Winning The Hearts and Spines of Medical Tourists

We asked QUO Director of Healthcare + Wellness, Ruben Toral, where are the trends around the intersection between travel and healthcare and what do they mean for destinations wanting to position themselves as medical tourism hotspots.

QUO: Given the sustained growth in healthcare, wellness, travel and tourism, what do you see trending in this space?

RT: What I see more than anything is the convergence of players in the healthcare, wellness, hospitality and travel space. More hospitality players are looking at health and wellness and more healthcare players are looking at offering more of their services outside the hospital. In the centre of the Venn diagram is medical tourism, wellness tourism, healthy hospitality and retirement/active living.

QUO: In your view, which destinations are winning in medical tourism and what are they doing to achieve this success?

RT: The most successful medical tourism destinations are typically countries or cities (think: Houston, Bangkok, Delhi, Singapore and Seoul) that offer access to unique medical expertise. Houston, for example, is known as a ‘medical city’ because it is home to some of the world’s top medical brands including Texas Medical Center, MD Anderson and The Texas Heart Institute. It is also one of the largest passenger hubs for United Airlines. These medical hubs typically develop organically over time based on the strength and reputation of a particular institution (like Bumrungrad International in Bangkok) or expertise (cosmetic surgery in Seoul) and are within easy reach of feeder markets looking for better, faster, cheaper care.

The top destinations in Asia are Thailand, India and Singapore. In Europe, Germany, Turkey and Hungary are popular destinations. In the Americas, the US, Mexico and Costa Rica dominate.

QUO: Are there any specific growth areas or trends in terms of treatments? What is driving this?

RT: It very much depends on place and institution. Take Korea, for example. Twenty-five years ago, few would have considered travelling to Korea for cosmetic surgery. Today, it stands as the cosmetic surgery capital of the world. What changed in those 25 years? The rise of K-Pop.

In Asia, Korean artists dominate the entertainment landscape, and many aspire to emulate the looks of bands like Black Pink and BTS. Korea has become synonymous with cosmetic surgery, with media playing a significant role in driving this trend.

QUO: That’s interesting. In a holistic sense, especially with recovery and rehabilitation, surely the environment – whether it be climate, natural environments, wide spaces for rest – must play a key role? In other words, a destination with many beautiful and nurturing locations to complement treatments must have an advantage. How can hospitality do more to support the destination?

“While often portrayed as ‘sun, sand and surgery’ the reality of medical tourism is very different. People select healthcare destinations based on reputation and trust, and the best medical centres and doctors are usually found in major metropolitan cities.”

RT: That is the biggest misconception of medical tourism. While often portrayed as ‘sun, sand and surgery’ the reality of medical tourism is very different, and anyone who has travelled to Delhi in the heat of summer or Rochester, Minnesota (home of the Mayo Clinic) in the dead of winter will tell you the same. Medical travel requires extensive planning, paperwork and logistics coordination. When you add travel, accommodation, food and transport expenses on top of the already considerable medical expenses, it can be a considerable amount of money because patients and their families often stay for weeks and sometimes months at a time. This is what makes medical tourism such a high-value segment in the tourism industry.

The reality is that people select healthcare destinations based on reputation and trust, and the best medical centres and doctors are usually found in major metropolitan cities, not on the beach. Typically, people want to get treated and get back home as soon as they safely can.

QUO: What are the potential obstacles to growth for the market as a whole? For instance, is the regulatory and legal environment becoming easier or more difficult to navigate? How about international medical insurance – is this getting easier?

RT: The single biggest obstacle is cost. As mentioned, medical travel is not cheap when you factor in all the costs. For example, an American who decides to travel to Mexico for hip surgery may save 50%, BUT the out-of-pocket costs are still significant. Insurance is not an option for anyone travelling specifically for healthcare because most policies do not offer this as a benefit, even though the next cost could be cheaper.

QUO: Thanks, Ruben. Finally, from a brand perspective, how can a country approach promoting itself as an attractive, safe and future-facing medical tourism destination?

That is the million-dollar question. Trust in healthcare isn’t made but rather earned over time so there is no quick fix here. I have worked with many destinations on medical tourism and my advice focuses on the basics. One, building a brand means building a clear, compelling narrative that answers one simple question, ‘Why choose you?’ In a world full of options, why would a potential medical tourist choose your clinic, hospital or city over others? Two, keep it simple. Be very good at one thing and build a reputation around that. Three, remove friction. People travelling for medical care do not want surprises that will cost them time, money or stress. Four, your patients are your best advocates. Make their stories your story.

The Convergence of Healthcare and Hospitality

In an era where wellness and travel intertwine more than ever, the hospitality industry stands at the crossroads of change. We sat down with QUO Director of Healthcare + Wellness Ruben Toral to discuss the convergence of healthcare and hospitality. From the evolution of wellness in hotels to the future of ’healthy hospitality’, Ruben sheds light on the transformative journey of the industry.

QUO: Wellness now seems to be ‘everything everywhere all at once’ to quote the Oscar winning movie. Do you see it that way too?

Ruben Toral (RT): I do. Wellness is permeating industries from healthcare to hospitality and literally everyone everywhere is looking to develop a strategy in this space. 20 years ago wellness was fringe, 10 years ago it went mainstream and today it is a requirement. No hospitality, healthcare or property business can afford to ignore this segment, in my opinion, because it plays into macro-trends like ageing and rising healthcare costs and into micro-trends as well.

QUO: The Global Wellness Institute’s 2019 report valued the wellness tourism market at $639 billion. How does this compare to the general tourism market?

RT: The global tourism market is valued at $10.5 trillion and growing at a CAGR of 5%. So while the absolute number is big, on a relative basis the wellness related tourism market is only 6% of the total tourism market. However, wellness tourism is growing at double the rate of global tourism. If the surge I see in post-COVID medical tourism numbers is any reflection of the demand for wellness tourism, then we will see annual growth rates much higher than 10% in the coming years. Mind you, COVID is a reminder of how exogenous events can both propel and punish tourism.

QUO: How are the healthcare and hospitality industries responding to this surge in wellness interest?

RT: Healthcare, hospitals mainly, traditionally viewed wellness as a small, outlier business, consisting mainly of annual check ups. Today, they see wellness as a much bigger part of their business, and not just in terms of revenue, but as a requirement to deliver a ‘total care’ model of healthcare—one that offers customers ‘well’ care and ‘sick’ care. As a result, they are expanding their portfolio of services to include genetic testing, customised supplements, immunity boosters and more. Wellness has helped shift the model of care from episodic (use of healthcare only when sick) to a continuous model of care (use of healthcare more frequently for disease prevention).

Hospitality had a similar mindset to wellness in the past, and really viewed it through the lens of their spa business. For all intents and purposes, the spa was the wellness option for hospitality until very recently. Today, I think hospitality views wellness either as an amenity or as a philosophy that is woven into the fabric of everything they do. Viewed as an amenity, wellness is an expanded list of services that include, but are not limited, to the spa. Viewed as a philosophy, wellness is infused into restaurants, rooms, fitness centres as well as programming and staffing. It’s a holistic approach.

QUO: Is there now an overlap between healthcare and hospitality when it comes to wellness? Are they competitors or collaborators?

RT: There is overlap, but it’s not competitive. People are not saying to themselves, “should I go to a hospital or a hotel for wellness services?” As a rule, hospitality reaches out to healthcare if and when they decide to offer medical services, because hotel brands and operators do not want the risk, costs or liability associated with delivering medical care. If they do decide to offer medical services, it is usually in partnership with a doctor, clinic or hospital that has the medical licence, staff and expertise. Those arrangements can range from offering services to leasing space to full blown partnerships.

The area where collaboration opportunities are greatest is in wellness resorts. Hospitality companies are moving aggressively to build more destination wellness resorts and hospitals are looking for new ways to expand their reach beyond the clinic or hospital. At QUO, we see new businesses and brands being created around these partnerships, and that trend will continue, I believe.

QUO: You isolated wellness resorts as a growing category within wellness. What do you see happening in this space?

RT: A lot of activity, that’s for sure. Increasingly, developers and hospitality companies are looking at wellness retreats as the product to attract high value, long stay guests who want an experience that goes beyond room and restaurant. Over the next 3-5 years we will see an explosion of wellness retreats around the world catering to this guest typology. This opens the doors for a lot of new players, partnerships and concepts, so I think this will be one of the most active categories in hospitality and healthcare over the next decade—and that’s exciting.

I temper this enthusiasm with the caveat that this space is also at risk of oversaturation. Everyone will see this segment as the next El Dorado and go for the gold. That scenario leads to ‘wellness wars’ where companies compete to see who has the biggest facilities and the most amenities. The product cycle will be shorter as innovation quickly turns to normalisation, if not commoditisation. We saw that in the spa category.

QUO: Is the same true for the large hotel chains that have spas and are shifting to wellness?

RT: It’s my experience that mass market hotels view wellness more as an amenity rather than as a driver of stay, i.e. a reason to choose. These guests have a shorter length of stay and may ‘get a little wellness on the side’, but their intent is more room focused than wellness focused. From this lens, the goal is to enhance guest experience and drive incremental spend. The more forward-looking chains are looking to weave wellness into the stay or elevate the wellness offering so it is a stand-out rather than a side dish. There is whitespace here, I think, but the window of opportunity gets smaller over time as more brands come to market with their interpretation on wellness.

QUO: If commoditisation is a potential threat for wellness, then how do you protect against it?

RT: I believe it comes down to specialisation. To provide real value requires understanding your audience, having a clear purpose, great programming and ultimately delivering on a desired outcome. The fundamental ingredients of wellness are known, but the value is baking those into a cake that people want to buy and recommend to others. The healthcare industry is a good teacher in this regard. Everyone pays more to see a specialist rather than a generalist, because they have narrow but deep expertise in their field of medicine. People always want to know what a given hospital specialises in, because that influences their choice. The same will apply to wellness. Without specialisation you have commoditisation, and no one pays a premium for a commodity.

QUO: What role does branding play in wellness? How important is this to the guest and the operator?

RT: I would say it is very important. To differentiate, to generate a price premium and to retain customers you must have a brand that communicates purpose and branding that drives awareness, choice, pricing premium and loyalty. Guests will not spend more or stay longer for a generic, non-branded experience. They don’t do it in any other segment or sector, why would they do it in wellness? In fact, I would say it is even more important in areas like healthcare and wellness, because guests (or patients) make their selection on the basis of trust. No one will select a care provider they do not trust, at any price.

Branding in wellness needs to go beyond facilities and amenities and focus on purpose and outcome. Full stop.

QUO: You talk about ‘healthy hospitality’. Is that the same or different from wellness?

RT: Healthy hospitality is the outcome. Wellness is the way. My view is that if you can make a stay feel healthier then you win the hearts and minds of guests, because you appeal to their emotions and intellect. If I select a hotel and they have healthier menu items, better fitness facilities and programmes and sleep-friendly rooms, then chances are I leave the hotel feeling better than when I walked in. That’s a win at every level.

As I have said before many times, ‘wellness’ can be anything. The word almost has no borders. Therein lies the risk of commoditisation, because there is no barrier or restriction to label something as ‘wellness’. ‘Healthy’ is more tangible and visceral. People know when they feel healthy. They have more energy, more endurance and more clarity of mind. My sense is that if you offer people a ‘healthier way to stay’ that they will reward you in loyalty.

From Trust to Profitability

In a competitive landscape of rising costs and disruptive technologies, providers and investors must harness their brand as a key business asset. Director of Healthcare + Wellness Ruben Toral discusses the power of branding in healthcare M&A.

healthcare m&a

Investor enthusiasm for healthcare assets in Asia-Pacific is strong and getting stronger.

According to Deloitte, the global healthcare market is valued at over $8 trillion. In 2018 alone, global cross-border mergers and acquisitions (M&A) in healthcare totalled $182 billion. The report highlights Asia-Pacific as one of the fastest-growing regions in healthcare spending—a mega trend driven by demographics, lifestyles, disease rates, urbanisation, rising incomes and higher demand for private healthcare.

The takeaway is obvious. Healthcare is the place to be and no one understands that more than investors and private equity companies specialising in healthcare. Valuations are getting frothy, and as the pool of quality targets shrinks, deals become more competitive and valuation multiples rise. In that environment, providers and investors want to optimise every part of the business—and that should, but rarely does, include the brand.

Having a trusted brand in healthcare is not only desirable—it is critical. Consumers trust brands, and no industry is more trust-driven than healthcare. Strong hospital brands drive volume, acuity and loyalty and generate higher margins than their peers. They also attract medical tourists—a lucrative source of high value patients that will travel for higher acuity, specialty services.

McKinsey research shows that “top-ranked brands outperformed the world market by 74% as measured by return to shareholders.” Yet, brand value is rarely ever fully captured in M&A, because operators and investors focus on levers they can control to impact margins—cost optimisation, operational efficiencies and capital allocation. Brand is an intangible asset and as such not recognised on the balance sheet.

Yet, the same report emphasises that “the value of a strong brand cannot be underestimated in today’s fast-moving commercial environments, where customer loyalty is notoriously difficult to acquire and sustain.”

Globally, hospitals are investing billions of dollars—purchasing, acquiring, merging, integrating and upgrading—all with the goal of improving patient care and maintaining a sustainable, profitable business. But to connect with patients, healthcare providers and investors must recognise, invest and leverage one of their most important business assets—their brand.

Providers and investors at every level are now competing harder and spending more to acquire assets, grow their business and retain patients in the face of rising costs, disruptive players and digital technologies. The one constant in this sea of change is the role of a brand as a value creator that impacts choice, pricing, loyalty, advocacy and shareholder value.

The Doctor-Hospital Branding Conundrum


Consumerism is a mega-trend that is reshaping healthcare, and the internet has made it easier than ever to access endless sources of information. However, one area that lags behind all others is information and reviews about doctors, particularly here in Asia.

In the US, websites like Healthgrades, Vitals and WebMD provide consumers an independent source of information about doctors so that they can verify credentials  and validate the experiences of others. According to Healthgrades, 90% of patients use online reviews, 80% of customers trust these reviews as much as a personal recommendation and 77% use these online reviews to find a new doctor.

Here in Asia, most hospitals have information about their doctors, but the quality of those profiles tend to be weak when you take into account that 88% of patients view ‘clinical expertise on my condition’ as a ‘very’ or ‘extremely’ important reason for choosing their doctor.

Doctor profiles are a key touchpoint for customer engagement. So why do hospitals invest in the doctors, but paradoxically spend so little on branding them to their full potential.

Data shows that more people are using online channels to search and vet doctors, creating an unparalleled opportunity (or challenge) for providers to improve doctor branding. But doctor branding is a double edged sword for hospitals. Heavy promotion of doctors can lead to unintended consequences that create friction between the hospital and the doctors.

This creates a conundrum: how to promote doctors without eclipsing the hospital brand? Despite the challenges, the opportunity to pivot doctor branding from a lose-win scenario to a win-win solution is available. Let’s start with the facts:

  • The doctor appointment/referral is the start of the hospital’s revenue cycle. Nothing happens without seeing a doctor first—no orders are made, no medicines are prescribed and no admission is approved. So if the doctor is the start of the clinical journey, then it stands to reason that making doctor search-find-connect should be priority number one.
  • The doctor search starts online. If the clinical journey starts with the doctor, then the customer journey starts with Google. Anything that improves search ranking improves the chances of selection.  If doctor profiles are not optimised for search, internal and external, then ranking suffers.
  • Consumers rely on reviews and ratings for everything—restaurants, appliances, cars, etc.  Reviews and ratings are social proof mechanisms that help consumers make informed choices, but hospitals avoid physician reviews and rating at all costs, because they open a Pandora’s box of problems.

Ask any hospital CEO why patients choose their facility, and virtually every one will list their doctors as one of the top three reasons. Now ask the same CEO how much they invest in doctor branding and marketing. Typically the amount is negligible. There is clearly a disconnect between input and output, and much of it boils down to tactical execution. How to do it?

Bottom line, doctor branding and hospital branding are not mutually exclusive. On the contrary, smart doctor branding creates a virtuous cycle that impacts reputation, improves search and enhances customer experience.

An Interview with Ruben Toral, QUO’s New Director of Healthcare + Wellness

Ruben Toral is a healthcare industry veteran with decades of experience in hospital marketing and medical tourism. He has built healthcare businesses, brands and physician networks in Asia, Latin America and the Middle East, and his work has been featured in whitepapers, articles and books, including Fast Company and Aerotropolis: How We Will Live Next.

Tell us about your experiences working in healthcare and wellness. How did you get your start?

My career in healthcare spans over 25 years and started innocently enough while working on a wellness project for Noble Holdings, a Thailand-based property developer. That project morphed into a career in medical services that included co-founding a medical services company specialising in lithotripsy (shock wave therapy for kidney stones) and a two year stint in Mexico, where I set up the company’s Latin American operations.

While in Mexico, I was contacted by the CEO of Bumrungrad Hospital and offered the opportunity to lead the hospital’s international business development, which I did for 7 years. I then founded Medeguide, a portal to connect patients and doctors online. After Medeguide, I co-founded Intermedika Consulting, a healthcare consulting firm specialising in business strategy.  Our clients were primarily hospitals, investment companies and government health promotion agencies.

What is your role with QUO and why did you make the move to work with a branding company?

QUO is a leading branding agency specialising in hospitality, tourism, and advocacy. While the agency has worked with a handful of clients in healthcare and wellness, it has ambitions to expand its reach in the healthcare space. Given my experience in healthcare, strategy, and marketing, it was a natural fit. I have a longstanding personal and professional relationship with QUO CEO and Founder, David Keen, so the transition was easy.

Most people associate you with medical tourism and your work at Bumrungrad International.  Tell us more about your experience there.

Bumrungrad was one of those special career moments when you find yourself at the right place at the right time working with exceptionally talented people. I joined the hospital in 2001, and was in charge of developing relationships with referral doctors and clinics, creating a new international patient centre, building out the hospital’s overseas representative offices network in Asia and Middle East, and developing partnerships to support our medical tourism efforts. I also managed the brand, the public relations and media.

At that time, the term ‘medical tourism’ was unknown and Singapore was the go-to centre in Asia for patients seeking international standard medical care. By 2007, when I left the hospital, everything had changed. Medical tourism emerged as one of the hottest trends in healthcare and Bumrungrad was its epicentre. International patient revenue surpassed domestic patient revenue, and Bumrungrad was featured by virtually every major news outlet in the world. It was a very exciting time.

That’s a significant business transformation in a very short period of time. Was medical tourism the trigger?

I’ve often said that Bumrungrad won the medical tourism race due to ‘fast mover advantage’. By that I mean management was quick to understand and react to opportunities and challenges, including medical tourism. Bumrungrad was the first hospital in Asia to receive JCIA accreditation; it was the first to establish referral contracts in the Middle East; and we led the whole cosmetic surgery boom that started in the early 2000s.

We focused brand messaging around the hospital’s key differentiators e.g. hotel-like facilities and service, US trained doctors, international accreditation, and prices that were 30%-50% less than Singapore. As I used to say at the time, Bumrungrad offered a Mercedes product at a Toyota price. It was a simple message that everyone understood.

As part of Bumrungrad’s transformation, you also led the hospital’s rebranding in 2005. Is that correct?

Yes. Our international patient business was outpacing our domestic business 2 to 1, and it became clear that the brand originally created in 1980 no longer fit the business 25 years later. The business had evolved and the brand needed to evolve too. That’s where my association with QUO started. I selected QUO to help with the hospital rebrand. Together, we changed the name, tagline, colours, visuals, tone of voice, and applied it to signage, marketing collateral and all corporate identity materials. It was a significant undertaking, but well worth it. The rebrand repositioned Bumrungrad Hospital,  a Thai hospital treating international patients to Bumrungrad International, an international hospital in Thailand providing world-class medical care on par with top medical centres in Europe and the US.  It did what branding is supposed to do—define and differentiate.

How important is branding for hospitals and healthcare in general?  Bumrungrad made the change but not many others have followed.

Strong brands establish trust, and no industry is more trust-driven than healthcare. At the consumer level, strong brands drive consumer awareness, choice, loyalty and advocacy. At the business level, strong brands influence pricing power, profitability and share value.

As a rule, hospitals lag other industries, like hospitality, when it comes to branding. My experience is hospital owners and CEOs don’t see branding as a source of value creation so they don’t fix what they perceive isn’t broken. But brands evolve with the business, and branding supports reputation. Consumers, by and large, select healthcare providers based on reputation. Medical tourists even more so. If a hospital is not investing and cultivating its brand, it is effectively leaking value.

Wellness seems to be the big trend now.  Where do you see this going?

Wellness is a trend with lots of momentum. Over the past 10 years, wellness has been trending, but COVID supercharged it. That awakening, if you will, has driven industries and businesses to add wellness as a ‘new’ ingredient to make their products ‘healthier’.

My issue is that the term ‘wellness’ is very broad. It is everything and nothing. So, the challenge is taking an amorphous term and shaping it into a product or service that has value for the customer. Many companies simply re-label old products and services as ‘wellness’, and that’s not sustainable.

The combination of wellness and hospitality is an exciting hybrid space that is ripe for development, but it requires matching capabilities and needs with cost and risk. I have worked with hospitality companies, hospitals, wellness clinics and wellness resorts so I have a good sense of the issues, opportunities and challenges in the wellness space.

Finally, where are the new opportunities in the healthcare and wellness space?

That’s a huge question, but I see healthcare as one of the most exciting industries entering one of the most disruptive periods. In short, we are moving from the old analogue model of care that is doctor centric, focused on sick care, delivered episodically and in silos, and paid for by a third party, insurer or government. The new model is digitally enabled, continuous, connected, personalised and paid for by individuals through savings and incentives. The healthcare system we have today is built around sick care rather than well care.

Is Wellness a Cure or a Crisis for Hoteliers?

What is wellness?  If you are a half glass full person then it is a tool to help you live a healthier, happier, longer life.  If you are a glass half empty person then it is a branding ploy to get you to pay twice as much for something that may or may not have any real impact on your health and longevity.

Regardless of where you stand, McKinsey estimates that wellness is a $1.5 trillion market with a lot of room to run.  You may not believe in it, but you certainly cannot ignore it.  McKinsey breaks down the market into six segments ranging from fitness to sleep.

With the growing trend towards healthy living, more industries are trying to incorporate wellness into their offerings, including hotels, real estate, F&B, and tourism. Hotel companies, in particular, have been flirting with adding wellness and medical services to their offerings for years, but COVID-19 supercharged that intent, and now wellness is on the map to stay.

For hotels, wellness is a new channel to boost guest spend and create product differentiation, especially for resort hotels. Resort guests are relaxed, they eat better, sleep better, and have more time to exercise. But the challenge hoteliers face is  shrinking the broad concept of wellness into a tangible offer and delivering it to guests in a profitable, sustainable way.

There are typically three models when it comes to offering medical or wellness within hospitality.  The first is to bundle existing amenities like spa, fitness, and F&B and repackaging it under wellness.  The second is to rent space to a doctor or clinic specialising in wellness or aesthetics. This is often the easiest route because it fills space and generates rental income with almost no effort. The third is developing a bespoke wellness program and making it a signature feature of the property or brand.  That’s the heavy lift.

There are other models and variations on these three themes, but it all boils down to intent.  Is the goal to develop a wellness product that is strategic and sustainable or short term and opportunistic?

The bigger hotel companies like Accor are investing in bespoke, branded, scalable solutions, working with partners, and deploying digital technologies that keep guests connected on and off the property. The smaller hotel groups tend to explore wellness services and themes they can weave into the guest experience.  Individual properties may choose a highly specialised path focused on doing one thing and doing it well.

Regardless of their path, hospitality companies are actively looking to blend health into their amenities portfolio and will eventually need to settle on a strategic path forward.  One that ideally fits the brand, business and guest mix.