Spain is on an economic and cultural roll following decades of tyranny, recession and isolationism.
And the nation's healthcare system has become a showcase for how quality of life has improved since the death of dictator Francisco Franco in 1975. Most analysts agree that the nationalized Spanish healthcare system in 2000 offers decent service at a decent price.
One of the strong points is a well-organized primary-care infrastructure that is publicly financed and offers free services to all. Although a significant weakness is an aging hospital system dominated by multibed wards, the toughest challenges for the government are improving patient satisfaction and reducing waiting times for nonemergency procedures.
"The standard of living has improved, and expectations are high," says Alicia Granados, M.D., senior director of the Catalonia Health System, which manages medical care for 6 million residents in the autonomous region that includes Barcelona. Spain's healthcare money is funneled through 17 states, called "autonomous communities." Said Granados, "The Spanish people expect more from the healthcare system."
The two decades following Franco's death were marked by political instability, cultural upheaval, embarrassingly high unemployment and a roller-coaster economy. Healthcare also suffered. But in recent years, the Spanish have hit their stride. Business, the arts and sports have spawned Spanish superstars. The economy is strong, tourism is booming and joblessness is at its lowest level in 20 years.
As the standard of living rises, so does the demand for improved quality healthcare. That puts pressure on the government, but also creates opportunity in the private sector for those offering access, quality and service amenities.
Financing healthcare. General taxes finance more than 90% of the nation's $35 billion public healthcare budget, enough to insure most of Spain's 40 million residents, as well as fund medical education, 750 public hospitals and 1,700 primary-care centers. Social security revenue funds the remainder of the public health system, which accounts for about 80% of the nation's total medical expenditures.
Seven of Spain's autonomous states directly manage their healthcare systems. The federal government's National Institute for Health Care, known by its Spanish acronym of INSALUD, oversees care in the 10 other autonomous communities.
The government system is bolstered by a vibrant private healthcare sector, which controls about 20% of total health expenditures. About 6 million Spaniards have private insurance, while another 4 million buy supplemental coverage from private carriers. The nation's 2 million government workers can opt out of the public system. In fact, more than eight of 10 public-sector workers are privately insured, allowing them wider options and quicker access than those covered by the public system.
"It's one of Spain's great ironies," says Jonathan Lewis, president of the Academy for International Health Studies. Lewis earlier this year led a delegation of U.S. healthcare executives to Spain on a trade-study mission.
Physicians aplenty. On the provider side, Spain, by most standards, has an abundance of physicians, with 4.1 per 1,000 patients, compared with 3.1 in the U.S. and 3 within the 15-nation European Union. Most physicians earn less than $50,000 per year but work only 24 hours per week in the public sector. Many bolster their civil service incomes by working in private practice from midafternoon to early evening.
Private-sector hospitals also are becoming increasingly popular, with American chain Tenet Healthcare Corp. a major player in Barcelona. There are 142 privately owned hospitals operating in Spain.
But the real private-sector battleground is on the insurance side, where about 150 companies are competing in a market expected to grow in tandem with the Spanish economy.
Asisa is the biggest private insurer, with 1.6 million policyholders, a network of 21,800 physicians and 13 owned hospitals and clinics. Second-ranked Adeslas has 1.5 million policyholders. Asisa and Adeslas each have about 900,000 government employees on their membership rolls.
Sanitas, owned by the British United Provident Association, has 1 million enrollees, 15,100 physicians, two owned hospitals and 11 clinics. Partly because of its foreign roots, the company has enrolled only 20,000 government workers but has made inroads with multinational corporations that do business in Spain.
Sanitas' John De Zulueta notes that the Big Three insurers control 56% of the market.
Beyond insurance, the Spanish system has some quirks. Widespread use of pharmaceuticals is a hallmark, with drug costs accounting for about 23% of the public system's total healthcare spending.
"Most attempts at price controls (on drugs) have failed," says healthcare journalist Xavier Bosch. "Officials are encouraging physicians to prescribe more generic drugs, but it's a slow process." Generics account for only 2% of annual drug sales in Spain, and most drugs are imported.
Low satisfaction. Despite the public system's efficiency, it's not highly regarded by patients, especially those facing surgery and hospitalization. Lengthy waiting lists, limited choice of physicians and bureaucratic barriers are the most frequently cited patient complaints.
"More local autonomy and less centralization would help," Bosch says. "Providers will take on more responsibility and become more flexible if they have greater decisionmaking power."
Private hospitals have capitalized on the low patient-satisfaction scores of government facilities. Tenet's Centro Medico Teknon is a full-service, 193-bed acute-care facility at the foot of Tibidabo Mountain in Barcelona. Teknon Managing Director Robert Manson says the $70 million integrated medical campus is modeled after Tenet's 211-bed Delray Medical Center in Delray Beach, Fla.
Opened in 1994, Medico Teknon is running at a 78% occupancy level.
"We base our marketing strategy on quality medicine, quality hotel services, choice of physicians, scheduling flexibility, and a full-range of services and technology," Manson says.
All of Teknon's 350 physicians are specialists, because most patients continue to rely on the government system for their primary care.
In addition, Teknon has teamed with New York's Memorial Sloan-Kettering Cancer Center to open an oncology unit on its Barcelona campus. The ambulatory-care center, which opened in October, is designed to offer therapy to European cancer patients who have been treated at or later may need treatment at Sloan-Kettering in New York.
"It allows us an organized way to receive, consult and triage overseas patients," says Thomas Fahey Jr., M.D., Sloan-Kettering's director of international oncology programs. The New York hospital has similar clinic partnerships in Geneva; Istanbul, Turkey; Sao Paulo, Brazil; and soon in Singapore.
Manson says Teknon has hit its financial stride after a few rough years. The hospital lost about $1 million per month in its first two years, but results have improved every year since 1996. The past two years have been profitable, he says.
"We are becoming a regional referral provider for the Southern Europe-Mediterranean market," Manson says. "The partnership with Sloan-Kettering helps us solidify our reputation and establishes a launching pad for them."
Anchoring the system. Regardless of the successes of private-sector providers and their potential, the highly organized national health system remains the backbone of Spanish healthcare.
Neighborhoods and small towns are divided into health zones. Patients in each zone are then assigned to a care team, with each team having eight to 10 primary-care physicians as well as support staff. Each primary-care physician handles about 1,100 patients. Although freedom of choice is not encouraged, patients are allowed to leave their assigned physician for another primary-care doctor practicing in the health zone.
The health zones are clustered into one of the regional area health authorities. For example, Madrid's 5.1 million people are divided into 243 health zones and 11 health areas.
The U.S. delegation toured the Eloy Gonzalo Primary Health Center, in a middle-class neighborhood in Madrid. The clinic appeared busy yet efficient. The medical records room, for instance, is mostly paper-based, but the individual patient identifier system allows for an orderly process.
"If the care team works together, the operation runs smoothly," says Albino Navarro, a territorial director for INSALUD.
Perhaps the biggest barrier to improved patient satisfaction is the waiting list for nonemergency surgery. While INSALUD acknowledges the problem, it notes the average wait for 12 common surgical procedures was cut to 80 days last year from 210 days in 1996.
Quality improvement is another hurdle facing Spanish healthcare providers. Lluis Bohigas, director of the Avedis Donabedian Foundation, is a keeper of the quality flame.
The foundation, named after the famed Portuguese-born University of Michigan professor who specialized in healthcare quality, is devoted to organizational improvement, peer review and facility accreditation. To develop standards, the foundation has teamed up with America's Joint Commission on Accreditation of Healthcare Organizations. Two years ago, the Hospital General de Catalunya, a private facility in suburban Barcelona, became the first non-American hospital outside the U.S. or its military outposts to land the Joint Commission's seal of approval.
But most of the healthcare establishment remains skeptical. Only one other hospital and one ambulatory-care clinic have joined de Catalunya in receiving JCAHO accreditation. Private hospitals have shown only lukewarm interest, while the government stands by its internal evaluation program.
"We need to keep politics out of the accreditation process and work for international standards designed to encourage continuous improvement across the entire hospital organization," Bohigas says.