More than a year ago, the Hannaford Brothers grocery chain became one of the first employers in the country to encourage workers to go abroad for medical care. In the time since, the company has redefined the concept "medical tourism."

The original offer was this: Those who flew to Singapore to have joint replacements did not have to pay any out-of-pocket expenses. Plus the company would cover travel costs for both the employee and a companion.

"I think at that time it was probably on the outer edges of innovation to even offer it," says Hannaford spokesman Mike Norton. Norton says it was more cost-efficient for the company to send people to the Singapore hospital because it charged less than U.S. hospitals and had demonstrated strong patient outcomes.

"In their region of the world, they have the right credentials to assure that if they did a procedure you would get the outcome you want," Norton says. "A procedure like that, one of the biggest concerns to the member and the health plan is complications. A lot of the quality and cost savings are in not having any complications."

There was only one problem: No one wanted to go to Singapore.

"I wasn't going to go Singapore. I wasn't going to go outside the United States," says Jim Robertson, a retired law enforcement officer who lives outside Augusta. Robertson needed to replace his left knee, but he wasn't about to leave the Augusta area to get it. "Been out of the United States one time. We went to Scotland, and when I came back, when I got off the plane, I wanted to kiss the tarmac, I was so glad to be back in the United States."

His wife Bev, an office manager for a Hannaford store, carries her husband on her insurance. She had her own qualms about going to Singapore. "If we went and something went wrong with the surgery, I'd be alone by myself there, and so we said well I guess it's not worth it for us, you know."

As the Robertsons debated what to do about his knee, Hannaford and insurer Aetna, which administers its health plan, worked to find the same type of cost savings and quality they would get in Singapore -- closer to home.

"There was discussion more locally within the state about trying to model the program we developed for Hannaford in Singapore with other hospitals," says Dr. Joseph Agostini, the Medical Director for Aetna in Maine. "So hospitals within Maine heard about what was going on and we decided that it made sense that if hospitals locally wanted to be able to match the quality that could provided at the Singapore facility, and the cost-effective care that could be rendered there, that they also should be eligible to try to participate."

Enter St. Mary's Hospital in Lewiston. "This is the Center for Joint Replacement," says Len Farinas, coordinator of St. Mary's joint replacement program. The center opened in 2007, and has since performed just under 800 knee and hip replacements.

The center prides itself on tailoring the facility for joint patients. Farinas shows off one of the 16 patient rooms. It resembles a hotel room, with its wood paneling, taupe walls and brass sconces.

"So we have the patient's bed, which is set up so that they can get in and out of bed in a height that they can experience in at home," Farinas says. "We also have a custom armoire so that we can accommodate the patient's clothing and everything else that they need, but also function as storage for our larger equipment."

But Farinas is most proud of the patient outcomes at the center. HealthGrades, an independent medical rating company, gave the hospital the top rating for its hip replacements -- meaning that patients are 80 percent less likely to experience complications.

And, says Farinas, the ranking shows that the center is meeting expectations for its knee replacements. "It was great boost for us to actually receive that information, because it just solidifed that we are doing everything we can to keep our patients as safe as much as we can."

With these types of numbers, St. Mary's decided to invite Aetna -- with whom it was in the middle of contract negotations -- to come in and take a look. "And we asked them if you like what you see is there additional business you could bring our way?" says St. Mary's spokesman Russ Donahue.

Donahue says with more volume comes more revenue. And Donahue says that in the world of health care, it also means better quality because doctors get more experience, and improve with each case. "We really wanted to be known as a high-quality provider. We also recognized that we needed to bring in patients from outside the community."

Dr. Joe Agostino says Aetna and Hannaford were impressed by St. Mary's patient quality reports. He says the deal was clinched when St. Mary's agreed to charge one flat rate for the joint replacement.

"So, that would incorporate whether the patient spent extra time in the hospital, if they had gotten an infection or whether they got out of the hospital very quickly because no complications or safety issues occurred," Agostno says. "This was very important to us because this gives the hospital an incentive to provide really, good, efficient, high-quality care at a good rate."

Neither St. Mary's nor Aetna will say how much the hospital is charging for services. But Agostino says that it is comparable to what Hannaford would have to pay in Singapore, when major travel expenses are factored into the equation. Hannaford and its employees, he says, are saving at least $10,000 either way.

More importantly, for Jim Robertson, it meant he didn't have to go to Singapore to get a free knee replacement. He went to St. Mary's this summer for surgery. "I can go up and down stairs. I can go up and down ladders," he says.

For someone who doesn't like to leave his town, Robertson says this was his version of medical tourism. And he is grateful for it.
So far, about 10 people covered by Hannaford in Maine and several other northeastern states where it does business have taken the grocery chain up on its offer. A hospital in the Boston area is also participating, though Hannaford says it does not want to be named at this time.

In the meantime, St. Mary's is in talks with other major employers who are interested in making an arrangement similar to the one it has with Hannaford.