Research on the Model of Cross-Border Medical Tourism Decision-Making under the Background of Globalization

With the help of the wave of globalization, the new industry market is con-stantly emerging, showing a clear trend of “reverse globalization”. Among them, cross-border medical tourism and related industries are particularly effective. The flow of cross-border medical tourism patients has changed dra-matically. What is the development of international medical tourism industry? Which factors make the “reverse globalization” phenomenon occur on cross-border medical tourism? How do patients decide their medical tourism destination? This paper based on the analysis of relevant literatures and the development of international medical tourism industry, tries to summarize cross-border medical tourism decision-making process, and devel-ops a two-stage model for cross-border medical tourism. Through the analysis of the decision-making process of cross-border medical tourism, this paper considers that a country’s economic level, political climate and regulatory policies are important factors influencing people’s choice of cross-border medical tourism destinations. We also argue that medical treatment cost, hospital accreditation, quality of care, and physician experience influence patients’ choice of medical facility.


Introduction
With the development of science and technology, the industrial structure has been continuously upgraded and transformed, and new industries have emerged in the tide of globalization. Medical tourism and related industries have become total tourism revenue. The medical tourism market has broad prospects.
Tourism has a long history, dating back to the early 14th century when European rich people went to Greece to travel to spas, and modern medical tourism began to develop in the late 1990s. The medical tourism industry developed rapidly in the early 21st century, but so far there is no unified definition [4]. It is generally believed that medical tourism is a new type of tourism service for the purpose of medical, nursing, rehabilitation and tourism for the sake of economic, social and institutional factors [5]. Up to now, the cross-border flow of medical tourism has driven the rapid development of related industries, but it has also experienced a reverse change from the flow of less developed countries to developed countries to the flow of developed countries to new developing countries. In the past 20 years, the phenomenon of "reverse globalization" of medical tourism has become increasingly obvious. People have shown that they have sought medical services from developing countries such as the United States, Canada, the United Kingdom, and Australia to developing countries such as Thailand, India, Malaysia, Hungary, and South Africa [6]. The phenomenon of "reverse globalization" in the flow of cross-border medical tourism tourists is the result of the joint action of "thrust" and "pull" in international trade [7]. Up to now, more than 50 countries in the world have listed medical tourism in the national industrial development of key national development. The "thrust" that led to the surge in cross-border medical tourism and the soaring output value mainly include: high medical expenses, insufficient coverage of medical insurance or limited scope, (such as the United States), waiting for medical treatment for too long (such as Canada, the United Kingdom), backward medical technology (such as Vietnam, Cambodia); "pull" mainly includes: low cost of medical treatment, advanced medical technology, first-class medical services etc. [8]. The proximity of the same geographical system and the consistency of religious beliefs are also important pulls for the development of cross-border medical tourism.
Along with the deepening of globalization reform, the broad development prospects of the medical tourism industry have attracted many countries to compete in the cross-border medical tourism market, and have successively shaped their brand advantages with "first world technology, third world price". Asia is one of the most important medical tourism markets, with Thailand, India and Singapore occupying the top three positions [9]. Latin America's Brazil, Costa Rica, Mexico, the Middle East's Jordan, Israel, the United Arab Emirates, Europe's Hungary, Poland, and the Czech Republic will also develop cross-border medical tourism industry as an important economic growth point to play an important role in the international medical tourism arena. The medical tourism market is expanding day by day, and people's choices are becoming more and more abundant, making the decision-making process of cross-border medical tourism more important. Can accurately analyze and grasp the decision-making process and behavioral characteristics of cross-border medical tourism consumers to improve the competition of the domestic medical tourism industry? If a medical tourism destination country wants to take the initiative in fierce competition, acquire more customers, and seize a larger market share, it must fully consider the decision-making process of cross-border medical tourism consumers. With the continuous rise of cross-border medical tourism topics, research and reports on medical tourism at home and abroad have also increased significantly. However, most domestic scholars study the development status, challenges and countermeasures of medical tourism. Most foreign scholars focus on medical tourism case studies. There is relatively little research on the decision-making process and decision-making model of people's cross-border medical tourism. Cross-border medical tourism is a new type of medical industry that is formed by self-issuance at the individual level. The decision-making process of studying cross-border medical tourists has certain significance for industrial development and national strategy. China's medical tourism is still in its infancy, grasping the development status of the medical tourism industry and the decision-making psychology of consumers, which contributes to the strategic positioning and competitive advantage at the national level.
Based on the above analysis, this paper intends to summarize the definitions of medical tourism connotation and types by domestic and foreign scholars, select several representative representatives of medical tourism development, systematically explain the development status and dynamic trends of cross-border medical tourism industry, and combine the cross-border medical tourism industry. The "thrust" and "pull" of development, according to the sequential logic process to sort out the decision-making process of consumers in cross-border medical tourism, and then establish a two-stage decision-making model from the two dimensions of state and medical service, and grasp the cross-border medical tourism. The decision-making behavior and consumption preferences of the crowd are expected to provide reference for the study of medical tourism in China.

The Connotation and Types of Cross-Border Medical Tourism
In recent years, with the aging of the population, soaring medical costs and

Types and Typical Representatives of Cross-Border Medical Tourism
Medical tourism is an important branch that cannot be ignored in the field of health care. According to the difference in medical and tourism weights, cross-border medical tourism can be divided into narrow medical tourism and medical tourism with the aim of seeking medical services. According to whether or not surgery is the standard, some scholars divide medical tourism into three categories: general medical examination, invasive surgery and lifestyle medicine [11]. Early cross-border medical tourism provided high-quality medical services to high-income people in developing countries to developed countries. Horowitz and Jones (2007) motivated medical tourists into five categories: price-oriented-Because the cost of medical care in the country is too high to seek low-cost choices abroad; there is no medical insurance-including the uncovered population of medical insurance and the items not covered by medical insurance, resulting in higher costs; dissatisfied with the national medical policy-medical socialization leads to waiting time for medical treatment Long; ethical controversy-some medical services (such as abortion, IVF, stem cell transplant, euthanasia, etc.) that are not yet developed or prohibited by law or that cause ethical controversy abroad; protection of privacy-abroad Perform surgical treatments that require privacy protection (such as degenerative surgery, drug treatment, etc.) [12]. At present, cross-border medical tourism is booming in the international arena. It is a high value-added emerging industry with broad market prospects and has become an important economic growth point in many countries. Thailand, India and Singapore are typical representatives. After the Asian financial turmoil in 1997, the number of private medical institutions in Thailand decreased sharply due to the reduction in the number of medical treatments in the country. In order to revitalize the medical economy, the Thai government began to take measures to develop the medical tourism industry. In 2004, it began to expand overseas markets [13]. Thailand's medical beauty, plastic surgery (especially breast enhancement, transsexual) and other special specialist services are prominent. According to the official tourism bureau of Thailand, 600,000 medical tourists from all over the world went to Thailand for medical services in 2004, with an output value of 500 million US dollars. The number of medical tourists in the country reached 1.4 million, making it one of the fastest growing industries in Thailand with a growth rate of 20% per year. It is expected to complete the annual industry income of US$6 billion by the end of 2017 [14]. India is a rising star in cross-border medical tourism. It has been known worldwide for cardiovascular medicine, orthopedics and neurosurgery. It combines the advantages of traditional Chinese medicine to introduce Ayurvedic medicine, Siddha medicine, traditional yoga and other special products. India's medical tourists are growing at a rate of 25% a year, and India's medical tourism market revenue in 2013 reached $3 billion [15]. India's world-class medical standards, low medical costs, quality medical team and language advantages have become an important magic weapon for the development of cross-border medical tourism. The World Health Organization ranks Singapore as the best country in the Asian healthcare system, and its sophisticated medical services and high cost performance are important guarantees for the development of high-end medical tourism. Singapore's medical tourism industry revenue reached $1.5 billion in 2016 and maintained a growth rate of 13.6% per year. Compared with the United States, Thailand, India, and Singapore have obvious price advantages in medical tourism service projects (as shown in Table 1).

Analysis of Consumer Purchase Decision Process
Obviously, cross-border medical tourism integrates the medical industry with the tourism industry, involving industries such as hospitals, hotels, restaurants, and market profits are subject to national government and international Tourism agencies, medical institutions and policy makers attach great importance to turning medical tourism into a competitive new economic growth point [16].
Undoubtedly, the wave of globalization has brought new opportunities and challenges to the medical tourism industry. The "reverse globalization" of the source of tourists further highlights the importance of the decision-making process of cross-border medical tourists to the development of the industry. For the consumer purchase decision-making process, the research of foreign scholars started earlier. Suleyman Ozarslan systematically established a dynamic analysis framework for the consumer decision-making process, and proposed a 5-step decision-making process for demand, information collection, evaluation selection, decision purchase, and after-sales evaluation [17]. It is worth noting that although demand is the original driving force for consumers' desire to buy, price perception (such as cheap or expensive, reasonable or unreasonable) also plays an important role in the consumer's decision-making process. Some scholars pointed out that consumers' perception of price advantage helps to form purchasing preferences and brand loyalty, and is accustomed to measuring their purchase satisfaction by price standards [18].
It can be seen that the consumer purchase decision-making behavior is a dynamic process in which the consumer decides to purchase a specific product or service from mass-collecting information to objectively evaluate and select a product or service. The same is true for the decision-making process of cross-border medical tourists. It is a systematic and dynamic decision-making process, including the determination of requirements, the collection of information, the implementation of purchasing behavior and the evaluation of after-sales (see Figure 1). In the era of globalization, cross-border medical tourism is becoming the fastest-growing industry with the innovation of science and technology and the change of health concept. At the same time, the "reverse globalization" of passenger flow has intensified the competition in the countries of medical tourism. On the one hand, the rising cross-border medical tourism output value has made more countries rush into the medical tourism market, leading to increased market competition. On the other hand, the orderly competitive medical tourism market provides consumers with more choices. The flow is more diverse, and how to grasp the decision-making process of medical tourists to maximize the attraction of customers and seize market share has become the focus of policy makers.
In general, the decision-making process of cross-border medical tourism is a complex process. The first step is that patients' judge and identify their own

Analysis of Cross-Border Medical Tourism Decision-Making Process
Identifying needs is the first step in the process of medical tourists' sequential logic decision-making, and is an important driving force for the development of medical tourism industry. Scholars have conducted a lot of research on the motives of people's cross-border medical tourism, and found that identifying treatment needs is of great significance to the subsequent decision-making process.  [20]. Accurate identification of medical needs by medical tourists can help to collect information in a targeted manner. The precise identification of the medical needs of consumers in medical tourism destinations helps to develop their own industrial strategies. Macao's demand for accurate and high-quality medical examination services for medical tourists in mainland China has become an emerging cross-border medical tourism destination by taking advantage of price, language and geographical location [21].
Once chotherapy. The quality of service for medical tourism is highly valued [22]. Internet and friend recommendations are the main source of information for them. It is worth mentioning that the Japanese usually adopt the theoretical framework of planning behavior to plan their cross-border medical tourism. The long-term pressure from family, friends and work is the main reason for their travel to South Korea for psychotherapy [23].
Since the beginning of the 21st century, the cross-border medical tourism industry has undergone tremendous changes, and the flow of tourists has shown a complex and ever-changing situation. It turned out that the wealthy class has developed into a large-scale industry for the pursuit of quality medical services, and ordinary medical tourists hope more involved in the decision-making process. Whether cross-border medical tourism is the first choice node in the decision-making process affects people's follow-up consultation and in-depth research. It is worth noting that it is first decided whether to go out and consult the corresponding medical institution in a targeted manner, or to consult different institutions before making a decision on whether or not to leave the country. The scholars have different views for the order of the two processes.
Consultation with local medical institutions is likely to lead to decisions on receiving medical services in the local area. Consulting with foreign medical institutions or intermediaries can expand the range of people's choices, and finally decide to go abroad for medical services on the advice of foreign doctors [24].
The location of the consulting medical institution does not represent the destination of the final medical service, but the medical institution being consulted has a great influence on the decision-making of consumers and has certain advantages in giving priority to attracting customers. Therefore, the countries with

Discussion
The convenience of cross-border medical tourism has promoted the development of globalization and the medical market. According to data from American Insurance Association [26], the trend of industrial internationalization has enabled medical insurers and non-medical insurers in the United States to continue to seek various medical treatments abroad, and that medical tourism is The world's fastest-growing industry, and the growth trend of medical tourism is not only reflected in the level of individual behavior, many institutions are exploring the potential commercial value of the industry. For example, in order to reduce costs, corporate employers use cross-border medical tourism as employee medical benefits and supplementary medical insurance, and US insurance companies also include cross-border medical tourism in insurance programs [27].

Political Climate
Political stability and long-lasting is the premise of national development. For a long time, security is the first consideration for cross-border medical tourists.
The vigorous development of cross-border medical tourism industry requires a countries with stable political and terrorist threats to obtain specific medical services. Thailand is a leader in medical tourism in Asia, but its unstable political situation puts pressure on the cross-border medical tourism industry. A stable political climate makes it easier to gain the trust of cross-border medical tourists, and trust is critical to countries that are committed to developing medical tourism [30]. Building trust with consumers is likely to generate consumer loyalty.
The brand effect is used to drive the rapid development of the entire industry.

Factors Affecting the Choice of Cross-Border Medical Tourism Hospitals
As a new industry with great development potential and involving many stakeholders, cross-border medical tourism attracts the attention of the government, medical institutions, social citizens and other subjects. Brand familiarity, access to medical services, medical costs, medical quality and legality of medical services are the main driving forces for people to go abroad for medical tourism services. Brand medical service institutions have become the first choice for overseas medical tourists [32]. Therefore, studying how patients choose cross-border medical tourism hospitals is conducive to improving hospital income and visibility.

Medical Costs
In fact, high quality and low price are one of the important characteristics of medical tourism. Therefore, medical tourism expenses are one of the main factors affecting the development of cross-border medical tourism. In recent years, due to the high medical costs of developed countries, many developing countries have rapidly emerged with the advantage of price, becoming a medical tourism Bank research shows that medical costs in the United States are significantly higher than in other countries, and the price advantage of the US medical tourism industry continues to decline [33]. In the same medical project, the cost of medical treatment in Thailand and India is 50% -90% lower than that in the United States, which promotes the prevalence of cross-border medical tourism. Thailand

Professional Level of the Doctor
The professional level of doctors is the core element of the entire medical tour-

Conclusions
Medical tourism is a new type of industry formed by the intersection and inte- Firstly, identify self-development advantages and current competitive situation. China has a vast territory with rich medical tourism resources, from natural landscapes to historical sites, with the potential and advantages of developing cross-border medical tourism. Vigorously developing China's Chinese medical culture and developing China's cross-border medical tourism brand competitiveness will help develop the development of medical tourism, spread Chinese medicine culture, and add momentum to the development of China's medical tourism industry.
Secondly, understand the key factors affecting the development of cross-border medical tourism. Under the background of industrial internationalization, grasping the driving factors of customer flow will undoubtedly bring unlimited business opportunities to the development of medical tourism industry. The driving factor for the flow of cross-border medical tourism tourists is to break through the development of the medical tourism industry. To divide the market share in a highly competitive market, the state and medical institutions need to formulate specific strategies and countermeasures for each driver. The formation of brand loyalty plays a key role in consumer decision-making and the growth of industry output. Therefore, if China can develop its own cross-border medical tourism brand service project and carry out more professional medical tourism business, it will quickly improve China's international reputation of cross-border medical tourism.
Finally, improve regulatory policies and give policy support. The privacy protection and scientific ethics and legality disputes of medical tourism projects are the focus of a country's regulatory policy. At the same time, when the medical needs and interests of local residents and foreign medical tourists conflict, how to balance the relationship between fairness and interests is also the key issues.
Political developers need to consider when improving their regulatory policies.
Under the premise of limited medical resources, the development of cross-border medical tourism industry can not only focus on profit-seeking, but also to ensure fairness, avoid investment concentrated in the field of medical tourism, and make public medical investment insufficient, and high-quality medical person-

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.