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MMAPA CMOs: Managed Care Is Key to a Healthier Puerto Rico

By Dr. José Novoa: Dr. Novoa Chairs MMAPA’s Committee of Chief Medical Officers.

Full op-ed published in El Nuevo Dia on November 22, 2022.

In Puerto Rico, more than 9 out of 10 eligible Medicare beneficiaries have chosen the Medicare Advantage (MA) program to receive their benefits under a managed care model that offers them greater benefits at a lower cost.

This assessment prevails as 94% of seniors eligible in Puerto Rico opt for MA health plans as their choice to receive Medicare benefits. This program is based on a model of managed care to meet their healthcare needs and it is the selected option for nearly half of Medicare beneficiaries in the U.S.

Moreover, nearly 98% of eligible beneficiaries who also have Medicaid (those who are dually eligible) have selected Medicare Platinum to receive their Medicaid benefits jointly with those that are available under the MA platform. Nearly 98% of those who are beneficiaries of Medicaid with Medicare Parts A and B are affiliated to the Medicare Platinum program, with only 2% in the Vital program (Medicaid in Puerto Rico).

The combination of these factors makes the MA open enrollment period an event of singular importance for Puerto Rico’s healthcare system. That is why we, the Chief Medical Officers of the six healthcare companies in Puerto Rico, have come together to explain the importance this selection process has for eligible citizens and highlight that managed care is a key tool for the health of our seniors.

Our priority is to ensure that there is access to quality healthcare services, especially for our seniors. Currently, managed healthcare plans are the best option to ensure that our beneficiaries can save while they have access to the tools needed to have the healthiest life possible.

For example, the holistic approach of managed care addresses some of the social determinants of health—like lack of a vehicle or economic difficulties—that are related to poorer health outcomes, with MA plans providing benefits to buy groceries and other necessities and providing transportation to medical appointments, church, the store, and more. By offering benefits for the purchase of groceries or other needs and transportation for medical appointments, church, the supermarket and more, MA plans are addressing social factors, as encouraged by the federal government. Nowadays we know that a patient's access to transportation or healthy food is just as important as having control over their blood pressure or blood sugar levels.

Physicians in managed care models aren't a passive part of life that patients see just for an annual check-up or in an emergency—their success relies on close contact to ensure their patients receive the preventative care, chronic disease management, and medications they need. This frequent care is the best way we have to avoid the development of preventable conditions, detect disease in early stages that avoid health complications in the long run, and reduce the risk of death in many patients.

The rise of managed care in Puerto Rico comes both as a result and in spite of the harmful funding inequities that have damaged our territory's entire healthcare system. Over the last few decades, we've seen that funding gaps have resulted in traditional Medicare plans lacking the resources required to provide beneficiaries with the services they rely on. This has contributed to the shift toward MA among seniors, which can offer a greater variety of benefits to help beneficiaries meet their needs without breaking the bank.

Despite Puerto Rico receiving the lowest federal reimbursement rates for MA in the country, MA healthcare plans offer some of the best healthcare options on the island thanks to managed care. Imagine the good that this model could do for our communities if the federal government properly funded our MA program to pay for Part B premiums for the indigent population and addressed exclusions in benefits such as long-term care.

For decades, Puerto Rico’s healthcare system has not been funded adequately by the federal government. Compared to the citizens who live in the states, we have one of the lowest funding rates for the Medicare Advantage and Medicaid programs. This is in addition to being excluded from the federal low-income subsidy for Medicare Part D. Citizens living in Puerto Rico are excluded from that benefit. The disparity in funding has contributed to high rates of chronic disease and poverty among the citizens living in Puerto Rico, which has exposed millions to a greater disadvantage. Medicaid beneficiaries who have Medicare are the only ones in the U.S. who have to pay the Part B premium of $164.90 even if they are 100 percent under the federal poverty level.

Managed care is the backbone of our healthcare system for seniors and, as we recover from the disruption of Hurricane Fiona, it is imperative that our most vulnerable citizens continue to receive the care they need. There are over 60 MA plan options available now—we strongly encourage eligible seniors to review the benefits offered by each option, make sure their doctor is in network and medications are covered, and choose a plan that addresses their social determinants of health and meets all of their health needs.

Dr. Ángel Rivera Martínez (First Medical), Dr. Ivonne Vega (Humana), Dr. Inés Hernández Roses (MCS), Dr. Diego Rosso-Flores (MMM), Dr. Gregorio Cortés-Soto (Plan de Salud Menonita), and Dr. José Novoa (Triple-S) are Chief Medical Officers for the leading Medicaid and Medicare Advantage organizations in Puerto Rico, collectively known as MMAPA, the Medicaid and Medicare Advantage Products Association of Puerto Rico.

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