internation marketing

The Mayo Clinic, known for treating international leaders,

recently saw the president of a central Africa country in its halls.

Teodoro Obiang Nguema Mbasogo, the president of the Republic

of Equatorial Guinea, was in Rochester, New York, for a checkup,

clinic officials confirmed. Security officers and limousines—not

an uncommon sight in Rochester—signaled his visit.

Nguema Mbasogo assumed the leadership of his country

with a coup that overthrew his uncle. His country recently

began working with the U.S. Agency for International Devel-

opment, under the leadership of a dean of the University of

Minnesota’s Hubert H. Humphrey Institute of Public Affairs,

to improve Equatorial Guinea’s social services. Dean J. Brian

Atwood of the institute is overseeing this effort. He went to

Equatorial Guinea in June, and a second meeting is scheduled

for this month.

The Mayo Clinic has a long international history, providing

care to international patients since its inception. Despite its his-

tory and reputation, however, the marketing staff continues to

monitor the international market to gauge the level of awareness,

reputation, and attractiveness of the Mayo Clinic around the world.

This institution has used word-of-mouth marketing to maintain its

global reputation.

Marketing, as most formally defined, historically was not a

critical factor in delivering patients to Mayo Clinic. Indeed, the

marketing department at Mayo Clinic has existed for only the past

20 years, and patients have been coming for care for more than a

century. The Clinic believes that the marketing department pro-

vides valuable information to physicians and their support staff—

information that helps them deliver better care, highlights their

patients’ wants and needs, and educates them as to what’s going

on in the marketplace.

In reality, however, it’s the providers themselves—the doctors,

nurses, receptionists, and all the rest of the allied health staff—

who bring in business by creating positive experiences for patients.

Patients who leave Mayo Clinic highly satisfied with their care

will return to their communities in the United States and elsewhere

and say good things to their family and friends. And these family

members and friends in turn travel to Mayo Clinic when they need

tertiary or quaternary medical care. Although the marketing divi-

sion strives to provide excellent internal support, it is the doctors

and other care providers who have created and maintained a brand

of healthcare excellence.

Despite the hype surrounding what has been presented as

the highly lucrative international marketplace, “international”

is not something new at Mayo Clinic. Experience and research

indicates that “international” is a part of who the Clinic is, as

well as how the market defines it. Nearly 100 years ago, the

founders, a family of physicians named “Mayo,” created an

international legacy by traveling around the world to compare

notes and surgical approaches with physicians across the globe.

In some cases, they even returned with international patients

who were in need of additional expertise. As in so many other

areas of medical practice, the current Mayo Clinic continues in

these traditions.

In recent years, however, it has begun to study the international

patient population in particular and the international marketplace

in general. These studies fall into a few categories and grow in

number in proportion to the organization’s understanding (or per-

haps greater understanding of how much it does not know) of the

international marketplace.

First, the Mayo Clinic tracks international patient trends rather

carefully, which seems like an obvious place to start. But as in

most data tracking, the value of the concept is significantly more

straightforward than the logistics of acquiring consistently reliable

data. Internal data systems must be coordinated—a significant

undertaking for any institution, and particularly hard when deal-

ing with a large and complicated infrastructure. To give a simple

example, data fields must be made uniform—not just on one data

system, but on all of them. Rather than a free-text field, for exam-

ple, that allows a registrant to enter Venzuela, or Venosuela, or

Vensuala, or maybe even Venezuela, the Mayo Clinic pushes for a

predefined field that provides standardized information.

The Clinic monitors international data by the quarter, carefully

watching trends over time by country or region, tracking signifi-

cant changes in volume, hospitalization rates, and percentage of

new patients out of any given market. For example, it knows it

has between 9,000 and 10,000 patients, depending on the year,

from more than 160 different countries annually. Some are third-

generation patients—maybe their grandfather was cured there in

the 1930s—and others are brand new. Some are neighbors from

Ontario or Monterrey; others come all the way from Indonesia.

Some markets are significantly less predictable than others, and

some countries deliver more “new” patients than others. The Mayo

Clinic probes further to figure out why.

Second, it conducts research with internal salespeople—the

physicians and their support staff who deliver care to international

patients. Through carefully moderated focus groups, the Clinic

identifies the things that are going smoothly, as well as the barri-

ers to providing excellent care. And where appropriate, it makes

recommendations for change.

Third, just as with U.S.-based patients, the healthcare insti-

tute conducts both quantitative and qualitative research in the

international marketplace, including research with patients,

international physicians, and international healthcare con-

sumers, designed to help it understand why people choose to

leave their own communities for healthcare, why some of them

come to Mayo Clinic, and why others do not. It works hard to

understand how healthcare decisions are made so it can better

assist decision makers, physicians, and their staff in providing

care. The Clinic positions itself to offer counsel on where to

best expend valuable institutional resources, both human and

financial.

GLOBAL MARKET RESEARCH

The marketing department conducts periodic and ongoing patient

satisfaction studies with international patients, measuring their

assessment of various aspects of the care provided. To date, the

International Marketing Research at the Mayo Clinic

CASE 3-1

Cases 3 Assessing Global Market Opportunities

Mayo Clinic has surveyed nearly 1,500 patients in 20 countries, in

four different languages. As any market researcher knows, sound

patient satisfaction research requires great attention to detail to

ensure reliable data. Not surprisingly, international data collection

offers significant additional challenges. For example, according to

the Mayo Clinic:

The quality of our own data. The name and address fields

designed for clean U.S. addresses often are not sufficient to

hold reliable international detail. If we want to do it right,

we must manually “clean” thousands of patient records be-

fore fielding our studies.

Varying quality of international postal and telecommuni-

cations infrastructure. This variance can create significant

problems for either phone or mail surveys; consequently,

international studies take a lot more time than U.S.-based

studies and require much more patience.

Cultural dynamics. In some countries, individuals may be

suspicious of an international call; in others, they may spend

a lot of time outside of their homes. In still others, a nonfam-

ily “gatekeeper” must be diplomatically convinced to transfer

the call to the targeted respondents. These cultural dynamics

pose further delays and require special sensitivities.

High standards for quality. Our own standards for quality

compel us to maintain high quality language- and culture-

specific fielding of our various research projects. These

studies, whether managed internally or through an external

vendor, require more oversight than we are accustomed to

with U.S.-based research.

Despite these challenges, however, this international research

has taught the Mayo Clinic a lot. International patient satisfaction

studies demonstrate that the key driver of patients’ satisfaction

seems to hold across borders. This is excellent care—manifested

by listening, explaining, and thoroughness on the part of Mayo

Clinic physicians. Other factors in the healthcare experience are

important—for example, quality of language interpretation and

waiting times—but they do not consistently correlate with overall

satisfaction.

The power of word of mouth is also confirmed in the inter-

national marketplace. Most international patients indicate that

friends or relatives provided their most important influence in

choosing Mayo Clinic. This finding reinforces the most powerful

marketing “tool”—satisfied patients who say good things about

Mayo Clinic and influence others’ healthcare decisions. Exhibit 1

indicates the factors influencing choice of Mayo Clinic by patients

from Latin America and the Middle East.

Formal focus groups with international patients and nonpa-

tients in six cities around the world attempted to learn more about

how those populations make healthcare decisions, and whether the

process is the same or different from U.S. healthcare consumers.

As it turns out, for most aspects of decision making, the process is

very similar to that of U.S. consumers. However, for a few others,

the process is quite different.

The areas with the most differences across borders relate to the

role of health insurance. Three co-sponsored international research

projects have provided some good lessons and demonstrated that

international healthcare insurance is as different from that in the

United States as it is across countries and regions. Furthermore,

many assumptions taken for granted in the U.S. market—for exam-

ple, name recognition—simply do not hold in certain international

markets. Exhibit 2 is a graph of responses from a satisfaction study

of patients from Latin America and the Middle East, showing the

different history of Mayo Clinic brand awareness in those regions

Mayo Clinic awareness among patients was much more recent

in the Middle East than in Latin America. Other studies, however,

showed that awareness among nonpatients—even those who have

purchased health insurance policies that offer them Mayo Clinic

care as a benefit—is not as strong.

The international healthcare insurance market is expanding

rapidly, and many providers view this expansion as a significant

opportunity to glean additional patients from outside the United

States. Commercial and noncommercial contracts comprise a

significant body of business in U.S. healthcare. If this business

could be expanded to provide patients from markets outside the

United States, all the better. However, healthcare systems vary

significantly from country to country, and the knowledge and use

of health insurance vary even more. To study these differences in

Exhibit 1 Which Was Most Important in Your Decision to Choose Mayo Clinic?

International Patient Satisfaction

N 5 331 Middle Eastern patients; 755 Latin American patients.

0% 10% 20% 30% 40% 50% 60% 70%

Friend or relative

Media (TV, radio, newspaper)

Internet

Government

Doctor at home

Other

Latin America

Middle East

Part 6 Supplementary Material

detail, the Mayo Clinic cosponsored two quantitative studies of

healthcare insurance policyholders—in particular, holders of pol-

icies that offer some degree of coverage for care at Mayo Clinic.

The first study consisted of face-to-face interviews with

400 policyholders in a particular country and delivered a great deal

of information regarding policyholders’ preferences, healthcare

behavior, and demographics. In this country, as throughout most of

the world, the public healthcare system exists as a universal “safety

net” for all citizens. Even in markets where the private insurance

market has expanded, the public system continues to offer care for

all citizens. Therefore, if a private insurance policy does not offer

adequate coverage, especially for high-cost procedures, the public

system is used to reduce the consumer’s financial burden.

The private policy might cover, for example, access to primary

and secondary care at private rather than public clinics as well

as the price of a private room, or the option of receiving care at

a more upscale facility. But for high-cost, life-threatening pro-

cedures, the co-pay or deductible for having these procedures

conducted exclusively in the private sector remains significant.

The end result, of course, is that the lower cost procedures are

transferred to the private system, while the higher cost procedures

remain in the public safety net. The implication for U.S. tertiary

providers is that, while private insurance might reduce some of the

financial risk for traveling out of country for care, in many cases

the risk is not completely eliminated. Therefore, the policies might

not deliver the volume of patients initially anticipated.

Other factors, such as a lack of brand awareness and limited

perceived need for U.S. medical care, may be impediments to

attracting patients in the international healthcare insurance mar-

ket. In the first study, when the Clinic probed for brand awareness

among those 400 consumers who had purchased a health insur-

ance policy touting Mayo Clinic coverage as a benefit, no unaided

recall of that coverage emerged as a benefit of the policy. (See

Exhibit 3.) In an aided list, Mayo Clinic coverage was ranked as

the least important benefit of the policy, on a par with eyeglass

coverage at the bottom of the list.

Furthermore, when asked to name a leading medical center in

the United States, most policyholders (72 percent) did not know a

single one. Twenty-five percent (25 percent) named Mayo Clinic,

and the other 2 percent named other U.S. medical centers. It was

no real surprise that citizens in the studied country were not famil-

iar with Mayo Clinic. However, the Clinic was surprised that

policyholders who had purchased an insurance product that very

publicly advertised the Mayo Clinic benefit were unable to name

Mayo Clinic as a leading U.S. medical center.

As it turned out, many of these policyholders had no intention

of leaving their home country for medical care. They were buying

insurance to facilitate care in the more desirable private system.

Furthermore, most felt that the healthcare in their own country

was very good and that there would be little if any reason to ever

leave home to obtain care elsewhere. This phenomenon emerges

repeatedly in research with U.S. patients. Most believe in the abili-

ties of their own doctor and feel very confident about medical care

in their own community. Even though “quality” may be regionally

or culturally defined, almost everyone considers his or her doctor

to be a good one.

A second cosponsored study consisted of 353 telephone inter-

views with individuals who had purchased a healthcare insurance

policy specifically for international coverage. Once again, confi-

dence in local care was very high—in fact, significantly higher

than in the country of the first study. Nonetheless, this group of

individuals had purchased a product that offered them coverage

for medical care outside their home country, should they decide it

was necessary or appropriate. In this study, aided brand recogni-

tion among policyholders was higher than in the first; when

asked directly whether they had heard of Mayo Clinic, 75 percent

responded affirmatively. But when asked unaided to name the

best medical centers in the United States, the vast majority (nearly

70  percent) of policyholders indicated they did not know. And

while the majority had heard of Mayo Clinic, fewer than 10 percent

were aware of any benefit of their health insurance policy that

related to Mayo Clinic.

Exhibit 2 How Long Ago Did You First Hear of Mayo Clinic?

International Patient Satisfaction

N 5 331 Middle Eastern patients; 755 Latin American patients.

0% 10% 20% 30% 40% 50% 60% 70%

For as long as I can remember

Within past 2–5 years

Within past 1–2 years

Within past year

Latin America

Middle East

Cases 3 Assessing Global Market Opportunities

Both of these studies offered substantially more information

about the nature of international insurance agreements, policy-

holders’ wants and needs, and their disposition toward traveling

out of country for medical care. But they also showed that the

knowledge of the Mayo brand is limited outside the United States

and that a high number of policyholders does not necessarily

translate into a high number of patients. This research has taught

the Clinic to be more selective, to be cautious in expending signifi-

cant resources to pursue insurance arrangements, and to conduct

further research to expand understanding.

THE FUTURE

“International” will continue to be part of who the Mayo Clinic

is. Its doctors, hailing from all corners of the globe, will continue

to collaborate with their colleagues around the world. Mayo

Clinic researchers will conduct clinical trials in collaboration

with researchers on many continents. Students and residents

will continue to offer rich diversity, as Mayo international

alumni now number 1,500, representing 67 countries. But most

important, Mayo Clinic will strive to provide the best medical

care possible to those patients around the world who need it

the most.

To support that mission, members of the “marketing” depart-

ment will continue to support the medical staff by studying

Exhibit 3 Recall of Plan Benefits (unaided)

N 5 400 individuals who had purchased a health insurance policy advertising Mayo Clinic coverage as a benefit.

0% 10% 20% 30% 40% 50% 60% 70%

Hospitalization

Consult reimbursement

Exams/X-rays/lab tests

General medicine

Ambulatory coverage

High reimbursement %

Serious illness

Can choose clinic

patients’ wants, needs, preferences, and behavior patterns and

learning all that they can about the ever-changing, rich, and diverse

worldwide healthcare market. In the end, outstanding medical

care and sensitive service to patients and families will be the most

productive marketing strategy, because it creates positive word

of mouth about something very important—healthcare. As the

stories of satisfied patients churn—sometimes for decades—in the

minds of their friends and family, Mayo Clinic remains an option

if they ever need the care it offers.

QUESTION

Assume you are the new marketing vice president at the Mayo

Clinic. The CEO and the board have decided to expand their

international sales revenues by 100 percent over the next five years.

Write a memo to your staff outlining the marketing research that

will be needed to support such a strategy. Be specific about sources

of secondary data and the best places and media for gathering

primary data. Also, be specific about the best methods to use.

Sources: Misty Hathaway and Kent Seltman, “International Marketing Research

at the Mayo Clinic,” Marketing Health Services, Winter 2001, 21(4), pp. 18–23;

Jeff Kiger, “African President Gets Checkup at Mayo Clinic,” Post-Bulletin,

September  21, 2007; “Mayo Clinic Builds Center for International Patients,”

Post-Bulletin, February 3, 2009.