SAN JOSE, Costa Rica – Costa Rica’s scenic beaches, delicious food and vibrant culture have made it a tourist destination for decades. Its capital city, San Jose, sits surrounded by mountainous landscapes covered in lush green forests.
But we didn’t visit for any of that.
We went to Costa Rica to learn about the blossoming medical tourism industry and find out why a growing number of United States residents are traveling all the way to Central America to undergo medical procedures that are done every day in the U.S.
According to a study by the American Medical Journal, more than 1.4 million Americans went abroad for medical treatment in 2017. Those numbers were expected to grow by 25 percent each year after. That means almost 3 million Americans will leave the U.S. to see a doctor this year
Tony Martin is among them. He and his wife, Belinda, traveled from North Carolina to San Jose so Tony could get a total knee replacement.
"I jumped up, when I came back down, my knee went backwards instead of frontwards,” he said.
Tony tore his main knee ligament while playing basketball about 35 years ago. He says for the last few years, he’s been in a lot of pain.
“It’s been hard because he has to do a lot of walking at work and by the time he gets home, you know, he don’t feel like walking or doing much,” said Belinda.
Tony is a factory supervisor. He’s on his feet all day, which doesn’t help his knee too much.
“Some days I can’t hardly walk on it at all,” said Martin.
Tony said he wouldn’t be able to afford a knee replacement in the U.S. According to a study by Blue Cross Blue Shield, the average cost of a total knee replacement is almost $50,000 in the U.S. The same procedure might cost just over $20,000 in Costa Rica. If Tony had to do it at home, he’d be in debt.
“But this takes care of everything. Everything,” said Tony.
That’s because Tony’s bosses are footing the bill.
The company he works for, HSM, saves so much money sending employees out of the country for knee replacements and other procedures that his trip, his surgery, his airfare, hotel and food, it’s all free for Tony.
“When you talk about it, people are like what? No way, because everything is free. They pay you, buy you plane tickets, pay for your hotel room, they feed you, they pay for a companion to come with you,” he said.
When we arrived at CIMA hospital in San Jose for Tony’s pre-op appointments, we were met by Kim Ampie who was sort of like Tony’s personal guide through the surgery.
"Throughout the whole hospital experience, me as a patient coordinator is going to be at all times with you, patient and companion, guiding them, checking them into every point. They don’t have this feeling of, oh my god, I’m in a different country, I don’t know what to do. They are guided and accompanied through the whole experience,” Ampie explained.
Before the surgery, the doctor’s needed to make sure Tony was ready.
“So, the first thing that we’re going to be doing is blood work and x-rays. We just want to make sure that all of your levels are in perfect condition for tomorrow,” Ampie told Martin.
After the tests, Tony met with a physician to go over the results.
Finally, it was time to meet with the surgeon, Dr. Oscar Oeding Bermudez.
“In his particular case a very decreased medial, medial line compartment. You see some bone spurs right here, for example, here,” Oeding showed on the x-ray.
"We’re going to take all these bones parts out. We’re going to take it for metallic parts and in the middle, we’re going to place a very hard plastic device that it’s going to act like the meniscus, the old meniscus.”
Oeding has been working with medical tourism patients for more than 10 years. He says 30 percent of his patients are not from Costa Rica.
“Every month or every year, they’re going up,” he explained.
People are coming because they're saving money. But the savings are coming from a surprising place.
“The big piece of cake is not for the medical part at all, same implant, you can find it here for $3,000, you pay for that $20,000 in the states,” Oeding said.
Lower costs may raise some questions about health and safety, but Oeding says patients don't have to worry.
“The implants that we use here are the same implants that are used in the states. Whatever we use here is FDA approved, not only the implants but the medication, the protocols we use,” said Oeding.
If you’ve ever dealt with chronic pain or know someone who has, you know it can have a debilitating effect on their quality of life. For Tony, it keeps him from spending time with his grandson the way he’d like to.
“My grandson, he likes to ride bikes down at the beach and I can’t do that much.”
It’s a sentiment Belinda echoed.
“You know my grandson, he’s only 10, he’ll be 10 this month. He’s still young. We’re older but he wants to do things you know ride the bike, go outside, get on the go kart.”
For Oeding, it’s hard to watch.
“I have had patients, where I ask them, hey, how do you go to work eight hours a day. And what they answer is, I have to pay my mortgage, it’s very sad. I mean we are talking about the number one country in the world and not having a fair health system, for me it’s very sad,” Oeding said.
The next morning at 4:30, Tony was little quieter in the car.
“I don’t know, maybe a little edgy,” he whispered.
When we got to the hospital, Kim was there to meet us and helped get Tony checked in. And then, we headed up to Tony’s hospital room.
Tony changed into scrubs and just had time to say goodbye to Belinda before he was wheeled out to the pre-op room.
Tony was putting on a tough front for us, but you could tell he was much more subdued. And then without prompting, he mentioned his grandson.
“We got a place in Holden Beach, so we go down to Holden Beach, probably put our bicycles in the car and take them to the island and just ride down the island, we haven’t done that, so, I look forward to doing that with him,” said Tony.
The beach and bicycles are special to Tony and Belinda. As his pain has increased over the last year, it’s taken a toll on both of them.
“We used to walk all the way to the point and look for shells and he’ll walk a little bit but then we have to sit down some because his knee hurts so bad," she said.
“I mean, I can ride a bicycle just a short distance because my knees really burn. They burn when I ride a bicycle,” Tony said while waiting.
If it wasn’t for the program his company offers, he wouldn’t have gotten it taken care.
“I’ll be 60 in May, so it would be like five years till I’m on Medicare,” said Tony.
As the doctors and nurses prepped Tony for surgery, any differences between U.S. medical care and what was happening around him in South America began to melt away.
One of the things we talked about with Tony and Belinda the entire trip was how impressive the hospital and its staff are.
“Everything is in order, it’s like they’ve got it all planned out. From the time we get off the plane, to the motel, picking us up, taking us to the hospital, taking us back, therapy, they’ll come to the hospital and do therapy,” Belinda recollected.
That’s not necessarily what many Americans envision when they think of healthcare outside of the U.S. It’s a stigma Ampie says the hospital and the country of Costa Rica have to fight every day.
“Central America, the people had this idea that it’s just like a really bad third world country or not having the technology or the resources you know for high quality healthcare. I think that’s just a myth especially in Costa Rica has an excellent healthcare system,” said Ampie.
Josef Woodman is the founder of Patients Without Borders, an organization dedicated to helping medical tourist get accurate and safe information.
“The biggest fear that people have if they’ve never done it before is that they’re gonna come back dead or it’s going to be really botched and that’s a very legitimate concern,” said Woodman.
Woodman says younger Americans are much more open to the idea of leaving home to get healthy.
“They’re more comfortable with the idea that oh, they could go to a hospital and get some decent care rather than older folks who just see it as care in some mud hut with a rusty knife,” said Woodman.
There are some things you can look for if you’re considering medical tourism. For example, CIMA hospital, where Tony had his surgery, is JCI accredited
"The Joint Commission International is an organization that makes sure that the hospitals that are offering their services to travelers around the world for medical tourism have the same standard services. The rooms have to be a certain way, you know the ORs have to be very clean. They do several inspections a year just to make sure that they are complying with the requirements.”
You should also read hospital reviews and reach out to people who may have traveled for medical treatment already.
“Once the patient has had their experience, they go back home, and they start to share what happened and people will start to open their eyes to what really goes on here. They see it’s not what they think,” Ampie said.
Meanwhile, back in the OR, Tony’s surgeons started scrubbing in and prepping for surgery.
“This image here shows like the old ACL tunnels that he had, and we’re going to replace everything,” Oeding said.
It was organized chaos as the team got ready. Frenetic movement, but everyone had a place. It built and built until they were ready to get started. And then, everything fell into place.
Whether it’s Costa Rica, the U.S. or anywhere else in the world, open surgery isn’t for the faint of heart. The sounds of the crunching, cracking or drilling alone are enough to make you cringe.
But all the while, the surgeons carried on with their task, helping to ease Tony’s pain.
“He had very advanced arthritis. We had a few problems dealing with the tibia bone, because there was too much scar tissue inside, but so far everything is really good. Lack of cartilage, lots of lack of cartilage. Lot of bone exposed. Yeah, he needed it,” said Oeding.
Oeidng and his team removed parts of Tony’s leg bones and replaced them with a new implant that should help him start to feel like his old self.
Delicately, their nimble fingers pulled the final threads to sew the operation up, all while Tony slept and Belinda waited.
Almost 4,000 miles away from Tony’s hospital bed was the job where he’s worked for three decades, the factory owned by HSM Solutions. Some of his co-workers were just getting back from lunch.
Machines were clanking. Wire was spinning. Tony’s a supervisor there, but it’s no desk job. Everyone was on their feet, using their hands, doing something.
HSM makes parts for beds, furniture, cars, all sorts of things.
And for the more than 3,000 employees, their healthcare is one man’s responsibility – Tim Isenhower.
“I’ve worked with the health plan from starting self-insurance to where we are today,” he said.
Typically, in the U.S., employers contract with a health insurance company. The employer pays a large portion of the premium and the employee pays the rest.
In HSM’s case, they do not use a primary health insurance provider. They pay all the employee’s healthcare costs up to $350,000.
HSM uses a secondary insurance provider for two things: First they handle the administrative side of things, like teaching employees about the program and filing claims. They also cover the any cost beyond the $350,000.
And, if you don’t think the costs can get that expensive, then you haven’t had any serious medical issues in recent years. That brings us back to why HSM sends employees outside the country for some procedures.
“You do a knee replacement, it may cost, total all in the surgery, the stay, the physical therapy, about $23,000. Here, you go to the hospital, $40,000 to $60,000. That’s just the high cost of health care here in the U.S.,” Isenhower explained.
In Tony’s case, HSM saved $17,000 for his knee replacement. Spread that type of savings over more than 3,000 employees, that’s a lot of money.
“I’ve lost track of savings now, because we’ve been doing this for so long in the first few years, we saved close to $11 million we figured,” Isenhower said.
“The U.S. has great healthcare. They have great healthcare. Beautiful hospitals, big systems with a lot of research and technology, but not everybody has access to those hospitals,” Isenhower said.
HSM isn’t the only company in the U.S. that does this. They contract with Indus Health for their secondary insurance. Indus works with dozens of self-insured companies across the U.S. and sent about a quarter of a million people overseas for medical treatment.
Oh—one more thing about HSM’s all-inclusive health care travel plan – and this one’s a biggie to the employees.
“And we do give the patient 20 percent of what they save the company, up to $10,000,” said Isenhower.
Let’s recap: employees who go out of the U.S. get a bonus and go on a free trip for health care they don’t pay for.
“We did that to get people interested in the beginning and we just kept it because it’s been a good thing. We’re sharing the savings,” said Isenhower.
We did some rough math with Isenhower and estimated Tony will be getting a $3,400 bonus.
“Well I can’t wash my cars, I can’t push my lawn mower, I can’t cut, I can’t do none of the things, trim my trees and everything,” said Bobby Bender, another HSM employee.
In December, Bobby had back surgery after years of pain.
“It didn’t cost me a near penny, not near dime. One doctor told me it would cost me $40,000 and then $5,000 out of pocket. Who got $5,000 laying around outta they pocket? I don’t have that. Not unless I sign on the dotted line and get a loan,” Bender said.
Bender was at a physical therapy appointment.
“People really can’t afford therapy anymore. They may have a $50 copay so every time they come in, they got to fork out $50. And so, they’re not getting complete care in my opinion,” said Bobby's physical therapist, Michael Morrow.
But in Bobby’s case, he’s not paying for the PT. HSM is footing the bill again.
That’s where Tony will be two to three times a week when he gets back to Hickory. With a $50 copay per visit, his bill could be well over $1,000 if he had to pay himself.
“A lot of these people are blue collar people, you know, and they’re having trouble putting food on the table, so you know that’s a lot of money,” said Morrow.
While the savings is important, it’s about more than that for Isenhower.
“People don’t have to hurt and go to the emergency room. They don’t have to get addicted to opioids because they can’t afford a surgery. By giving them access to this healthcare, I think we’ve got healthier, happier employees and any company that got involved would see the same thing.”
Back in Costa Rica, Tony was just waking up. When we got to the hospital, Tony was in the middle of one of his physical therapy sessions. He was already up and walking the day after a 40-minute full-blown knee replacement surgery. Actually, it was Tony’s third walk. He was back on his feet just a few hours after surgery.
“Nice to see him walk yesterday, he done real good today. He walked a long way today. The doctor was surprised to see him walk as far as he did,” Belinda said.
"Now it’s sore. It’s huge too, it’s pretty swollen pretty good,” Tony said.
Tony’s recovery was just starting. He had 10 more days of PT in Costa Rica before heading home for more therapy there. He’s not scheduled to return to work for more than a month, but he has his own ideas.
“Well they put my time down for March the 10th, but I’m thinking I’ll go back before that,” said Tony.
As Tony sat back, we started to reflect on how the trip would impact his life back home.
"Not worrying about which way you step or where you step, it’s really, really weak,” said Tony. “My knee is really weak. If I step on a crack or something and you just about fall down.”
Tony’s message to people back in the U.S. is simple.
“If you get a chance, get it fixed, especially with the opportunity I had to come down and you know, it didn’t cost me nothing to come down to get it fixed,” said Tony.
We didn’t visit every hospital in Costa Rica, but what we did see was clean, state of the art facilities, skilled surgeons, and professional health care workers making sure Tony got the best care possible. It was all done for a lower cost to his employer compared to what the company could find in the U.S. and at no cost to him.
“I hear it over and over, the people that do get involved in it, it’s hard to get rid of once you have it. It’s just a program people really like,” Isenhower said.
“The surgical outcomes for the most part have been on par with what happens here,” said Morrow.
Tony is well on his road to recovery and will be back to spending time at the beach, riding bikes and fishing with his grandson.
“I mean we’ll fish and we’ll play in the water, hunt shells, play in the sand and every time I go, I got to dig a hole, I got to confess, I dig a huge hole for the kids to get in. Every time,” said Tony.
With the help of his new knee, Tony will be digging holes for many years to come.