A blog covering the health/care ecosystem and people.

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"Health is very addictive,” Michaela Deeley told me. “The way you feel once you start to feel good… you don't want to stop." Michaela is the manager at the Mandara Spa on the Norwegian Cruise Line’s ship, the Breakaway, which sails weekly from from New York City to Bermuda. I appreciated the opportunity to interview Michaela about how medical tourism is a growth business for the cruise industry, and a welcome on-ramp to health and wellness for passengers. “Health on a cruise ship?” you ask. In fact, this area of the146,000 ton ship [which accommodates 3,963 passengers and 1,657 crew is hiring more staff in response to cruising clients’ growing demand for health and wellness services on-board. When it comes to consumers and medical tourism, you must think beyond bingo, binge eating, and bar-hopping. “More passengers are flowing into the spa area looking for services,” Michaela told me. The primary demand prompting cruise ship passengers may be seeking a week of vacation of sun-tanning (using high-powered SPF to prevent sun damage, of course), dining 24x7, and casino gambling. But more people choosing to cruise are growing more health conscious, seeking opportunities to make personal health throughout the ship: from the kitchen and dining room to the fitness center and through experiencing dozens of health education classes available throughout the seven day ride on the Atlantic Ocean. What is prompting people to come into the Spa area of the ship, when there are so many other activity options? I asked Michaela. The simple answer is that our interest in health, vitality and wellness is growing, and particularly among people over 50 who want to age well. While some repeat passengers may know what they want after boarding the ship, most people need time to review the lengthy, descriptive spa menu. Staff are trained to ask clients about what’s motivated them to approach the spa in the first place. The client complaints and concerns cover the gamut: to relax more, to deal with pain, to boost wellness, and to be sure, to lose weight. While this may seem ironic given cruise ships’ stereotypical reputation for 24-hour buffets, unlimited drinks packages and 3 am room service, it is the case that many cruisers seek balance, participate in daily yoga classes, and order nutritious, clean food from restaurant menus. There are vegetarian and gluten-free options for people who want them among the nearly 20 dining venues. The spa service list is split into categories, some of which are the more typical salon and spa services available on land such as facials, massages, and mani/pedicures. The Medi-Spa services are less familiar to consumers new to the concept: body correction, acupuncture, and several branded dermatological treatments. These are generally available from dermatologists working on terra firma, but rarely under one roof with all the other services offered here – including the GOSMiLE branded tooth whitening procedure. The demographics of the passengers are important to call out: remember that this ship’s particular route travels from New York City to Bermuda. Michaela noted that the NYC clientele lead busy lives. If people can take advantage of several services over a week in one place, and while on a relaxing holiday, it optimizes peoples’ time. Convenience is king. A diverse portfolio of services is offered in one place. And for "patients" used to being responsible for one bill for every encounter, here, it's one bill at the end of the cruise with no sticker shock. Prices for each service are transparently shown. There are even discounts offered, Uber-style, at low-peak times such as in port in Bermuda. The thermal suite in the spa is equipped with modern amenities that speak to techniques used a century ago in Europe. Medical tourism goes way back to the era where patients were prescribed spa visits to Bath, England, and Baden Baden, Germany, to take in steam baths and salts. Here on the Breakaway, there is a Salt Room, a Sauna and Sanarium, and a thalassotherapy pool of seawater, salt, and other therapeutic ingredients to relieve (at least for the short-term) back, shoulder, and joint pain. The demand for acupuncture services afloat is growing. Acupuncture has dozens of applications, most notably for pain – a topic getting appropriately more attention in mass media owing to the opioid crisis. Another health issue for which acupuncture gets growing application is for sleep. “People get used to a lack of sleep and lack of energy and they don't know the difference,” Michaela observed. I shared with Michaela research I’ve used in my work and discussed here in Health Populi and in the Huffington Post on the Stress in America survey from the American Psychological Association. The most recent poll, published in the midst of the autumn 2016 election season, found that 52% of Americans said the 2016 Presidential election was a significant source of stress, compromising sleep and other health issues. Of course, exercise has been found to be a stress-reliever and sleep-enhancer, and there is no shortage of fitness classes to be found on the NCL Breakaway. Each day, the ship’s calendar (the “Freestyle Daily”) lists all the day’s activities, including fitness and health meet-ups. On Day 3, for example, there were classes meeting for “stretch & abs,” fun cardio dance, Ryde indoor cycling, body sculpt boot camp, relieving back pain with good feet, a salsa dance class, and many sporting choices from basketball and shuffleboard to scaling a rock climbing wall and doing an evening stretch. I’ll give a special shout-out for the Ryde indoor cycling class, which is akin to Soul-Cycle-At-Sea. Indoor cycling for fitness has gained great traction on land, and so as a fan of cycling, I’m glad to see this fitness trend reach cruising so that consumers who want to try it out can do so in a relaxed, non-intimidating environment. What’s intriguing about the Ryde class is that riders wear a heart monitor so they can viscerally feel what it’s like to push their personal fitness: the monitor communicates an exerciser’s real-time activity which is digitally posted to a wall graphic, and a personal trainer can educate the rider on how hard to push. At $20, it’s a fair deal compared with prices on land. At the end of the day (or cruise week), the big remaining question and wild card is whether a passenger on a holiday will continue keeping up a health regimen on-land, day-to-day, once normal workdays, workflows, and stressors enter back into our normal lives. “We are realistic,” Michaela said, “not to tell someone, for example, to change their diet. On board, people have our support. When you go home, you must have your partner or friends support you. On-board, personal trainers show people how to do new exercises, weight lift routines, yoga poses, and good posture form in a relaxing, supportive environment. But behavior change is hard, so seeing repeat customers throughout the year (especially accessible for health consumers living around the New York metro area) is one way the spa staff knows they are impacting peoples’ lives. Health Populi's Hot Points: In the past year, since I first met up in the Breakaway’s Mandara Spa for an interview, I see the breadth of services offered expanding, and health consuming cruisers getting more savvy and demanding. Several market forces are driving this phenomenon: 1. For American passengers boarding the ship, the growth of high-deductible health plans and out-of-pocket costs are dramatically reshaping US patients into healthcare consumers. 2. As consumers, people are seeking convenient care in formats, places, and at prices they find representing value – value, on their personal terms based on taste, culture, respect, and indeed, price. 3. Healthcare consumers are morphing into health/care consumers, re-defining what inputs are useful for their lifestyles, lives, and medical conditions. If dealing with pain, learning about and accessing acupuncture, posture, or massage may be of interest. If managing weight, a re-set over the course of a week of pampering and meditation could help one re-focus and re-commit to the objective. Ditto for sleep issues. Michaela, who hails from the United Kingdom, has observed that American patients appear quick to get medications and surgical procedures. “Guests we see now want to look for alternatives. Today, they are more knowledgeable about options and availability” via, for example, watching TV programs like The Biggest Loser, YouTube videos featuring doctors and nutritionists, or reading blogs by health experts and would-be ones (a current example is the brewing controversy between Gwyneth Paltrow’s Goop and Dr. Jen Gunter, an OB-GYN). As in all healthcare providers and suppliers going direct-to-consumer, people need to be educated and aware of their health risks as well as the quality of the services they choose to purchase. Caveat emptor is always advised, and a lot of research can be done ahead of time before any medical tourism choice, whether on a ship or to a foreign country. As people look to slow age, enjoy vitality and more energy, and get good sleep, we’ll keep searching for services and experiences that bring those benefits. For thousands of cruise passengers boarding ships every week, these services will be available. Consumers looking to take advantage of these – especially medical procedures – can review these online in advance, and also check with health insurance plans to see if they can be covered by insurance or claimable in medical or health savings accounts. Our THINK-Health forecasts expect more, and more diverse, opportunities in the retail health landscape for medical tourism and spas morphing closer and closer to health/care. As health consumers pay more out-of-pocket for healthcare, they'll be looking for services where they live, work, play....and travel.

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