By: Dr. Jose R. Davilla

1. Current Issues Affecting Cancer
Care in Puerto Rico
José R. Dávila, MD
Immediate Past President
AHOMPR

2. PR Cancer Incidence: 2008-2012

3. Incidence: Increasing trend

4. Cancer Mortality 2008-2012

5. Mortality: Decreasing trend

6. Cancer as leading cause of death for
PR men as of 2010

7. Medical Oncology in Puerto Rico
• Two training programs:
– University of Puerto Rico (2 fellows/year)
– SJCH/VAH (Average 2-3 fellows/year)
• 100-120 practicing oncologists
• Most are Community Oncology Practices
– 1-5 physician groups
– Physician owned, self-standing clinics
• Few are Hospital-Based

8. Survey: 24 of 133

9. Health Care in Puerto Rico: Medicaid
• Medicaid a.k.a. “Reforma” or “Mi Salud”
accounts for 1, 565, 019 lives of the estimated
3,474,000 (45%)
• Mainland US much lower

10. Medicaid: 8 regions

11. 4 “Administrators”

12. What this means in Oncology
• Limits access or continuity of care for patients
living in “borderline” areas or who move while
on treatment

13. Most Oncologists in PR are Medicaid
providers

14. “Cubierta Especial”
• Cancer is an illness for which a “special
coverage” allows for patients on active
chemotherapy or radiation therapy to get
treatment without a “referral” from primary
physician
• Many ancillary medications are denied:
– Doxycycline for Cetuximab-associated rash
– Tamoxifen for patients with DCIS
– Tamoxifen/AI for patients once off chemo

15. Cubierta Especial still requires pre-
authorization process
• Even with “cubierta” most chemotherapy
medications need to undergo pre-authorization
process
• Will vary among the 4 administrators
• Fax-based, time-consuming
• Some are approved on a month by month basis
• Leads to delay in therapy while increasing
administrative burden on small practices with
limited personnel

16. 80% spend “too much time” on
pre-auth process

17. Pre-auth and delays in therapy

18. Medicare in Puerto Rico
• Over 500,000 lives = 20% population
• 75%-80% patients are under a Medicare HMO
(Medicare Advantage)
– MMM/PMC
– Triple SSS
– MCS
– Constellation
– Humana

19. Few “pure” Medicare patients in
Oncology practices

20. Medicare
Rates 2016 vs 2017
99213
(2016)
99213
(2017)
96413
(2016)
96413
(2017)
Puerto Rico $ 60.96 $ 67.76
(up 9%)
$ 97.95 $ 120.34
(up 19%)
USVI $ 71.94
(+ 16%)
$ 74.13
(+ 8%)
$131.46
(+ 25%)
$140.35
(+ 14%)
Florida
(avg)
$ 75.78
(+ 20%)
$ 78.90
(+ 14%)
$139.77
(+ 30%)
$147.92
(+ 19%)

21. “Medicare parity”
• Increase in 2017 rates are a result of revised GPCI
and scheduled for another increase in 2018
• Unfortunately only 20-25% of all Medicare
patients
• Part B drugs are not adjusted based on locality
(shipping, etc not taken into account)
• Small practices with less “purchasing power” for
competitive drug pricing results in high
percentage of underwater drugs
• Sequestration applied to drug reimbursement

22. Medicare Advantage

23. Medicare Advantage:
Disadvantage

24. SSS and MCS Advantage Rates
2017 are based on 2016 rates
MA
99213
Medicare
99213
MA
96413
Medicare
96413
Puerto Rico $ 60.96
(- 9%)
$ 67.76 $ 97.95
(-19%)
$ 120.34

25. MMM/PMC
Medicare MMM/PMC
99213 $ 67. 76 $ 55 (-19%)
99214 $ 100.07 $ 55 (-45%)
99215 $ 135.09 $ 55 (-60%)

26. Too much time spent on preauth

27. Delayed treatments as a result of
preauth

28. Across all plans

29. Clinical Pathways
• Are a means of controlling the escalating costs
of cancer care
• Have become more and more prevalent
• Most are insurance company-driven
• Can’t have a different pathway for each
insurance company
• Not all patients can fit the same “box”, have to
allow for some variability

31. ASCO Recommendations
• Pursue a collaborative, national approach to reduce the unsustainable administrative burdens
associated with the unmanaged proliferation of oncology pathways.
• Adopt a process for development of oncology pathways that is consistent and transparent to all
stakeholders.
• Ensure that pathways address the full spectrum of cancer care, from diagnostic evaluation through
medical, surgical and radiation treatments, and include imaging, laboratory testing, survivorship
and end-of-life care.
• Update pathways continuously to reflect new scientific knowledge, as well as insights gained from
clinical experience and patient outcomes, to promote the best possible evidence-based care.
• Recognize patient variability and autonomy and allow for physicians to easily diverge from
pathways when evidence and patient needs dictate.
• Implement oncology pathways in ways that promote administrative efficiencies for both oncology
providers and payers.
• Promote education, research and access to clinical trials in oncology clinical pathways.
• Develop robust criteria to support certification of oncology pathway programs; pathway programs
should be required to qualify based on these criteria, and payers should accept all oncology
pathway programs that achieve certification through such a process.
• Support research to understand the impact of pathways on care and outcomes.

32. Clinical Pathways in PR
• Two of the MA companies (MMM/PMC and
MCS) have contracted with SAS
• Not transparent as no access to pathways
• Not efficient
– Fax-based process in era of EMRs
– Increased administrative burden
• Delays in therapy very common
• “14 day rule” should NOT be applied in
Oncology

33. Timing of pre-authorization

34. Use of Specialty Pharmacy
• Most are in Metro-San Juan area
• Limited access for patient-pharmacy interaction
• Increases administrative burden to physician’s
office (which is NOT billable)
• Pre-authorization process tedious
• Poor communication between pharmacy and
insurance company
• Increasing steps results in delay of therapy
• However, SP still necessary with increasing drug
prices

35. The “one month rule”

36. In-office Dispensing
• As an option for oral drugs vs SP:
– Direct patient supervision and monitoring
– Access to Medical Records
– Refill access immediate
– Improvement in compliance
Cost savings vs PMBs?
• Frequently used in most mainland US
practices (where legal)
• Illegal in Puerto Rico as per Pharmacy Law

37. What are CMS rules?

38. Final thoughts
• We are ALL part of the problem
• Challenges lie ahead and times are changing
• We need to stay current with changes
• We will remain focused on our priority: OUR
PATIENTS and their ADEQUATE CARE
• Appreciate the partners met along the way:
– FLASCO
– COA
– ASCO