Observations from an American Medical Practice Executive
By Eric Weaver, FACMPE, FACHE
In late January 2014, I traveled to Cuba as part of a healthcare executive delegation. (American travel to Cuba is allowed — but only for ambassadorship and educational purposes.) This healthcare-specific trip to Cuba was riveting, and my thoughts and emotions are still swirling in a frenzy trying to make sense of this ideologically and historically-complicated place. I fell in love with the beautiful and resilient people, the eclectic Baroque and Colonial architecture, and the vintage 1950’s American cars that are everywhere. Cuba’s almost mystical allure and charm, along with its famous and infamous leaders, and its five decade arm-wrestle with the United States engenders an impassioned and often angry debate. I will keep my remarks without political commentary. But I do want to describe what I observed of the Cuban healthcare system during my visit.
Health policy specialists in the United States have been intrigued by Cuba’s health care system for many years. Cuba produces a disproportionate number of doctors compared to our country, and it has posted relatively strong health statistics in international comparisons, especially considering the country’s shortage of material goods and economic wealth. Following the Cuban Revolution in 1959, universal healthcare became a top planning priority for the newly-formed Socialist state.
The Cuban government instituted, from the ground up, a national health system that assumes complete fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. As a Cuban citizen, healthcare services are provided entirely at no cost to the patient. You can receive the full spectrum of medical care for free – everything from primary care and heart surgery to state-sponsored sex change operations.
Although heavily-subsidized by the government, medicines are the only aspect of the Cuban healthcare system that cost the patient any money out of pocket. The price of pharmaceuticals for a Cuban is “pennies on the dollar” compared to what the same drug would cost in the United States; however, the poverty experienced by Cubans is of concern when considering their access to prescription drugs.
During my trip, for example, I enjoyed a pleasant conversation with a Cuban man in Cienfuegos who taught English at a local school and had a dream to someday visit America. He could not afford the 9 dollars to purchase antibiotics for a leg infection. (The average wage for a Cuban is 12-25 dollars monthly.) It gave me great pleasure to provide him with over-the-counter medicine from my own personal supply, as well as the financial means to purchase an antibiotic from the local pharmacy.
Generally speaking, I found that Cubans are very pleased with their healthcare system. Access to care was seen as a great societal benefit by most people that I spoke with. The same could not be said about the financial standard of living in Cuba.
Wages are indeed very low which invariably influences health outcomes in the country. From a macro perspective, however, the Cuban healthcare system does have very good outcomes. This is illustrated by the last healthcare systems ranking report from the World Health Organization where Cuban Healthcare ranked #40 in the world (the United States Healthcare system ranked #37).
Further evidence of Cuba’s healthcare success shows up in infant mortality rates. According to the CIA Factbook, the Cuba infant mortality rate was estimated 4.76 deaths per 1,000 live births in 2013, compared to 5.90 for the United States. Life expectancy is another positive outcomes indicator. According to 2013 WHO data, life expectancy was 79.4 years in Cuba, compared to 79.8 years in the U.S.
Low infant mortality rates in Cuba are directly attributable to the comprehensive prenatal care that is provided. Pregnant women in Cuba are provided free prenatal visits to their doctors very frequently, get adequate and regular ultrasound screenings and health checks, including vitamin and mineral supplements, and get the proper remedies if something is amiss. Cuba does have a very low infant mortality rate, but pregnant women are treated with very authoritarian tactics to maintain these favorable statistics. For example, I was told by a doctor that if a pregnant woman misses her prenatal checkup, he will personally go to her home to render the care. If the woman has relocated without updating the government, the Ministry of Health will get involved and scour the entire country in search of the missing patient.
The physician-patient relationship in Cuba is fascinating. A medical doctor is very much a part of the community for the patients that he or she represents. In Cuba, a primary care physician and an accompanying nurse are assigned 120 families to be responsible for. Physicians are required by the government to actually live in the same neighborhood with their patients which allows them to form strong bonds with each family. They are a trusted advisor and counselor on all aspects of health and life, including social matters. To this extent, the physician is held entirely accountable by the community for quality outcomes.
There is no medical malpractice litigation whatsoever, but if the physician’s outcomes continually fail the community, he or she will be shunned and ultimately lose their right to practice medicine. As for patient engagement, the government requires that all citizens (even those patients who are healthy) see their family physician at least once per year. Failure to do so could result in punitive action by the government.
The economics of practicing medicine is also intriguing. Physicians are paid a paltry wage for certain. The average salary for a Cuban physician is around 25 dollars per month! Because income is so low, the main motivator for doctors is societal prestige and respect. For those who are not motivated to practice medicine for such intangible benefit, they leave the profession to pursue other work. For example, I met an endocrinologist at a restaurant who left medicine and started singing with a band that performs for tourists. (Jobs associated with the Cuban tourism industry are the highest paying in the country.)
The community-oriented model that emphasizes primary care over specialty care – coupled with extremely low physician salaries and limited access to technology – give rise to a healthcare system that spends very little per capita in comparison to other countries. Cuba spends $414 per capita (10% of GDP), compare to the United States at $8,233 per capita (18% of GDP).
Cuba is a country that is mostly devoid of economic natural resources with the exception of nickel, sugarcane (rum), and tobacco (cigars). Interestingly, the biggest financial contributor to Cuba’s economy is the export of physicians to other countries. A Cuban medical school trains its physicians to not only practice in their home country. Cuba, with the second-highest per capita number of physicians in the world (behind Italy), sends tens of thousands of doctors to other countries as aid for humanitarian reasons and also in terms of favorable economic trade. This export of human medical capital to countries throughout Latin America, Africa, and elsewhere actually generates more income to the country than does the tourism industry which is Cuba’s second leading economic contributor!
The pathway to become a physician is very different than the United States. A student will typically enter medical school at 18 years of age, upon completion of high school. Admissions standards are high, and students are required to have a solid academic record. The Cuban government foots the bill for each student — around $10,000 to $15,000 a year. Almost all residents go into family medicine, focusing on primary care for all ages. Once that residency is completed, about thirty-percent go on and specialize. The primary care-to-specialist ratio is the exact opposite of what we have in the United States.
Remarkably, I had the chance to meet a first-year American medical student when I visited the medical school in Havana. He was an African American male from Brooklyn who was unable to afford tuition to a medical school in the U.S. He made the bold move to accept a full scholarship from the Cuban medical school and commit at least the next seven years of his life in Cuba, estranged from the United States and unable to see his family. He did not know the Spanish language upon matriculation so the medical school will allow him to spend his first year learning the language. His commitment to make the sacrifices necessary to become a doctor is commendable. I hope he is able to achieve his dream of moving back to the United States to practice medicine.
Another strikingly apparent observation from my experience in Cuba was the limited access to technology. Medical technology used to care for patients is antiquated, and access to parts to maintain this equipment is challenging due to the embargo. Healthcare IT is non-existent, and all care is delivered through paper-based charting. The government employs several statisticians at each community clinic (“polyclinic”) to document data into an Excel spreadsheet, which is then uploaded to the country’s health agency for quality reporting purposes. Because health information technology is so limited, patient records are not routinely distributed to the family physician from specialists that render care. Instead the primary care physician actually accompanies the patient during the specialist office visit in order to actively participate in the care that is provided at the polyclinic.
Despite the lack of electronic health records, the Cuban government does a pretty good job of keeping the family doctor informed. In this communication process, it is important to note that a patient in Cuba has absolutely no privacy expectations whatsoever. It is reasonable to assume that all health information is unprotected and available for anyone to access.
Although I didn’t get a chance to visit a Cuban hospital, I understand that the conditions of the facilities and the quality of the outcomes are quite good. Because of this the Cuban government is turning to medical tourism as a means to generate revenue for the country. Thousands of foreign patients travel to Cuba, particularly from Latin America and Europe, attracted by the reputation of Cuban doctors, the low prices, and nearby beaches on which to recuperate.
Medical treatments include joint replacement, cancer treatment, eye surgery, cosmetic surgery and addiction rehabilitation. Costs are about 60 to 80 percent less than US costs. Interestingly, on this trip, I was informed that Félix Rodríguez – the exiled Cuban who went on to become an American CIA officer known for executing Che Guevara – actually visited Cuba as a medical tourist to receive eye surgery!
As a medical practice executive, I feel there are many lessons that we could learn from the Cuban healthcare system. With healthcare costs in the United States spiraling out of control, Cuba is a prime example of how a country can deliver care efficiently with little bloat in the system. Likewise, their community-based care model that emphasizes primary care and population health is similar to what our country is attempting to accomplish with patient-centered medical homes (PCMHs) and accountable care organizations (ACOs).
Although I am a capitalist, I visited Cuba with an open mind and a compassionate heart. In doing so I experienced a trip that was invaluable in terms of education and cultural awareness. American medical practice executives can learn a great deal from how healthcare is delivered in other countries, even one that is a Third World, socialist island nation.