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Este informe no está disponible en español. CARIBBEAN BUSINESSThe Doctor Is In: Can Puerto Rico Become The Medical Hub Of The Caribbean?Healing near home: Puerto Rico’s hospitals now offer locals and Caribbean neighbors the latest in medical facilities and servicesBy TAINA ROSAJanuary 9, 2003 The number of local patients who leave Puerto Rico for health treatment has in general decreased in the past 10 years while the number of patients who come to Puerto Rico for treatment from other islands in the Caribbean has increased. This trend suggests Puerto Rico has the potential to become the medical hub of the region. Local hospitals have invested millions of dollars to modernize both their equipment and facilities. In fact, local hospitals such as Auxilio Mutuo, PaviaHealth, Ashford Presbyterian, and San Pablo Health System, have invested an estimated $65 million in infrastructure upgrades since 1999, according to the project announcements each hospital has made in the past three years. Procedures that were once unheard of in Puerto Rico--such as heart transplants--are now available on the island. In many cases they rival services offered at the best hospitals on the U.S. mainland and more are in the works. Patients from all over the Caribbean--but particularly the U.S. Virgin Islands--flock to Puerto Rico for treatment. Industry sources say they come because the specific treatment they need isn’t available in their home country or because they feel facilities there aren’t as advanced as they are in Puerto Rico. Patients from other Caribbean islands also choose Puerto Rico for their health needs because it is closer to home in comparison to any location in the mainland U.S. and easier for their families to visit them. It is also cheaper to be treated here than in the States. But recent trends--such as the increase of the elderly population covered by Medicare--are threatening to thwart Puerto Rico’s hopes of becoming a medical destination because of the financial difficulties this change represents. According to hospital executives, although local hospitals are offering many sought-after medical specialties and have brought in a lot of the latest technology, they still have a long way to go before becoming another Houston or Miami, two places on the U.S. mainland that are already considered medical hubs. Arriving in Puerto Rico’s hospitals "Patients from all over the Caribbean--but especially from the Virgin Islands--come to Puerto Rico to receive all sorts of tertiary diagnostic and treatment services," said San Pablo Health System CEO Milton Cruz. Tertiary services, he explained, are medical subspecialties such as cardiovascular surgery and pediatric oncology. "Patients come to Puerto Rico for these specialties because our medical offerings are on a par with those on the U.S. mainland. They also come to receive complementary services that aren’t available in other places," he said. Complementary services are those medical services that are performed to treat complications of the main illness from which a patient is suffering. For example, an HIV patient could catch pneumonia. In this case, the treatment for pneumonia would be a complementary service. Auxilio Mutuo Hospital Administrator Ivan Colon told CARIBBEAN BUSINESS foreign patients also visit Puerto Rico’s medical facilities to undergo specialized surgical procedures and cancer therapy. "In the case of specialized surgery, we have seen that patients from other countries come here for eye surgery and orthopedic surgery. In the case of cancer therapy, they come looking for services that aren’t available in their own countries." Pedro Gonzalez, executive director of Ashford Presbyterian Hospital in Condado, said patients from other Caribbean islands come here for nuclear medicine services, which are basically dedicated to performing diagnostics. "Within diagnostics, they come mainly for cardiovascular diagnostic tests," he said. Gonzalez agreed with Colon and Cruz that many also come in search of specialized surgical procedures such as pediatric orthopedic surgery and urology surgery. "At Pavia most nonlocal patients, if not all, come from the U.S. Virgin Islands," said PaviaHealth Executive Vice President Alfredo Volckers. "They come for tertiary services, but also for ambulatory services, such as magnetic resonance imaging (MRI) and catheterization laboratories." He added that many of these patients come to Puerto Rico because they perceive local physicians as better qualified. Gonzalez said according to statistics from Ashford Presbyterian, the great majority of nonlocal patients receiving medical attention in this hospital are from other Caribbean islands, with most coming from St. Thomas, U.S. Virgin Islands (see chart). "We see an average of 70 patients from other Caribbean islands every month, which represents revenue of about $25,000 to $30,000 a month. About half of these patients are full-pay while the other half are covered by health plans," explained Gonzalez. Colon said at Auxilio Mutuo, most of these patients are full-pay patients, while Volckers observed this isn’t necessarily the case at Pavia, where most nonlocal patients are covered by health plans, although he said many do pay cash for services. Ludi Madera, admissions coordinator at physical rehabilitation hospital HealthSouth, said that institution treated about 10 patients from the U.S. Virgin Islands in 2002. She added they were referred by their own local hospitals, which don’t have the necessary infrastructure to offer the rehabilitative therapy, and their expenses were covered by Medicare. Sources at Clinica Las Americas, a medical office complex in Hato Rey offering all kinds of medical specialties, couldn’t give precise figures, but said "all medical offices here constantly receive patients from the Virgin Islands." Industry sources said that as local hospitals continue upgrading their medical technology and adding new specialized procedures and treatments to their roster of services, more nonlocal patients are bound to come to the island for medical needs. Marketing health services to foreigners Although Puerto Rico receives visits from residents of other Caribbean islands who come for medical purposes, no local hospital is currently pursuing these patients through marketing campaigns. Doing so could attract more patients--including full-pay patients--and increase their chances of attracting much-needed funds. "At Pavia we did once develop marketing efforts aimed at residents of the U.S. Virgin Islands and we also gave seminars to physicians over there. Once we even considered purchasing hospitals in Central and South America and traveled to see them, but we concluded it wasn’t the right time to do so," said Volckers. Volckers said he doesn’t know of any local hospital currently marketing its services outside of Puerto Rico. "Under the Rossello administration the Puerto Rico Industrial Development Co. (Pridco) developed a committee to attract foreign patients, but this never got a chance to really take off, although the committee still exists," he added. Puerto Rican patients going stateside "Nowadays there’s no reason for a local patient to travel to the U.S. mainland to receive treatment, unless the patient has a rare condition that requires supra-tertiary services with a special protocol," said Volckers. An example of a supra-tertiary service is lithotrity surgery, performed to crush bladder stones. Cruz is of the same opinion. "There are cases of local patients going to Texas for cancer therapy, but that doesn’t mean that service isn’t available here. We have everything here," he said. Colon said local patients go to the U.S. mainland to be treated for uncommon types of cancer, some types of transplants, or for certain types of specialized surgery. "For example, many people still go to the States for pediatric surgery to correct congenital defects or for treating extremely complex neurological conditions. They also go for liver or pancreas transplants which aren’t still performed here." Gonzalez’s opinion was in line with the others. "Puerto Ricans leave the island for some oncology treatments, and bone marrow or liver transplants." According to information provided by the Catastrophic Illness Fund (CIF) of the local Health Department, there were 554 cases of local patients receiving treatment in the States during fiscal year 2001-02. The CIF contributed almost $19 million for local economically disadvantaged patients to undergo life-saving operations. Liver transplants alone, which aren’t performed locally, represented 99 cases--or $8.4 million--during the year and were performed at stateside institutions such as Jackson Memorial Hospital, Tampa General Hospital and the Mayo Clinic in Florida; Mount Sinai Hospital in New York, and Ochsner Clinic in New Orleans. The cost of this type of transplant ranges between $230,000 and $300,000, according to the CIF. In fiscal 02, CIF also covered 32 allogeneic (from a donor) bone marrow transplants, 15 heart transplants, 15 transplants of cornea, lung, kidney, or pancreas, and more. Although some of these transplants--such as heart transplants--are performed in Puerto Rico, many patients are put on waiting lists in different hospitals both here and stateside and are sent to the institution that first comes up with the organ they need, explained Ivonne Del Moral, director of the CIF. But it’s more than just specialty and transplant patients. Affluent locals still go to the States not realizing that in many cases the medical services here are just as good. What it takes to become the medical center of the Caribbean Although most medical specialties are available in Puerto Rico, the island is still a long way from becoming as sophisticated as Houston or Miami, already considered medical destinations on the U.S. mainland, according to Volckers. Some of the best known medical institutions in Texas are Saint Luke’s--specializing in cardiovascular health--and M.D. Anderson, specializing in oncology. Meanwhile, some of Miami’s top facilities are Jackson Memorial and the Miami Heart Institute. "In Miami, there is a structured effort to market medical services, which doesn’t exist here. There are affordable hotels that service the hospitals that treat nonlocal patients, and this isn’t quite the situation here, where hotels are very expensive. Imagine, at Pavia we were able to negotiate deals with the Best Western Pierre Hotel and with another hotel in Santurce that provide rates of about $90 per night, which is still very expensive," Volkers said. Houston has a similar set up, including shuttle services between hotels and medical centers. The stateside medical hubs also interact with medical schools and researchers at the medical facilities. Steps in the right direction The light at the end of the tunnel still shines and Puerto Rico’s hopes of becoming the medical hub of the Caribbean could be fulfilled if hospitals continue staying abreast of the latest medical technology and procedures. But local hospitals also need the federal government to chip in, particularly when it comes to Medicare reimbursements. Puerto Rico hospitals are reimbursed up to 75% of the cost of care while stateside hospitals receive 100% reimbursement for Medicare patients. Parity in Medicare payments is necessary for local hospitals to achieve solid financial health and be able to market their services to patients in other countries. Local hospitals plan to continue investing in their facilities this year. Colon said Auxilio Mutuo will focus on enhancing its oncology, pediatric, and cardiovascular services. "In oncology we want to increase the level of technological complexity and we recently opened our state-of-the-art Cancer Center. In the pediatric area, we have seen an increase in patients and we will continue to search for specialists; we have already identified some we will pursue. In the cardiovascular area we plan to enhance the care we offer our patients and achieve better morbidity rates." "In the [next few] months we should finish remodeling the emergency room and the neonatal intensive care unit, which represents an investment of about $1 million," said Gonzalez. "We are also investing about $7 million to increase the number of beds for surgical recovery from 184 to 207, the limit allowed by our Certificate of Need & Convenience. That investment also includes the purchase of equipment for the operating room and outpatient surgery room." Investments at Ashford Presbyterian continue as well. "We are also planning to invest about $2 million in the obstetrics area to double the beds in our labor, delivery, and recovery rooms from eight to 16," said Gonzalez. Pavia is also planning investments this year. "This year we will invest around $2 million in equipment for our catheter lab, to digitalize our radiology area, and to automate our information systems," said Volckers. Warning signs Despite the fact the Health Department spent more than $18 million in FY 2002 to cover the transplant expenses of local patients on the U.S. mainland, there are no new transplant programs being developed by local hospitals, according to information provided by LifeLink of Puerto Rico. "There are currently two hospitals that perform transplants in Puerto Rico. Auxilio Mutuo does kidney transplants and the Cardiovascular center does heart transplants, but we don’t know of any other local institution developing services for transplanting livers, pancreas, or anything other than heart and kidney," said Maritere Mendez, public relations director. However, keeping up with technology and trends won’t suffice to make Puerto Rico the medical center of the Caribbean. Trends point in the direction of an increase in the size of the elderly population. This, coupled with insufficient Medicare reimbursements will spell financial danger for hospitals, in fact it already does. "Hospitals should consider developing or enhancing their geriatrics services. The elderly population is bound to grow as the general population grows and life expectancy increases," said Gonzalez. According to the District of Columbia Consortium for Nursing Education & Practice, by 2030, the over 65 age group in the mainland U.S. is expected to increase from 39.4 million in 2000 to 69.4 million, or 20% of the population. The local health executives said the trend should be similar for Puerto Rico. The problem arises because so many elderly are Medicare beneficiaries, and Medicare reimbursements to Puerto Rico are lower than those of any state. "We lose money with every Medicare case and if reimbursements aren’t increased to 100% in a matter of six months, many local hospitals will have to seriously consider not accepting Medicare patients," said Volckers. He added that at the moment, Medicare patients represent half the patients the hospital receives. "Now, only half of our patients are Medicare beneficiaries and we are in serious financial problems. Imagine how it will be when they compose a larger percentage of our patients. If this problem isn’t solved immediately, Puerto Rico can stop dreaming of becoming the medical center of the Caribbean." Medical facilities in the U.S. Virgin Islands improving but still small compared with P.R. facilities A travel guide for the U.S. Virgin Islands informs travelers there are "hospitals on the islands, but due to our [the territory’s] smaller. . . population they can’t offer every service you might need; you might have to go to Puerto Rico or the States in an emergency." It is no wonder then that Puerto Rico’s hospitals continue to receive visits from patients in the U.S. Virgin Islands, though the medical facilities in the region have been improving through the years. For instance, the Gov. Juan F. Luis Hospital & Medical Center in St. Croix announced on its website that it plans to develop state-of-the-art medical care facilities, including a diagnostic cardiology catheterizaton laboratory. It also announced the expansion of its physical therapy department, to offer more extensive services for acute-care patients and those requiring cardiac rehabilitation. Formerly known as the St. Croix Community Hospital, the hospital was rebuilt in the early 1990s, at an investment of $18 million, after it was damaged by Hurricane Hugo, according to the Office of Insular Affairs (OIA) of the U.S. Department of the Interior. The OIA also reported St. Thomas Hospital was built in 1982 as a full-service medical center with a 250-bed capacity and, like the Gov. Juan F. Luis Hospital & Medical Center, was renovated in the early ’90s. Additional medical facilities on the islands include the Eldra L.M. Schulterbrandt Community Health Center for the psychologically unbalanced, the Ingeborg Nesbitt Clinic & Urgency Center, and the Myra Keating Clinic. Caribbean Patients Visiting Ashford Presbyterian Hospital Pedro Gonzalez, executive officer of Ashford Presbyterian Hospital in Condado, told CARIBBEAN BUSINESS the hospital receives an average of 70 patients from other Caribbean islands each month. Following is more information on these visitors: Where are the patients from? 70% come from St. Thomas and St. Croix; 30% come from St. Maarten, St. John, Tortola, and Antigua. What services do they seek? 40% seek treatments or procedures such as specialized surgery; 60% seek diagnostic tests or nuclear medicine services. Local hospitals cover practically every medical specialty "Puerto Rico’s hospitals are comparable to those on the U.S. mainland. We can offer the same services here," said Alfredo Volckers, executive vice president of Pavia Health. There is no need for local patients to go stateside for treatment in most cases, he added. This Caribbean Business article appears courtesy of Casiano Communications.
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