The theoretical research carried out within the literature of the subject and documents governing the rules of providing health resort services and health tourism services in health resort enterprises, as well as empirical studies over the business model of 17 of the largest health tourism enterprises in Poland point to a complex structure of mutual market relations. It is associated mostly with the complexity of the process of providing value for patients. This complexity results from the necessity to reconcile both social goals within the public health initiatives implemented by the spa treatment and economic goals. An important partner of health resort enterprises is usually the national health insurer, which is the key service purchaser. This complexity also results from spa product creation process complexity that can be based on multiple therapeutic raw materials that depend on health resort localization (mineral water, brines, thermal springs, peat, seawater, salt, and therapeutic properties of the climate). The complexity of spa products is enhanced by its mixed service nature, covering both treatment and tourist services, as well as hotels, transport, catering, and even cosmetic services.
4.1. Using the Business Model and Characteristics of Selected Model Elements
The empirical studies allowed us to not only to assess the key relations with customers and partners in the environment and recipients’ segments, but also the usability of business models associated with the forces of influence of the environment.
The observations made during indepth interviews with health resort enterprise managers indicated that the managers of 5 out of the 17 studied spa enterprises declared that they know and use business models when running their health resort business. However, when the research was deepened in this scope, it turned out that the actual knowledge of business models was scarce and, in general, it referred to their abstract understanding, but without textual or graphic representation, of linked model architecture structures or services that the enterprise was offering. Nonetheless, every third manager taking part in the study had a description concerning particular elements of the business being carried out. In general, the components that underwent modeling were key activities, market segments, communication channels, and customer relations. However, no concise characteristics of business model components were observed; for example, in the form of a detailed description of value proposals for the customer.
The interviews carried out in health resort enterprises proved that, currently, three main segments of recipients of spa services can be identified. Managers of health resort facilities named primarily:
the segment of institutional recipients (contract);
the segment of individual recipients (commercial);
the segment of business recipients.
The first—segment of institutional recipients (also known as contract recipients)—is a group of leading health and social insurers, including National Health Fund (NFZ), Social Insurance Institution (ZUS), Farmers’ Social Security Fund (KRUS), and State Fund for Rehabilitation of People with Disabilities (PFRON). These insurers sign contracts for health resort services. Beneficiaries of such services are persons insured by these funds, who, once such a need is requested and justified by a general practitioner and then by a balneologist, receive such services in a specified order. A characteristic feature of this market segment is the fact that a direct recipient of health resort services is not the direct payer of the acquired services. It means that the institutional recipient, when acquiring the package of health resort services, does not benefit from it but becomes a holder of such a service.
As it results from the interviews carried out on health resort facilities, from the perspective of health resorts, contracts with insurers are characterized by a low level of profitability due to the adopted contracting criteria. In general, what is decisive is the low price of services, which determines the low attractiveness of stay and limited selection of offered natural therapy treatments. However, the low profitability of contracts does not limit the willingness to win them as, in general, revenues generated thanks to these contracts cover the day-to-day operating costs and ensure stability and possibility of carrying out business activity in other sectors. The source of additional revenue is servicing the second segment of health resort service recipients, being the individual recipients. This is a segment of patients that pay for the stay in the health resort themselves.
The research also indicated that contract and individual recipient groups are key market segments of Polish spa enterprises. Contract patients constitute, on average, 69.9% ± 13.5% of serviced beneficiaries, 23.2% ± 11.9% are national individual patients, and 7.5% ± 7.9% are foreign patients (due to the fact that they pay for their stay themselves, they are classified as individual customers).
Some health resort enterprises generate the greatest profitability from the segment of business recipients. These stays, however, are incidental. This is the most complex segment as it covers stays of varying nature—from corporate team building and recreational trips for employees of a particular facility to industry conferences and special tourist or sports events.
The most important sources of revenue of health resort enterprises are the revenue on hotel activity (accommodation) and treatment services in the form of balneology and physical medicine treatments. Next, categories of revenue cover gastronomy and sale of resources, being at the enterprise’s disposal, and then the rental of the premises. The revenues from spa and wellness services and activities of the health resort clinic come next. This structure of revenue sources indicates how important it is for a spa company to maintain lasting relationships with clients in the individual market segments.
Maintaining good relations with loyal customers is one of the basic tasks of every entrepreneur, as it is the level of these relations that quite often decides the profitability and survival of the enterprise on the market. This is also the case for health resorts, although not every patient is treated the same. This results from the fact that contract patients cannot influence the price of offered services (including the service quality) as the direct payer of the benefits is the insurer (who is, in general, guided by the price criterion). Since the return of the contract patient to the facility also does not depend on them, the relations between the personnel and the contract patients are of lesser importance for the service providers in the enterprise than the relations with individual and business customers.
Segments of individual and business customers are the target ones in terms of building positive relations, as this relation should result in the return of the customer to the facility, or at least in positive feedback on the received services via word-of-mouth marketing among potential patients, carried out by the current patients.
The analysis of health resort enterprise activities indicated that the main partners of health resort enterprises are entities, the cooperation with which provides the enterprise with value to capture. The state health and social insurers are of greatest importance, as they make it possible for health resort facilities to make profits on contract implementation. Travel agencies also benefit from individual customers traveling to reach the health resort enterprises.
Just as important as a partner is the spa commune, meaning the self-government administering the health resort, which is responsible for the maintenance of health resort status and caring for the quality of health resort assets (e.g., parks, pump rooms, graduation towers). The commune authorities influence the attractiveness of the health resort as a place of health resort treatment and an area of tourist attractions, which is also important for the perception of the health resort offer and the reception of the whole treatment. It is such an important partner that its importance exceeds the importance of key suppliers.
The role of key partners is also played by the suppliers of natural resources, competitors, with whom they cooperate on the basis of competition, outsourcing companies, and advertising agencies. In one facility, it was stated that volunteers are also important partners.
4.2. The Four-Factor Approach to Design Space Analysis of Business Model
Using the four-factor approach to
design space analysis of A. Osterwalder and Y. Pigneur [
3], in the analysis of the health resort enterprise environment, the following forces were subject to assessment: (1) forces influencing the market, (2) forces present in the industry, (3) the most important trends, and (4) general economic forces (
Figure 1).
4.2.1. Key Trends of Health Resort Market
The first group of factors of the environment that influences health resort enterprises, which will be subject to characterization, are key market trends, within which the market segments, needs and expectations, market problems, changes costs, and revenue attractiveness were identified.
New trends that emerged in the health resort market are the factors that have allowed for the rebirth of health resort business activity in the past two decades. Nevertheless, this category is also associated with problematic factors for the whole community.
In this category, several main problems can be named. One of them is demographic changes, especially the aging of society and the associated low fertility rates. It is an extremely crucial factor that influences the offer of Polish spas. Statistics indicate that Poland has one of the lowest fertility rates (1.3) [
49]. It also means that the natural generation renewal cannot be observed and that Polish society, or rather European society, is aging at a fast rate. There are a growing number of people of a postworking age, as compared with the number of people of working and preworking ages. These changes also result in greater demand for services associated with the needs requested by the segment of the elderly. These are mostly services associated with health and physical conditions, as well as all forms of spending free time with people of similar characteristics (e.g., seniors, widowers and widows, lonely people).
The influence of the named changes on the market of health resort services is significant as these are seniors who are the main group of recipients of these services, and the forecasted increase in the number of elderly should translate into the increase of the number of beds available in health resorts [
50]. It is not, however, obvious, as the example of privatization of multiple health resorts indicates that political activity may squander the development opportunity of a promising market.
Nevertheless, it must be remembered that, along with the aging of Polish society, the change of trends concerning the care of one’s body among younger generations must be noted. Therefore, the growth rate for the demand for health services can be greater than the growth of the number of elderly in society.
The second factor is the social and cultural changes that, in the context of public health, take on the characteristics of a healthy lifestyle trend. A manifestation of such attitudes is the more and more frequent rejection of mass products and looking for those created for individual needs. More and more often, it is not the price that is the basic criterion when it comes to making a decision to buy therapeutic goods and services, but the effectiveness and durability of the therapy effect. The increase in society revenues has made it possible to increase the standard of living of the poorest people. Along with growing revenues, the demand for services meeting higher-order needs also increases. The therapeutic treatment, although it refers to human health, is not a so-called bare necessity. It is a complementation of hospitalization, therapy carried out by general practitioner or specialist, and sometimes it has an entirely prophylactic character, as a manner of health prevention.
The healthy lifestyle trend is also manifested in the growing popularity of sports facilities and initiatives on the side of local self-government to build open-air gyms financed by way of participatory budgets. What can also be observed is the growing number of spa and wellness centers (especially in health resorts), as well as shops with so-called organic food. More and more often, consumers are choosing more expensive products of higher quality that better meet the demand of society.
Another factor is economic changes linked with the marketization of health resort business activity and changes in ownership. The reform of state health care facilities, including health resort facilities, carried out in Poland in the 1990s, resulted in a radical change in the situation of these entities. State health resort enterprises, so far fully financed from the state budget, were faced with the necessity of independent fund-raising to finance their activity. The health resort services were still financed from social funds but were acquired on the basis of tenders, where the criterion was the lowest price. This resulted in a decrease in the quality of health resort services (the quality of accommodation, catering) and, at the same time, limited the availability of treatment financed by the state. This phenomenon resulted in a new segment of recipients of health resort services, being patients agreeing to undergo fully-paid therapy.
The ownership changes mentioned before, which took place in the years 2005–2016 in the health resort sector, resulted in the almost complete resale of state health resort companies. Part of the sold enterprises became the property of other state companies, becoming their additional activity. As a consequence of the marketization of health resort enterprises, the willingness to implement social goals decreased for economic goals, as currently in health resort facilities, it is more profitable to accommodate patients who pay for their stay themselves than patients referred for therapy by the insurers.
Another factor that influences the business relations model in health resorts is health programs financed by the local government units and government, as well as government policy associated with the preventive medicine of Poles. All activities promoting a healthy lifestyle can raise awareness on preventive medicine and reduce the possibility of premature death. Contact with nature in a natural environment and staying away from work and everyday life is one of the best ways to combat modern-age diseases.
One of the most important influencing factors is the observed trends of biological and spiritual renewal (spa and wellness). More and more often, offering therapy that combines a stay at a spa has a specific mental impact that can be observed. These are services covering complex activities in the scope of individual needs of the patient, not only in the sphere of treatment but also in the sphere of relaxation directed towards psycho–physical balance. Rest in a place that fosters relaxation is complemented with cosmetic services, rehabilitation, and relaxation classes (especially relaxation techniques having their sources in Eastern cultures).
The influence of these trends on the model of mutual relations between the entities of this sector can be linked with the necessity to propose additional offers in health resort enterprises in the scope of services improving the mental state of the patients (spiritual exercises, relaxation techniques, and cosmetic services). Even though these are not services directly linked with health resort treatment, it is perhaps worth considering the so-called hybrid therapies complementing traditional health resort therapy, with services regulating psychological and physical balance.
4.2.2. Forces of the Health Resort Industry
In the case of forces of the health resort industry, an important element influencing the relations in health resort enterprises is the influence of state health and social insurers, meaning the National Health Fund (NFZ), the Social Insurance Institution (ZUS), the Farmers’ Social Security Fund (KRUS), and the State Fund for Rehabilitation of People with Disabilities (PFRON). The strength of their influence results from their role as an administrator of funds, having their source in the state budget. These are, in general, the main recipients of health resort services in Polish health resorts. They play the role of a payer for the health resort services on behalf of the patient, as the contributions paid by the patient to the state budget are administered by the insurers who, when the need to use the health resort therapy arises, cover the costs of the patient’s stay in part or in whole.
It can, therefore, be stated that even though state insurers are not the direct beneficiaries of health resort services, often they act as a payer and contractor, ordering the benefits by being in direct contact with health resort enterprises. It is worth emphasizing that the maintenance of traditional balneology and rehabilitation medicine is possible mainly thanks to the contracts signed with state insurers, as this is still the main source of financing of natural therapy treatments and stays in spas and spa hospitals.
Another group of key contractors of health resort enterprises is the suppliers of natural medical raw materials and the medical employees responsible for therapy at the facility. It must be stated that both the suppliers and medical services can form a part of the health resort facility, yet in the majority of cases, these are separate economic entities, with whom constant cooperation is concluded. These entities, for example, deliver peat, brines, and mineral waters or provide specific therapeutic services (for example, physical exercises in the pool). As such, they play the role of one of the key partners of the health resort enterprise.
Another factor that influences the industry forces is the spa commune and its administration. This results from the fact that, in Polish law, a health resort is a territorial area being administered by local authorities. This is the spa commune that submits the request to the state to be granted the status of a health resort, as well as creating and financing the health resort survey that is the basis of the request to be granted such a status. The spa commune is also responsible for determining and supervising the health resort spheres, taking care of health resort assets (health resort park, graduation towers, pump rooms), and collecting local tax from the guests coming to the health resort (tourists and patients). The spa commune administration is responsible for many control and coordination obligations, associated with the implementation of the provisions of the Act of 28 July 2005, on health resort treatment, health resorts and areas of health resort protection, and spa communes (Journal of Laws 2005, no. 167, item 1399 [
6]).
Influence on the health resort sector is also associated with the presence of health resort competitors. These are not only entities providing substitution services, but also direct competition in the industry, meaning other health resort facilities functioning in the same or neighboring health resort.
Even though the approach to the described model is universal—applying, in general, to health resort enterprises and not to a specific enterprise—one must also take into account this competitive surrounding. The entities rendering the same or similar services in the same or neighboring area can undertake varied forms of cooperation (cooperation, competition) or focus on their own specialization and attempt to differentiate themself from the competition.
In some health resorts, it can be noticed that one health resort or a complex of health resorts with one management dominates, and, in some cases, the market is divided between scarce entities of a similar influence. There are also such health resorts areas where only one health resort is present (that does not have a direct competition). The influence of the competition on the business model of a specific entity in each of these cases will be different and must be analyzed separately.
One of the substitution competitors is facilities and centers offering spa and wellness services, meaning services within the health and wellness-oriented stays. These facilities aim to integrate the physical, psychological, and spiritual spheres of a person using these services in order to achieve a balance in the natural and social environments [
51].
Due to the implemented business activity profile, these facilities do not use health resort therapy (balneology and rehabilitation) and more often reach for unconventional therapeutic methods, in general, complementing the health resort offer.
A direct competitor of the health resort facilities is also the tourist facilities located in the health resort as they render similar services as the health resort enterprises. They do not have a natural therapy base, but they use the available therapy services with the cooperation of the health resort.
4.2.3. Forces of the Health Resort Market
The health resort market, being a part of a healthcare market, has varied forces of influence on the business model associated with segments of recipients and the needs voiced by them. The health resort market is based on the need to restore or maintain the health of the patients, but its main parts are also nonmedical services rendered for the guests staying in the health resorts for various specific purposes. These services benefit the health and recreational (tourist) objectives, as well those associated with the specific specialization of the health resort product.
One of the needs voiced in health resorts and spa and wellness facilities is the need for hybrid therapy (covering with its scope the body and soul). This therapy has already been mentioned when discussing the present therapeutic trends. It is a form of health resort product that combines therapy influencing the body with treatments referring to the mental and spiritual states of the person visiting the facility. Therapeutic treatments concerning the body are mostly rehabilitation and balneology. Treatments concerning the mental and spiritual states can cover many forms of more or less intensive influence (e.g., visits to salt grottos, consultation or psychotherapy, meditation exercises, relaxation techniques, and prayers).
Some needs of the patients result from their desire to live their lives in good psycho–physical conditions. Thus, their needs are not based on the current situation, but rather take into consideration the distant future. Therefore, they have a preventative character, with reference to old age. Other needs result from the desire to extend the health resort therapy at home by continuing some therapeutic methods. It is strictly associated with another task of the health resort therapy, where, apart from treatments, they should provide health education.
All the mentioned human needs are supported by the philosophy that states that human health is the most precious physical good that a man can have and that it is not constant. Therefore, it requires care in order to be maintained as long as possible. Along with the needs that emerge on the health resort market, it is also worth attempting to identify basic market segments. Apart from the already mentioned division of recipients (institutional, individual, and business), other divisions can also be identified. They most often result from the age criteria, dividing recipients of services into seniors (65+) and other patients (younger than 65 years old). Still, this division, although necessary, is also insufficient, as, within the identified age groups, subgroups with varied characteristics can be named. Taking into account the changes in the offer directed towards younger market segments, the age criterion should be made more specific. It is, therefore, proposed to distinguish the recipients of health resort services, also taking into account the typology criterion, which is associated, for example, with the manner of how the treatment is financed, what the objective of the stay is, and if the patient needs to make use of specialist programs.
The first criterion of segmentation should be the age of patients (for example, 65 +) as, in the times of aging society, this group of recipients will significantly increase the market potential. However, when it comes to the remaining part of the society (up to the age of 65), it is worth identifying additional segments of specific needs. One such market segment is, undoubtedly, the segment of children and youth (up to the age of 18), for whom special offers and even health resorts’ profiles are prepared (an example of a children’s health resort is Rabka Zdrój). Another age segment consists of patients over 40 years old, who, during and after their intensive career or as a result of everyday hardships, feel the need to rest in a place where one can regenerate.
One of the basic methods of dividing patients, apart from age, is the already described division into individual patients (who pay for the stay themselves) and contract patients (institutional ones), meaning beneficiaries of health resort treatments paid by the insurer. A subgroup of patients that pay for their stay themselves, although less numerous than the group of contract patients, is the most profitable group. This group encompasses foreign patients. What is characteristic for this group of recipients is the fact that they are the decision-makers when it comes to the place, time, and duration of the treatment. This is not the case for the contract subgroup, which goes to the place of treatment indicated by the insurer and balneologist for a specific period (21 days) and at the time dictated by the insurer (in general, taking into account the queue managed by the insurer).
Another division is focused on the segment of tourists, who are not accommodated in the spas and spa hospitals, but elsewhere (guest houses, hotels, family), but they use the treatments offered by the natural therapy facility under the supervision of balneologists. Such a stay can cover both the treatments financed by the health insurer (within outpatient treatment), as well as treatments financed independently by their beneficiary. This group is neither subject to the health resort regime nor to medical and nurses’ supervision in the place of accommodation.
It is worth mentioning that there are two other main segments of recipients. First is the segment of women using beauty and relaxation treatments. In this case, the health resort therapy serves mostly treatments of cosmetic and relaxation purposes and, by the way, also health purposes. There is no inconsistency with the objective of health resort function, as many treatments offered by natural therapy facilities are also treatments not only with health properties but also influencing body care (pearl baths, brine baths).
Another group of recipients is the segment concerning the needs of businessmen, both in the aspect of entrepreneurs, managers, as well as authorities, who, burdened with stress, feel the need for antistress therapy. In this segment, employees can also be found, where, as a reward for their work, they are sent to relax in a health resort.
One can name many other segments of the health resort market of lesser importance and influence on the business model. These can be individual or group recipients for whom a special offer was prepared, for example, a stay for mental support groups within health resort therapy (for war veterans, pregnant women, mothers with children) or training camps for biological renewal.
4.2.4. General Economic Forces
The influence of the forces discussed so far (industry, market, and trends) can be complemented with general economic influence concerning the remaining aspects of the environment. In this case, factors and phenomena that can influence the business model structure were taken into account. One such factor is undoubtedly the HR situation in healthcare and, especially, the lack of specialist doctors [
52]. The lack of necessary medical staff can decrease the quality of services and, in some cases, even limit the ability to render health resort services. In a spa business at a health resort, it is necessary to have specialization in balneology and rehabilitation.
In addition, worth noticing is the phenomenon of health resort treatment regress globally. There is a limited number of state health care systems that consider health resort treatment to be an integral part of it (as is the case in Poland [
6]). In the majority of countries, traditional balneology treatments are often an element complementing the stay in spa cities and facilities and even on mobile health resorts (ships) [
53]. This is not the case in Europe, where traditional health resort treatment, based on minerals and health properties of the climate, is still developing [
54], expanding the scope of benefits.
An important factor is the development of health resort infrastructure and nonhealth resort infrastructure (communication, transport, buildings). It concerns the availability of health resort services, which are specific services offered only in health resorts, that need to be accessed individually to make use of the therapy. This is a factor that has both positive and negative influences on the health resorts: the development of infrastructure positively influences the business, but it is not always beneficial for the natural environment. At the same time, quite often, this factor becomes an obstacle associated with the excess of infrastructure and excess of critical levels of capacity and tourist absorption of the spa area, after which health resort degradation and the degradation of tourist and health functions take place [
55].
The increase of revenues, especially in the group of the poorest, opens new possibilities for the health resorts. These are health resorts that are often a place of relaxation and treatment for those with the lowest income (retirement pension and pension holders, unemployed), as they can make use of accommodation that is financed from public funds. It is also quite often a challenge, as this segment is often not aware of the possibility of making use of the, so far, unattainable health benefits and holiday services. Additional revenues also mean the extension of the scope and number of communication channels with potential patients (for example, the Internet). It undoubtedly has an influence on business processes, especially in the scope of segments, channels, and streams of revenue.
The last factor of influence on health resort activity is the law that governs the functioning of health resorts and, in general, the functioning of tourist enterprises and areas. This is, however, an issue that varies depending on a country.
The performed analysis of health resort enterprises and their environment has made it possible to characterize the mechanisms and business relations concerning the health resort sector. The complementation of the analyses is the graphic model of business relations in the health resort environment. In the scope of relations of the first type, where the cooperation model is present, being about entities that complement one another, the business relations model was presented in the form developed by the Board of Innovation [
16]. It can be seen in
Figure 2.
The relations shown in
Figure 2 are based on the business objectives of particular entities, but it is also worth indicating their links with the objectives of sustainable tourism. In modern times, it becomes necessary to develop sustainable policy in the scope of implementation of sustainable development rules. In the case of health resorts, these rules should be defined separately for internal relations of business model elements and separately for external relations focusing on local cooperation. The internal sustainable policy should take into account as criteria proposed by the Global Sustainable Tourism Council (GSTC) [
5] in the scope of proecological behaviors, in particular, concerning economic use of natural resources (both used for health resort treatment and for other purposes) and reduction of pollution (gas emission, transport, water, and electric energy), as well as combating the results of overtourism, overpopulation, and excess infrastructure. The internal sustainable policy should also cover the education of behaviors that protect the natural environment and local culture, directed towards the recipients of health resort services. It is one of the missions of socioeconomic entities, carried out to increase the responsibility for the health resort and cultural resources of the commune being visited, and for the place where the patient functions every day.
The external sustainable policy should be based on providing information on the implemented practices within the internal sustainable policy, encouraging people to undertake and maintain proecological behaviors among suppliers and contractors, and even among competitors.
During field research, carried out in Polish health resorts, what was also identified were the interorganizational networks of the second type, where the entities combine forces within a joint effort and resource sharing in order to achieve a common goal. Several such networks were identified among Polish health resort enterprises. The greatest network is composed of several health resorts named Polska Grupa Uzdrowisk (PGU) (Poland, Wrocław, 2-8 W. Sikorskiego Street) [
56]. It is a company established on the basis of business relations of five health resort enterprises: Uzdrowisko Cieplice Grupa PGU, Uzdrowisko Połczyn Grupa PGU, Uzdrowisko Świeradów-Czerniawa Grupa PGU, Uzdrowiska Kłodzkie Grupa PGU, and Interferie Medical Spa. The owner of this network is KGHM Polska Miedź I Fundusz Inwestycyjny Zamknięty Aktywów Niepublicznych (First Closed Investment Fund of Non-Public Assets) (Poland, Lublin, 48 M. Skodowskiej-Curie Street), which focuses its activity on protecting health in health resorts and on promoting leisure activity. According to the information of the owner of KGHM TFI, the long-term strategy of the development of PGU [
56], adopted at the beginning of 2015, resulted in an increase in the financial results of health resort companies belonging to PGU. This is due to the adopted investment policy that assumes a constant increase of hotel infrastructure standard and the standard of treatment equipment, as well as due to the development policy associated with extending the institutional contracts and effective winning of customers from the country and abroad, who pay for their stays themselves.
The interorganizational network of this type is based on slightly different relations than the ones present in
Figure 2. Therefore, it will be a subject for further studies. This is also an area that the author considers to be a base for further analyses, this time of an interorganizational nature, based on the rules of competition of competitors functioning in separate territories.