Interview with Beauty from Afar author, Jeff Schult (transcript)

David Williams: This is David Williams, CEO of MedTripInfo. Today I'm speaking with Jeff Schult, author of Beauty from Afar: A Medical Tourist's Guide to Affordable and Quality Cosmetic Care Outside the U.S.
Jeff began writing the book when he journeyed to Costa Rica for major dental work. What started out as a magazine article turned into a full length book once he got to Costa Rica and learned the extent of the medical travel phenomenon.

David: Jeff, thanks for coming to speak with me today.

Jeff Schult: It's a pleasure to be here.

David: What made you decide to write the book Beauty from Afar?

Jeff: After a lot of research, I went to Costa Rica to have my own dental work done. And when I was in Costa Rica I was already writing a magazine piece about my own experience but when I was in Costa Rica, a lot of Americans were in Costa Rica, in San Jose, for a variety of treatments, medical care, etcetera.
I realized there was something going on here. When I came back to the States, I wrote the magazine article about my own dental work, but I kept researching and the magazine article I did let directly to some interest from publishers and I ended up writing Beauty from Afar in 2005.

David: Why in the book did you focus just on dental and cosmetic surgery, not on some of the broader sorts of treatments?

Jeff: I looked at those as the tip of the iceberg for medical care in general. It was the one where most of it was being done overseas, it was the easiest, it had been going on the longest, there was more data to look at, more doctors to look at, and more hospitals who were involved with it.
And though I certainly looked at more serious procedures that were being done, dental and cosmetic remain a substantial part of what medical tourism is, at least in America.

David: You talked about emailing your dentist several times back and forth and having extensive conversations, being able to speak with physicians on the phone. Why does that exist, that sort of level of service overseas?

Jeff: I think it's part of what they feel they have to do to attract overseas patients. It's certainly part of the marketing. They provide a high level of personal service, even when you go over there. There are great doctors in the United States, and in fact, I came out of writing the book with a higher opinion of American medical practitioners than I probably had going in.
But they are overwhelmed with patient loads, with paperwork. Overseas doctors, surgeons, dentists who are catering to an international clientele understand that this is part of what the business is about.

David: Do you think that that sort of level of service will hold up over time, or will those physicians as they're increasingly busy or maybe burdened with paperwork fall back into more of a customer service style that we're used to here in the U.S.?

Jeff: Well, I caution readers of Beauty from Afar and patients. It's one of the reasons why I hesitate to recommend specific doctors and surgeons sometimes. I was very careful about recommending in the book. Certainly those doctors and facilities and surgeons I mentioned have excellent reputations and I think they will hold up.
But things can change over time. I can recall reading about a particular plastic surgeon in Mexico, for example, who was great and people were raving about him on the Internet and he was doing outstanding work. And he became almost insanely popular. And if you read about his work and his patient service over time, it declined. There were more unhappy people.

David: I noticed that some people are using medical travel agents or travel facilitators to plan their trips. It sounds like you planned yours directly. But how do you feel about using a medical travel agent?

Jeff: A lot of these businesses have grown up and I do mention some of them in Beauty From Afar. I was a little bit cautious about it. Again, for the same reason: what's there today and what might be great, might not be tomorrow. And I wanted the book to hold up over time.
I think they provide a significant service for patients who don't want to do their own research and who might be uncomfortable with traveling overseas. In particular, for a lot of people who are perhaps not as educated on medical matters on their own medical conditions as other people are.
For people who might be intimidated by doctors, these companies can provide the information and the care and sort of the personal infrastructure so that people can do this, save money, and travel and come home safely.
At the same time, if you look at the people who are going, most people in particular for minor procedures or dental or cosmetic surgery most people are doing this on their own on the Internet. There's enough information out there at this point in time that most people are comfortable with that.
There's some suspicion still, at this point, of anybody getting in the middle between the doctor and the patient.

David: Now, this is a pretty new phenomenon, although as you talk about in your book, there have been hundreds of thousands of people from the U.S. who have already gone overseas for medical care. Do you think, as the phenomenon grows and more and more people read your book and hear about it, that there will be a greater impact on the U.S. healthcare system, as it goes from more of trickle to more of possibly a flood of people going abroad?

Jeff: I look at it as sort of a long, rolling wave. Certainly people have been doing this for a long time. But not many people knew about it. Modern medical tourism really started to come of age with the Internet, as more and more information about medical facilities internationally became available.
I don't think all of the sudden everybody's going. And I would estimate that it's growing at 10 20% a year coming out of the U.S. The tipping point, perhaps, for it is going to be as it is accepted by medical insurers, HMOs in the United States. And we start sending patients out of the country for treatment that way.

David: Tell me a little bit more about insurance coverage. My impression is that services like cosmetic surgery and dentistry tend to be self pay, which is one reason that probably people have gone abroad on their own. So what about insurance companies? Will they begin to pay for treatment? Do you see that happening already?

Jeff: Oh, it certainly is happening already. In fact, in Southern California, Blue Cross/Blue Shield and a couple of companies offer insurance that provides that patients go to Mexico for non emergency care and pays that way. And it's been it's not commonly known but it's been written about down in the San Diego area. It's for businesses and individuals within 50 miles of the Mexican border. And that's worked out very well. I believe they have a couple of hundred thousand participants in those plans.
More recently, now we're seeing Blue Cross/Blue Shield of South Carolina getting involved in medical tourism and actually signing a deal that brings Bumrungrad Hospital in Thailand in network essentially. They are looking at signing up with perhaps 10 more international facilities and offering that as a care option.

David: Now in the Southern California example, would people actually be getting primary care in Mexico, or is it just for procedures?

Jeff: They're actually going for primary care.

David: And in the South Carolina example where you talk about bringing international hospitals into their network, how do the existing network hospitals feel about that? Have they had any kind of reaction yet?

Jeff: I don't know. I have not read of a reaction nor has anybody talked to me about that. For the most part, when I've talked to American facilities people who might look at this as a competitive situation they look at it with some alarm and also some resignation. They see it coming.

David: In your book you took at shot at trying to make an estimate of the number of people that are going overseas. Is there anyone that's keeping official statistics, or do you expect that to start?

Jeff: I don't see anyone keeping official statistics. There are various people who have taken a stab at it, as I have. I know you talked with Joe Woodman, and he came up with an estimate that I don't disagree with. What I tell people is that it depends on how you count them. There's obviously, in the media, it's the Far East India and Thailand that have gotten the lion's share of the attention, really.
But most American patients, most of what I call medical tourists from America, aren't going there. Proximity matters, and most of it is going to Mexico. It's just not that well known. It's been going on for years. Again, a lot of it is dental and cosmetic surgery. But if you throw in the people who just drive to the border, if you count all dental and cosmetic and if you count all other procedures, I put the total that way at over 500,000 annually.
On the other hand, if you just want to count people who go on planes for serious procedures, the number's far lower. I've heard medical tourism companies say that perhaps the market for that is at this point only perhaps 20,000 patients a year.

David: Talk a little bit more about the role of these different countries and different geographies, because South and Central America seem to have more cosmetic and dental procedures. And over in Asia, not only do they actually have the dental and cosmetic as you mentioned in your book but also some of these more serious operations like hip replacements or hip resurfacing or valve replacement for the heart.
Do you expect that segmentation will continue or will South and Central American countries actually become competitive in some of these major procedures as well?

Jeff: I think they're becoming competitive, but it's a slower process, because medical tourism in South and Central America has grown primarily through the work of individual surgeons, small practices, etcetera, in plastic surgery and dentistry. It's really been an entrepreneurial situation there.
It has not been major medical facilities until recently in South Central America that have gotten involved in this. When the Asian hospitals and medical facilities got involved, they got involved with full hospital medical services such as Bumrungrad, Bangkok Hospital, Apollo in India, etcetera, the big names in the business over there.
As time goes on, some of the major facilities and medical hospital owning companies in Central and South America are moving into that space and are determined to be competitive with Asia. Though so far it seems that they can't quite compete completely on price, they can compete on proximity and I think they're going to do well.

David: What role are national governments playing in this? You talk about different companies, but my impression is that, at least in Asia, some of the governments have been involved in sort of a national strategy of attracting medical tourists.

Jeff: I think the government tourism boards and the economic development agencies of the Far East look at this as a significant economic sector, an area of growth, an area for an exchange and the governments are putting money into backing it and to marketing it.
And I think that's a big advantage that the Far Eastern countries have going forward. That's not happening in Central and South America. You don't see it happening at this point either in Europe, which I think is a prime market for medical tourism but is largely undeveloped for it.

David: So what about some of the supporting infrastructure? Because the hospitals themselves and the physicians are obviously important, and so are air connections and having hotels where people can recuperate and even basic sorts of infrastructural things in the countries. Are those being coordinated along with the development of the actual medical infrastructure?

Jeff: In writing Beauty from Afar, one of my more or less subjective criteria for what got included was not just do they have great doctors and great care in that particular country or city, but did they have the modern infrastructure? Can a little old lady from Iowa who's never been out of the country go there and have a satisfactory experience and come home happy and telling people that she had a terrific time, that the care was terrific and that it was everything that she had hoped it would be?
And in Asia, certainly, they're building near resort like facilities to complement the surgical and medical part of medical travel. In other countries, they are starting to recognize that they have to do such a thing.
Costa Rica has long had a sort of a home grown system with "recovery retreats," almost like little lodges that cater to medical tourists. Now you're starting to see larger facilities for care and after care being built.

David: One thing I think that's fairly striking in the whole medical tourism area is the success of Thailand, maybe relative to India. When you think about overall outsourcing, you never hear outside of the medical context you always hear about India and you really never hear about Thailand.
And yet it seems in attracting medical customers, patients, from abroad, that Thailand is quite successful. Is that true? And what would explain that?

Jeff: I think it is true. I think that Thailand remains out in front in the Far East as far as reputation goes, if not actual, total number of patients. But in the Far East specifically for Americans and maybe for the UK Thailand is best known, and I think it's because they started earlier and they did it right.
Specifically, Bumrungrad Hospital got involved with marketing medical tourism and setting up to cater to medical tourists in the late '90s, before anybody really thought that there was going to be a big market for it.
India certainly has terrific doctors and everything else, but as I indicated before, they came a little late to the game. And India is perceived as perhaps not quite as an attractive destination, at this point anyway, as Thailand.
A lot more Americans have been to Thailand than to India, going back to the Vietnam War. And Thailand is still more of, in general, a tourist destination than India has been.

David: Now, you mentioned European countries, and those being underdeveloped. Do you have any particular countries in mind? What are you thinking there?

Jeff: Well specifically when I wrote Beauty From Afar, I was looking at the Eastern European countries that were coming into the European Union. And they certainly can compete on price and they have long had good medical facilities. They have not reached out so much to the United States yet, though a lot of people from the UK and from within Europe go there.
I heard, early on in my research, that German dentists were up in arms because all the Germans go to Hungary for dental care now.
More recently a few other countries in Europe have raised their heads and said, "We're in this too and we can compete." And I'm thinking specifically of Portugal and Spain, which I think could be if they're competitive on price and procedures, which I think they can be I think is a terrific destination for Americans, especially from the East Coast.
In America, rightly or wrongly, we perceive Europe as being more like us.

David: If you're traveling to a country where the native language is not English, it sounds like a lot of the physicians who are catering to Americans medical travelers do speak English. But how about other people who work with them, like the nurses or their office staff? Are they likely to speak English as well?

Jeff: I think that can be hit or miss. I think it's more likely in some of the Asian countries, certainly, where English is almost a second language. In South and Central America, it can be a little bit hit or miss, and I think that's something patients should ask about.
I mean, there are stories of people having surgery and coming out of anesthesia and being a little disoriented and not finding anybody immediately available who speaks English. And that can be a problem. It's something that patients who are concerned about should ask about.

David: In doing your research, it seems as though you... I think you mentioned in the book that you read thousands and thousands of chat room messages. And I'm wondering, are there a lot of lively chat rooms, or are there any particular ones that you would recommend to people?

Jeff: I wouldn't say there's so much chat rooms, though there are some sites that have chat rooms. A lot more of it has been forums and Internet mailing lists. Specifically one website and one forum site that I got a lot of help and support in writing the book about was one called plasticsurgeryjourneys.com.

David: Jeff, what's next for you, are you writing another book? Is there going to be a second edition?

Jeff: I hope there's going to be a second edition. The book has done pretty well, but publishing's a tough business and it may take a year or two before my publisher decides that there's a big enough market.
One of the reasons, also, that I focused more on plastic surgery and dentistry, is that there is a bigger market in that. I think you're not going to find a New York publisher who's interested in a book just on hip replacement abroad.
I'm also doing some writing for a European magazine called "Healthcare Options." And in the next month, in conjunction with a company called CPR Communications, we're going to be launching a medical tourism newsletter.

David: Now, you mentioned at the very start of your book when you were looking for a dentist, you wanted somebody who would also be comfortable with the fact that you were going to be writing a magazine article about the experience.
Has you dentist actually read the article and read the book? And what did she think of it?

Jeff: It increased my comfort level that my dentist jumped at the opportunity to have something about her appear in the media in the United States. I thought, "Well, she's pretty confident. If she's going to wreck my teeth, that probably wouldn't be very good for her business when I wrote about it."
My dentist, specifically, was thrilled, and the exposure that she got in the United States increased the number of patients coming in rather dramatically, from what I understand.

David: I've been speaking today with Jeff Schult, author of Beauty from Afar: A Medical Tourists Guide to Affordable and Quality Cosmetic Care Outside the U.S.
Jeff, thanks very much for speaking with me today.

Jeff: It was a pleasure, David.