the market that represent guidelines or travel guides for medical tourists. Examples are: “The Medical Tourism Travel Guide” by Paul Gahlinger or “Patients Beyond Borders” by Josef Woodman. They try to give the patient an overview of the various destinations and their medical tourism offers. The following map shows the most attractive destinations on the provider side (see Figure 4).

Figure not included in this excerpt

Figure 4: Medical tourism destinations

More than two thirds of all international patients go to Asian countries to receive medical services (see Juszczak 2008/1, p.25). The pioneers among the destinations there are India with around 1.5 million medical tourists annually and Thailand with 1.2 million foreign patients per year (see Juszczak 2008/1, p.23). Many people from Great Britain, Scandinavia, Eastern Europe or the Netherlands are increasingly looking for medical help here. Because in some medical fields, such as orthopedics, cardiology or ophthalmology, there is a medical shortage in these countries (see Juszczak 2008/1, p.24). This sometimes leads to long waiting times for treatment, which for health reasons forces the patient to have the procedure carried out abroad. Other destinations that are successfully asserting themselves in the medical tourism business in Asia are Singapore and Malaysia with 400,000 and 230,000 medical tourists, respectively, as well as the Philippines, South Korea and Hong Kong with 20,000 patients per year (see Juszczak 2008/1, p. 23). The remaining third of all international patients are distributed in roughly equal proportions across Europe and South and Central America (see Juszczak 2008/1, p. 24). Over a hundred thousand patients from many Western European countries and Russia, for example, request outpatient interventions in the fields of cosmetic and plastic surgery, dentistry and ophthalmology every year in Hungary, Poland, the Czech Republic, Turkey or the Ukraine (see Juszczak 2008/1, P.24). Medical tourism to South and Central America arises mainly from travelers from the United States and from South America itself (see Juszczak 2008/1, p.24). Every year tens of thousands of patients, mainly from Venezuela and the Caribbean, travel to Cuba, the country with the highest density of doctors in the world (see Juszczak 2008/1, p.24). In Africa, on the other hand, there are so far only a few countries that have specialized in medical tourism. Examples of this are Tunisia with 20,000 foreign patients per year and South Africa with a medical tourism turnover of 27 million euros per year (see Juszczak 2008/1, page 24).

3.2.1 The market for medical tourism in Germany

As mentioned at the beginning, the medical tourism market in Germany can be divided into three different currents (see Boehm 2007, p. 5):

- Foreign patients who use medical services in German clinics
- the treatment of German patients abroad and
- German patients who request medical services outside of their place of residence or permanent residence within their own country

The following analysis of the medical tourism offer for the source market Germany will, however, only refer to the trend listed here in second place. This restriction is due to the fact that foreign patients who request medical services in German clinics do not belong to the target group of the medical tourism offer for the source market Germany. The same applies to German patients who receive medical treatment within Germany outside of their usual place of residence. The investigation of the offer for sick people within Germany who want to request medical services abroad should begin with the description of the extent, the research of the causes and the preparation of a prognosis of the medical tourism in Germany.

3.2.2 Extent of medical tourism from Germany

In addition to the Americans and the British, German patients also make a large contribution to the positive development of medical tourism. According to estimates by the health insurance associations, the total number of German medical tourists is currently around 300,000 each year (see Ferenczi / Güsten / Hoffmann 2007, page 58). However, the number of those who want to benefit from the inexpensive offers abroad is continuously increasing. A study by Ernst Young, according to which the market for privately paid health offers in Germany will add up to 150 billion euros in the next 15 years, supports this assumption (see Rössing 2006, p. 32). A survey by the Techniker Krankenkasse found that more than 40 percent of the participants could consider outpatient medical treatment and dentures abroad. According to this, around 25 percent would also carry out hospital treatment abroad (see Juszczak / Ebel 2006, p.18). This illustrates the great potential that medical tourism from Germany still holds.

German patients favor facilities in Eastern Europe, first and foremost Poland and Hungary. (see Hickling 2007). In 2005, around 50 percent of the 300,000 German medical travelers annually went to Poland and, together with the other medical tourists, spent over 50 million euros in practices and clinics (see Ferenczi / Güsten / Hoffmann 2007, p.59). The Polish dental practice communities near the border alone treat almost 1,000 German patients per year (see Juszczak 2008/1, page 24). Poland is reacting to this development and is training state-certified patient carers at the University of Lodz who study German, learn empathic behavior and are trained to deal with sick people in crisis situations (see Ferenczi / Güsten / Hoffmann 2007, p.59). All of this is only happening to increase the flow of patients in the German population. In addition, around 5,000 citizens flew abroad in 2005 for laser eye surgery (cf. Späth 2005, p. 25), which Turkey is striving for, as it is the absolute number one in this field should be (see Drinkuth 2008). But the offers of Czech opticians are also very much used by German patients for such interventions (see Veselá 2007). Many mediation agencies for medical travel are picking up on this trend and specializing in offers in Eastern European countries, such as "Health Planet". But other countries are also increasingly successfully attracting the interest of German patients. The "Bangkok Hospital Medical Center" in Thailand, for example, was the travel destination of more than 1,600 Germans in 2006, who saved up to 50 percent of the usual cost of cosmetic surgery and dental treatment in this country (see Ferenczi / Güsten / Hoffmann 2007, p.58) .

Although the medical tourism market is becoming more and more important, the data situation in Germany still has large gaps and is in great need of improvement. Unfortunately, there is currently no statistical data to classify the extent of medical tourism and its economic importance in Germany more precisely.

3.2.3 Causes for medical tourism from Germany

In his study “Patient Imports and Health Tourism”, Illing names several trends that promote the mobility of German patients (see Illing 2000, quoted from Barth / Werner 2005, p.59f.):

- the globalization of social and health service providers
- the demographic development
- the restrictive allocation policy of the state
- the increasing pressure to rationalize hospitals
- the increasing willingness to invest in one's own health and
- the expansion of airports

In doing so, he records the most important causes that are responsible for the development of medical tourism in Germany. These will be characterized in more detail below.

The globalization of social and health service providers The possibility of using medical services abroad, which has existed since 1.1.2004, paved the way (see umbrella organizations of health insurance funds / German Liaison Office for Health Insurance - Abroad 2008, pp. 1ff.) (see section 5.2). More and more healthcare companies are recognizing the potential of medical tourism and opening branches abroad where they can operate more cheaply. The health insurance companies are also becoming increasingly aware of the importance of medical tourism and are increasingly concluding agreements with foreign service providers in order to send their insured persons abroad for inexpensive interventions. For example, AOK Brandenburg, which offers its German insured persons in Poland free dentures through its service company Medpolska (see Juszczak 2007, page 4).

The demographic development in Germany leads to an increasing number of older people in society. The proportion of 65-year-olds will increase from 16 percent in 2000 to 22 percent in 2025 and 27.5 percent in 2050 (see Gruber 2002). Unfortunately, this is also associated with a growing number of sickness and care cases, because with the increase in older people in society, aging diseases and signs of wear and tear are increasing on a massive scale (see Dörr / Gassner 1997, p. 43). The working life will also increase due to the demographic development. In order to maintain the workforce, people must try to stay healthy even at an advanced age (see Richter 2007, p. 40). The demand for medical services, also abroad in an emergency, will swell as a result. In addition, in contrast to the past, old people are more willing to consume and spend today. Their willingness to travel and, as a result, to receive treatment abroad has therefore increased continuously.

The restrictive allocation policy of the state can be seen in the rationalization measures of the health reforms in recent years. There is a reduced "... solidarity-based responsibility of society for the health of the individual" (Rulle 2003, p.163). This is characterized by the fact that the benefits of the statutory health insurance are continuously reduced and the medical costs are increasingly privatized. This means that the personal contribution for health services is increasing and the German population has to record increasing health expenditures as a result. As a result, Germans are becoming more and more aware of price-conscious handling of medical services, because they are forced to keep the costs of health services as low as possible. This results in an increase in the number of treatments that are carried out in inexpensive foreign countries.

The increasing pressure to rationalize hospitals is also created by the health reforms of recent years. The hospitals are increasingly forced to make do with lower state benefits. This increases the pressure to rationalize in the facilities considerably and often results in a reduction in the number of beds or even the closure of entire hospitals. This is confirmed by a study by the German Hospital Society, according to which the number of German hospitals fell from 2,411 in 1991 to 2,139 in 2005 and is even expected to fall well below 2,000 in the future (see Deutsche Krankenhausgesellschaft 2007, p.16). The key figures on hospital beds show a similar decline. In the same period, the number fell from 665,565 to 523,824, which represents a decrease of 21 percent (see Deutsche Krankenhausgesellschaft 2007, p.16). The rationalizations carried out mean that the German population has fewer medical capacities available. This increases dissatisfaction with the German health system, which increasingly prompts the German population to inquire about certain medical services abroad.

The increasing willingness of Germans to invest in their own health arises from the changing health awareness of people. It is increasingly accepted that everyone is responsible for their own health. In addition, health has become a benchmark for social recognition and is increasingly viewed as a sign of success at work and in private life. As a result of these factors, Germans' health expenditures increase and thus also the willingness to undergo treatment abroad. The reason for this is the fast pace of today's society, which means that people's time is becoming increasingly scarce and precious and they are therefore forced to combine vacation and health. Medical trips are also favored by the fact that people have ever greater incomes, know more and more about the world and are therefore also willing to travel (see Bookman / Bookman 2007, p. 3).

The expansion of airports As a result, German patients can reach more and more destinations with an unprecedented ease. As fuel prices rise, flying is becoming an increasingly lucrative and convenient way of getting around. The increase in low-cost airlines to Eastern European countries and the availability of inexpensive long-haul flights are also leading to an increasing number of German patients receiving treatment abroad (see Rose 2008).

3.2.4 Forecast for medical tourism from Germany

The market life cycle is divided into the phases of development, growth, maturity and decline (see Ansoff 1990, quoted from Stettler / Lanz Kaufmann / Jost 2007, p.107). An examination of the medical tourism market shows that it is only in the initial phase of the market life cycle. Therefore, one can assume that the industry will see very high growth compared to the overall health tourism market in the coming years. There are several arguments to support this assumption. The media write, for example: “A look at the demand side shows that the tendency to seek treatment abroad is increasing worldwide” (Rhensius / Stich 2007, p.1), or “In many EU countries there is therefore increased patient tourism to be expected within the European Union ”(see Laing / Forzi / Rhensius / 2006, p.185). The knowledge that the demand for medical travel will grow, the more people learn about this possibility, the more positive and numerous the experience reports become and the more mediation agencies and insurance providers pave the way for this development with their offers also supports this assumption (see Vacikova 2008). The reaction of officials in Brussels also confirms the assumption that medical tourism is growing. According to the Focus, they are certain that the mobility of the patients will continue to increase. In order to promote the flow of patients in Europe, they are even working on a new guideline to simplify travel for patients (see Ferenczi / Güsten / Hoffmann 2007, p. 62). The steadily rising prices in Germany are also a reason for the positive development of medical tourism and will mean that German patients will come to foreign clinics more often in the future looking for cheap offers (see Vogt 2008). The statements of the experts prove this. According to the interviews carried out, all agencies enjoy a continuously growing number of customers (see Bauer / Drinkuth / Vacikova / Vogt 2008)

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