Notes on Medical Tourism from the Past 2 Weeks
Fertility, Longevity, Stem Cells, Gene Editing, Honduras, Turkey, Costa Rica
Last week I wrote How to Build Conviction in a Startup, an abstract topic for startup founders.
This week I want to take it back to medical tourism and the domain-specific problems and insights I discovered talking to patients, practitioners, administrators, investors, and founders who are or were in the world of health and travel.
Thank you to Yazin Alirhayim, the founder of Amal Invest (YC W22), for being our first paid subscriber. Amal Invest make US mutual funds and ETFs halal by filtering out non-shariah-compliant stocks. Mashallah!
Table of Contents
Patients
Practitioners
Administrators
Investors
Founders
İdil Kilic, Co-founder of Treataway (UK <> Turkey medical tourism startup)
Burçin Advani, Co-founder of Best Parents (education travel marketplace)
Yarden Horwitz, Co-founder of Spate (beauty and wellness trend analysis platform)
Jonathon Howard, Co-founder of Emissary (an “Airbnb for medical tourism”, acqui-hired in 2016)
Patients
Matt Harriman
What medical tourism did you do?
Me and a family member went together to Costa Rica a few weeks ago. I didn’t get anything done, but they did dental work. We were in Costa Rica for a total of 10 days.
What was the cost?
For the dental procedures, we were quoted $25-30k in America. It ended up being about $5k in Costa Rica.
Including trips to the beach, tourism, Airbnb, and roundtrip flights for 2 adults, it ended up being $10k all in for about 10 days.
Went to the most expensive place in Costa Rica as well, which is about 2x more expensive than most places there.
What was the process like?
Janky. Felt a little bait and switch.
When we got there, the doctors on the website were not the doctors that treated us.
Could tell that the place we went to was trying very hard to market themselves towards Americans.
Found clearly biased reviews on Google Maps, Trip Advisor, and ranking articles and websites.
What was the work you did leading up to it?
For a few weeks or a month, read a lot on Google and forums. Only one clinic seemed viable, so called them a few times back and forth for information, logistics, and dental questions.
A lot of the research was normal tour guide-type information.
Getting around: Uber vs renting a car
Living: which neighborhoods are good and safe
How to avoid getting scammed
Food, water, etc.
How confident were you in this clinic leading up to it?
We were 60-70% confident before we got there. Once we got there and talked to the dentists, could tell they were legit, and it went to 100%.
The clinic had bungalows and transportation packages, but we ended up renting our own Airbnb and whatnot because we didn't know if we should fully trust them or not.
Figured that the worst-case scenario would be that we just don't do the procedures and get a vacation.
Would you do it again?
Would definitely do it again. It was awesome. Probably wouldn't go with the same clinic now that we know that they are 2x more expensive than others and not necessarily better.
Practitioners
Isabel, Doctor of Optometry
Who are your patients?
I specialize in hard contact lenses, which are needed for people who have trauma on their eyes from infection or potentially complications with LASIK.
About 10% of my patients are people who did LASIK abroad when they weren't good candidates for it because their cornea was too thin for the operation.
How much do hard contacts cost?
The initial fitting costs patients around $3400.
Then, it's $1200 for new contacts, which you might need every 2 years if you take care of them.
It costs about $600 to get new contacts directly from the lab.
What do you think about the American healthcare system?
As a patient, I get fucked by insurance.
As a doctor, I get fucked by insurance.
Insurance companies make the most money, and they aren't doing much.
It's not clear how insurance companies set their prices. It's constantly moving goal posts. Each insurance co is constantly changing their policies.
Insurance companies almost never pay the amount that they are billed by the hospital.
When did you realize the American healthcare system was fucked?
In optometry school. The billing lady was stressed out all the day. There were no clear rules for what to expect from insurance companies. It just felt totally out of our control.
I wanted to start a private practice before that point to work for myself. But the work required dealing with insurance companies was a huge turn-off.
What are the the differences between private practices and hospitals?
Private practices do not necessarily work with insurance companies. Instead, patients pay out-of-pocket with cash. If private practices do want to accept insurance, they have to register with each insurance company, which is incredibly redundant and bureaucratic.
We are sort of unique because we are a hospital that is also affiliated with a university. We get grants from the school, as well as royalties from patents. I get paid whether I have patients or not. Private practices, on the other hand, make money entirely off their patients (if they are not using insurance), which means they have to market themselves and be more aggressive.
What do you think about doing medicine abroad?
Think it's great, assuming the care is actually good and things like liability are sorted out. It's not just "Groupon for LASIK" which happened in the past.
In the US, there is a huge deficit of healthcare. I am booked out 3 months in advance.
There are world-renowned doctors everywhere. Some of the best ophthalmologists/ophthalmology clinics in the world are in India.
Why is LASIK not covered by medical insurance?
Good question! There isn't a good answer. It is probably twisted incentives between the vision insurance and medical insurance companies. Neither is incentivized to pay for the others'.
Ashley, Stem Cell and Hormone Therapist, Nurse Practitioner
Why do people do stem cell therapy?
At our clinic, people did stem cell therapy to heal medium/large joints, such as knees, hips, shoulders.
Who are the kinds of people who did stem cell therapy?
Wide range. Young athletes who want to heal faster or geriatric people who want to try an alternative to something like an invasive, expensive hip replacement surgery.
Generally speaking, it is wealthier, educated people. Wealthier because stem cells are out-of-pocket and educated because stem cells are not a super common thing yet.
Where did you get your stem cells from?
We got stem cells from umbliical cords and placentas.
We bought them from 2 companies. One called Signature Biologics.
Some hospitals will offer to freeze a child's stem cells when they are born, and then keep it frozen for $200/month.
How much do stem cells cost?
We would buy stem cells for $1000.
The client cost might be $5000.
An ultrasound machine that is used to guide stem cell therapy costs around $20k. Ultrasound-guided therapies increase accuracy from 30% to 85%.
Are there any risks with doing stem cell therapy?
The only contraindication is cancer. Stem cells can cause cancer cells to multiply.
What is PRP?
PRP stands for platelet-rich plasma, another injection therapy which we would commonly do for 3 weeks leading up to a stem cell injection.
PRP is when you draw blood from someone, enrich it with proteins, leptins, collagen, and reinject it.
How much does PRP cost?
PRP costs the patient about $1000.
The machine that spins the blood costs $100. The tubes that we use for blood cost about 25¢. There is essentially no overhead cost.
Why do people do hormone therapy?
People do hormone therapy because perhaps they have low amounts of testosterone or estrogen.
We test and do lab work before we determine whether a patient qualifies for hormones or not. In general, we are conservative in terms of who we treat. Not all clinics are, because it's a cash-only, unregulated therapy.
Why are stem cells not covered by medical insurance?
Because they are not FDA-regulated.
Why are stem cells not FDA-regulated?
Because they haven't passed through clinical trials.
Why are haven't they passed through clinical trials?
Because clinical trials are very expensive, and you need someone to bankroll them, such as a big pharma company.
How come big pharma companies are not paying for clinical trials for stem cells?
Because you can't patent stem cells.
Administrators
Chris, FDA administrator
Bachelor's and Master's in Biomedical Engineering. Currently works at the FDA overseeing clinical trials. Research in school focused on stem cells and bone marrow.
What is the history of stem cells?
Stem cells have actually been around for quite a few decades.
Given that you studied stem cells for your bachelor's and master's, why aren't you using continuing to work on them directly?
Stem cell research is very pie in the sky. There are big promises, but the number of industry applications we've found is limited by comparison.
Can you use anybody's stem cells?
No, there has to be some genetic overlap. It is best to use your own. In school we learned about a family who, in part, had a second child just to give their first child stem cells.
Why are FDA trials so expensive?
Because human lives are expensive! What do you think a human life is worth?
Investors
Niklas Anzinger, Investor at Infinita VC
Niklas and his wife are moving to Próspera, a charter city in Honduras, this June.
Minicircle is a biotech startup running clinical trials in Próspera. One of their gene therapies would cure HIV, and the other would treat or delay ALS and follistatin muscular dystrophy.
Cost
The average cost of phase 1, 2, and 3 clinical trials across therapeutic areas is around $4, 13, and 20 million respectively.
Each patient is around $30k-50k.
Biotech startups can do their pre-clinical and Phase I trials faster and at an order of magnitude less cost, getting, for instance, 10 shots on goal rather than 3 in the US in the earliest stages.
Biohacking for the brave. I could go to Próspera and do the follistatin gene therapy, which has proven (on mice) to improve bone density, muscle mass, decrease bodyfat, improve insulin sensitivity, improve cholesterol balance, and reduce the epigenetic rate of aging, i.e. you can live longer (longevity) and get more ripped. You can apply to join a trial here!
GARM Clinic is a clinic in Roatán, Honduras founded by Glenn Terry, M.D.
Dr. Terry is a U.S. Board Certified orthopaedic surgeon, who was a head physician for the US Olympics.
GARM Clinic provides stem cell therapy, products & supplements, and other clinical and lab services.
BIFAT is a peptide therapy, weight loss, and wellness clinic in Roatán, Honduras.
The founders are Dr. Nikki Javit (Doctorate in Pharmacy) and Matt Javit (MBA).
BIFAT offers peptides like semaglutide (for weight loss), and soon will offer BPC-157 (decreases inflammation and increases blood flow to damaged tissues) and CJC-1295 (growth hormone for muscle build-up and fat loss).
They advertise their cost to be $350/month, compared to $1399/mo in LA, $1100/mo in NYC, $950/mo in Chicago, and $800/mo in Miami.
Niklas is hosting a biotech conference at Próspera in April 2023. You should go if you're a biotech/health founder or investor!
Founders
Wesley Jacobs, Founder of Apollo Medical Travel (medical tourism writer and concierge service in Costa Rica)
Hard to scale / Operationally difficult
Language: Spent 6-12 months intensively studying Spanish. Reads paperwork, taxes, etc. in Spanish.
Culture: Took another year to understand cultural differences of another country.
Direct service, support, sales: Wesley has to do a lot of phone calls, emailing, and chat. Himself learned the intricacies of dental, e.g. the types of veneers, the costs, etc.
Other countries have a lot of edge cases.
Cartels, gangs, extortion. One of his patients literally had to wait a week to get their procedure done because there was a conflict between gangs and the police. The gangs blocked the main road for a week, so no one could get through.
Wesley is living in Costa Rica now, not Colombia or Mexico, because of security concerns.
Medicine has a lot of edge cases.
Had a patient who got a mouth infection on the way to Costa Rica, which wasn't caught by the X-ray they did in the US. The quote was changed quite a bit because of this.
Had a patient who didn't report that they were taking oxycotin because they didn't want to get denied the procedure. Turns out Colombia has a strict ban on doctors prescribing oxys, as a reaction to what's happening the US.
Fairly wealthy people do medical tourism.
Has patients who are US doctors, who come down to Colombia to do medical tourism while also looking at second homes.
Reminds me of the anecdote that US pharmacists always buy generics rather than branded OTC medicine.
He initially expected people in the 40% of wealth to do MT. What he discovered is that people in the 60-70% of wealth do MT.
Likes dental because it's medium complexity and potentially high cost.
For serious dental, could go from $50k -> $10k.
For cosmetic, could go from $10k -> $5k.
Celebrity doctors are an interesting phenomenon.
Dr. Mario Montoya in Colombia became famous for treating Tekashi69 and Rick Ross. Turns out he treated Tekashi for free, and his teeth fell off anyway and had to get them redone. He's not even that good.
Plastic surgeons who treat K-Pop or Hollywood stars are booked out years in advance.
There is no "medical tourism guy" yet.
Trust is important.
ZocDoc is probably a better model to look at than Airbnb.
You will need to commit to a niche at some point: procedure + geo.
Shauny Ullman, Founder of fertility startup
In the US, there are 30M women who want fertility treatment and only 500 clinics. Demand far exceeds supply.
The US historically has a doctor-centric model. You have to talk to an overbooked doctor several times over multiple months, who doesn't actually do much besides be an intermediary. Shauny imagines in a few years women will work directly with labs and technicians, who do all the actual work, bypassing endocrinologists.
US insurance and healthcare is oriented towards infertility, not fertility.
Your insurance won't cover fertility, because it's elective.
Your insurance, if it does at all, is more likely to cover infertility, but you have to work very hard to demonstrate that you would have trouble having children, which is reactive and maybe too late.
Generally speaking, one systemic issue with US healthcare and insurance is that it is setup to be reactive rather than preventive.
Europe and Australia have the opposite problem: far more supply than demand. This is because they have public healthcare, and fertility is covered by it (rather than infertility).
Spain has the best and most fertility clinics, for some reason.
In a post Roe v. Wade world, there may be greater motivation for doing fertility work abroad, because women are afraid of having their fertility data documented.
Another big issue in healthcare is that it is like big tech companies. Companies will sell patient data to pharma companies, profit off of it, without patients' awareness or getting anything from it.
Fertility is more of an involved journey than a facelift.
Virtual care would have to be a core function for a fertility-centric medical tourism company. Preliminary intake, labs, scans. Follow-up calls, medication, etc.
Data interoperability and portability between countries, labs, patients, etc. would also be critical.
Believes consumer/public opinion will drive an inflection point for fertility in the US.
Look at the policy trends on "Mandate to offer".
İdil Kilic, Co-founder of Treataway (UK ↔ Turkey medical tourism agency)
There is propaganda in the UK against medical tourism to Turkey: “Turkey Teeth”
She had patients who were offered money by journalists, who were likely offered money by UK dentists, to publicize negative reviews and experiences of their dental tourism trip.
The Turkish government provides generous incentives for medical tourism companies. Does require a lot of paperwork.
Turkish hospitals don't want to do paperwork or invoicing. They want cash.
The hard part is operations.
Must have great customer support.
Once a patient lands in Turkey, they are assigned a personal host who is physically on call with them the entire time.
After care: 30% of dental patients need follow-up care. How do we manage hand-off of care or continued relationships between doctors and patients abroad?
Marketplace advice: give patients a lot of options, esp. if they are concerned with the reviews or qualities of some clinics.
John Loeber, Co-founder of Limit (Series A insurtech)
Did a 6-week deep dive in 2019 to explore the idea "Airbnb for Medical Tourism". Ultimately, couldn't get to conviction on a billion dollar thesis.
Cons
Down side risk and liability
The downside risk of a medical marketplace is higher than cars (Uber) and hotels (Airbnb).
Complications and malpractice has real downside risk.
A single bad PR story could kill a startup.
Demand constraints
Most of the people who are the best candidates for medical tourism can't actually go.
People with no insurance.
People who need emergency surgery.
People who probably can't afford flying roundtrip abroad anyways.
The TAM of medical tourism from the US is not all 330M Americans.
Supply constraints
The best hospitals in any given country are likely booked out, and adding supply isn't as easy as adding cars (Uber) or short-term rentals (Airbnb). At a certain point, you'd have to train more doctors and create hospitals to match demand.
Operations
Tons of operational work. Have to manage clinics, get transportation, etc.
Pros
Lots of small/medium companies and niches that could succeed.
Niches that might work well
Picking up generic drugs in Mexico.
In Vitro Fertilization (IVF)
Patients are young and healthy.
Expensive in the US.
Specialized.
Not covered by insurance.
Generally very safe.
Leo Zaroff, Founder (Stealth)
Medical tourism might not be one market but 100 separate markets.
Two glimmers of hope:
Could you win one niche and expand to others?
Can you expand the demand-side, by creating a new market we wouldn't think about otherwise?
Burçin Advani, Co-founder of Best Parents (Education Travel Marketplace)
Marketplace advice: give parents a lot of options! Variety, variety, variety.
Marketplace advice: it's all about SEO!
Yarden Horwitz, Co-founder of Spate (beauty and wellness trend analysis platform)
Travel to Turkey for hair treatments is trending.
Travel to S. Korea for spa is early but trending.
Longevity and aging is trending. Every wealthy woman in the US has an "age doctor" now.
Jonathan Howard, Co-founder of Emissary (medical tourism marketplace, acqui-hired in 2016)
US doctors and dentists blatantly violate HIPAA to prevent portability of data.
MT is super fragmented because the economics don't work below a certain scale.
Something to the approach of making it "sexy" to attract young professionals
Conclusion
No synthesis yet. Just processing it all.
Thanks to everyone who chatted with me these past 2 weeks. I’ve learned so much from you all.