Medical Tourism Booking Part II: Fun With Friction!

Among Valley holy grails is “reducing friction,” which can be a great concept when employed properly in the correct situation.
In reality, it’s just another MBA milspeak buzzword for “make it easier for people to do stuff they already do” — where “stuff” is usually something that makes money for the company reducing the friction.
Common example:
You used to have to call a cab company or hail a taxi, with very mixed results — especially outside highly populated cities. Now you click a button on your phone and a car picks you up and takes you where you want to go.
Magic!
Leave aside the other debates about Uber and its competitors, no one argues whether they “reduced friction” by making booking a ride easier for people worldwide.
They did.
In that sense alone, ride apps are a very successful application of reducing friction.
At renuval, we were either the first company, or among the first, to try this in medical tourism with our interactive mobile app and booking engine. We were also, I believe, the first to ditch the idea and all our technology in 2015 because it doesn’t really work — but also because it creates a huge new problem that there’s no fix for.
I’ve never talked or written about it publicly before, because even the hospital departments hit by it didn’t yet seem to understand the problem or how to think about it, but the canary in the coal mine hit this month. Dr. X.
Friction is officially a recognized problem in our industry — which was predictable (I know, because I spent years telling people this was coming).
I’ll explain what happened with Dr. X at the end of the article, but first we need a canvas upon which to paint our picture, because this stuff isn’t obvious if you don’t do it 24/7 like we do.
Friction: A Paint By Numbers Guide
To visualize friction as it looks to marketers and technology process people, I’ve drawn up some very complicated diagrams. Please enjoy.

This is a simplified process diagram for how you taxis were booked previously. I’ve left out the advantages of new apps, like price discovery and tracking, and just focused on the pre-existing problems with the pre-existing process.
The higher the red ball, the bigger the point of friction.
So, for example, standing on a street corner trying to flag down a taxi and having them pass you by — or booking a taxi and waiting forever for it to come with no idea about arrival time. That was a huge point of friction.
Then, if you hail a taxi, maybe the driver doesn’t want to go where you want to go. Smaller point of friction in most major cities, but a big one in some places, like Bangkok.
Finally, payment — maybe you don’t have enough cash or you think you were overcharged, whatever. Smallest point of friction, but it existed.
All of these points of friction were reducible through technology:

Voila, friction successfully reduced. The singularity is upon us!
With the friction reduced:
- The number of successful inquiries by riders seeking rides goes up.
- The number of successful conversions of drivers accepting rides goes up.
- The number of successful fulfilled transactions of riders delivered and paying for rides goes up.
Because all those points of friction were just manual processes that could be automated, the work was offloaded to technology. More people got what they wanted with less overall work involved. Hizzah!
The First Law Of Frictodynamics
What people don’t like to talk about is the externality of the sausage-making process in friction reduction.
Reducing friction in a process can, and often does, create new friction somewhere else. In other words, the diagram above isn’t completely accurate. Some new friction was created.
In Bangkok, for example, many drivers will be on both Grab and Uber simultaneously — riders sometimes check both. People don’t know the specifics of the ride, they just know they want to go from A to B and they want to see options.
The market gives them options in the form of multiple channels (i.e. multiple ride apps) to evaluate options through.
Ride app companies typically forbade drivers from driving for competitors, but it’s been a common practice for a long time.
The ride app companies probably didn’t care too much about solving this problem of multiple inquiries through multiple channels, except where it affected cancellations, because they probably didn’t consider it their problem. They solved it inherently in their model anyway, though.
From a 30,000 foot view, the process really looks more like this:

In other words, with no countermeasure in place, some riders would book a ride on two separate services and take the first one to arrive, effectively wasting the time of the driver who arrives second.
Thanks to technology, though, this is the reality:

By introducing price discovery without the need to signal intent to the driver, and by introducing cancellation policies enforced through logic, the apps have nearly negated multiple bookings. Rider ratings probably help too to a degree.
In other words, you can see which one is cheaper and faster before you click the button, and if you try to game the system then the system only has two outlets and they will both shut you down.
Why bother?
Just click the button what goes with the best applicable option.
It’s true that some people, for reasons that are beyond the scope of this discussion, will create multiple bookings anyway, but it’s not something that’s ever discussed as a major issue as far as I know because:
- There are usually only two major channels for booking inquiry, meaning that once you exhaust them you’re out of options (e.g. Uber and Grab here in Bangkok).
- There are penalties in place for serial cancellations.
- Rider ratings of no-show riders plummet if they game the system and accounts are likely suspended, or become useless.
- The drivers aren’t supposed to be working for both apps anyway, so from the point of view of the ride apps they’re creating the problem for themselves.
All of this means that while the potential for some remaining friction in this process exists, it’s quickly reducible and surely very minor.
That’s a lot of detail about ride apps and friction, I know. You might be asking what the Hell it has to do with medical tourism or renuval. Or, more likely, you’ve already closed the tab.
If not, thank you, I’ll get to the point.
Friction In Booking Medical Care Abroad
We’ll get to packaging and marketing inventory later in this series, but let’s make some sweeping generalizations (always a good idea) to help get to the point quickly.
Carving out the very basic bookings with no medical response needed before travel, we can focus on cases like one we just finished with, a total hip replacement in Thailand at Bangkok Hospital Chinatown.
Before travel, almost all clients (patients, for hospitals) want a medical recommendation that includes the following information — give or take:
- What does it cost?
- How long does it take?
- What’s included in the cost?
- What kind of implant is used and how long will it last?
- When will I be able to ______ again?
- When can I come?
Sure, there are a ton of smaller questions, but those are the most common — and they’re completely reasonable.
We can put a representation of answers to those questions in a database (and, of course, we have) and represent them again on a web page (and, of course, we did), and to let you evaluate them and make an initial decision to ask for a recommendation or not on your own (and, yes, we do).
It’s worth noting that working with a partner like renuval is worth your time not only because we don’t charge money for our service, but also because we work really hard to try to convey the total cost of ownership, as we say in the states.
This is a longer discussion, but, as with any complex good or service, the sticker price up front may not convey the total cost involved once you add in investigation, post-op imaging, medications (etc) and drive your new hip off the lot.
If you asked someone else, even the hospital, they may not have thought to tell you about the 2,600 THB pre-op test fee for GA surgery at that facility — or the 2,200 THB in x-rays that might commonly be done during your consult. Who knows? We do — info@renuval.com :)
Commercial break over.
Let’s say you want a surgeon’s recommendation on the answers above. That involves a highly skilled surgeon, the surgeon’s nurse team (in this case the SMART Joint Center at Bangkok Hospital China Town), and then a team both at renuval and at the hospital all going through a process that doesn’t really exist in the ride app friction diagram above.
Congratulations, You’ve Clicked A New Workflow Into Existence!
When you’re booking a ride, the key details in deciding purchasing intent are understandable and predicted upon your request, the driver’s location and the app’s internal logic that declares price and schedule information.
You signal your intent, price and schedule info pops up, you make a decision, the driver acknowledges and it’s pretty much done.
Neither you nor the driver had to go to school for years, endure residency and perform hundreds or thousands of highly complex medical procedures to figure this out.
All the Lambda Functions in the world can’t replicate the medical evaluation process yet, and it’s going to be a while regardless of what the PR flaks are putting out there — longer until the humans on the other end accept it, believe me.
So, every time you click that button and submit that request for a surgeon’s recommendation, here’s what happens:

The first thing to note is that this is actually simplified. In other words, things like post-evaluation Q&A, negotiation and many other small process points aren’t covered in there.
Next most important there are the poop-colored orangey-brown balls, labeled “Points Of Potential Input Gathering Bottlenecks” which represent points at which the process can, and often does come to a halt while more information is gathered.
Maybe the surgeon needs a new MRI, maybe we catch an error in the cost before sending and have to go back and forth — who knows? Happens constantly.
After that, note the bile colored green balls, labeled “Points Of Friction Seemingly Reducible, But Not Really.”
Those are points that seem to digerati utopians like they can be eliminated, but in reality cannot — and for a very good reason.
Sure, it might seem like you can just bypass processes, but think about an airplane. The ground crew does checks, the cabin crew does checks, the pilot does checks, the co-pilot checks the checks, etc. This is exactly how a responsible JCI Accredited international hospital works.
Your info needs human review on the way in and on the way out, because not only is it the medically ethical and responsible thing to do, but you’re going to base a very expensive decision to book hotels and flights, and have surgery in a foreign country, largely on this answer.
It’s gotta be right.
There’s definitely room to reduce some friction in there, and some we didn’t even list above, but it’s a very small gain.
This isn’t John Q. Public and John Q. Rideappdriver matching rides on a rainy night in Melbourne, this is years of medical training and skill deciding, based on information gathered elsewhere and transmitted over the internet, whether you need to be put to sleep, cut open, have your hip bone sawed off and have it replaced by a highly advanced, imported hip implant.
The friction created by the medical evaluation process? You’re going to want some of that friction in there. This is good friction. This is the-plane-gets-there-safely-every-time friction. I promise you, when you are on the plane, it won’t feel academic. It’ll feel very real. Because it is.
Anatomy Of Today’s Medical Tourism Booking Mess
Above, I explained the entirely new process set in motion every time you click that button asking for a quote. You tap, up to 10+ people across multiple teams just saw their workload increase.
Now, to be fair, there are special cases that exist in plastic surgery, dermatology, sometimes dental and other cases where you can produce your own inputs (e.g. photos) and the doctor or dentist works alone and can produce his or her own output (e.g. the recommendation) and the process can be greatly reduced.
You’re young, healthy and want larger breasts? Thinking about veneers? Feel like some BOTOX and fillers might freshen things up? No problem. Send over your basic medical info and some photos, we can handle it.
It’s not fair to deny this particular selective segment of the market, but even in these fields the depiction of aggressive friction reduction is not always accurate — and the volume of inbound work created by reducing friction on your end is becoming a problem on the medical end, as we’ll discuss at the end of this article.
(For more information on selective procedures, see the first article in this series — Medical Tourism Booking Part I: It Ain’t Hotels)
Outside of that, it’s a different world.
At renuval, we currently have, among others:
- A client in hospital after spinal surgery
- Three clients flying in this week for spinal care (possibly surgery)
- One client in for complicated revision liposuction
- One long-term client here for diabetes wound treatment and digital amputation
- One client who just flew home after a hip replacement
- One client flying in for intense psychiatric care after a family tragedy
- Another client flying in for rehabilitation related to a knee injury (possible TKR)
- One client who just left after a breast cancer biopsy and mass removal (benign, thankfully)
- …and the list goes on to cardiology, neurology, hepatology, nephrology, pediatrics and more.
Doctors in these fields need complex inputs like MRIs or PET-CT scans or lab results along with extensive medical reports. They work in teams. Their diagnoses are qualitatively different and, because of the amount of inputs and precision involved, quantitatively different.
That’s not, by the way, to deny the work and skill of other doctors and dentists, who are a Hell of a lot smarter and more skilled than I will ever be.
We work with some very diligent and fantastic plastic surgeons, for example, like Dr. Chartchai and Dr. Poonpissamai, and dermatologists like Dr. Prisana or Dr. Duangkamol, who take great care and spend a great deal of time on every evaluation and with every client — in fact Dr. Poonpissamai just finished surgery on two of our clients this week and we have two more coming in for surgery with her in the next day or so, as well as skin appointments with Dr. Duangkamol.
We wouldn’t work with these professionals if we didn’t trust them, and they feel the same way about us by all accounts.
The reality is, though, that when your needs are largely physically visible, then you don’t need to get and send an MRI and a series of x-rays and a medical report and lab results and the doctor doesn’t need to verify all of it, have someone evaluate your lab results and consult a team to complete the recommendation process (in most cases).
In cases where extensive, complex inputs are required, though, you can’t produce an MRI or the like yourself, and the doctors or dentists involved often can’t produce the deliverable (i.e. your recommendation) working alone. It’s very precise stuff, it can require an entire team to evaluate and a lot of safeguards are in place precisely because no one wants to make a single error that’s avoidable.
So, let’s update the ride app friction diagrams from the first part of the article to reflect medical tourism booking:

Reduced Friction Has Created A Mess
I could diagram out the rest of the process, but the point is already pretty clear.
There’s just a ton of hidden, irreducible friction and it’s not going to change anytime soon — for ethical and bureaucratic reasons, but also because technology won’t be able to diagnose your hip replacement needs soon and because it will take years of removing safeguards and consumer education and experience before that kind of diagnosis is accepted anyway.
As with most AI-related things, the AI belongs on the provider side first, anyway, not the consumer side, but that’s a different article :)
Look at that diagram again:

Imagine how many times that occurs each day.
Someone searches, finds an option, fills out a form, clicks a button, creates a workflow for a booking engine company who then creates a separate workflow for a referral team, nurses, doctors and estimates department at a hospital or clinic. Not to mention people like us.
While “reducing friction” is a holy grail for booking taxis, ordering pizza and anything else, in fields where pricing is highly complex and requires highly skilled human intervention, there’s a hidden cost that isn’t taken into account that’s pretty big — and with the proliferation of booking engines and spammy directory sites, the medical partners are starting to notice.
Now, we don’t really have this problem at renuval. A few years ago, one of our partners, Samitivej Sukhumvit, had an excellent referral department and one of their best people called us up to very politely ask a very simple question:
Hi, I’ve got a list of the patients you’ve referred and we’d like to go through the ones who didn’t come for treatment and ask why.
I’m a 20 year online marketer, so I understand conversion rates and all the rest and I knew immediately what they were really asking, which is, “Are you wasting our time?”
In truth, we kinda were.
We didn’t mean to be, we were doing what we thought we were supposed to be doing: telling clients about medical services and then sending their information to the hospitals to get medical recommendations and quotes and then sending that information back to the clients.
Sounds right, doesn’t it?
There are two problems:
- We weren’t really screening clients properly because our system was automated.
- There are now many companies doing exactly this coming from all over the world.
How We Became Screen Queens
Speaking to the first issue, screening, we introduced a very specific human process to pre-evaluate the needs of people who were inquiring. Like we say, we put the button there, they’re clicking it, no one did anything wrong — especially not you, the client — but reducing that friction had an unanticipated result:
Tons of highly skilled human labor and effort by teams of people.
If you’re a leadgen marketer, or have spent your entire life marketing simple products like FMCG, or complex products where evaluation can be automated through logic, like insurance quotes, creating friction probably sounds nuts to you. Reducing friction is the goal!
Think back to what I described about the hidden workflow in this field, though.
There is no way to automate ethical medical evaluation in the vast majority of cases. Clicking that “Send My Free Quote!” button immediately creates work for one or more doctors, nurses, referral staff and us.
After introducing screening, our conversion rates went way up even though the total number of cases referred went down and I can proudly say that, today, a number of our partners have complimented us on the quality of our cases and work.
They may not even know what conversion rates and abandon rates and such are, but they know that client cases we send to them are much richer and more likely to come for care, and be supported during that care, than is the case across the industry.
We’re proud of that, not just because of the numbers, but because it means that we — and our partners — spend more personal time with each client who really wants or needs care, which translates to better informed clients up front, better informed medical staff prior to visit, more aligned expectations and better results and post-op or post-visit experiences.
Outcomes are everything. Outcomes are the goal. You’ll agree when it’s your outcome that matters.
More != Better
The other problem, mentioned above, is that more and more companies have moved into this field — almost every single one of them headquartered in another country and backed by foreign investors. With very rare exceptions, they don’t know Thailand or the medical community here well at all, and we’re friendly competitors with the one key exception who is doing good work.
What the other competitors do know is the tried and true model of booking engines and directory plays. Scrape a bunch of content, slap it on your site and generate leads. In some cases, these sites even have scraped (i.e. stolen) watermarked photos or patient testimonials from the other competitor sites or from hospitals presented as their own. Doesn’t exactly scream “high quality.”
Instead of thinking about the big picture and end results, they’re focused on friction reduction and “scalability” (on the wrong end of the equation) in simple markets and the concepts are applied without adjusting for the very specific, complex medical field we are in.
Among many other side effects, I can tell you from first hand accounts that the number of inquiries has risen across the board while conversions, while often not tracked by the hospitals in a meaningful way, have not risen commensurately.
In other words, the referral teams, nurses and doctors are doing more and more work helping people who, when they clicked that “Get Your Surgeon’s Recommendation Now!” button, just thought they were doing a price check the same way you would on a hotel site or an airline site.
Like I say, it’s not the client’s responsibility, the problem is being created by the providers companies in the middle and it’s their job to clean up.
We’re doing our part and we’re now being asked to help others do the same.
Dr. X: The Canary In The Coal Mine
At the start, I mentioned that we’ve just seen the canary in the coal mine, Dr. X. Here’s the story of the first systemic, policy-driven response to the flood of speculative inquiries caused by what I’ve described in this article.
Our client had inquired with one of these hilariously named Australian boobie holiday agencies for surgery with Dr. X, a well-known plastic surgeon. DentiMediRestiBeautyGetiTraviTouriWhatever.com — they all sound the same.
The client had received a full recommendation and quote for Dr. X from this agency and, for whatever reason, the client was unhappy with the agency and came to renuval to book direct with Dr. X.
This is a totally normal situation, happens all the time.
Hospitals, clinics and doctors work with a huge basket of companies, each of them puts up their own marketing (many of them claiming their own prices in other currencies or creating packages, something we don’t do) and the result is that clients can reach the same surgeon through many different channels — and often do.
The client cannot be responsible for this, they’re just doing what the agents, and the doctor, by making agreements with those agents, asked them to do.
It feels as a client like you’re comparing options, because that’s what it’s been made to feel like by the proliferation of agents allowed by the providers. In reality, you’re comparing the same thing over and over.
What happened this week was a first for us, though.
This client, as mentioned, inquired with Dr. X through another agent and then inquired with Dr. X through us. Everything was going normally and then, bam:
We heard back from Dr. X’s representative that he was refusing the case due to multiple inquiries.
In other words, because the client inquired with another agency and then with us, meaning he had received the client’s information twice, the doctor had decided not to accept the client as a patient anymore.
Now, we’re ultimately interested in our clients getting the medical care they want or need as long as it’s ethical and makes sense, which this did, so we did our best to change the result.
We contacted Dr. X’s representative and asked him to reconsider, but their hands were tied.
We then contacted Dr. X’s personal assistant, whom we know, and were told that the doctor doesn’t interfere with the booking process. In other words, he had a policy and wasn’t going to change his mind.
Finally, we said, look, forget renuval, the other agent or any other consideration, will you just take this client on directly as your patient?
Unfortunately, the answer was final and Dr. X will not be performing surgery on this client.
The Beginning Of The End
This is it.
I’ve been talking to hospital managers and clinic managers and doctors even for years about monitoring conversion rates and adding contract clauses to reduce multiple inquiries and so on.
Dr. X is an independent doctor who moves fast and can make his own decisions, so while the hospitals will be much slower to react and the clinics somewhere in between, Dr. X just showed the first signs of the system straining under the weight of all this reduced friction — all these clicked “Get A Free Quote!” buttons that create all these workflows.
Every agent the hospitals, clinics and doctors bring on advertises the same good, however they do it, and clients are told over and over to just click here for a personal recommendation from a surgeon and that creates the workflow I mentioned at the top.
On booking engine sites and directory plays, the model is taken from lead generation industries where more leads never hurt anyone, but in our field every new lead creates more work for some very busy referral departments, nurses and doctors, as described.
Dr. X was the first person to react, and we don’t agree with how he handled it, but the sign is clear:
We’ve finally hit the point where the hospitals, clinics and doctors are getting tired of doing tons of highly skilled, free work for no end result. While this is in no way the fault of clients, who are being encouraged to do this by the system in place, the consequences are now impacting the clients.
Dr. X is just the first. Many will follow.
Good.
We just want the system to focus its attention on the problem, which is not the clients, it’s the intermediaries. The agents. It’s the contracts signed with no thought to the extra work created and no metrics for monitoring quality of service, conversion rates and abandon rates and so on.
We’ve built a great team and over a year’s worth of custom technology, ongoing, to address this and other problems and we’re now being asked by our partners to assist in solving exactly this problem.
The answer to how and what is proprietary, but the writing is on the wall and the days of rampant agent contract expansion with no thought to downstream effects is just seeing the beginning of the end.
Again, good.
We’ll still be here :)
renuval partners with 30 hospitals, clinics and centers in 3 countries (primarily Thailand) to offer medical care to clients from over 30 countries. Our teams, now in five countries, offer assistance in English, Thai, Arabic, Japanese, Khmer and a couple of other languages, with more planned. It’s not about us, it’s about the rest of the world.
