The definition of medical tourism varies among researchers depending on the choice of place and location (domestic or foreign) of medical tourism, the method and procedure applied, application, and/or processes. Generally, it is referred to as tourism activities related to medical treatments or activities to improve tourists’ well-being. The Medical Tourism Association  defines medical tourism as “where people who live in one country travel to another country to receive medical, dental and surgical care while at the same time receiving equal to or greater care than they would have in their own country, and are traveling for medical care because of affordability, better access to care or a higher level of quality of care.” Wongkit and Mckercher  defined medical tourism as “the travel of people to specific destinations to seek medical help that forms the primary purpose of their trip.”
The Tourism Research and Marketing  presented treatment of illnesses, enhancement/cosmetic surgery, wellness, and fertility-related treatments as types of medical tourism. Lunt et al.  described the range of treatments in the medical tourism sector, focusing mainly on the common factors suggested in many previous studies: “cosmetic surgery (breast, face, liposuction); dentistry (cosmetic and reconstruction); cardiology/cardiac surgery (bypass, valve replacement); orthopedic surgery (hip replacement, resurfacing, knee replacement, joint surgery); bariatric surgery (gastric bypass, gastric banding); fertility/reproductive system (IVF, gender reassignment); organ, cell and tissue transplantation (organ transplantation; stem cell); eye surgery and diagnostics and check-ups.”
The quality of medical services is one of the factors that potential customers consider most important . This implies that the quality of medical service and its costs are the most important influencers in their decision on the destination for their medical tourism . Lunt et al.  emphasized that customers should be informed of the potential benefits of medical tourism regarding credible evidence of quality care and safety of their stay. In particular, when compared to other service industries, where word-of-mouth plays a big role, the medical industry is relatively slow in adopting a business model focused on customer satisfaction. With the right focus on quality and outcomes of the medical service processes, including customer interaction with service providers, healthcare organizations should try to improve patient satisfaction. This will have a positive effect on attracting potential future customers, thus promoting medical tourism .
Ehrbeck et al.  suggested five factors that promote medical tourism through a survey of 49,980 patients: most advanced technology (40%), better-quality care for medically necessary procedures (32%), quicker access to medically necessary procedures (15%), lower-cost care for medically necessary procedures (9%), and lower-cost care for discretionary procedures (4%). Crook et al.  presented the following as the most frequently discussed topics on patient experience: (1) decision-making (e.g., push-and-pull factors that shape patients’ decisions); (2) motivations (e.g., procedure, costs, and travel-based factors motivating patients to seek care abroad); (3) risks (e.g., health and travel risks); and (4) first-hand accounts (e.g., patients’ experiential accounts of having gone abroad for medical care). Thus, we consider combining the factors suggested by Ehrbeck et al.  and Crook et al.  to devise new strategic measures for medical tourism.
Few potential medical tourists are aware of what products or services are available through medical tourism. Some may have misconceptions and fear of various situations, including anxiety about traveling possible dangers, culture shock, and language barriers. In addition, it is very difficult for medical tourists to search for healthcare providers with accurate information in different countries individually for the treatment of diseases and for finding relevant wellness/sightseeing information.
In general, unlike making a decision to buy commercial products or services, the decision-making process for medical tourism is very complicated as it also involves emotional aspects that lead to multidimensional behaviors . A variety of factors can affect decision-making of medical tourism because it influences not only physical (medical services) but also mental (tour) health conditions during and after activities [22, 23].
Medical tourism advertisements tend to focus too much on treatment results and outcomes rather than quality improvements and safety . When customers base their decisions on over- or underestimated advertisements, there tends to be a gap between the expected and actual outcomes. The increasing media interest in medical tourism has made it popular on a global platform, and today, we can obtain information on medical tourism destinations through various channels, including newspapers, magazines, radio, and television programs . Online marketing efforts via web help publicize medical tourism [26, 27]. Ormond and Sothern  analyzed five medical tourism guide books and found that a common factor among the books was to encourage potential customers to tour rather than introduce destinations and international choices for medical services. Thus, a sufficient preliminary investigation in advance is necessary for medical tourism. Customers can make the final decision through proper search of a variety of information and comparing them with services offered by providers in other regions or countries. It is suggested that a synergistic approach is more effective when it is done in a comprehensive way than in a piecemeal information survey .
Medical services comprise those put into the service (patients and medical staff), organization (service providers, service or products), treatment procedures, and outcomes . As each process generates activities for medical treatment through interaction with patients, Lee  divided the process of value creation into preprocessing, responding process, and resulting processes. The preprocessing refers to a set of preparative activities in advance of care services, the responding process as the one to respond to interactions during treatment, and the resulting processes as related to the prevention and outcome of disease. Thus, sufficient information should be provided to customers about the entire process rather than at the time of experiencing each process. Once customers achieve their goal of getting the desired outcome, they will go back home and may come back for further treatments for better quality of life or wellness (repurchase or any positive activities) or the other way around (negative activities). Customers make their decisions based on what they searched before selecting the destination. It means that they would first experience medical tourism through Googling; feedback from colleagues, friends, or family; or direct communication with the hospital.
Medical tourism is a major decision problem for the patient; it is much more involved than deciding to visit a local healthcare provider. The customer’s experience of medical tourism is the main factor that influences his/her satisfaction which in turn would influence revisit intention. Thus, it should be a major strategic priority for medical tourism hospitals and their administrators to develop a system that can provide positive experience to customers. Many tourism hospitals have a one-stop service system for their customers that may include such services as government documents (visa service), transportation (air flight reservations, airport pickup, shuttle service, etc.), language help, local hotel reservations, insurance processing, financial arrangements, local tour attractions, and the like. For example, Bumrungrad Hospital in Bangkok, Thailand, which is ranked ninth in the top ten hospitals in the world, provides a very efficient one-stop service to foreign customers (VIP airport transfers, interpreters, concierge services, embassy assistance, international insurance arrangements, and medical coordinators, see http://www.bangkok.com/hospitals-private-hospitals.htm).
Experience of customers
Since customers’ overall satisfaction may be subjective, recent studies have emphasized the importance of customer experience and strategic approaches to improve the quality of medical services .
Merlino and Raman (, p.113) suggested that patient experience is a strategic priority and provided a broad definition: “The patient experience was everyone and everything people encountered from the time they decided to go to the clinic until they were discharged.” Meyer and Schwager (, p.118) defined customer experience as “the internal and subjective response customers have to any direct or indirect contact with a company”, and De Keyser et al. (, p.23) also suggested customer experience as “comprised of the cognitive, emotional, physical, sensorial, spiritual, and social elements.” These definitions imply that patient experience includes cognitive activities (e.g., checking reputation and searching other relevant information) before going to the hospital to the post-discharge behaviors (e.g., recommendation and feedback) with patient’s own emotional and subjective judgments.
In particular, medical tourism needs to be investigated thoroughly prior to the travel, because it focuses not only on information of medical institutions but also on the region or country where they will receive treatment. New advanced technologies can earn positive reviews from consumers and succeed only if they are unique in terms of their functions, convenience, and attractiveness. The positive images created from this could generate favorable responses from customers as they make comparisons based on actual use or indirect experience. In other words, customers’ direct or indirect experiences can affect their future repurchase intention.
The direct and indirect experience gained during the preliminary investigation will affect the process of receiving the actual medical service . Further, if the gap between expectation and reality increases, there will be a decline in satisfaction. It will also affect revisit intention. In addition, since the medical services provided to patients with various diagnoses and administration services that are multidimensional, it is difficult to directly measure patient experience. As customer satisfaction might be improved based on their experience, customer satisfaction should also be included in the behavior of the customers’ preparation before arriving at the destination .
Verhoef et al.  suggested customer experience as “the total experience, including the search, purchase, consumption, and after-sale phases of the experience.” The prior experience occurs before purchase and consumption, and the purchase and consumption represents current experience, and after-sale/consumption experience represents post-experience. Therefore, in this study, the patient experience in medical tourism can be divided into prior experience for deciding on medical tourism, current experience during the treatment and/or medical tour, and post-experience after treatment and/or tour.
The prior experience includes the direct or indirect experience of customers during various activities before actually experiencing the main service, medical tourism. Patients can search various information, such as reputation, specialized treatment, and interesting tour destinations, directly or indirectly before choosing a hospital for the best possible treatment and service. Since the customer’s decision-making is based on a thorough prior investigation , sufficient communication with the customer is necessary. Patients can of course directly consult with the medical staff or service personnel of a hospital via video chatting (e. g., Skype or FaceTime) or telephone. In this study, the prior experience was categorized into checking reputation, searching information, and communication.
Through prior experience, customers make their final decisions for medical tourism, receive actual medical services, and have various other experiences. They are involved in direct communication with service providers, direct engagement in the service provision processes, and witnessing a gap between what they expected and the service actually received. Therefore, the current experience in this study refers to customer experience while engaging in various activities at the hospital, including interaction with service providers or other customers, use of information and comminutions technology (ICT), and enjoying the service environment. The current experience was categorized into checking costs, care quality, and supporting system and other relevant information.
Customers come to evaluate their own experience based on expectations, current experience, and other activities. Their experiences may generate either positive or negative impact on others. From the customers’ perspective, the post-experience influences the intention to repurchase or has a positive word-of-mouth. Service providers, on the other hand, may search for new ways to retain customers and improve their satisfaction through their post-experience (i.e., surveys or social networking). Sridhar and Srinivasan  suggested that the reviews customers read in advance actually influence purchase intention or encourage them to share their own feedback online after purchase and encouraged organizations to work hard to create positive customer experiences for “leaving good memories.” Thus, the post-experience of customers extends the processes continuously as it affects their prior, current, and post experience . Consequently, the post-experience in this study refers to experiences that will influence patients’ decision on what to do after service provision. The post-experience includes relationship building, recommendation, and feedback.
As discussed earlier, decision-making for medical tourism can be determined with a variety of patient experiences. Thus, this study examines the effects of experience of medical tourists on the decision-making process. The proposed research model is shown in Fig. 1.