World focus: Turkey HOSPITALS REVIEW 2015

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2 HOSPITALS REVIEW 2015 World focus: Turkey Turkey has witnessed a hospital building boom in recent years. Robin Gauldie takes a looks at the healthcare market both private and public in Turkey today and assesses how it s meeting the needs of international patients More hospitals should mean more choice for patients and a more competitive market. That s the theory, anyway. But despite rapid expansion of the private hospital sector in Turkey and massive growth planned for the public sector, it doesn t seem to be happening, some industry sources claim. Ten years ago, Turkey had fewer than 300 private hospitals with, on average, 50 beds each, according to OHSAD, Turkey s Association of Private Hospitals and Health Institutions. Today, there 24 are more than 600, with more on the way. Most have at least 100 beds. Turkey also has 52 Joint Commission International-accredited hospitals more than any other country except the UAE (which has 114) and Brazil (which also has 52). While fewer than one in five hospital beds and fewer than one in four specialist physicians are in private facilities, the private sector accounts for a significant proportion of complex medical care. Forty per cent of intensive care unit beds, for example, are provided by private hospitals. Private hospitals have many advantages compared to public hospitals in terms of the number of physicians available, state-of-the-art technology for diagnostics and treatment, no waiting lists, international accreditations and more patient-focused services, said Asli Akyavas, international services director at the Johns Hopkins-affiliated Anadolu Medical Center. Other supporting factors include dedicated staff to assist patients during admission and throughout their stay, translation services in many languages, and transportation. It s a similar story to that in many other countries, then, but what has led to this boom? President Recep Tayyip Erdogan made healthcare a top priority for his administration when he came to power in According to market research consultancy Frost and Sullivan, the country has doubled its healthcare budget over the last decade, and now spends $62.3 billion annually. Healthcare reforms, including the opening up of the public hospitals sector to private investment, have led to the emergence of a number of competing private hospital groups, while the public sector looks set to grow thanks to the most recent round of government initiatives.

3 HOSPITALS REVIEW 2015 Turkey has 52 Joint Commission International accredited hospitals more than any other country except the UAE (which has 114) and Brazil (which also has 52) that have opened in and around Turkey s most popular tourism areas. But this has pros and cons for medical providers: for Turkey s private hospitals, the extreme seasonality of Turkey s tourism industry is an issue. Cultural, heritage and city-break tourism draws visitors to Istanbul year-round. But for beach destinations such as Antalya, Bodrum, Marmaris and Kusadasi the season runs only from May to October, peaking between June and midseptember. That leaves hospitals with empty beds for half the year. They are legally barred from laying off staff in the low season, so their year-round operating costs are very high. As a result they have to squeeze every lira they can out of the summer months. Thus, not all private hospital operators in Turkey are over-focused on tourism. Several of the country s largest private healthcare companies place much more emphasis on developing markets in Turkey s big cities which apart from Istanbul see relatively few tourists. Acibadem Hospitals Group, which became part of the Malaysian group IHH Healthcare in 2012, has added six general hospitals to its portfolio since then and now has 17 hospitals and 13 medical centres all over Turkey. Almost all its hospitals are in major Turkish cities. Only one, Acibadem Bodrum Hospital, is in a resort area. Medical Park International, another major player, has 18 hospitals in all. Only two, in Izmir and Antalya, are in tourism hubs. At the same time, more than one in four private hospitals in Turkey just over 150 are in Istanbul, according to the Investment Support and Promotion Agency of Turkey. That can hardly be called over-supply, especially considering that Turkey s largest city (and the largest city in Europe) has a population of 14 million, and receives around 11 million foreign visitors annually. Ankara, Turkey s capital and its second largest city, with a population of 4.6 million, has 29 private hospitals. Antalya, however, has 26 private hospitals to serve just over one million residents and around four million visitors a year. Dr Ayce Birercin, general manager and medical supervisor of Euro-Center Istanbul, an assistance company, says that despite the growth in tourism numbers, the number of hospitals available in Turkey generally exceeds demand. And instead of competition driving down the cost of hospital treatment for patients, assistance companies, and insurers, a situation has developed that has seen hospitals forming cosy relationships with hotels and tour operators under which the latter guarantee to refer a minimum number of cases to the partner hospital each season. Also driving up costs is endemic over-treatment, says Dr Birercin. Referral mechanisms do not exist in the public health sector in Turkey and Turkish people prefer treatments with multiple investigations and multiple prescriptions. [Thus,] hospitals have a tendency to overdo compared to Europe, she claimed. This prevailing attitude encourages overtreatment of foreign visitors too. Writing in ITIJ s Cost Containment Review in October 2012, Dr Birercin said the real problem was the escalation of simple outpatient cases into inpatient care. Patients suffering from common ailments that do not normally call for hospital care such as otitis or gastroenteritis are routinely referred for inpatient hospital treatment by hotel clinics, she said. This over-cosy relationship may be about to change, according to Hans Biekmann, CEO of Eurocross Turkey, an assistance company. Biekmann said the Antalya Chamber of >> Private sector consolidation Private healthcare services in Turkey are now worth some $10 billion annually, with around 30 per cent of that revenue going to the 10 largest private hospital chains. Some of this increase in revenue comes from a government-backed push to attract health travellers, the world-class reputation of a number of the country s internationally affiliated medical facilities, and, of course, Turkey s enduring allure for international visitors. In fact, Turkey s popularity as a tourism destination continues to grow, with almost 37 million visitor arrivals last year, a 5.5 per cent increase on Unsurprisingly, many private hospital companies perceive this burgeoning tourism industry as a rich source of revenue. As a result, some health and assistance sector sources argue that there has been disproportionate growth in the number of hospitals 25

4 HOSPITALS REVIEW 2015 Private healthcare services in Turkey are now worth some $10 billion annually, with around 30 per cent of that revenue going to the 10 largest private hospital chains Physicians, based in Turkey s busiest beach holiday region, has begun legal action to bar private health institutions and private hospitals from opening clinics and health units in resorts and tourism-certificated hotels. The organisation cites existing legislation, including Turkey s Private Hospitals Act, which it claims does not allow private health institutions to provide services in hotels and resorts. The Chamber is seeking a legal decision that will suspend contracts between hotels and hospitals and ensure that health services in tourism-licensed hotels is provided by independent physicians. The outcome could lead to a nationwide ban. This would be a very positive development, said Biekmann. It could be trendsetting for the rest of Turkey. We may get a more independent assessment of care and less referral to hospitals and clinics. However, Biekmann cautioned, the new rules are so far only proposals. Even if accepted, they would apply only to the Antalya region in the first instance. Hotels, travel agents and tour operators can still make deals with hospitals and clinics, finding their way around the hotel doctor, he continued. He also questions how the independence of hotelbased doctors can be guaranteed, and claims that private hospitals have great influence at government level. While over-treatment of minor cases is a headache for insurance and assistance companies, more serious cases are skilfully managed, concede industry insiders. The quality of treatment has shown a spectacular increase in recent decades, according to Biekmann. In many cases, treatment and care in Turkey s new private hospitals is as good as, or better than in many equivalent facilities in western European countries. So, what can help to drive down the cost of private medical care in Turkey for international insurers? Akyavas says better communication between medical providers and insurers and assistance providers is key to resolving the issue of over-treatment in private hospitals. Healthcare providers in Turkey are eager to increase their network of insurance companies through formal agreements, where the scope of coverage, benefits and eligibility terms are well defined along with the payment processes, she said. Customer service becomes crucial in communication between the medical providers and insurance and assistance companies due to the fact that response time is highly important. Our experience with some assistance companies has been troublesome in terms of the level of customer service, which also affected our internal processes, including delayed treatments, due to a prolonged preauthorisation period. [Good customer service] is also crucial [in order] to increase patient satisfaction and enable them to go through this process in a hassle-free environment. Akyavas added that insurance companies should approach hospitals to sign provider agreements: It would be wise to agree on a particular fee list on contracts with insurance or assistance companies. I believe transparency is the most crucial issue for both parties. So, what of the future with regards to infrastructure in the private sector in Turkey? Turkey s private hospital sector appears to be consolidating, not expanding in terms of the number of new private hospitals being built. In 2008 following a five-year private hospital building boom the Ministry of Health placed >> 26

5 HOSPITALS REVIEW 2015 a ban on new private hospital projects, incentivising hospital groups instead to invest in upgrading their existing facilities to meet international standards. The ban on new building also led many hospital groups to continue growing their portfolios through mergers and acquisitions rather than building new facilities: the value of such deals in Turkey exceeded US$1.4 billion between 2009 and 2012, according to the Investment Support and Promotion Agency of Turkey. Going public If private sector expansion seems to be stalled for now, Turkey s public sector is poised for expansion. In 2013, after changing the rules to make private involvement in the public sector easier, the government signed public-private partnership (PPP) agreements worth TL15.7 billion (US$7.8 billion) for the construction of 15 city hospitals. The government plans to open around 60 hospitals around Turkey under such PPP agreements, and has secured a 433-million financing package to this end, around half of which comes from the European Bank for Reconstruction and Development. However, expansion of the public sector seems unlikely to provide foreign insurers and assistance companies with a significantly cheaper or better alternative to the private sector. Treatment of foreigners in public hospitals is subject to a price list for foreigners set by the Ministry of Health, notes Ayce Birercin. This price list is not always a lot cheaper than its private competitors. Also, public hospitals do not have dedicated departments for tourism, so language becomes a barrier for the policy holder and obtaining written reports or even verbal reports is always a challenge for the insurer. Other schemes that may add to the supply of hospital beds and outpatient and accident emergency facilities available to insureds who fall ill or suffer accidents while holidaying in Turkey are the proposed medical free zones (which are generally regarded as outside of customs areas and are not or only partly subject to commercial and financial laws of the country in which they are located). Announced by the previous government administration in 2011, these would be based in or near major cities and would be aimed at the expanding medical tourism sector. According to Turkey s Ministry of Health, they will include hospitals, rehabilitation centres, thermal tourism facilities, nursing homes, health techno-cities and research and development centres. However, these grandiose schemes do not yet appear to have got beyond the planning stage. In 2012, some media reported that Wallcott Holdings, a US investor specialising in international medical tourism zones, would invest US$1.8 billion in one such project in Turkey. However, the Hospitals Review has not been able to verify these reports. No further the Antalya Chamber of Physicians has begun legal action to bar private health institutions and private hospitals from opening clinics and health units in resorts and tourismcertificated hotels announcements have been made by Turkish government sources or by Wallcott Holdings. In elections in June this year, after 13 continuous years in power, President Erdogan s AK party failed to win an absolute majority. Negotiations to form a coalition government were ongoing as the Hospitals Review went to print. As far as Turkey s healthcare sector is concerned, however, government commitment to ongoing expansion, primarily through PPPs, seems unlikely to change. Meanwhile, political uncertainty has driven the Turkish lira to record lows against the currencies of key tourism markets. That may make Turkey s resorts even more popular. One thing is for sure, though: there are enough hospitals to cope with any likely increase in international patients. 28

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