Do You Know the Way to San José? Medical Tourism

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Keywords: medical tourism; globalization of health care; Costa Rica. Resumen ... Journal of Latin American Geography. This paper .... medical tourists to India, Thailand, Singapore, Mexico, Venezuela, Colombia, Malaysia,. Cuba, the ...

Medical Tourism in Costa Rica

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Do You Know the Way to San José? Medical Tourism in Costa Rica Barney Warf

Department of Geography University of Kansas

Abstract

In the face of rapidly rising health care costs and a large uninsured or underinsured population, the number of U.S. medical tourists seeking assistance abroad has grown. A relative newcomer to this field, Costa Rica offers a number of unique advantages that have positioned it advantageously to cater to Americans. This paper explores the rise of the country’s medical tourism sector, the cost differentials between services performed there and in the U.S., and factors that shape the supply of medical services, including medical accreditation and aftercare facilities. In doing so, it addresses the local implications of the globalization of health care, particularly as it concerns the troubled U.S. health care system. Keywords: medical tourism; globalization of health care; Costa Rica

Resumen

A la vista del rápido aumento de los costos de atención de salud y una población sin o con seguro insuficiente, el número de turistas médicas de los EE.UU. que buscan asistencia médica en el extranjero ha crecido. Un recién llegado a este campo, Costa Rica ofrece una serie de ventajas únicas que la han posicionado ventajosamente para atender a los estadounidenses. Este trabajo explora el surgimiento del sector de turismo médico del país, las diferencias de costos entre los servicios prestados allá y en los EE.UU., y los factores que determinan la oferta de servicios médicos, incluidas la acreditación médica y los servicios de mantenimiento posterior. Al hacerlo, se ocupa de las repercusiones locales de la globalización de la atención de la salud, especialmente en lo que se refiere a la problemática de sistema de atención de salud de los EE.UU. Palabras clave: turismo médica, globalización de atención de salud, Costa Rica Kim McClellan has a medical problem that is also a financial one. In her 50s, with a job that offers limited health care insurance, she urgently needs dental care that she cannot afford. After scanning the web, she decides – albeit with considerable trepidation – to venture to a foreign country, where health care services are generally offered at a fraction of the price demanded in the U.S. Although she does not speak the language, and is intimidated by seeking medical help in a culture she does not understand, Ms. McClellan’s financial circumstances compel her to use the services of a foreign dentist. After scouring the Web for information, she selects a provider overseas, and purchases her airline ticket. This story is replicated countless times in the on-going saga of an American health care system with significant problems containing costs and covering large segments of the population (Harrington, Estes, and Hollister 2008).

Journal of Latin American Geography, 9 (1), 2010 © Conference of Latin Americanist Geographers

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This paper examines the growth and impacts of medical tourism in Costa Rica. Relatively small compared to other, larger, better known destinations, Costa Rica has nonetheless successfully carved out a niche for itself in the rapidly expanding and lucrative medical tourism market to attract American tourists. The discussion opens with a brief review of the globalization of health services and the nature of medical tourism. It then explores the rise and growth of Costa Rica’s medical tourism industry, estimates of the number of such tourists, the types of procedures sought after, and cost differences between that country and the U.S. Third, it turns to the supply side, including the institutions providing medical services, the role of the government in promoting this sector, and the impacts on Costa Rican society. The conclusion summarizes the major findings and points to implications for the U.S. health care system. Data for this paper were collected from a variety of sources, including secondary data, including newspapers and trade journals, as well as 12 open-ended, semi-structured interviews conducted in the summer of 2009 with Costa Rican physicians, dentists, hospital administrators, public health officials, academics, and the national offices of tourism and export promotion.

The Globalization of Health Services and Medical Tourism

While the globalization of many economic sectors has received considerable scrutiny, the internationalization of health care, arguably in its infancy, has been studied far less frequently. While there is a large and robust literature on the geography of tourism (e.g., Lew et al. 2008; Williams 2009), its health care component has received short shrift. Medical tourism may be theorized in a number of ways, including the profound geographic disparities in access to and cost of health care that reflect the uneven spatial development of global capitalism more generally (Jenner 2008), as well as the rounds of intense globalization that have reshaped virtually all industries. Notable in this context is the onslaught of neoliberalism, which has accentuated inequalities in access to medical care worldwide. Critical medical anthropologists and legal theorists (e.g., Farmer and Gastineau 2002; Rabinow 2005) have also weighed in on this topic, equating health care to human rights and deploying the “structural violence” that neoliberalism has waged against the health status of the working class. In this light, medical tourism may also be viewed as an issue of ethics; as Pennings (2007, p. 505) puts it, Access to high quality health care is a fundamental right. As a consequence, it is one of the basic tasks of the government to guarantee this right. Social security systems are based on solidarity, collective responsibility and equal contributions in order to ensure accessibility of high quality health care for all. Universal access also implies that health care should be provided on the basis of need rather than on the ability to pay. Thus, critical social theorists have noted the growing contest between notions of medical care as a right and as a commodity; as Waitzkin (2000, p. 7) argues, given neoliberalism’s hegemony, “from the standpoint of private profit, there is no reason that corporations should view medicine differently from other goods and services.” Traditionally, health care has been relatively unaffected by international trade, and health care markets were relatively closed national entities (Adlung 2002). However, institutions such as the World Trade Organization and agreements such as the General Agreement on Trade in Services (GATS) have steadily opened up these markets to foreign competition, typically focusing only on privately-provided health care (Smith 2006a, 2006b). International trade in health care services has grown steadily (Blouin 2005), including such venues as medical tourism, telemedicine,

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temporary movements of medical professionals across borders, and affiliate offices of health care corporations abroad. Many countries worry about the impacts of this trend on national health care systems, particularly regarding potential “brain drain” disruptions in service to the poor and under-served places such as rural areas, or from the public to the private sector, and skewed national health care priorities that emphasize foreigners over domestic citizens. However, the GATS specifically exempts publicly-provided health services that do not compete with privately provided ones and allows member countries to choose to what extent they may wish to liberalize health services, if at all (Smith et al. 2008). As with many services traded internationally, medical services trade is often hampered by non-tariff barriers, notably licensing requirements, and many states have policies that charge foreigners extra for treatment. The United States, with a notoriously inefficient and inequitable health care insurance system (the only industrialized country without publicly provided national health insurance), has witnessed health care costs rise dramatically to roughly 15 percent of its GDP, significantly higher than Canada, Japan, or Western Europe. Rising employment opportunities in this sector have been complemented by imported labor from a variety of countries, particularly India and the Philippines. An aging baby boom of 80 million people (including 11,000 Americans who turn 50 daily, or one every eight seconds) has led many to seek medical care abroad (Reinhardt 2000). The U.S. is also home to large numbers of uninsured people (47 million) as well as 108 million who lack dental insurance. Many American “working poor” earn too much to qualify for Medicaid but lack jobs that provide health care insurance. In addition, there are countless others who are underinsured, i.e., with health care insurance policies that cover only the bare minimum, leaving them to pay for many procedures on their own. Indeed, high medical costs are responsible for 62 percent of personal bankruptcies in the United States (Arnst 2009). This population, faced with steadily rising medical costs, has generated most of the demand for health care from foreign providers, generating a steady exodus of medical tourists to India, Thailand, Singapore, Mexico, Venezuela, Colombia, Malaysia, Cuba, the Philippines, Turkey, the United Arab Emirates, and elsewhere (Doheny 2007). Medical tourism, in which the person physically travels to another country for purposes of obtaining either medically-necessary or optional health-related services, should be differentiated from the outsourcing of medical functions via the Web, such as teleradiology, or interpretations of U.S. CAT-scans by doctors in India (Wachter 2006). Estimates of the number of Americans traveling abroad annually to seek medical care vary considerably, depending on the source, but typically range between 180,000 and 750,000, spending at least $2.2 billion (Reier 2004; Herrick 2007; Woodman 2008b; Deloitte 2009). Exact data are not available because payments to foreign hospitals and physicians are not treated as a separate category in balance-of-payment statistics. Medical tourism represents a reversal of a long-standing trend in international health care delivery whereby doctors visited countries with pools of clients in need; rather, the patients travel to the physicians (Khanna 2007). It also represents the evolution of health care in some developing countries toward specialized services oriented to the more lucrative parts of the health care market. Increasingly, hospitals in the developing world have developed the necessary infrastructure to serve medical tourists, including specialized skills and equipment and support staff. As the opportunities for treatment abroad have multiplied, medical tourists have availed themselves of them (Woodman 2008a). Initially synonymous with plastic surgery, medical tourism has long surpassed its early, purely cosmetic affiliation to include vital, even life-saving operations. Milstein and Smith (2006) estimate that 80 percent of Americans seeking health care abroad do so for non-cosmetic reasons. For many countries, it is the most rapidly growing segment of the

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tourist market (Bookman and Bookman 2007). Nonetheless, many potential patients are deeply fearful of the quality and reliability of overseas medical care, often associating it with poor quality care or organs stolen from impoverished donors: “State-of-the-art technology in India? Delicate eye surgery in Thailand? Trusting one’s child to a doctor in Costa Rica? The mere names of these countries bring to mind images of heat, unpaved roads, mud huts, and hungry children” (Bookman and Bookman 2007, p. 1). Concerns over medical tourism generally center on the quality of care received and liability in the advent of malpractice in the absence of an international body to regulate the industry (Mirrer-Singer 2007). Courts are usually reluctant to assert jurisdiction over physicians in other countries, and medical tourism plaintiffs face a long, uphill battle in attempts to gain compensation for botched procedures overseas. In this context, debates over negligence, liability, fraud, misrepresentation of credentials or risks, or lack of informed consent can be the Achilles’ heel of medical tourism. Unlike recreational tourists, who have sufficient disposable income to travel for leisure, many medical tourists are individuals and families of modest means, for whom out-of-pocket health-related costs are an onerous burden. As Milstein and Smith (2006) note, “These patients are not ‘medical tourists’ seeking low-cost aesthetic enhancement. They are middle-income Americans evading impoverishment by expensive, medically necessary operations.” Avoiding bankruptcy and protecting assets such as home equity are often prime motivations for medical tourists. Of course, not all medical tourists are on the brink of financial collapse: many are comfortably middle class and do have health insurance but prefer to avoid paying the steep co-payments or higher premiums that they would still encounter in the U.S., particularly in the case of expensive medical procedures. Very few medical tourists originate from the most destitute segments of U.S. society.

The Demand for Medical Tourism Services in Costa Rica

Costa Rica, a small nation of 4.5 million residents, has long enjoyed a reputation as something of a “Cinderella country” in Central America, with a long tradition of political stability, relative lack of corruption, comparatively high standard of living, and generous public services. In part, this status can be traced to the abolition of the country’s military in 1948, which diverted significant government resources to education and health care. With almost universal literacy, and universal, publicly funded health care insurance, the country has made steady economic and social progress. Today, the country boasts health care statistics that elevate it above most developing countries: Life expectancy in Costa Rica is 77.6 years, roughly at par with the U.S. (78.1 years) and the highest in Latin America. In the World Health Organization’s 2000 widely cited survey of health care systems (http://www.photius. com/rankings/healthranks.html), Costa Rica ranked 36, ahead of the U.S. (37). Medical tourism to Costa Rica has origins dating to the 1980s, when occasional visitors searching for low cost cosmetic surgery began to venture into the nation. The country’s health tourist market rose in earnest, however, during the mid1990s, when a group of plastic surgeons led by Drs. Arnoldo Fournier, Ernesto Martén, Ronald Pino, and Gabriel Alberto Peralta, all trained in Miami, began utilizing their connections to the U.S. to draw foreigners more systematically (Arce 2009). As in many national medical tourism markets, in Costa Rica’s medical tourism early stages the sector was essentially synonymous with face lifts, Botox treatments, and liposuction. Plastic surgery continues to be an important part of the tourist-oriented health care sector, and Costa Rica today boasts of 40 certified cosmetic surgeons. However, medical tourism to the country has moved far beyond the aesthetic into more “vital” (i.e., medically

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necessary, not simply optional) procedures. The growth of the World Wide Web played a key role in facilitating the industry’s expansion, and it remains most patients’ primary source of information about foreign opportunities. For example, a Google search with two terms “medical tourism” and “Costa Rica” turned up 75,000 webpages. The exact number of medical tourists to Costa Rica varies depending on the source of information utilized. Entry forms administered to foreign visitors at airports requesting the reason for their visit point to roughly 6,000 medical tourists annually, although this is surely an undercount as many patients refuse to answer on privacy grounds. The Costa Rican government, relying upon surveys of hospitals, reports that between 20,000 and 25,000 people may be classified as medical tourists in 2008, up from an estimated 5,000 in 2000. Tourists who enter for leisure purposes but seek medical assistance once in the country (e.g., for common problems such as diarrhea) are not counted as medical tourists. Likewise, foreign residents living in Costa Rica who utilize health care services there, including the sizable American community of 50,000, are not counted as medical tourists. By this measure, health tourists comprise roughly 1.5 percent of the roughly 1.4 million tourists who visit the country annually. The average foreign patient in 2008 stayed for 11 days in the country and spent $6,284. More than 95 percent originated in the U.S. (Magee 2008), with its dysfunctional health care insurance system, and the remainder includes small numbers of Germans and Canadians, who generally seek to escape relatively long waiting times. The growth of the Costa Rican market has been fueled, among other things, by the relatively short flight times required to reach San José, i.e., two hours from Miami as opposed to 15 to 20 or more hours required to reach Asia (Stephano 2008). Tourism is one of Costa Rica’s largest industries (12 percent of GDP in 2008) and sources of foreign revenues, including not only traditional forms but niche markets such as ecotourism, “adventure tourism,” and “community tourism,” in which foreigners work in solidarity with denizens of rural locales. Many medical tourists combine their medical visits to the country with recreational pursuits, integrating health care into a vacation of sorts. Medical tourism, which President Oscar Arias proclaimed in February 2009 to be a development priority, has come to assume pride of place in Costa Rica’s attempts to diversify economically and establish a competitive niche internationally. Indeed, several public officials explained in interviews that they view the medical complex in San José, as well as related pharmaceutical and biotechnology firms, as generating a potential complex of synergistic institutions enjoying agglomerative advantages in the form popularized by Michael Porter (1998) and economic geographers (e.g., Benneworth and Henry 2004; Vorley 2008). As the country’s medical tourism sector has expanded, the types of procedures demanded have become more diverse (Table 1). Today, the most common form of medical procedure demanded by tourists involves various forms of dentistry (36 percent), particularly dental implants. Bariatric and gastric surgery, including intestinal bypass, comprises another 15 percent, particularly measures to alleviate obesity, of which an epidemic threatens the U.S., where 60 percent of the adult population is technically fat or obese (Gard 2005). Plastic surgery comprises an additional 12 percent. “Other Medical Treatments” include a wide range of procedures, including hip and knee replacements, heart bypass operations, hysterectomies, hormone replacement, stem cell therapy, and cancer treatments. Finally, ophthalmology (generally cataract removal or laser eye surgery) includes just one percent. However, Costa Rica lacks a capacity to serve reproductive tourists (e.g., those seeking in vitro fertilization) due to prohibitive laws; indeed, Costa Ricans must travel abroad to obtain this service, forming an export rather than import of medical tourists (Bookman and Bookman 2007).

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Procedure Dental Services Other Surgeries Gastric Surgeries Other Medical Treatments Plastic Surgery Ophthalmology

% of Visits 36 22 15 14 12 1

Source: Procomer 2006, unpublished data.

Table 1: Major Medical Services Demanded by Medical Tourists in Costa Rica, 2006. In total, such procedures generated $37 million in foreign revenues for the Costa Rican economy in 2006 (Table 2), a dimension of the industry that gave rise to the common label cirugías de oro (“surgeries of gold”). Because there are wide variations in the costs of procedures, the revenues generated by different medical services resemble but do not exactly mirror the frequency distribution of types of procedures. Dental services alone generated $12.7 million, while ophthalmological services led to only $375,000. However, revenues for such procedures grew rapidly – 425 percent over four years, or roughly 45 percent annually.

Procedure Dental Services Other Surgeries Gastric Surgeries Other Medical Treatments Plastic Surgery Ophthalmology Total

2002

2003

2004

2005

2006

1,789.7 1,063.5 1,259.3 1,495.3 1,001.5 168.6 8,779.9

2,606.8 274.9 2,984.7 4,100.1 443.1 99.4 12,512.0

8,314.0 1,636.5 743.5 1,628.0 1,865.7 12.7 16,204.4

1,576.5 1,064.7 1,432.8 1,885.5 5,931.7 67.1 13,963.3

12,720.7 7,820.8 5,167.2 5,119.9 4,131.0 375.2 37,340.8

Source: Procomer 2006, unpublished data

Table 2: Receipts from Medical Tourism by Type of Procedure, 2002-2006 (US $ 000s). The driving force behind tourists’ demand for medical services abroad is, as one might suspect, the significant cost differences for different procedures between the U.S. and other countries. American health care costs are generally higher due to several factors, including insufficient preventative health care, higher overhead and administrative expenses, a focus on specialized rather than primary care, higher salaries of physicians, the cost of malpractice insurance, and the sophisticated, expensive, capital-intensive medical equipment, and the large number of medical tests performed, often motivated by fear of litigation (Agency for Health Care Research and Quality 2006). The costs for procedures performed in Costa Rica typically run between 25 and 60 percent of those done in the U.S. (Table 3), although for a very few procedures Costa Rica is actually more expensive. For expensive surgeries such as heart bypass operations, the savings can be as high as $75,000; for more modest operations such as valvuplasty, atrial defect repairs, hip and knee replacements, and gastric bypass, savings lie in the range of $20,000 to $35,000. In general, the more expensive is the surgical procedure, the greater are the cost savings from going abroad, even including transport costs. For patients who are uninsured or underinsured, such savings can be more than simply enticing, but may mean the difference between having a needed operation or not.

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Procedure Heart Bypass Spinal Fusion Valvuplasty Atrial Septal Defect Repair Hip Replacement Coronary Angioplasty Knee Replacement, Total Laparoscopic Gastric Bypass Laparoscopic Gastric Banding Cleft Lip/Palate Repair Knee Replacement, Partial Breast Reduction Breast Lift Face Lift Vericose Vein Surgery Liposuction Hysterectomy Abdominoplasty Tubal Ligation Coronary Angiography Hernia Repair Breast Augmentation Rhinoplasty Cataract Extraction Tonsillectomy Dental Implants Dental Crowns

U.S.

Costa Rica

Savings

100.0 62.0 50.0 48.0 40.0 35.0 35.0 30.0 30.0 30.0 20.0 20.0 9.0 8.5 8.0 7.0 6.5 6.4 6.4 6.4 5.4 5.0 4.2 4.1 3.8 3.0 .8

25.0 25.0 15.0 15.0 10.0 15.0 9.5 10.9 4.9 4.0 6.0 5.2 6.1 5.6 2.7 4.5 6.1 6.5 3.9 3.9 3.9 4.5 7.8 2.6 2.2 .8 .6

75.0 37.0 35.0 33.0 30.0 20.0 25.5 19.1 25.1 26.0 14.0 14.8 2.9 2.9 5.3 2.5 0.4 -0.1 2.5 2.5 1.5 0.5 -3.6 1.5 1.6 2.2 .2

Source: Deloitte Center for Health Solutions 2008.

Costa Rica as % of U.S. 25.0 40.3 30.0 31.3 25.0 42.9 27.1 36.3 16.3 13.3 30.0 26.0 67.8 65.9 33.8 64.3 93.8 101.6 60.9 60.9 72.2 90.0 185.7 63.4 57.9 26.7 75.0

Table 3: Comparative Average Medical Procedures Costs in the U.S. and Costa Rica, 2008 (U.S. $ 000s).

Supplying Medical Services to Foreign Tourists

Several factors figure into the lower costs of providing health care in Costa Rica, including lower overhead and labor costs, relatively inexpensive malpractice insurance, fewer unnecessary tests, and fewer attempts to shift the costs of charity care to paying patients (Herrick 2007). In addition to lower costs, many medical tourists to Costa Rica comment favorably on the quality of care before and after surgery, noting the nation’s tradition of hospitality extends to the health care field: doctors in San José spend more time with their patients compared to physicians in the U.S., and conduct more frequent follow-up visits. Anecdotal accounts in newspapers provide a wealth of evidence to this effect. The psychic benefits of such a phenomenon, while impossible to measure empirically, are no doubt not insubstantial. In addition, foreign hospitalization often allows shorter waiting times. The intersections between medical tourism and U.S. health insurance companies are complex and rapidly changing. Most insurance companies are unwilling to cover the costs of foreign health care for non-emergency procedures due to fears of malpractice and the costs of follow-up procedures. While initially all medical tourists were uninsured – and even today roughly one-half of medical tourists to Costa Rica pay for medical services there by themselves – some insurance companies, while still generally reluctant to use foreign suppliers, have gradually, if grudgingly, come to ac-

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cept medical tourism as a means of reducing their payments to policy holders. The issue of accreditation of foreign providers (about which more momentarily) looms large in this respect. As the cost savings from foreign treatment have become more apparent, larger numbers of insurance companies have encouraged their clients to seek help abroad. For example, Blue Cross/Blue Shield established Companion Global Health Care for clients going overseas, as well as Access Baja for Americans traveling specifically to Mexico. (Nonetheless, significant border obstacles to medical tourism remain despite the expansion of trade relations under NAFTA; see Judkins 2007). No U.S. insurance carrier, however, currently offers explicit financial incentives to patients to seek foreign medical assistance, although this situation may be changing (Seelye 2009). However, many large, self-insured employers are interested in the potential savings of offshore treatment. For many insurance companies, issues of foreign malpractice liability are still ambiguous. To reduce the uncertainty surrounding these issues, a private medical consortium, Costa Rica Medical Holding, formed by 21 doctors, has cultivated regularized relations with American insurance companies (Magee 2008). The supply of highly skilled medical practitioners in Costa Rica, including physicians, dentists, and nurses, arises from the country’s eight medical schools, of which the largest is the University of Costa Rica, which combined produce approximately 400 physicians annually. However, among those requiring advanced specialized training and board certification, 100 percent go abroad for their education, primarily to the United States. Today, health care employs roughly 10,100 professionals in Costa Rica, not including a large, indeterminate number of other people working in related support capacities and aftercare. Costa Rican health care providers catering to foreign patients are acutely sensitive to the fears and concerns of a largely American clientele that is considering seeking help abroad, including differences in language, culture, and health care standards. For the vast bulk of patients, seeking health care in a foreign culture is a stressful and intimidating experience, a fact not lost on those seeking to attract such visitors. Front and center in their attempts to alleviate the concerns of potential clients abroad as well as insurance companies is accreditation by the Joint Commission International (JCI), the world’s foremost body that monitors the quality of health care facilities (including 200 hospitals in 33 countries). JCI is the international arm of the Joint Commission, the health monitoring organization endorsed by the U.S. Department of Health and Human Services. JCI assesses 300 standards that hospitals must meet in order to acquire accreditation, including the size, hygiene, and equipment of facilities and food preparation, the rigor of training for medical staff, pre- and post-surgical care, staff/patient ratios, history of malpractice claims, care plans for patients, medical information technology, patient satisfaction surveys, partnerships with teaching facilities, and a variety of other concerns. Accreditation requires that every patient is spoken to in a language that she can understand and that patients are involved in their care decisions. JCI accreditation thus forms the centerpiece of non-U.S. based hospitals’ attempts to reduce risk and to create confidence and alleviate anxieties in potential clients by being deemed an institution that provides qualified and high-quality heath care; it is also essential to institutions seeking reimbursement from U.S. health insurance companies, and such a status figures prominently in their advertising. Three major hospitals in San José comprise the core of Costa Rican health care providers for medical tourists, all of which are JCI accredited: Clínica Bíblica, Hospital la Católica, and the Center for International Medical Advanced (CIMA). Clínica Bíblica, with 120 rooms, is the oldest facility oriented to foreigners (Cook 2007): founded by Protestant missionaries in 1927, it was then sold to private investors in the 1990s (Figure 1). It retains an affiliation with Tulane University in New Orleans. While it originally outsourced services such as plastic surgery and dental care to local providers, the hospital

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engaged in rounds of vertical integration (the incorporation of once-externalized procedures “in house”) as part of a long terms strategy plan to cater to foreigners, boasting “five-star healthcare quality at an affordable price” (Figure 2). Today, it serves roughly 40 foreign patients per month (roughly one-fifth of its total patient load) in a dedicated Medical Tourism Department, which comprises one entire floor, with an English-speaking staff. Ninety-five percent of its patients are Americans, drawing largely from Florida, Texas (with the highest rate of uninsured adults in the U.S.), New York, and Colorado. The procedures that are most frequently demanded by its medical tourists include plastic surgery (the patients for which are 80 percent women), particularly face lifts, liposuction, and breast and tummy tucks, weight loss via bariatric bypass, and orthopedic surgery (where patients are predominantly elderly men). Hospital la Católica, founded by Catholic nuns in 1963, is a similar but slightly smaller institution that received accreditation only in 2009.

Figure 1. Clinica Bíblica (Source: author) The Center for International Medicine Advanced (CIMA), run by the International Hospital Corporation and affiliated with Baylor University Medical Center in Dallas, began in 2000 and is one of eight such centers in Latin America. In comparison to Clínica Bíblica and Hospital la Cathólica, which were founded by religious orders and retain a certain legacy of caring from that era, CIMA represents the most fully corporatized and commodified Costa Rican medical tourist facility. A large and expanding facility with 400 physicians (Figure 3), it boasts an entire wing devoted to foreign patients, special offices catering to U.S. veterans (it is the only hospital in Latin America accredited by the U.S. Department of Veterans Affairs), an IMAX theater and helipad, and an entire administrative division devoted to overcoming insurance paperwork and problems. It also seeks to integrate post-operative care via a wing of “hospital hotel” apartments for patients requiring long term assistance. Costa Rican medical tourist health care providers commonly utilize the services of “facilitators,” private companies that operate like brokers or travel agents focused on recruiting foreign patients, easing their concerns about seeking help abroad, providing logistical support, and persuading insurance companies that foreign treatment is cost-effective. Examples include U.S.-based firms PreviMed, Premier MedEscape, and Healthbase. A few offer complete package tours, including air travel, airport pickup, concierge services, and transportation to and from the hospital, sometimes with

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recreational side-trips. While most firms in this niche market are relatively small, the industry shows signs of gradual oligopolization via organized networks. For example, the Satori network of facilitators coordinates patient recruitment for a variety of hospitals in different countries, as does the Global Health Network, which is preferred by Blue Cross/Blue Shield.

Figure 2: Clinica Bíblica Advertisement (Source: Clinica Bíblica) In addition to the major hospitals, Costa Rica offers a unique institution catering to medical tourists in the form of “recovery centers,” small, family-owned boutique hotels and bed-and-breakfasts that cater to patients recovering from hospital visits. Largely concentrated in the affluent San José suburb of Escazú, not far from the major hospitals catering to foreigners and thus an easy drive for doctors making home after-care visits, these facilities range widely in size and type of services offered. Some cater only to patients requiring minimal care, whereas others have

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Figure 3. Center for International Medical Advanced (CIMA) (Source: author) full time, on-site nurses. For example, one of the largest, CheticaRanch, consists of a spacious facility outside of San José with a full-time professional staff (Figure 4). Following the lead of smaller such institutions, corporate giants have sought to enter this niche, including the Intercontinental Hotel Group, which owns Crowne Plaza Hotels, Holiday Inn, Staybridge Suites, and Candlewood Suits (Stephano 2008). The Costa Rican government has actively encouraged medical tourism as a means of stimulating foreign revenues, employment, and human capital development. For example, Procomer, the public agency designed to promote services exports from the country, has initiated a series of trade missions to U.S. cities to facilitate interactions with insurance companies, facilitators, and travel agencies. Face-to-face contact and the exchange of tacit knowledge are vital to this process, reflecting a theme common among economic geographers sensitive to the “cultural turn” (Thrift and Olds 1996; Barnes 2001), which inter alia affirms the inseparability of the economic and the cultural. Procomer has also initiated inquiries into attracting Canadian patients facing queues at home. In addition, Costa Rican physicians, hospitals, and government agencies formed a public-private partnership, the Council for the International Promotion of Costa Rica Medicine (PROMED), which began in November, 2007. Interviews suggested that medical tourism has had modest, indirect impacts on the Costa Rican public health system. Foreign tourists to the country rarely use public health facilities (although systematic data on this issue are poor), and their visits to private providers are invariably paid for via their savings or insurance companies. Indirectly, however, the rising demand for health care staff catering to foreigners has drawn a number of younger professionals into the lucrative specialities catering to tourists. To alleviate what it fears may become a shortage of general practitioners, the Costa Rican government has quietly turned to Cuba as a source of physicians, recruiting roughly 100 annually to work in the country. Public health resources in the country are aimed

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disproportionately at the large immigrant Nicaraguan and Colombian communities, which number between 400,000 and 600,000 people, as well as its tiny indigenous populations.

Figure 4. Advertisement for CheticaRanch, a Costa Rican Recovery Center (Source: CheticaRanch) Finally, it should be noted that in addition to formal medical tourism, Costa Rica also exhibits a large network of practitioners in the nebulous field of “alternative medicine.” Such forms of treatment include homeopathic medicine, chiropractors, yoga, massage therapy, acupuncture, thermal hot springs, herbal medicines, midwives, and traditional indigenous healers (brujerías and curanderos), some of whom attract visitors from Europe and North America. Estimates of the number of foreigners utilizing such services average

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around 280,000 annually, which dwarfs the volume of formal medical tourists, although it is debatable whether seekers of alternative medicine should be counted as medical tourists. Unlike medical tourism, non-traditional medical fields are entirely unregulated, thus falling outside the purview of the state (as well as the Catholic Church). Interviews with public health authorities indicated that this alternative medicine universe began to grow in earnest in the 1960s, in part due to the import of “hippie culture” from the U.S.

Concluding Thoughts

What lessons can we derive from these observations of medical tourism in Costa Rica? From all that has been said above, it may be concluded that the U.S. generates a substantial pool of potential medical tourists in several distinct ways: an aging baby boom; its large uninsured and underinsured population; its high medical costs; and the obesity epidemic that is creating significant health-related costs in the country. Costa Rica, responding as have several countries to the lack of affordable care in the U.S., has prospered from an influx of medical tourists that has grown fivefold in the last eight years. The diversity of procedures offers, driven largely by the large cost differentials with those performed in the U.S., indicates that medical tourism has long since shed its image of purely cosmetic or plastic surgery to encompass much more severe, even life-threatening, disorders. An expanding network of firms has risen to cater to this demand, including hospitals, facilitators, and recovery centers. For foreign providers of surgical services, international accreditation, i.e., via the JCI, is essential to assuaging patients and compensation from insurers. The severe economic crisis of 2007-2009 has had unanticipated impacts on Costa Rican medical tourism. While the overall volume of tourism to the country has stagnated, medical tourism has actually risen; the financial crisis in the U.S. has apparently encouraged patients and insurance companies alike to seek cost savings by going abroad. The globalization of health care via medical tourism (which are admittedly not synonymous, if closely connected) has apparently induced some American hospitals to begin lowering their costs in order to retain patients who otherwise may go abroad for treatment. Thus, for the U.S., where total health care costs are increasing by eight percent annually, expanding medical tourism may serve as a means of rationing prices in an industry in which they have soared uncontrollably for decades. This trend should be viewed cautiously, however, as the number of medical tourists is too small to have dramatic effects on the industry in the U.S. As Milstein and Smith (2006, p. 1639) point out, “Offshore surgery, which currently represents an opportunity to lower prices for at most 1 to 2% of U.S. health care spending for worker households, is a symptom of, not a solution to, our affordability problem” (see also Milstein and Smith 2007). Finally, Costa Rica’s medical tourism industry should be seen in light of growing international competition. Just as Latin American countries have sought to capture some of the market initially dominated by Asian giants in the field such as India and Thailand, so too have other nations followed Costa Rica’s lead. Interviews suggested that providers in the country viewed Mexico, Panama, and Colombia as the primary sources of competition in this regard, but the political instability there may work to Costa Rica’s advantage. Nonetheless, such insecurities are likely well deserved: local advantages under hypermobile capitalism are always transitory, and windows of opportunity both open and close with great regularity.

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Acknowledgements

The author would like to thank the following for their assistance: the University of Kansas Costa Rica Research Exchange; Mr. Massimo Manzi, Programa Nacional de Competitividad y Mejora Regulatoria; William Cook, Hospital Clínica Bíblica; Carlos Beer Argüello, Procomer; María Eugenia Murillo, Instituto Costarricense de Turismo; Mauricio Herrera, Dept. of Geography, University of Costa Rica; Ginette and Dolly of Casa Laurin.

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