Navigating the World of Health Tourism Lessons From 40 Years of Patient Experience

By Pamela Tames

If you’ve ever planned a trip abroad for healthcare, you know it can be a maze, sometimes even a minefield, trying to find suitable care. The growth industry known as medical or health tourism has many reputable operators but also, no shortage of bad players. The latter may include, so-called, “facilitators,” who promise to find you top medical care and then refer you to the healthcare provider that pays them top commission. Christian El-Khouri, an industry consultant based in Germany, has seen it all. Growing up, he helped his family in their medical tourism business which his father had started in the late 19070s. Today, Christian consults exclusively with governments, hospitals and other healthcare stakeholders. Previously, though, he spent a decade helping patients and describes medical tourism as a true passion. I talked with him about what’s going on in the world of medical tourism today and got his checklist for finding good care.

You have a unique perspective on medical tourism since your family is in the business. How did the family business get started? I always say I was born into medical tourism because my parents were the first to provide medical tourism facilitation in Germany in the late 1970’s. My father had immigrated from Syria to Germany and spoke fluent German, Arabic and English. He was able to respond to a need to help Arabic speaking patients from the GCC (Gulf Cooperation Council comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) who were seeking treatment in Germany. From there, the company, which is called The MESC International Patient Service GmbH, evolved and grew.

How did you learn the business?

I’m not sure how familiar you are with the Middle East or the GCC, but typically, the day starts later and goes well into the morning due to the heat and other reasons. So it was quite normal for us to have the phone ring at 2 a.m. at our home because they couldn’t reach anybody in the office. At some point my parents realized it would be a good idea to train myself and my older brother to cover when they weren’t available. They taught us how to handle these calls, ask

the right questions, and get the details – especially the entire name, because there are very similar name variations in the Middle East. It was a rather tough reign since my parents wanted to ensure we really learned the business from the ground up. All that thorough training – being diligent about every small step in the process –later translated into me being very critical of patient service outside our family company. It’s not a job you take lightly because at the end of the day, it’s a patient or a family member trusting you – a person they might not know – with their health while dealing with all the complexities of traveling to another country with a different culture, language and legal system to receive medical treatment without friends and family close by. It’s incredibly stressful and we take it very seriously.

With MESC, your family’s business, where were most of clients coming from and what kinds of services were being offered?

Initially, MESC worked with Arabic speaking patients but today the business is international with people coming from Russia, the EU, Africa, Asia and to a lesser degree, the US. We did not target the American market directly, but because the US operates an Army base in Wiesbaden, MESC does get American patients. Essentially, mes operates as the international office of a hospital here that provides primarily diagnostic services. This hospital was modeled after the Mayo Clinic approach of providing integrated, multidisciplinary care. MESC has an exclusive agreement with them to handle both their marketing and patient services. It is a unique arrangement in mesc, being privately owned, is not constrained by the dictates of the hospital group. This gives MESC the freedom to operate in the best interests of the patient. Once a patient gets a diagnosis, MESC helps them find the best treatment in Germany and provides guidance on pricing to help ensure they’re fairly charged.

What are important criteria for assessing where to send patients for treatment?

The doctors at the diagnostic hospital will often make a recommendation regarding where to go for treatment. Another good option is a university teaching hospitals, since they are very

or health tourism has many reputable operators but also, no shortage of bad players. The latter may include, so-called, “facilitators,” who promise to find you top medical care and then refer you to the healthcare provider that pays them top commission. Christian El-Khouri, an industry consultant based in Germany, has seen it all. Growing up, he helped his family in their medical tourism business which his father had started in the late 19070s. Today, Christian consults exclusively with governments, hospitals and other healthcare stakeholders. Previously, though, he spent a decade helping patients and describes medical tourism as a true passion. I talked with him about what’s going on in the world of medical tourism today and got his checklist for finding good care.

highly regarded in Germany. MESC uses a screening process that involves meeting with the hospitals, assessing the scope and quality of expertise, and examining any available metrics, such as, complication rates of surgeries. The good thing about Germany is that the standard and quality of care is very high so there are many good hospitals. On the non-medical side, criteria include hospitals having good processes and resources in place for accommodating and supporting international patients. This might include offering great halal food for Middle Eastern patients, providing a welcoming experience that helps to reduce patient stress, and having doctors who know how to reassure patients so they feel confident about the care they are getting.

El-Khouri, health tourism consultant, is based in Germany.

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In researching medical tourism, I’ve noticed there are a lot of facilitators out there but not a lot of transparency about how they’re paid. Why is that?

You have a unique perspective on medical tourism since your family is in the business. How did the family business get started?

What drives patients to seek care in Germany specifically?

There is a segment of people who want the best healthcare available and can afford to go anywhere whether it be MD Anderson for cancer care in the US or University Hospital of Heidelberg in Germany. Another segment includes people who are looking for better care, not the best, but better than what is available in their home country. Germany caters to both these segments, offering best-in-class care in some areas and better care than is available in many other countries. I strongly believe that the level of healthcare service offered in the United States, Israel and Germany are more or less on par. The German healthcare system is over 120 years old and has garnered a trusted reputation. We have the added benefit of strict price controls to help protect against corruption. There’s pricing transparency and although the pricing is complicated and hard to understand at least it exists, establishing a legal limit. The other difference is that Germany has a more conservative approach to treatment and some consider this to be an advantage. Instead of jumping to surgical or pharmaceutical intervention, for example, you’d do rehab or physical therapy.

I always say I was born into medical tourism because my parents were the first to provide medical tourism facilitation in Germany in the late 1970’s. My father had immigrated from Syria to Germany and spoke fluent German, Arabic and English. He was able to respond to a need to help Arabic speaking patients from the GCC (Gulf Cooperation Council comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) who were seeking treatment in Germany. From there, the company, which is called The MESC International Patient Service GmbH, evolved and grew.

How did you learn the business?

Typically medical tourism facilitators are paid a commission – a percentage of the revenue generated by the patient for the healthcare provider. In some cases, the commission is up to 25%. This is common practice around the world. Since 2011, however, charging a percentage commission for the referral of an international patient has not been allowed in Germany and constitutes a violation of the Civic Code.

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How does MESC get paid for its services?

The family business’ patient service business unit does not take a commission but charges the patient for the services provided. The fee for each service being provided is itemized and patients pay us directly. This transparent approach has fostered trust over the years. MESC is now seeing the third generation of clients’ families solely on the basis of positive word of mouth.

How can people protect themselves from unfair or illegal pricing practices? What should a patient watch for?

In both Germany and the US, you see a tiered pricing structure in which the best care is often the most expensive. However, unlike in the US, Germany has the benefit of very strict price controls aimed at capping what you are allowed to charge. But as happens

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El-Khouri, health tourism consultant, is based in Germany.

everywhere, bad operators – including hospitals and doctors and facilitators –find ways to workaround the system to enrich themselves with all kinds of illicit schemes. For instance, we’ve had patients come to us with requests to investigate hospital invoices that seem too high. We’ll look into it, trying to understand the pricing. Sometimes it’s justified but in some cases, the hospital would tell us they didn’t issue the invoice. Turned out, the facilitator was marking up the invoice and pocketing the difference. This is why I say, an ideal world for me is one where there is no medical tourism facilitator. Instead, the hospitals would be trained, structured and equipped to deal with international patients directly. However, there are problems with that since hospitals don’t want the bad PR of being seen to prioritize international patients, who are usually more profitable, over domestic patients.

The Joint Commission International (JCI) and Temos are two groups that provide accreditation to hospitals that meet certain criteria. Is accreditation a good indicator of quality care?

I cannot speak to the validity of accreditation offered by either the JCI or Temos because I just don’t know. In general though, I would say that you cannot assume accreditation indicates quality care because it may be a pay-toplay scheme. What I mean by that is the hospital may be paying for accreditation in which case, there’s a conflict of interest built in. If the accreditation is actually earned, and the criteria for accreditation are meaningful then it may be useful. But then again, you have to wonder, who’s checking that the accreditation standards are being maintained 6 months later and who’s enforcing standards?

One source says the medical tourism industry is booming, with annual growth estimated at 15-25% and contributing over $100 billion annually to the global economy. Does this more or less reflect what you’re seeing?

I do think it’s a growth industry, but I question some of the big numbers being thrown around. For instance, how are they calculating medical tourism revenue? Is it only medical care costs? Or does it include revenue from other retail and service providers that are peripheral to medical tourism? One thing is clear, it seems everybody wants to get into medical tourism. There are so many people jumping in calling themselves facilitators and the level of professionalism is frightening. Some facilitators create WhatsApp groups of 100 or more facilitators and they’ll sell referrals to patients to the highest bidder. Some of these facilitators are calling themselves medical experts and using ChatGPT to write their content. I call these bad players out where I see it. It’s so unprofessional. Patients put their trust in you and you need to protect them— not send them to somebody you’ve connected with on WhatsApp a week ago.