Editor’s note: Patrick Courneya, MD, is executive vice president, Hospitals, Quality and Care Delivery Excellence and chief medical officer, Medicare Advantage, Cost and Prescription Drug Plans, for Kaiser Permanente. He recently traveled to Cuba with several Kaiser Permanente colleagues to learn more about Cuba’s health care system. He shared his observations in this essay.
It has been a very busy time these last two months with a lot of travel, and it is good to have a period now when I am not away from Oakland quite so much.
As a part of my recent travel, I had the privilege to visit Cuba with a team of leaders from Kaiser Permanente. We spent a full week learning about how the Cuban people in a very different system have managed to achieve first world population health results with very limited resources. According to the WHO’s World Health Statistics 2016 Report, Cuban overall life expectancy at birth in 2015 was 79.1 and 79.3 in the United States. In that same report, Cuban healthy life expectancy at birth in 2015 was 69.2 years, compared with 69.1 in the United States. In addition, under age 5 mortality for Cuba in 2013 was 6/1,000 live births (U.S. 7/1,000), immunization percentages are in the high 90s, and 100 percent of women get a get at least four prenatal visits (U.S. 97 percent). They have done this while spending only 11.1 percent of GDP on health in 2014, compared with 17.1 percent for the United States.
This is not to say they do not have challenges. According to World Bank data in 2015, the maternal mortality ratio in Cuba was 39/100,000 live births, a drop from 58 in 1990, while in the United States the maternal mortality ratio was 14. It is important to note that the baseline rate for the United States in 1990 was 12, showing the United States is going in the wrong direction. Obesity is rising, elevated blood glucose rates are similar to the U.S. and one third of men and nearly 29 percent of women over 25 have elevated blood pressure. They have work to do and they understand that well.
The year 1990, used for baseline in the statistics above, has special meaning for Cuba given the events that hit them soon after. The next year, 1991, the Soviet Union collapsed, and with that momentous and historic change, Cuba lost its biggest customer and most generous patron. The Cuban GDP dropped by 34 percent, as 80 percent of Cuban import and export business evaporated. Coupled with tightened U.S. sanctions in 1992 and 1996, the period of the 1990s became one of the most severe and sustained economic downturns in Cuban history. The Cubans refer to it as the “Special Period,” and it has left a deep mark.
So why is this important for the Cuban health care system, and what did we learn from it during our visit? Faced with the impact of the Special Period, Cuba did not have and could not afford the technology and pharmaceuticals that the developed world takes for granted. In response, they did some remarkable things. They dramatically increased their attention to prevention and doubled down on a system focused on primary care at the neighborhood level.
They also built their own pharmaceutical industry that now provides 90 percent of the medications Cubans use, including specialty pharmaceuticals. Like they have with the famous 1950s cars that fill the roadways, Cubans have used remarkable ingenuity to keep their health systems going. The story of how they have done it is complex, and I will share just one example.
In Cuba, family physicians lead teams including nurses, vector control specialists, psychologists and other health care workers that take responsibility for a panel of approximately 1,000 patients. Each patient is given a health risk score from I to IV and detailed statistics are reported regularly to the referral district. The risk score is used to guide the efforts of the primary care team. The data include the prevalence and level of control for key chronic diseases such as hypertension, diabetes, and lung disease, as well as immunization rates, other preventive services and maternal child health statistics.
The family physician/nurse team staffs a typical neighborhood clinic, seeing patients both at the clinic and in their homes. The team’s knowledge of the family, their living situation, their behavioral health challenges and other social/non-medical factors is deep, and the ability to respond at the community level is strong. The results are pretty amazing, as the statistics show.
Here is what I found most remarkable, though. Within Cuban health care, they depend on accurate statistics and analysis to guide actions, and their level of transparency is admirable. Each month, for instance, the family doctors serving a given referral region gather together to compare their un-blinded population health statistics, reviewing results and strategizing on how to solve problems revealed by the data.
I must admit I felt as if the results they were getting were too good to be true, so I pressed the question of data accuracy repeatedly during the week I was there. The most compelling response came from a United States journalist who has lived in Cuba for 14 years and is not afraid to say and write what she really thinks. When I asked her how we could be sure that the data was accurate, what she pointed out was profound.
Cuba is on an extremely tight budget and their constitution obligates them to provide care to everyone. In betting on prevention, they have committed to the idea that whatever they do to prevent disease has to work if they are going to be able to afford to provide care. If they make decisions and push interventions based on bad data, they will make expensive mistakes from which they are in no position to recover.
In essence, they have committed the system to the idea that high-quality leads to lower cost and lower burden of morbidity and mortality. With just over 11 million people, with a focus on population health and understanding that they must attend to social/non-medical needs in addition to providing health care, Cuba is getting great results. Affordability and high quality improving the health of the communities they serve. Sound familiar?