Carlos Atencio is responding to the failing healthcare system in Venezuela by introducing a new model of care based on family practice medicine and centered on community participation and responsibility. His Family Medicine Foundation provides affordable primary care (that resolves 85% of health issues in low income communities), trains medical professionals in family medicine techniques, and makes patients aware of their role in their own healthcare. As a result, Carlos is reducing medical costs, reviving a dying “specialty”, and putting communities in charge of their wellness.
La idea nueva
In Venezuela and across Latin America, healthcare is more and more geared toward curing the sick, and is increasingly hospital-based. In a related trend, for the last century, doctors have become more and more specialized instead of having a broad base of medical knowledge. In Venezuela, the healthcare system is particularly fractured for those two reasons but also due to a waning population of doctors and two separate health systems -- public and private -- neither of which adequately cover care for the population. In this context, Carlos Atencio and his Fundación Medicina Familiar (Family Medicine Foundation, (FMF)) are offering a new model to flip the hospital and sickness-focused paradigm to one of home and wellness.
To do this, FMF is reviving a family medicine/general practitioner approach with preventive and primary care that is based on proximity to the patients and integrated medical knowledge. The FMF model separates the financer (whether state or private), from the practitioner (the health center), and quality monitor (the community), increasing trust and community participation. FMF has small community outpatient centers that serve as a place close to home where families can go for preventative and emergency healthcare. The same team of doctors and nurses always care for the same families, even treating them at their homes if necessary. While the FMF staff of 70 medical professionals are practicing medicine at the health centers, Carlos is moving to focus FMF’s efforts on training, research, and replication.
The four FMF health centers serve as test sites for different financing options and evaluation practices. While each is based on four pillars (integration, training, sustainability, and citizen participation), each center runs on a different financing model and adapts their community health outreach to each particular community. Meanwhile, Carlos has partnered with two universities to train new doctors in family medicine, and offer continuing education courses to current physicians who want to specialize in the practice. The FMF general practitioners are able to treat 85% of health issues they see, and only those 15% that are not resolved are referred to specialists or larger hospitals. Carlos estimates that this method, by focusing on prevention, early detection, and personalized care incurs only 20% of current private healthcare costs. Nearly 500,000 patients have come through FMF health centers in the last five years, and 11 universities have begun offering courses in family medicine. Carlos is dedicated to taking this model across the country and beyond.
Venezuelan society spends about 90 dollars per capita annually on healthcare. Just over half of that, 50 dollars, comes from public funding. This falls short of other countries in Latin America, which on average spend about 105 dollars per person per year on healthcare, and is far from the 1,860 dollars industrialized countries budget for healthcare. Despite efforts to improve the quality of the country’s healthcare, especially in recent years, Venezuela continues to invest much less than other countries in their population’s health. The system is in a in a state of disrepair for several reasons.
The first issue is the two models of healthcare, both with their faults: public and private. Public hospitals are the dominant care providers, providing free care and covering uninsured (and usually from a lower socioeconomic status) patients. Private doctors take those who can pay – through insurance or out of pocket -- meaning they tend to see those of a higher income. Both kinds of care providers are supplied by the state to some extent; however, the public system relies almost entirely on the government for their supplies. Given the tight state regulations on most products, there is inadequate equipment, medicine, and other medical supplies in general, but most especially in the public hospitals. The public system has mechanisms for public participation in its policies; however, in practice, citizens have little leverage in causing reforms. Meanwhile, there are questions about the price tag of private care.
Another part of the problem is in the training and employment of medical professionals. First, six of every ten doctors leave Venezuela for another country, and medical schools are struggling to fill their classes. Second, those doctors that do stay are opting for specialties, such as plastic surgery or ophthalmology, that offer higher salaries and are housed in mostly private practices. In contrast, an agreement between Cuba and Venezuela’s former President Hugo Chavez, Cuba supplies 30,000 trained medical professionals to work in Venezuela’s social medical programs and set up free clinics, in exchange for oil. However, this is proving to be a less than ideal solution: there are philosophic differences in training which leads to difficulties both in collaboration among healthcare professionals and in regards patients who do not want to be treated by medical professionals coming from the Cuban program. Furthermore, since Chavez’s death, the Cuban professionals are leaving by the thousands, adding to the gaps in care.
An estimated 25% of the population seeks some level of medical attention every month. From this number, only 1% require intensive or specialized treatment, often meaning hospitalizations, surgical intervention, and cutting edge techniques. However, more and more there is a culture of relying on specialists to treat symptoms instead of having preventative, integrated care. This drives up the price of healthcare from unnecessary tests and procedures and makes care more and more fragmented. Patients themselves are not qualified to determine whether or not the care is inadequate or excessive, and fragmented patient data makes follow up or evaluation difficult. As a result, neither those attempting to monitor healthcare across the board, nor the patients themselves are able to qualify the care and know where it can be improved and where unnecessary or ineffective practices can be eliminated or changed. In Venezuela in particular, patients in some cases can even go directly to a specialist without a referral from a general practitioner, jumping over a point of centralized care.
This movement towards increasing specialization, a global trend in medicine since the beginning of the 20th Century, has led to more siloed professions and specialized physicians, and institutions focused on the treatment of a particular disease or organ system. Movement away from integrated and preventative care has caused the concept of general practice to decline. There are now fewer doctors entering this area, although in previous centuries all medical professionals were essentially general practitioners (GPs).
Carlos Atencio is creating a new model of healthcare for Venezuela in which every citizen will have access to high quality primary medical care at a local level. His model blends both the public and private systems, but turns on community participation and input. To do this, Carlos started the Fundación Medicina Familiar (Family Medicine Foundation), based on the concept of Primary Health Care (PHC) and the strategy of family practice, all with the goal of healthcare for all. PHC, as defined by the World Health Organization, is “essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination.” Carlos’s model allows for quality primary care, and a carefully constructed referral system to channel those needed more complex or specialized treatment to the appropriate outlets.
Seeing the cost and inefficiency of specialized and fragmented medical care, Carlos and the Fundación Medicina Familiar (FMF) instead propose a community medical center based on the philosophy of family or general practice, where the same physician provides regular, preventative care for everyone in the same household. Patients come to the center, and doctors also go to the families. The FMF model is based on four pillars, each intentionally addressing a different barrier in the current health system.
The first pillar is continuity and integration. This plays out in several ways. First, the health center itself is located in the community it serves. The center takes regular appointments but also has an emergency service, meaning it is always available to attend to patients. Second, the same health team always attends the same individual or family, both for routine checkups and for sick appointments. This team, usually a doctor and a nurse, is able to resolve 85 percent of health issues. The team continues to follow up with the other 15 percent of cases that need to be referred to outside help. The idea here is that the team knows the patient and his or her health history, leading to a relationship of trust. The health team will make house visits when necessary, in addition to seeing the patients in the Center.
The second pillar is productivity and sustainability. The financial model has been designed to maximize costs. Carlos estimates that expenditures in the FMF model are 20 percent of the spending in private practices, per month. This is based on a blend of public and private healthcare, as well as fees for service. FMF staff are paid according to the number cases they see. The private aspect is the services such as lab work and radiology that are contracted out to small and medium businesses. Patients pay a fee for these, but the cost is 50 to 70 percent less than what the procedures would cost in private health centers. To generate revenue, FMF offers a healthcare plan to commercial businesses and insurers, at a fee that is 20 to 30 percent less than what private health centers charge. Two percent of these fees then go to a fund to subsidize community patients who are not able to pay for their care. However, even those very low income patients are encouraged to pay anything they can (even if it is after treatment), as a sign of responsibility and as an investment in the health of the community.
The third pillar is training and quality. Carlos has developed a training and evaluation system to ensure consistent quality in FMF care. All of the medical professionals at FMF are trained in PHC. Doctors receive a post-doctorate, in Family Medicine from the University of Zulia, which also offers continuing education in person and at through distance learning. Meanwhile, a large part of the health centers’ work is health and wellness training and programming in the communities they serve. Additionally, Carlos has designed an evaluation system for each aspect of the Center. FMF uses indicators, measured on a monthly basis such as productivity, financial health, and satisfaction. User experience is critical, so surveys question all stakeholders, patients, staff, and the client companies.
The final pillar is community participation. FMF is governed and monitored in part by an association of other community organizations, called the UNIMEFA association. Other groups, such as Alcoholics Anonymous or the Secretary of Culture, also organize health-related activities in conjunction with FMF. The patients themselves monitor the quality of the care through their hand in governance and evaluations, but also through these trainings and seminars on health topics, to learn to take care of themselves and take responsibility for their own wellness.
FMF is based in the city of Maracaibo, (the second largest in the country, in the northwest), and has four Centers total across the state of Zulia, each one testing a different model of financing, and helping to support the Foundation overall. One serves as the home base for training and research, in addition to its usual activities as a community health center. Another finances itself primarily through contracts with businesses. A third is working on a financing system through families in the community itself. The fourth is in an earlier stage, and is testing financing through insurance companies.
The FMF team consists of both administrative staff and medical professionals, and led by an Administrative Manager, Medical Manager, Program Director, and Human Resources Director that are based in Maracaibo. Spread among the four centers are nearly 50 doctors and 20 nurses and a team of volunteers, mostly from the UNIMEFA Association, that help with administrative tasks and general health promotion within the community. In the last 5 years in the four centers, nearly 75,000 people have scheduled appointments, over 62,000 have used emergency services, for a total of nearly half a million in total have passed through FMF centers to receive secondary treatment such as lab work.
Carlos is planning to influence all of Venezuela, and beyond, moving to countries with similar healthcare barriers. To do this, he knows that FMF cannot be the one who is directly providing healthcare to all Venezuelans. Instead, he sees FMF as the designer, trainer, and instigator that sparks a country-wide change in how healthcare works. His four centers are only a preliminary step that enables research, testing, and teaching of new models. He knows that the FMF Centers, which are already gaining recognition for their success, will lead the way, and that the job of FMF will be to ensure the models’ adoption and replication by others. As FMF shifts to this new role, in the short term, Carlos is working on three main objectives. First, a distance learning center will offer standard and quality training for physicians and nurses who want to “specialize” in Family Medicine. (Some of these classes are already underway.) Second, FMF will have Family Medicine Centers functioning in the five main cities across Venezuela. And third, each Center will be financially sustainable through patients of mixed socioeconomic levels, businesses, and government entities. In the long term, Carlos sees this mixed model being taken up across Venezuela as the way to resolve the current demands on the healthcare system and its inability to meet them.
Carlos has already achieved partnerships with varied allies in the private, public, and citizen sectors that each offer an important asset, thereby paying attention to the model and taking a stake in its success. Several prominent foundations provide monetary support and counsel. Pharmaceutical and insurance companies, both domestic and international, have contracted with the Center to provide care for their employees. One partner of particular note, the Medical Association of Rescarven is helping to spread its training model across Venezuela. Based on Carlos’s success, they have changed their own training to one based in Family Medicine. In the winter of 2014, the Association began offering a post-doctorate in Family Medicine in partnership with University of the Andes, completely free for qualified doctors.
Given these factors, Carlos is now at an inflection point. He has, on several occasions, attempted to expand the FMF model without success, but has learned much along the way. At first, he sought help directly from the government, both regional and national. Then, he tried to transform public health centers by using the FMF model. In those cases, he encountered opposition from unions or political opposition that blocked the community members’ participation. A third time, he went through Venezuela Petroleum (PDVSA), one of the wealthiest state-run companies with independence and influence. However, just as he was working with them, there were radical changes within the company, and the new regime put an end to the partnership with FMF. However, now the scene is different. Carlos has more solid and diverse partners from a myriad of sectors. Furthermore, the current political situation is more conducive to spreading across the country that it was during his former attempts.
At the age of 6, Carlos Atencio decided that he wanted to be a doctor. At 9 years-old, his experience as a Boy Scout showed him he enjoyed working and volunteering with his community. In 1985, Carlos formed a neighborhood association in his suburb with the goal of responding to local problems such as potholes, broken lights, and other neighborhood issues.
Carlos did go on to study medicine, and in that time, he was able to meet pioneers in the field of Family Medicine in Venezuela, and viewed them very much as mentors. Their example made him even more determined to serve the population in Venezuela that was most excluded from quality healthcare. One of those mentors, whom he met through his neighborhood association, was Dr. Pedro Iturbe who was responsible for eradicating Tuberculosis in the state of Zulia and who had treated Carlos’s grandfather.
After medical school, Carlos went to the US to study Community Medicine on a scholarship. The scholarship allowed him to study in 14 different cities across the country, many of them in extreme poverty. When he returned to Venezuela, he worked as the Director of the Comprehensive Family Center until he left in 1996 to found the Venezuelan Family Medicine Foundation. Since then, other mentors, like Ashoka Fellow Elías Santana, have continued to show him the importance of passion for one’s work and perseverance.