September 11, 2015

This BOG Update is brought to you by Juan C. Sotomonte, MD, FACC, Governor-Elect of the Puerto Rico Chapter of the ACC.

Puerto Rico, with a population of almost 3.6 million people is suffering from one of its most serious economic, social and political crises since becoming a US territory in 1898. Richard Finger of the Huffington Post summed it up well when he wrote earlier this year; "Puerto Rico labors under a debt load so burdensome it is little more than a patient on life support."

After nine years of economic contraction and an exodus of nearly 10 percent of its population, Puerto Rico is no longer able to maintain its current level of spending. As health care is a significant component of the overall economy, the health care system is understandably facing unprecedented challenges and uncertainty.

The government is responsible for the health care of approximately 2.2 million people through Medicare and Medicaid programs. It is this relative dependence on federal health care programs, and the unequal federal funding treatment towards Puerto Rico, that has placed the entire health care system in a precarious state. Because of its territorial status and the use of figures that do not fairly reflect local market values, reimbursement rates and funding for both programs in Puerto Rico are significantly lower than in the 50 states. For example, Medicare reimbursement rates for hospitals and physicians are on average 25 percent lower in Puerto Rico than in the states.

More troubling is the fact that the dire economic situation of the island has recently compromised the government's ability to meet certain funding requirements related to the Medicaid populations, thus putting into question the very survival of the island's health care system. The future of this program hinges on the ability of local authorities to convince federal regulators to permanently lift the caps and funding limits imposed on Puerto Rico, which have been based mostly on its territorial status.

Medicare has approximately 750,000 beneficiaries in Puerto Rico, 75 percent of whom are enrolled in Medicare Advantage (MA) Plans. While states are receiving a three percent increase in MA funding in 2016, Puerto Rico's MA funding is slated to be cut by 11 percent, as the programs have yet to demonstrate claims of higher costs relating to the "dual eligible" populations. Since, at the end, the MA plans are run by for-profit corporations, those cuts are expected to flow directly to providers and patients, placing additional stress on the system. MA's exceptionally high penetration rate (70 percent vs. 30 percent in the U.S. mainland) in itself is a clear demonstration of how local factors affect final delivery of care.

Outcomes in the U.S. territories (of which Puerto Rico is the largest) for multiple cardiovascular conditions in Medicare beneficiaries are demonstrably inferior to those in the states. While it is true that the reasons for said findings are multifactorial, it is evident that payment inequality is a large contributing factor.

The increasing obstacles faced by health care providers in Puerto Rico are forcing many physicians to relocate to the U.S. mainland. If increasing practice costs and decreasing fees weren't enough, physicians, and by extension their patients, must also contend with ever more limited patient access, decreasing size of networks, insurers' refusal to give provider numbers to recent graduates (mostly for MA programs), scarce opportunities for preventive care and unfair competition from large systems who have their feet in both insurance and providers pools.

These economic and systemic challenges are unfortunately coinciding with very important demographic shifts in Puerto Rico. A declining birth rate and an aging population have made cardiovascular disease ever more prevalent, increasing demand for cardiovascular specialists.

The current health care system in Puerto Rico requires fundamental change. It is imperative, and we owe it to our patients, that we be part of the solution by becoming more involved in shaping the course of that change. We must place patients' well-being as our first priority and promote quality, inclusiveness, appropriate use of technology and lifelong education.

Metrics and objective comparable data will be key to determining effective changes in resource allocation. Our Chapter has helped introduce NCDR, and it will become a fundamental tool to help achieve our goals; it is no small task when one considers the obstacles noted above. We can no longer rely on others (politicians, regulators, insurance providers, etc.) to take the necessary actions required to fix the ailing system. We must make our voices heard and actively engage in crafting a sustainable solution.

Every crisis brings opportunity, and this crisis is giving us the opportunity to be instruments of positive change as we advocate for and help create a better health care system for all.