Second in a Three-Part Series on Health Care in Costa Rica
Hundreds of thousands of people pass through the doors of the country’s public medical clinics each year to receive services and medicines made available to them by the Costa Rican government.
The 67-year-old health care giant dispenses a cross section of services on a slim budget, and it still maintains one of the healthiest populations in the Americas.
Yet, most Costa Ricans agree that their health care system would fall short were it not balanced by its private arm. For all the acclaim the Costa Rican Social Security System (Caja) has received over the years, private services plug the holes that the government-run entity can’t reach, and it does so with an agility the lumbering Caja can’t match.
Whether it’s the day-bright halls and up-to-date facilities of Escazú’s CIMAHospital or the airy and homey common spaces of Hospital Bíblica in downtown San José, Costa Ricans celebrate the fact they have private health care alternatives.
“Many people come here because Social Security hospitals and clinics have long waiting lists,” said Jorge Cortés, chief medical officer at the Hospital Clínica Bíblica. “So if they need an exam or if they need a diagnosis, they can get it here today.”
And it’s not just many Ticos who praise the private medical care. In recent years, Costa Rica’s private health care option has caught the attention of people worldwide. Each year, hundreds of tourists arrive in Costa Rica to receive medical attention. The Council for International Promotion of Costa Rican Medicine (PROMED) estimates that 25,000 foreigners came in 2008 for procedures ranging from dental work to plastic surgery.
That number is expected to continue to climb. The majority of international patients come from the United States, where high-priced medical care pushes them to search for cheaper options abroad.
Although the trend towards more American seeking health care abroad is significant, said Paul Keckley, executive director of the Deloitte Center for Health Solutions in the U.S., it’s not enough to have a noticeable impact on the ongoing health care debate in that country.
“It’s a pretty small part of a very big industry,” said Keckley, who added that the approximately $5 billion spent outside the U.S. on medical tourism only accounts for 0.2 percent of a $2.36 trillion health care market. “I can’t imagine it will change the ongoing discussion.”
But it is having a big impact here. Private hospitals have installed English speakers at their front desks, undergone multi-million-dollar remodeling projects and invested heavily in marketing (including Web site redesigns specifically targeting international patients).
The market for medical tourism dollars expands beyond the hospital, with many hotels and other tourism-related businesses hoping to capture a share of the wealth. PROMED, which includes non-medical businesses such as transportation services and travel agencies among its members, estimates that a medical tourist pays five times more than someone who comes here simply on vacation.
Asked whether medical tourism could impact the accessibility of hospital services for Costa Ricans by driving up prices or capitalizing on the supply, Luis Diego Osborne, vice president of PROMED, shook his head.
“We want the medical services to continue to be accessible to both tourists and Costa Ricans,” he said. “And when higher demand is combined with more services, prices are going to go lower, not higher.”
Blending Public and Private Care Roughly 33 percent of Costa Ricans take advantage of private services.
For many Costa Ricans, the public system offers the same care, with the same doctors, with the same equipment. Yet, unlike private services, the public system requires no cash outlay. Many health professionals say the only drawback to the state-run Social Security System is a wait time that can delay medical procedures for years.
“The reason there are not more people using private hospitals is very simple,” Cortés said. “Because paying Social Security is obligatory … People can’t choose where to put this money. So if you want other insurance, you have to pay Social Security, plus that other insurance. The mentality is, ‘If this Social Security is required, I am going to take advantage of it.’”
Like many other Costa Ricans, Edwin Ramírez combines the services.
“I always use the public system,” said Ramírez, who recently underwent surgery at the public CalderónGuardiaHospital in San José. “But for more significant procedures or medical advice, I will get a second opinion at the private LaCatólicaHospital in Moravia (a northern suburb of San José).”
Many doctors also divide their time between the two systems.
Danilo González, a private physician in Escazú, spent 15 years in the public system. Some of his colleagues, he said, spend the mornings working in the public hospitals and the afternoons seeing patients in their private practices.
“They are between two worlds,” he said. “They want to work in a public hospital because it offers more opportunity to practice, more experience and more patients. A private hospital offers fewer patients, but much more income.”
González estimates that a physician working in a public hospital makes $1,500 monthly, while in a private hospital that same doctor can make $10,000 per month. Although the split shift promotes integration and shared experiences, it also has some drawbacks.
“Personally, I think it is very difficult to mix the two jobs,” González said. “Doctors have to work eight hours in a public hospital, and later, when they are tired, they go to work in a private hospital.
“But, there is another problem. What happens when a patient from a doctor’s private practice calls when the doctor is on a shift in the public hospital? Because they are in the public hospital, they can’t leave to attend that person.”
Of the 1,500 doctors who work at Hospital Clínica Bíblica, only 300 of them work exclusively in private care. The rest divide their time between the two sectors. Asked why more doctors don’t work exclusively in private care, Cortés said that it is a competitive position.
“Not everyone can work in the private sector because there is not the volume of patients,” he said.
For many Costa Ricans, the quality of care offered by both public and private hospitals is comparable. Private doctors and administrators readily agree.
“Why is the quality of service in the public hospital excellent? Because it’s a teaching hospital,” said González. “There are many academics who have been studying medicine for years. There is also a high volume of patients, which exposes doctors to many cases.”
Cortés said the major differences are reduced wait time, accessibility to doctors (private care physicians often give their cell phone numbers to patients) and infrastructure. Some say that the quality of care is no different than that offered in the United States.
“The doctors who work here – the great majority (90 percent) – graduated from U.S. colleges and universities,” said Osborne. “They had additional practicums in the U.S. So there is really no difference between the education of the doctors here and in the U.S. Also, the infrastructure is equal or better than that in the U.S. We are accredited with international institutions, and many of our protocols are the same.”
One factor that definitely differentiates Costa Rica’s system from that of its northern neighbor – and a factor which makes the cost of caregiving more competitive here – is the relative lack of lawsuits brought against doctors for alleged malpractice.
“Doctors here do not need to buy insurance on top of insurance on top of insurance to protect themselves,” Osborne said.
Paying for Private Care
Costa Ricans who make use of the private system are a mix of the wealthy and the privately insured middle class. For years, the National Insurance Institute (INS) held a monopoly on medical insurance in Costa Rica. INS offers a variety of plans, which average $800 a year. Most policies require patients to pay up front and have a maximum they will pay out per ailment or per year.
But, as the Central America Free Trade Agreement with the United States opens up the market, new insurers are moving in. Health experts say costs and medical services can only improve with more private insurance companies competing for clients.
“There will be an opening of the market to insurance firms and more multinational companies,” Osborne said. “We expect this to make the private market more attractive for tourists and for Costa Ricans.”
But with prices as low as $50 or $60 for an annual check up in a private clinic or hospital, many people simply pay cash.
Cortés estimates that 40 percent of his patients have medical insurance and the other 60 percent pay in cash.
The cost does keep many people away, turning them toward the long lines of the Caja or alternative programs like Asembis (see related article, page 2.)
Whether people always can afford private services or they use them only periodically, most agree that it’s not necessarily the doctorsor the technology or the infrastructure that makes Costa Rica’s health care system work, but it’s the opportunity to choose a medical experience.
Asembis:A Third Way
A third health care option is growing in the gap between the socialized medical care offered by the Caja and the more costly private insurance option.
Finding its clientele among those who have seemingly fallen into the divide that separates the two systems, Asembis treats patients for less than $2 per visit.
Founded in 1991 to address a deficiency in the availability of eye care, the clinic has expanded to occupy eight buildings nationwide and services include many specialties (including cardiology and gynecology). Asembis treats close to 360,000 patients a year.
The association is entirely self-sustaining, balancing its budget on the volume of patients who visit the clinic daily.
“In Costa Rica, there is Social Security and then there are services at the private level,” said Rebeca Villalobos, founder and executive director. “The Caja (the public system) is very good in certain areas, but deficient in other specialities.
And then there is the private care that not too many people can afford.
“We are in the middle,” she continued. “With us, people can access the services they need at prices they can afford. How do we achieve it? With volume, by seeing 70 or 80 patients a day, instead of three or four.”
Villalobos began the clinic with the hope of reversing a disturbing trend she’d seen in schools and rural communities. Children were repeating grades solely because they couldn’t see, and people were losing their sight because they weren’t getting timely surgery.
With $500 and the help of former colleagues, she opened Asembis 18 years ago. Since then, her clinic has seen over three million patients and done 27,000 cataract surgeries.
The success of Asembis has helped it amass enough capital to expand to other Central American countries, something it expects to do in the coming years.
Does Medicare Insurance for U.S.
Citizens Work in Costa Rica?
No. Medicare’s coverage does not extend abroad. Coverage is only provided in the U.S, and there are currently no plans to make Medicare insurance available here, according to the U.S. Embassy.
The only option for non-resident U.S. citizens is to pay cash for health services or use international insurance plans.
Foreigners who are legal residents in Costa Rica may obtain insurance from the National Insurance Institute (INS), or they may join the Caja, making them eligible to use public health services for a monthly fee, either independently or through their employer.
Others, including non-residents or those unemployed or not legally registered to work in Costa Rica, can use public medical services, but they will be billed for services, which is usually only a fraction of the cost of private care.