My First Week in Costa Rica Exploring Medical Tourism
9 Dental Clinics, 1 Vision Clinic, and 1 Ayahuasca Center
Table of Contents
9 Dental Clinics
On Monday I talked to 9 Dental Clinics from Potrero to Tamarindo, on the north pacific side of Costa Rica.
To preface, I should start by saying that I got in touch with Eugene Khotianov, the CEO and co-founder of Bookimed, one of the largest medical tourism marketplaces.
We discussed a hypothetical partnership where I would get $X per clinic that onboards successfully onto their platform, and then Y% revenue on patients that convert through Bookimed, i.e. goes to a clinic through Bookimed.
It should be noted that kick-backs, or when a physician pays commission for patient referrals, are illegal in the US, but much more common outside. Therefore, I do not advise or condone anyone to do this or go to any doctors, and I am not a doctor or medical practitioner myself. Please speak to your own doctor before doing anything.
Anyhow, I basically described Bookimed’s service and showed them a presentation Bookimed gave me to gauge their thoughts.
Last note, this week was a government holiday week because of Easter. A lot of services were closed and many people were on holiday, so that probably affected things.
What follows are some notes on my clinic visits.
Tamarindo
Tamarindo has two clusters of clinics. One is by the beach side, where the party and tourists are at, and the second is just outside the beach area, where there is a brand spanking new plaza where expats shop and hangout.
Beach Side
Very close to the beach, prime real estate.
Facilities were quite small — just one room.
2 ladies were there, neither spoke great English. I’m okay Spanish, took it for a few years in grade school, but I need to get better.
Said they would get back to me.
The location of this was right in the most congested part of the single road. This town and road is sort of like South Beach, Miami. Insanely busy. Big party vibes.
The parking and heat were so bad that I didn’t go in.
Clinica Dental del Pacifico and Clínica Dental OCI Tamarindo both had locations on G Maps, but I couldn’t find them, so I don’t think they were around anymore, if ever.
Plaza
This is the only dental clinic that is within the new plaza proper.
I briefly spoke to the dentist, who actually grew up in New Jersey and sounded like it. She had to treat a patient though, so we didn’t have too much time to talk.
I asked for how much a cleaning was, and it turned out to be $90, which is $20 more than the 2 other prices I was quoted nearby.
The interior was designed very shiny and nice, but I asked some people around the store what their experience was like, and they said the service could be better in terms of being on time and scheduling.
This is in an alley behind/to the side of the plaza. It is up a dirt/gravel road that isn’t super nice to walk up to, compared to the plaza.
However, the dentist there was very patient with my Spanish and I was able to relax in the A/C for a while.
Apparently, this was in fact the very first dentist in Tamarindo, 20 years old, which would explain why this clinic has the most reviews in Tamarindo.
And later that day, a surf legend, Robert August, was supposedly coming in, who is very close with the owner of Tamarindo Dentist. That’s a strong testimonial!
The dentist said she would get back to me next week, once she read the presentation more and when the owner comes back.
Pacific Smile is across from the plaza, and connected to a few other stores and shops.
This is the only place where I actually made an appointment and did a check-up and cleaning.
This is the only place that made me wear a mask.
I primarily made an appointment so I could see the dentist.
Hopping in the chair, I was quite nervous once the cleaning started, to be honest. I never had braces or aligners or had serious cavities, so I always enjoyed going to the dentist as a kid. I’ve always had the same dentist my whole life (besides last year when I got a cavity filled in Lisbon).
Having a brand new stranger working with my teeth was a little uncomfortable. But luckily, it was just a cleaning, and nothing bad happened.
The dentist spoke fluent English and was in fact 1/4 Chinese, which she was very happy to talk to me about (because I’m ethnically Chinese).
After the cleaning, she gave my jaw massage with lavender oil. I have never actually had a jaw massage before, and it turned out to be one of the best massages of my life. I’ve realized only in the past year that I clench my jaw when I sleep, and since then, I’ve noticed I carry a TON of tension in my jaw. I would pay just for jaw massages like this again. If there are any fellow jaw clenchers out there, I would appreciate any tips 🙏
After the jaw massage, she flossed my teeth with clove oil and cinnamon flavored floss. I have never had such a flavor, but it was tingly and I quite liked it.
There was a nice little cartoon iguana on the ceiling that I could look at. It reminded me of my dentist back home. I love when there are animals on the ceilings.
Me and my new Costa Rican dentist!
After the cleaning, I told her about Bookimed. She said she would look into it, let the owner know, who was on vacation, and get back to me.
$70 for a check-up and cleaning.
Villareal
Clínica Médica-Dental Villarreal
Since the other clinics that only had 1 review on G Maps did not exist, I expected this one not to, and almost didn’t go.
So I was pleasantly surprised when I pulled up and there was a clinic.
The assistants said that I’d have to schedule if I wanted to see something, but I said I just wanted a quick check-up, and then after a minute they took me to the dentist.
I told the dentist, who was an owner of the clinic in this case, about Bookimed, and she was very nice about it. She was also fluent in English and sounded very American because her English teacher growing up was American.
To my untrained eye, they had the best and nicest actual equipment and facilities.
I told her how I surprised I was about her lack of reviews, and she said they were really bad at it, but that she was booked out for multiple weeks. She’s been running this clinic for 16 years now, and has so much recurring business and loyal customers that she doesn’t need reviews or marketing help.
Nonetheless, she said she would get back to me.
The doctor/owner for this clinic gave me a ton of great market intel.
He is actually signed up on WhatClinic, a competitor to Bookimed, another one of the bigger medical tourism marketplaces still around, since 2015.
What Clinic’s biz model is to have clinics pay for leads.
He pays 350 Euros for 50 leads, but only 60% of these leads converts. Sometimes a lead might even be someone clicks once and only makes it through one step or page through the funnel, and they contest that.
Less than 2% of their patients come from WhatClinic.
50% are organic/direct
15% from g maps
The rest are from Facebook (I think?)
Do lots of FB ad targeting and posts in the FB community because that’s where their patients are (older folks).
Post the same content to IG too, but not really a big driver.
Love to target Alaskans.
Pre-pandemic
90% of their patients came from US/Canada, primarily expats
1st year of the pandemic, only 60% were
Now they are back up to 80% US/Canada again
I asked if he charges Costa Rican and expats/tourists the same.
He said Costa Rica has a national dental association that dictates a floor on price. Dentists are not allowed to charge below that. The reasons may be to make sure dentists don’t compete on price, and drive each other out of business, or to allegedly ensure some level of quality control.
In terms of driving business, it is cyclical/seasonal. They get a lot of business when the northern hemisphere is colder and holidays like spring/summer/winter break, and less business when the US is warmer and Costa Rica is in its wet season.
They get more business when it’s a tourist season, but it’s mainly small emergencies with young people, like a chipped tooth ~ $100 stuff.
The bigger operations like implants or crowns could go from $3k to $25k, but that requires a lot of time on the phone, education, etc.
Huacas
Dentist/owner.
Been open for 20 years, strong WOM and loyalty.
A lot of expats moved here full time since COVID.
Various pockets of Italians, French, Argentines, etc.
Right now is the best the business has ever been. No plans to retire soon!
In fact, may be hiring more dentists, in which case having Bookimed to drive more traffic might be good.
Potrero
Flamingo
Spoke to a dentist there. He said the owner would come in the next day, but I didn’t make it back because I had food poisoning.
Thoughts on Dental Clinics in Potrero, Tamarindo, Villareal, and Huacas
Discoverability
There were quite a few clinics that were on G Maps, but I didn’t find them IRL or they didn’t exist anymore.
There were a few clinics that were not on G Maps, but had physical presences. They mostly seemed closed or abandoned, but might’ve been open, I don’t know.
I later found out that there were other dentists I didn’t find via G Maps, in some cases because they were part of a general medical practice, and not just dentists.
Adverse Selection
One of the best clinics with the most business had only 1 review on G Maps.
Several clinics were having the most business they’ve ever had, due to being in business for 10-20 years and because so many people are immigrating here.
It seems like in any geography or country, across any medical category, the best doctors and clinics have far more demand than supply. They do not need third party marketing or even G Maps reviews because the local WOM is so strong.
The ones that do need help with marketing would generally be newly minted doctors or clinics that do not have a good reputation yet. It’s a chicken-and egg-problem hustling for their first few patients and testimonials.
Once you do have a reputation and recurring patient base, however, it seems like it’s inevitable to be Crushing It™ as a doctor.
Best Marketing != Best Product
That said, the clinics that are the best at outbound marketing, G Maps reviews, social media, English fluency, etc. do not necessarily have the best product either.
The best marketed and perhaps well known dental clinic is not actually the best in terms of quality, and is certainly overcharging. I’ve heard this from a dental tourism expert in Costa Rica as well as a patient.
Likewise, the best marketed and perhaps well known plant medicine center is actually just good at targeting first timers, and has a reputation for upselling people after doing their retreat on expensive stem cell therapies (~$30k).
Quality
Similar to previous point.
Ultimately, I am not knowledgable enough with dentistry to evaluate the true quality of the dentists or facilities.
There is a wide variance in how nice the facilities look. But it seems that “looking nice” is not necessarily correlated with true quality, experience, or patient satisfaction. A place that looks nice and costs more might not have good quality, and a place that looks not nice might actually provide great service.
Demographic breakdown
The majority of patients are not medical tourists (coming to CR just for a surgery), not tourist tourists (just here for a spring break and maybe chipped their tooth accidentally), not digital nomads (like myself at the moment), but retired expats who own real estate here and probably stay in CR full or part-time (3-6 months a year).
Business is cyclical/seasonal, both for tourist tourists as well as expat snowbirds.
Ownership structure
There is always an owner who is a dentist. Sometimes there are multiple co-owners that have different specializations (e.g. general dentist, orthodonist, periodontist, root canal specialist.). Then they will hire on non-owner dentists to expand or to retire/semi-retire and just manage.
English
There is a wide variance in English fluency.
When I asked dental facilitator Wesley Jacobs about what I should ask clinics, this is what he told me:
Take extensive notes on the capabilities of clinics, the tooling they have, their lab or lab partner, the education of the doctors, cleanliness, sterilization procedures, English fluency.
I didn’t do a great job of asking about these things. I mostly just walked in and tried to get time with the doctor. There were various levels of receptiveness and business. There was better luck at the very start and end of the day, when there weren’t any more patients.
I also had not used the Bookimed apps very much when I talked to these clinics. I didn’t have answers to pretty basic questions.
My Spanish is not nearly good enough to talk to all the dental clinics. But as an American patient I’d weigh pretty heavily English fluency anyways in order to be as comfortable as I could be with potential doctors.
If I was very aggressive about onboarding clinics to Bookimed, I’d probably try to do it on the spot with my own laptop going forward.
1 Vision Clinic
I met up with Patrick Allen, a UC Berkeley Grad and startup founder who moved to Costa Rica a year ago. He’s creating a luxury vision clinic and retailer with his wife Roya Habibi called Ojos del Mar.
Roya is quite literally one of the best and most famous eye doctors in the world — confirmed by my Harvard-trained eye doctor friend Isabel. Roya is the host of TryNot2Blink, the world’s largest optometry podcast.
I cannot divulge too much of their secret sauce, but let’s just say I am very bullish on what Roya and Patrick are doing.
In my conversation with Patrick, I was reminded of the power of Vertical Integration, which I also got talking to a dental expert last week, who operated dental clinics and labs in Costa Rica and Vietnam for 25 years, and now does M&A for a dental lab conglomerate in the US.
Dental and vision can vertically integrate from consumer-facing retailer/clinics to supply warehouses and distribution to logistics and supply chain to manufacturing and more.
Ultimately, to provide the best product and service as a business that operates in the real-world, vertical integration is not a nice-to-have but a need-to-have in order to provide the best quality and speed. This is why so many hard-tech companies vertically integrate (e.g. SpaceX, Tesla, Anduril). Yes, you capture more of the value chain, but more importantly, you have quality and speed control, which is the most important thing for serving customers.
Something great about Ojos del Mar is that for every vision exam someone buys, Ojos del Mar donates one back to the community, typically back to a local Costa Rican child. Because of this, they have built an enormous amount of goodwill with local politicians, regulators, licensors, etc., which has greatly accelerated their development. It is not easy setting up a business as an expat in Costa Rica. Local competitors will do everything they can do to prevent it.
Forming deep partnerships with local authorities is a key capability of building a medical tourism business, or really any healthcare or regulated company. If you can’t get the right people on your side, your business is dead on arrival. If you do, you have a sort of divine mandate. Again, I think about the defensibility that Anduril has now, or that of companies that have successfully sold into hospitals.
The foil is of course SaaS companies, where one can demonstrate value easily, but can which also be copied quickly, with a low barrier to entry and thus many competitors. This was essentially where I was with my previous startup Athens, a note-taking app, and where AI companies building on top of LLM APIs are now.
If it was easy for you, it will probably be easy for others. If it was hard for you, then it will be probably hard for others.
1 Ayahuasca Center
Finally, I visited Tim Sae Koo at Reunion, a not-for-profit plant medicine center that facilitates ayahuasca and psilocybin retreats.
I first talked to Tim a few weeks ago, connected via Anthony Emberley, co-founder of Flok (YC W21), a company retreat planner / off-site as a service.
The funny thing about ayahuasca retreats (or meditation and yoga retreats) is that they probably wouldn’t be the first thing to come to mind when thinking about medical tourism. But indeed, if one is going to a destination country such as Costa Rica and working with plant medicine, then I’d say that is most certainly a kind of medical tourism.
It was fun to see Tim and the other’s at Reunion hear my definition and say, “Oh wow, now we can tell people we’re a medical tourism company!”
And indeed, they do more than just woo-woo ceremonies.
They have a Costa Rican medical license.
They have a spa center, a gym (needs more barbell IMO), and multiple body workers and massage therapists.
They have a former NFL linebacker and a Sochi Olympics silver medalist figure skater on-site (who I both met, both delightful).
They are constructing a longevity center as well as ice baths and sweat lodges.
Lastly, their medical director has an MD in Critical Care, Pulmonary, and Sleep Medicine. He did his residency and fellowship at two Harvard-affiliated hospitals, and has a masters from MIT.
On the business side of things, I noted again the challenge of obtaining permits for construction and medicine, and the importance of knowing how to navigate local rules and regulations.
This content comes in two parts. The first part is a video tour of Reunion.
The second part is a more standard podcast talking about Tim’s journey, Reunion, and his outlook on startups, plant medicine, and life. I’ll make another Substack post for this podcast as well.
You can podcast listen to this podcast on Spotify, Apple, or YouTube.
We talk:
The hard pivot he made from B2C to B2B for his first startup.
The growth hacks he did to bootstrap to millions of ARR and get acquired, and how the product is still running and making money today!
Some of his angel investments like Third Wave and Weekend Fund (as an LP).
Why he invests in plant-based alternatives both for personal reasons as well as from a thesis point of view.
The life hard pivots he made from tech founder to nomad to ayahuasca facilitator.
The upbringing which led to the chip on his shoulder, and how it went away.
Background on the founder of Reunion, Brad, who built a hundred million dollar+ company over 25 years, did ayahuasca, which prompted him to sell his company to a PE firm, come out of the closet as a gay man, and together with his wife amicably conclude their 25-year marriage.
The difference between religion, which is necessarily coupled with power structures versus plants, which have no ego.
The three common personas of people who do ayahuasca retreats.
How he explains what he does to his Christian, Asian immigrant mom.
What advice he has for founders, creators, and leaders hard pivoting.
Why people in the normal western world are addicted to food, their phones, alcohol, and work.
Why you gotta “feel the feels to heal.”
How psychedelics are really a crusade against pharmaceutical world: anti depressants, SSRIs, anti anxiety, etc.
How plant medicine lets people reinterpret the relationships and narratives they have with trauma.
How entrepreneurs can weave surrender, spirituality, and consciousness into their startups and lives, leading to magic and intention.
Conclusion
I’d love to thank all the people and clinics I’ve mentioned in this post for sharing their time with me.
Here are some half-baked, incomplete ideas and slogans that I’ve been thinking about from this week:
ClassPass meets Priority Pass for Nomadic Founders.
Equinox / Soho House for Nomadic Founders.
At the intersection of travelhacking & biohacking.
At the intersection of The Points Guy & Kneesovertoesguy.
Investment syndicates for clinics and real estate in up-and-coming areas.
Do any of these resonate with you?
Links of the Week
https://twitter.com/tangjeff0/status/1643660751867871239?s=20
https://twitter.com/tangjeff0/status/1642734279225487360?s=20
https://twitter.com/levelsio/status/1643846152020967424?s=12
https://twitter.com/jmatthewmcgarry/status/1643958792449835010?s=12
https://twitter.com/nikillinit/status/1643061369325907968?s=20
Great read!
“At the intersection of travelhacking & biohacking.”
Love this. Immediate mental picture of what it encompasses but leaves a ton of wiggle room for execution.