Monday, March 12, 2007

Cuban-style clinics may be a model for U.S.

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Posted on Mon, Mar. 12, 2007

Cuban-style clinics may be a model for U.S.

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At the new Leon Medical Center in Hialeah, a white-gloved and uniformed doorman welcomes seniors in front of bubbling waterfalls. Inside, along with marbled restrooms, seniors get free dental and vision care -- care that regular Medicare recipients must pay for themselves.

In Westchester, at a CAC Florida clinic, seniors are participating in free exercise classes, playing dominoes and competing in bingo tournaments, as well as getting free coffee and breakfast pastries.

In both places, everything is paid for by taxpayer dollars.

Most importantly, in these clinics and others like them, seniors get easy access to primary care physicians -- care intended to stop conditions from getting serious so that patients can avoid aggravating and expensive trips to the emergency room.

These clinics, which trace their roots to pre-Castro Cuba, could well be a vision of the future of healthcare in America. ''This is a very good model,'' says Steven Ullmann, a healthcare economist at the University of Miami.

Seniors tend to love the places. ''I feel good here,'' says Gerardo Gonzalez, 78, who went to the CAC clinic in Westchester one recent morning for a blood test and stayed to play dominoes. ``I feel at home.''


So far the clinics, true to their Cuban origins, have focused primarily on Hispanic areas, but that's changing. CAC plans to expand into Liberty City within the next year, and Benjamín León Jr., CEO and founder of Leon Medical Centers, says he's thinking of franchising his concept after getting inquiries from entrepreneurs in Arkansas, New Jersey and Puerto Rico.

Some experts argue that the clinics are good only because the Bush administration has put massive amounts of federal funding into the Medicare HMOs that these clinics depend on -- a push to shift a government program to for-profit corporations, on the theory that the private sector can do a better job managing money than can Washington bureaucrats.

''They've thrown a lot of money at this,'' says Robert Berenson, a healthcare specialist with the Urban Institute. It used to be a Medicare HMO received 95 percent of what a senior in a given area would be expected to cost each year. Now, it's 102 to 112 percent of expected traditional costs, says Berenson.
As Dartmouth researchers and others have shown, the average senior in Miami costs Medicare about twice as much per year as a senior in Minneapolis.

Because of that, the government reimburses HMOs in South Florida far more than most other places. An HMO in Miami-Dade gets $1,199 a month for each senior it signs up. In Broward, it's $1,026. In Minneapolis-St. Paul, an HMO gets $732 a month per member, according to a Medicare database provided by spokeswoman Sharon Fisher.

Over a year, that means a South Florida HMO gets up to an additional $5,600 to spend on each senior -- and that's why it can lavish extra benefits on them.

Not surprisingly, seniors love those benefits. Put that together with a strong Hispanic tradition of using clinics and it means almost half of Miami-Dade seniors -- 48 percent -- are in HMOs. In Broward, it's 43 percent. Both counties are more than double the national average of 19 percent.

This is such a lucrative field in South Florida that national players are getting involved. Humana has purchased the CAC clinics, and Goldman Sachs, the New York investment group, recently purchased a controlling interest in MCCI Medical Group, a local firm with clinics throughout South Florida, according to Bruce March, a Greenberg Traurig attorney who helped broker the deal.

ContinuCare, with healthcare entrepreneur Phillip Frost as its main investor, has 15 primary-care clinics in Miami-Dade and Broward serving a broad range of patients. Chief Executive Richard Pfenniger Jr. says that facilities in Hispanic areas will offer the coffee and ''social-related activities'' that the competition offers.


Mike Fernandez, a Coral Gables entrepreneur who helped develop the CAC model, says that the Cuban-style clinics will prosper even without boosted funding from Washington because they're able to provide more value at lower cost. ``Historically, these clinics have provided way beyond what anyone else was offering.''

UM's Ullmann says the clinics prosper because of two keys: ``First, they're culturally sensitive, and second they have a focus on primary care.''

The clinics emphasize a ''warm and friendly'' atmosphere, says Fernandez, with service reps hovering to help patients negotiate the system. The CAC Westchester clinic even puts photos on the walls of patients' recent birthday parties, and service is extensive. Many clinics are open 7 a.m. to 5 p.m. weekdays and Saturday mornings.

Still, the core is primary care. Elders tend to have a lot of aches and pains, and a good many of them are worriers. ''They love to see their doctor,'' says Ausberto Bianchi, the physician-in-charge at CAC's Westchester center.

The clinics don't try to limit those visits. ''Why do that?'' asks León. ``If they can't see their doctor, they'll just go to the ER.''

Most clinics bring in specialists on certain days of the week, but the primary physician recommends a specialist only when he or she feels there's a particular need.

Barbara Starfield, a Johns Hopkins professor, says a key reason why Europeans tend to live longer than Americans but spend only half the healthcare dollars is that in most European countries, about half the doctors are devoted to primary care, while only a third are in America.

Primary physicians tend to do a better job treating basic ailments, her research found, at much lower cost.

The Dartmouth studies show specialists drive up costs. South Florida has 45 percent more specialists per 100,000 residents than does Minneapolis - and about 20 percent more than the national average. Specialists tend to bounce patients between each other -- the gastroenterologist sends someone with backache to an orthopedist -- at much higher per hour charges than primary care doctors charge. And each specialist is likely to conduct his own tests. The average senior with traditional Medicare in Miami gets about twice as many lab tests a year as a senior in Minneapolis.


In the clinics, all test results are centralized with the primary doctor, and so there is virtually no repetition.

The clinics don't directly discourage trips to emergency rooms, but they do work hard to make it easier for patients to get quick care at the clinic. Leon has a 24-hour hotline that seniors can call to ask whether a condition is serious enough to warrant an ER trip. CAC Westchester has a walk-in urgent care center with long hours.

Leon's new facility in Hialeah even has a quasi-ER, where there are 10 beds separated by curtains. Benjamín León III insists this isn't meant to replace the ER, but offers a place for ailing seniors to lay down as they wait to see their doctor.

Some are suspicious about the clinics' motives, because they're for-profit companies trying to maximize returns, which can be done by keeping costs low.


Ullmann of UM doesn't think that should deter patients. If one clinic doesn't treat them well, they can switch to another -- just like most American consumers do in other matters. ``You're looking for value at a good cost. Why is that any different than picking a Dell or a Gateway?''

Ironically, a critic of the for-profit HMOs is a conservative, Michael F. Cannon, a scholar with the Cato Institute and author of Healthy Competition.

Cannon points out that with the HMO, the customer still can't control his healthcare dollars and, like many liberals, he wonders whether the Medicare HMOs are ''cherry-picking'' their customers.

That's against federal law, but there are subtle ways to do it, and Cannon wonders if CAC's wellness programs -- offering daily exercise classes -- attract the most active and healthiest seniors, while the sickest tend to stay with traditional care, so they can see the specialists and get the customized treatment they feel they need.
''This is called screening,'' he says.

In fact, CAC's social and wellness programs are the one major difference between it and Leon.


CAC provides many daily social events, including English classes, and those who do the morning exercises are rewarded with a free lunch. CAC execs say exercise classes keep seniors fit -- and means they're less likely to need expensive trips to ERs.

''But there's also the mental health aspect,'' says Hilda Lago, a CAC administrator. The senior sitting at home, often alone, has time to dwell on aches and pains, while going to a center to be with others can brighten a day.

''Every day I come here,'' says Emma Rodriguez, 75, a regular at a CAC exercise class. ``That's better for me.''

León Jr. says his clinics offer no exercise or
dominoes -- and never will. ``We take the dollars and put them into healthcare.''

When Fernandez, a creator of the CAC dominoes-bingo style, heard that comment, he thought of the Leon clinics elaborate entrances and responded: ``Well, healthcare -- and waterfalls.''
Leon says Congressmen from around the country have visited his centers, wondering if they can serve as a national model.

UM's Ullmann doesn't see why not. ''If they put one in Chinatown in San Francisco, they'd have to be sensitive to different cultural needs, but the basic model'' -- personal attention and strong primary care -- ``would work just as well.''

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