**4. Low-cost medical tourism of Italians**

In this section, we will deal with the case of the health travels of Italians to foreign destinations where there are specialized institutions in dental care.

Thousands of Italians are contacting low-cost dental clinics in countries belonging mainly to Eastern Europe, and as we have mentioned before, it is a growing phenomenon.

Countries such as Croatia, Bulgaria, Romania, Slovenia, Poland, and Albania are in the last years the European leaders in dental health tourism market.

In recent years, we are seeing a proliferation of so-called low-cost dental centers, or commercial chains, mostly franchised, offer dental services at low prices.

Several clinics offer "all inclusive packages" at very low prices. In the "all inclusive," beyond the costs directly attributable to the dental expenses in the strict sense, in many cases, the costs of travel, the stay in the place where the clinic and excursions in the area is located are included.

The very low cost relative to the "all inclusive package," is due, according to what these clinics confirm, to the fact that "everything costs less" than the other countries of Western Europe: the rental of commercial premises, the average salary of a dentist, the cost of electricity, water, heating, expenses for advertising, administrative costs, taxes [14]. Indeed, the Italian president of the National Council of dentists, Dr. Giuseppe Renzo, in a 2015 interview said that "Italians look for alternative health services to cope with the crisis period" and because of the high prices of dental care in Italy according to Istat "over 8 million citizens would prefer not to heal mouth and teeth." In fact, in an article in the Italian newspaper "Il fatto quotidiano" in talking about low-cost dental tourism is reported an interview with an Apulian lady who alleged that she was aware of the possible risks to go to Albania to dental care, but the Italian prices would not have permitted to care of her teeth; moreover, it would have taken little time to arrive in Albania, and that she was very satisfied with the reception saying "they treat me like a queen, they cuddle me, they offer me the stay and make me visit the castles" [15]. Furthermore, Dr. Renzo stated that "dentistry in Italy is based in large part on a private network of professional firms whose basic costs are on average four times higher than those faced by professionals from other countries. The tax is 22% compared to 4; VAT cannot be deducted; the costs for collaborators are a weight on the cost, but their presence is essential to ensure safety and hygiene" [16]. On the other hand, the Italian dentists assign to the low cost of dental services low quality [17], mainly with respect to sanitary regulations, the respect of clinicians time, and the necessity of subsequent checks [18].

There are more than 200,000 Italians who are traveling because of sanitary issues. At least, a quarter of this, 200,000 Italians ask for medical care dentistry. Most treatments in specialized health tourism dental are in Eastern European countries, Croatia, Hungary, and Romania (with Albania that's growing up). For the Italians, it is easy to get there in these countries, especially if they live near the airport. It is quite clear that these are countries where the cost of dental care is much lower than in Italy. Often the dentists (in these countries) have even studied abroad. The promotion of health treatment is very aggressive and aims almost exclusively on the Web support; in addition, all medical treatments are combined, with the basic tourist services like accommodation, food, shuttle service, etc. and excursions in the area who takes

In this section, we will deal with the case of the health travels of Italians to foreign destina-

Thousands of Italians are contacting low-cost dental clinics in countries belonging mainly to

Countries such as Croatia, Bulgaria, Romania, Slovenia, Poland, and Albania are in the last

In recent years, we are seeing a proliferation of so-called low-cost dental centers, or commer-

Several clinics offer "all inclusive packages" at very low prices. In the "all inclusive," beyond the costs directly attributable to the dental expenses in the strict sense, in many cases, the costs of travel, the stay in the place where the clinic and excursions in the area is

The very low cost relative to the "all inclusive package," is due, according to what these clinics confirm, to the fact that "everything costs less" than the other countries of Western Europe: the rental of commercial premises, the average salary of a dentist, the cost of electricity, water, heating, expenses for advertising, administrative costs, taxes [14]. Indeed, the Italian president of the National Council of dentists, Dr. Giuseppe Renzo, in a 2015 interview said that "Italians look for alternative health services to cope with the crisis period" and because of the high prices of dental care in Italy according to Istat "over 8 million citizens would prefer not to heal mouth and teeth." In fact, in an article in the Italian newspaper "Il fatto quotidiano" in talking about low-cost dental tourism is reported an interview with an Apulian lady who alleged that she was aware of the possible risks to go to Albania to dental care, but the Italian prices would not have permitted to care of her teeth; moreover, it would have taken little time to arrive in Albania, and that she was very satisfied with the reception saying "they treat me like a queen, they cuddle me, they offer me the stay and make me visit the castles" [15]. Furthermore, Dr. Renzo stated that "dentistry in Italy is based in large part on a private

Eastern Europe, and as we have mentioned before, it is a growing phenomenon.

care to these tourists who speak Italian.

8 Advances in Health Management

located are included.

**4. Low-cost medical tourism of Italians**

tions where there are specialized institutions in dental care.

years the European leaders in dental health tourism market.

cial chains, mostly franchised, offer dental services at low prices.

Precisely of this type of health tourism, we will deal in the next section.

The dental tourism in recent years has made its history to Albania. There are several clinics on the Albanian territory, as many are also, the individual dental practices. Among the different realities encountered in our research, we wanted to analyze the case of "Dentists in Albania– Viaggiare e sorridere" [19].

In their Web page, they immediately show the fact that in Albania many of them speak, even correctly, the Italian (75% of the population) putting the possible Italian customer at ease and reassuring him, as well, also, they reassure on professionalism and quality of materials used (that they define high), they perform the relevant certifications and that they offer 5 years Warranty [20].

Albanian dentists reassure the potential customers on the qualitative aspect of their services, explain why their prices are so low compared to Italian dentists, attributing the reason to lower taxes, saying that in Albania tax pressure affects 10% while in Italy 55%, and the lower labor costs are due to a lower cost of living. In their opinion, it would lead to savings for the Italian patient tourists by 60% compared to what they could spend in Italy.

Another element that it should entice potential Italian customers to turn to them is the so-called word of mouth. In fact, on the website, dozens of testimonials were published that highlight the quality of services offered, the main motivation of the trip, that is, the economic issue and the tourist aspect. A witness, in fact, declares: "I hope nobody feels offended, I want just to tell my experience: in Italy, our doctors charge 4 times the cost of performances more than the Albanians, often abusing of the good faith of our patients and of our lack of information with the result of a medical service of the third world! This is what happened to me in Italy. That's why I want everyone to know about my experience with Viaggiare e sorridere. In Albania, for three certified dental implants made in Europe and the extraction of teeth 3, I spent EUR 1,400.00, and I was operated by a skilled doctor, who teaches Dental Implantology at the University of Tirana and by her husband too. The intervention lasted only 55 minutes as opposed to Italy, in fact the Italian dentists to justify the excessive price make you go several times ending up losing even 3 months. I saw people from all social backgrounds enter in this clinic equipped with the best three-dimensional machinery and hygiene at par with the best clinics in the world, I saw people, which they hugged each to other and then they decided to exchange they phone numbers, people pleased to have found a smile without signing a mortgage. A unique professionalism, many money saved and the stay is free, as also the taxi for and by Tirana to airport on arrival and departure and outings to discover the beauty of their land with the company of reception staff who speak Italian. A real holiday of well-being, which is why I thank and advise everyone the clinic Viaggiare e sorridere" [21]. Among other things, each patient/tourist who has left his testimony has left their contact information in case any potential customer wants to know more.

In Albania, low prices are not the only element to attract customers' attention, there are other elements as: a detailed range of interventions and services offered, the curriculum of some dentists and professionals who are part of the medical staff and not, the reviews (all positive) of their patients/tourists; "Dentists in Albania" also uses the "card" of the holiday, offering, among other things, a free stay for two people, and both the transfer to the hotel and the reception service: at the airport, there will be an attendant who will speak properly in Italian and that he will welcome them, he will be available to patients-tourists from 9 AM to 21 PM to resolve any problems on the stay or even to play the role of tour guide of the city. In addition, the reception agent will be available 24–24h contacting him by telephone. Even before the trip, they offer their availability to clients in the organization of the trip, advising how to reach Tirana "stress-free and save a lot of money." The tourist aspect is repeatedly quoted on the website where, among other things, you can read "beyond to low-cost professional dental care, you will have the opportunity to take a holiday in a wonderful city like Tirana, all without spending just a euro for the stay and benefiting of all the services that you want."

It is some years now, that some of these dental clinics have opened offices in Italy where they exclusively, do free visits with the purpose of provide quotes. Among them, there is the case "Dentists Croatia low-cost," which opened an office in Verona for "a free estimate, to explain the treatments, prices, to answer all your questions freely, and to give you all the information related to your stay in Croatia."

For free, no-obligation appointments call us at our number "…Cell…Email…" [22]. Also in this case, the bus trip, starting from some cities reported on the website, is free. It is to be noted that accommodation is free sometimes subjected to the cost of the performance that a patient goes to support it and, in any case, the patient's accommodation does not happen in a hotel but in an apartment. In particular, the dental office specifies: "During your dental care, we offer a FREE comfortable apartment in the center of RIJEKA/RIVER Croatia near the sea with five beds. The apartment is free if you spend at least € 1000/1500 in dental care" [23].

Actually, in this case, by some researches carried out on the Web, it is not a dental clinic, but it concerns a real travel agency that manages the health travels. Indeed, by analyzing other websites offering low-cost dental care in Croatia, we realized that another website had the same addresses of "Dentists Croatia low-cost," and it is the following website www.viaggideldente.info [24]. The latter, it is known as the "Tour operator of dental savings," offering free travels by bus from some cities in northern Italy, low-cost dental care "in the best dental practice in Croatia" [25] and the opportunity to book your stay at favorable prices in the apartment.

However, the proliferation of dental clinics and dental low-cost studies in recent years has become an increasingly important phenomenon, and, therefore, the online offering of lowcost dental tourism is really impressive. Even in Italy dental centers specialized low cost are springing to try to attract these patients/tourists who want to be cured at a lower price. Although, now, as we have seen, competition in the European scenario, in terms of cost and quality, it really is ever more.
