He looked nervous, this rangy, six-foot-one Gringo with the towhead and pencil mustache.
His Army fatigue shorts revealed an 8-inch U-shaped scar just under his left knee - the result of a failed operation and the reason why Vince Dugdale, 47, was standing in the waiting room of the Clínica Bíblica Hospital in San José.
After two injuries and 11 surgeries, Dugdale needed a new knee. But as one of the nearly 50 million U.S. citizens with no health insurance, he'd been out of luck for seven years.
"You get to a point where you can't afford medical costs and they just exclude you," he said.
So Dugdale came here, a developing country far from his home in Sioux City, Iowa, to get what he couldn't find in the United States: Major surgery he could afford out of pocket.
"It's been a long road for me," Dugdale told The Tico Times just before a technician led him into the X-ray room. The next day, Dugdale would go under the knife for what he hoped would be the last time.
A New Kind of Medical Tourism
An Affordable Knee: A surgical team at the private Clínica Bíblica Hospital in San José works to replace a patient's knee in one of the various types of surgeries becoming more popular among a growing number of tourists attracted to Costa Rica for its quality affordable health care.
Ronald Reyes | Tico Times
Medical tourism is nothing new to Costa Rica. Since at least the 1970s, this country has been a hotspot for cheap, high-quality dental work and cosmetic surgery.
But increasingly, say the representatives of Costa Rica's two biggest private hospitals, medical tourism is taking on a more serious character.
Foreigners aren't just popping down for whiter teeth or larger breasts - they come seeking major surgeries such as knee replacements, hip replacements and angioplasties that Costa Rican hospitals offer at steep savings over U.S. prices.
Lower costs for drugs, hospital stays and doctor fees mean that many surgeries cost half what they would in the United States, and some even less than that, said Jonathan Edelheit, vice-president of OptiMed Health, a U.S. health-care company.
Edelheit said he was so impressed by the Clínica Bíblica and CIMA Hospital (a hospital that is part of the International Hospital Corporation) that the first issue of a medical tourism magazine the company is launching this month will focus exclusively on Costa Rica.
"I'm hoping to create this huge boom for medical tourism, because I think it's about to explode," Edelheit said.
Customers like Dugdale are where Edelheit and others think the greatest opportunity is to be found.
A former truck driver, carpenter and jack of all blue-collar trades, Dugdale is probably as close as one could get to the "American everyman." He first hurt his knee on the job in 1996, when his foot slipped through a grate and twisted, tearing his meniscus, part of the knee cartilage.
After several surgeries covered by his health insurance, Dugdale injured himself again in 2000 at an Allman Brothers Band concert, where he slipped on a plastic bottle and wrenched his knee around again.
"I just had people pick me up and hold me and grabbed a beer and watched the whole performance," he said.
But a few operations later, Dugdale's knee still wasn't up to snuff; even worse he'd lost his health insurance after losing his job at Wilson Trailer. Dugdale had one last operation on the IowaCare public health plan, where the doctors tried to sever a nerve to stop his constant pain.
"And that's when they told me to have a nice day," Dugdale said.
It was after he saw a feature about Clínica Bíblica on the TV show 20/20 and called to see what it could offer that Dugdale became part of the growing number of "baby boomers" and uninsured U.S. citizens showing interest in Costa Rican medical services, said Bill Cook, the hospital's medical tourism coordinator.
Even without much publicity, the hospital gets half a dozen foreign patients a month seeking major surgery. Carole Veloso, the CEO of CIMA Hospital, west of San José, said her hospital is seeing something similar.
"We've seen a huge shift," she said, noting that CIMA gets a lot of small-business owners from the United States who pay for their own health care.
The most popular operations in both hospitals are orthopedic surgery, some heart surgery and weight-loss surgeries, all of which are offered at steep savings.
For example, Dugdale's knee replacement surgery, which in the States generally costs near $45,000, in Costa Rica ran Dugdale around $12,000.
"We expect this to be like a snowball," said Brad Cook, Bill's brother and the general manager of Clínica Bíblica's International Department.
"It will just keep growing and growing."
Both hospitals are taking action to help the snowball along. For one thing, they have opened up new floors and facilities designed exclusively for this new wave of medical tourism (TT, April 13).
More importantly, by the end of the year both hospitals are on track to be certified by the Joint Commission International, the standards organization that certifies U.S. hospitals.
"That will open the door for a lot of Americans coming over to Costa Rica," Edelheit said.
Under the Knife
Recovering: U.S. citizen Vince Dugdale recovers from knee surgery he couldn't afford back home.
Christopher Huber | Tico Times
The day after his X-ray a different door opened, this one into the operating room where Dugdale would have his knee replaced. Dugdale lay on the operating table slowly passing out at the hands of an anesthesiologist while a team prepped him for surgery.
Dr. Oscar Oeding, the orthopedic surgeon who would be doing the operation, pointed to an X-ray of Dugdale's knee.
"It's bone against bone here," he said. With no cartilage left to cushion the joint, the knee would be replaced by unfeeling titanium.
With the knee bent at a 45-degree angle, Dr. Oeding made a vertical incision and pulled aside the skin and the kneecap, exposing the white bulges that made up the bottom of Dugdale's left femur.
After sawing off the bulges, Oeding replaced them with a titanium implant. He did the same on the bottom, then straightened the leg, and flexed it up and down - a perfect fit. He sewed up the knee, and then closed the incision with several dozen staples.
The whole thing took less than two hours.
Oeding, who studied medicine at the University of Costa Rica (UCR) and is a member of the American Orthopedic Academy, said he's done more than 500 knee replacements, and does an average of a dozen orthopedic operations a month - increasingly on medical tourists.
"I feel like it's going to increase a lot," he said.
While this type of medical tourism may be growing in Costa Rica, medical tourists have been traveling to India, Thailand and Singapore for many years for these kinds of operations, Edelheit said.
Costs in those countries remain lower than in Costa Rica, a country with a relatively high standard of living.
Veloso said that is something private Costa Rican hospitals will have to deal with as the market matures, although the five-hour flights to Costa Rica from the United States will remain a distinct advantage over the sometimes 24-hour flight to East Asia.
Meanwhile, a publicity campaign is about to kick off, with both the OptiMed Health magazine featuring Costa Rica and a CNN feature on Clínca Bíblica set to run in the U.S. market, according to Bill Cook.
As for Dugdale, he has already started his own publicity campaign. Propped up in bed in his hotel room with an ice pack on his knee a few days after the operation, Dugdale was practically giddy.
"You ain't gonna get this s*** in the United States, I'll tell you that much," he said, adding that he is going to recommend Costa Rican hospitals to a relative, who needs his own knee replacement.
The only drawback, Dugdale said, is the food, which he declared "unedible."
"I'm going back to America," he said. "I'm gonna get me a T-bone, throw it on the grill, and get me a baked potato."