People always want to know what health care is like when you choose to live overseas. So I would like to share with you my experience from last year, dealing with a problem that required surgery.
First off, Rita and I have not signed up for IESS, which includes national health insurance here in Ecuador. It is very affordable, but we do not like that we could only use the designated state doctors, hospitals and clinics. We prefer a little flexibility in our options. For a few months, we used a private insurance carrier, Salud. However, in practice it proved to be a tedious procedure to get reimbursed, involving a trip to their office in Guayaquil to file in person. Our decision then was that health care here is so inexpensive, we would be better off just banking the payments each month, and using pay-as-you-go.
The biggest objection to that is usually catastrophic care – what would you do in case of an accident or major illness? This is of course a personal decision for everyone, but our feeling is that we are reasonably healthy, and in the event of something like that we would use emergency rooms and/or credit cards to stabilize, then return to the US (where we still have health care) for further treatment. Mostly for us I think it comes down to we prefer to live our lives looking forward to a healthy and happy future, rather than betting for the worst to happen.
This time last year, that philosophy was put to the test when I began having pain in my left shoulder. My range of pain-free mobility became smaller and smaller, to the point of where it was even difficult to find a comfortable position in which to sleep. About a year before we left the US, I had an injury to my right shoulder that required on operation to correct, so I was familiar with the pain and I was pretty sure I was going to require arthroscopic surgery.
With that in mind, I began looking for a good orthopedic surgeon that also spoke some English. And before anyone points out how I could have done this cheaper, let me state that I am aware that this does not represent the cheapest way to get health care in Ecuador. My search criteria were for a professional level of care with a bilingual doctor at a modern and well-equipped facility of my choice – for a reasonable fee.
I began by visiting hospital websites and emailing orthopedic specialists at the OmniHospital and Grupo Kennedy Clinica, in Guayaquil (we live in Salinas). I found a doctor with the Grupo Kennedy Clinics system who gave me an appointment the very same day for an exam. He spoke English very well (Hebrew too, actually), and quickly determined that yes, I did indeed have a problem with my left shoulder. He sent us downstairs for a sonogram while he waited, and after examining the results, also ordered an MRI, which we scheduled for a few days later. He was willing to schedule it immediately, but it was late and we needed to take care of a few things at home before returning to Guayaquil. The total costs of two consultation visits, an ultrasound, MRI and transportation came to about $615.
As I expected, the results of the MRI indicated that I could benefit from arthroscopic surgery. The procedure would be to shave some bone in the socket part of the joint to allow more room for movement, and to remove a calcified area. My doctor recommended a colleague for the surgery who specializes in this type of procedure as the lead surgeon, although he would still assist.
I met with the new surgeon at the Samborondon branch of the Kennedy Clinica. He confirmed the diagnosis, and explained that there was no emergency, but that I should consider getting it taken care of within a year or so. Since I was already in pain daily, I decided to proceed without delay.
I saw the surgeon on a Wednesday. He informed me he could do the surgery either the next Tuesday or Thursday. Also, since Samborondon is in a rather well-to-do section of Guayaquil, he let me know if I chose to have the surgery performed in the Alborada Kennedy branch, it would be the same doctors, same equipment, same procedure, but it would cost me 20-30% less.
Another consideration was that while at the Samborondon hospital everything could be put on a credit card, at the Alborada branch only the hospital fee could be charged – the rest would have to be paid in cash. Since we would need time to withdraw the money, I asked for Tuesday. He clicked around on WhatsApp for a few seconds, then said “OK, we have the operating room”. A few seconds later, he confirmed the anesthesiologist, and said we were scheduled for Tuesday morning at 8am. He told me to arrive at the hospital by 7am to check in, and that I would be staying overnight. He also confirmed my wife could stay in the room.
If you’ve never gone through this in the US before, let me tell you how incredible this was. I literally sat in his office while he scheduled a surgical procedure for six days later – and it could have been two days if I had wanted. When I needed a similar operation in the states, it was over four months between the diagnosis and the surgery.
And we weren’t finished yet – the doctor then wrote up three orders. In Ecuador, a doctor may order a particular test or drug. It is not exactly what you would consider a “prescription” in the US but similar. For instance, farmacias will sell you whatever drug you ask for (if they have it). The doctor’s order just helps you get the right drug/dosage – but you keep the order, and you can go back to the farmacia and get more anytime you like. You can also go into any farmacia and tell them what symptoms you have, and they will be happy to sell you what they think you need.
In this case, he had ordered a set of blood tests, a chest x-ray, and an EKG. These were requirements for the anesthesiologist. I was able to go upstairs in the clinica to a cardiologist, show him the order, and he did the test right on the spot. I wasn’t in his office more than 15 minutes, and left with the EKG and a letter stating he saw no problems with proceeding. He charged $120.
Down to the first floor and a short wait to get the x-ray. They also gave me the film and a report, whole procedure took maybe 30 minutes, and cost $38. The only other expense that evening was the surgeon’s office visit fee, $70.
For the blood test, I took the order the next day to a local testing center in La Libertad. $22 for the blood panel, and it was ready for pickup that afternoon.
Again, in Ecuador there is some personal responsibility in these things. The doctor gave me orders for what I needed, but I had to go out and get them, and collect the results to bring with me to the hospital.
We spent Monday night at a nearby hotel in Guayaquil so we could arrive at the hospital Tuesday morning at 7am, and by 7:30 I was in my room. A nice, large private room with a TV, a refrigerator, a fold-out bed for my wife, and a private bathroom and shower.
They didn’t waste any time. Right on schedule at 8am, I was in a hospital gown and lying on a bed in the prep room. I remember as I was lying there thinking, “well, it’s put up or shut up time.” I’ll admit that I did have second, third and fourth thoughts about it, and could easily imagine myself getting up and saying “You know what? I’m good with an arm and a half, I’ll just be going now.”
Looking back, mostly it was just the normal fears you would have in any hospital getting ready to go under the knife. But it is true that being surrounded by people who for the most part did not speak my language was also a little uncomfortable. Especially when the nurse came in to start my IV, and I had to tell her she was doing it in the wrong arm. “No, la cirugia es en este hombro” I told her, pantomiming outrageously.
Soon the IV was running, in the correct arm, and they wheeled me into the operating room. As far as I could see from my vantage point, it was a nice, modern facility. There were computer screens and flat screen color monitors on the walls to display the ‘scope’s camera, and the comforting sounds of things going “whoosh” and “ping” and so on. The anesthesiologist introduced himself, asked a few questions (again, in Spanish), and we were off. Once he put the mask on me, I was quickly O-U-T, and it was a smooth transition to waking up while being moved back to the transport bed.
I was in the recovery area for maybe 30-45 minutes. I did not feel any nausea or after effects from the anesthesia, just felt cold. And, you should excuse the expression, I had to piss like a racehorse. This was the only time in the whole procedure I was really uncomfortable. I also learned a valuable lesson in Spanish, the difference between “Yo quiero un baño” and “Yo NECISITO un baño”. I had just about decided that I wasn’t wearing any of my clothes, and these aren’t my sheets, so what the heck, when I finally was able to communicate the need to a nurse, who brought me a plastic bottle.
Much relieved, I was back in my room with my wife by noon, and had no problems eating lunch. A very nice dinner was provided, and breakfast the next day.
Post-op, I was checked on by both doctors, and there were the usual checks by nurses on IV, blood pressure, temperature, and so on. All in all, it was a very positive experience. I felt like I was being cared for in a friendly and professional manner. More importantly, I felt like I was being treated as a person, not just a hospital chart.
Check out the next day was a little unusual. The doctor said I was free to go, but he did not “order” the release. It was up to me to decide when I wanted to leave, and the procedure starts once you or your representative goes down to the cashier to pay the hospital bill.
A word about payment. Remember that in the Samborondon Clinica, we could have used a credit card for the whole visit. Part of the reason it is cheaper in the other clinicas is because while you can still pay all or part of the hospital’s bill by card, you pay the doctors, anesthesiologist, and some incidental charges in cash. For example, during the surgery they found a small rupture on one of my tendons. They tacked it down using a kind of small implant, so I also got a bill for those materials used.
So after Rita paid the hospital bill with AMEX, I had a parade of doctors to my bedside with their bills, which we doled out to everyone in cash.
Here’s the breakdown for the surgery and a 28 hour hospital stay.
Private Room $295
Use of Operating Room & nurses $1170
Oxygen in OR $80
Use of other medical equipment
(including IV, drugs, nurses, food, etc.) $1230.64
Oxygen in Recovery $3.90
Sub-Total for Hospital Fee: $2779.54
Assisting surgeon $400
Implant and sutures $560
Sub-total for Professionals and materials: $2560
Total for the procedure: $5339.54
So adding in my initial costs for diagnosis and consultations, allowing for travel expenses, one hotel stay, and additional follow-up visits and therapy (which I was able to get at the military base a mile from our home at $10/session), the whole experience totaled about $6200. Compare that to the total cost of similar surgery in the US a few years ago of just over $16,000.
A couple of disclaimers – the surgery in the US was the result of an injury, and more extensive repairs were needed. However, it was also on an out-patient arrangement, no hospital stay, and only one surgeon present. And of course, in both cases I’m giving you the total charges, not out of pocket expense. In the US insurance paid the bulk of that, and I used an HSA for the deductibles. But likewise, although I paid cash for the procedure in Ecuador, I can also be reimbursed from my HSA.
In summary, a few other comments and comparisons between similar surgeries in the US vs Ecuador.
- I was impressed with the speed with which things happened. In the US, it was over 4 months between my initial consultation and the surgery. The delay is partly because insurance companies require you try medication and/or injections first, and also because things like MRI and EKGs had to be scheduled and the facilities are often very busy. Even the OR had to be scheduled weeks in advance. In Ecuador, My initial visit was on October the 26th, the surgery on November 10th, only 15 days later. In fact, it might have been even sooner but for the 4 day holiday at the end of October.
- In both countries, I felt like my surgeons were very good and knew what they were doing. The levels of care for both were very high. I’d have to say in Ecuador there was a more “human” feel to things though. I felt like I was treated more as a human than just a faceless patient. Also, it seemed obvious to them that of course your wife will want to stay in your room, and they even made sure she had a sheet set and pillows.
- As mentioned in other posts, in Ecuador there is a lot of personal responsibility. The upside of that is you have more control in the process, and you have all of the test results and information, making it easier for a second opinion.
- I looked for English speaking doctors, because I wanted to make sure there was no miscommunication between us when discussing the diagnosis and treatment. This was not a problem. However, if you want to be a successful expat, this does NOT excuse you from learning some Spanish! Keep in mind that even if your doctor is fluent in English, most of the support people you will interact with probably will speak little or no English. I still needed to be able to communicate with the testing centers, imaging centers, technicians, nurses, admissions in the hospital, and so on.
As I said, surgery was performed on November 10th, 2015. I began physical therapy at the beginning of December, which lasted 8 weeks. Within three months of the surgery, I had full motion in my left arm and shoulder, with no pain at all. Now, almost exactly one year later, the shoulder is as good as new, 100% functional and healed. In fact, I can barely find the incision points now.
Conclusions? Well, my purpose of putting all this down in writing is more to provide people thinking of living in Ecuador with some actual numbers and real world experience than to tell you what is best for you. My wife and I are here because we choose to live here for the climate, healthy food, and the experience of a different culture. We are not here as “economic refugees” to use author Dan Prescher’s term, or because we cannot afford health care in the US. So I am not trying to say come to Ecuador and get cheap health services. What I do hope will come across is that if you are thinking of moving to Ecuador and are reasonably healthy, you don’t have to be worried that you will not be able to get quality health care at a good price.