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The Health Department Gets A Check Up


March 1, 2001
Copyright © 2001 CARIBBEAN BUSINESS. All Rights Reserved.

To make the business of providing health services to Puerto Rico residents more cost effective, Health Secretary Johnny V. Rullan plans to slash costs, promote preventive health programs, increase the use of statistics in decision-making, and create regional medical webs.

Rullan, chosen by Gov. Sila Calderon to lead the island’s Health Department, envisions a department that takes pride in protecting and promoting the good health of the population. Although he agrees with efforts by the past administration of Gov. Pedro Rossello to provide health services to the medically indigent, Rullan has found a number of problems that must be dealt with if services are to be properly provided.

First, there’s the $87 million operational deficit left behind by the prior administration. The problem, according to Rullan, is mainly due to a duplication of administrative efforts and a large number of unnecessary costs. This shortfall, added to an annual 16% rise in medical costs in Puerto Rico, calls for immediate action.

"The health reform implemented by the past administration was a titanic effort that completely transformed the way in which medicine is practiced in Puerto Rico," Rullan, a renowned epidemiologist told CARIBBEAN BUSINESS. "Providing a health plan to all 78 municipalities in only eight years is admirable. From that perspective, I would say it was a great idea, but the question is about content."

The operational deficit

Because of the agency’s deficit, which has done away with the department ability to buy on credit, Rullan said they must purchase supplies C.O.D. In researching why the shortfall is so high, Rullan has found unnecessary professional services and computer maintenance contracts, too many cellular phones and obsolete vehicles.

"We found that there are many positions that can be eliminated. There were many unnecessary contracts with legal advisers, whose job can easily be performed by internal lawyers," he said. "We have Puerto Rico’s best lawyers in the Justice Department. There is no need for external resources in that aspect."

Telephone use also represents a big expense. CARIBBEAN BUSINESS learned that the department’s most recent phone bill totaled $600,000. Rullan said this is mainly because "everyone has cellular phones." He added that telephone service has been disconnected at least once for lack of payment.

The new Health chief also found that the previous administration bought several cars that aren’t needed, which he plans to sell. Rullan said he found that four mobile medical units —which cost an estimated $100,000 each— have been in the shop for repairs for two years and have not been fixed. "By now they must be completely obsolete," he said.

The root of many of these relatively small, but compounded problems is the fact that the past administration focused 100% of its energy in implementing the health reform, abandoning many other areas that need urgent attention, Rullan said.

The reform

The health reform, the Rossello administration’s pet project, also faces problems that must be solved as soon as possible if costs are to be contained. Data shows that during the eight years that Rossello was in power no one was denied the government-paid insurance card.

"This is probably the reason why a health plan intended to provide medical services to the island’s 900,000 medically indigent is being used by 1.8 million people," Rullan said.

This cannot continue, especially given the marked hike in medical costs each year. Keeping up with the current rhythm of expenses could translate in added costs of $200 million a year.

"I am totally in favor of looking out for the health of all Puerto Ricans, but I believe we must offer access to quality medical services at a reasonable price and we cannot keep going on like this if that is our plan," he said.

When asked whether he intends to take away the reform card from those who are not really eligible, he said no, noting that instead he would prefer to have them pay for the services obtained in accordance to their income.

Cost-containment strategies

    a. Preventive health

    "A disease prevented is a cost not incurred" is one of Rullan’s favorite sayings and it encompasses his vision of how wellness or preventive health programs can benefit the health industry and patients.

    "In wellness programs, for every $1 you invest, you get $5 back in improved image, productivity, and reduced health costs in the long term. This is a proven strategy, you just have to make it available," he said.

    Examples of how prevention and wellness programs help reduce or contain costs are many and they support Rullan’s point.

    According to an article in the Human Resources Executive magazine, Johnson & Johnson cut hospital costs in 1993 by 34% after three years of implementing a wellness program for employees.

    Another U.S. magazine, called Business and Health, reported in 1992 that a stress management program for employees and families instituted by Waste Management Inc., reduced the total number of health claims. This resulted in an estimated savings of between $3,750 and $15,000 per participant per year.

    Rullan emphasized that 80% of all deaths are due to specific lifestyles choices, such as tobacco use, non-controlled hypertension, alcohol abuse, poor nutrition habits, and a sedentary life.

    In addition, Rullan said in the last 10 years obesity has increased by 57%, while diabetes increases at a rate of 6% every year. These are mainly caused by the prevailing lifestyles mentioned above.

    To keep lifestyles from causing any more deaths, and to control the incidence of conditions such as obesity and diabetes, Rullan is promoting the implementation of prevention programs. This would allow the population to adapt their lifestyles and in the long run reduce the incidence of very expensive health conditions.

    One example of just such an easily prevented condition is heart disease, which according to an article written by Rullan, cost the U.S. about $52.4 billion in 1990. The Puerto Rican Heart Association reported that heart disease is the main cause of death on the island.

    To provide preventive health programs to the population, Rullan plans to adapt his B-Well concept to a community-based model. In addition, he hopes to improve already existing preventive efforts.

    "The past administration tried to implement many preventive programs and even spoke about them as theories. The good intentions were there, but the implementation of the health reform absorbed everything, and rightly so because it was a titanic effort," said Rullan.

    For example, he said the Rossello administration did many things it considered necessary to reduce the number of children that begin smoking. "Many laws were passed to prevent children from acquiring smoking habits, but still more and more children start smoking every day," he said, adding that this is an ascending trend despite all the prohibitions related to cigarette consumption, which have not solved the problem.

    To tackle the cigarette use among youth, Rullan’s team has already designed a campaign in conjunction with the Puerto Rico Lung Association, which aims at reducing the rate of smokers in the island by 10% this year. Currently, only an estimated 2% of smokers kick the habit every year in Puerto Rico, according to Puerto Rican Lung Association officials.

    This campaign, parts of which are already in motion, aims to prevent smoking habits in children aged 11 and 12 — the age when most smokers acquire the habit. It also targets adult smokers and provides information and resources to kick the smoking habit.

    Rullan said 2,500 people die every year in the island due to tobacco use. He added that Puerto Ricans spend $381 million annually buying cigarettes, and that treating the many diseases caused by smoking costs $54 million a year.

    b. Information for action

    Implementing sound prevention programs and finding other ways to contain mushrooming medical costs depends greatly on the gathering of statistics. According to Rullan, the past administration did not place much importance on statistics, and now there is a lack of information on prevailing health trends on the island.

    "Epidemiologic information to know what are the prevailing lifestyles was not obtained," he said. "Statistics must be updated so we can make informed decisions." Knowing which diseases are the most common, what causes them, and which are the risk factors associated to them helps design plans to prevent and eradicate the diseases, Rullan added.

    Moreover, knowing which medications are most widely used by the population can help the government obtain discounts in prices from pharmaceutical companies, he added.

    "Health crises cannot be solved unless you have an intelligence system that tells you what is going on," he noted.

    To solve the statistical problem, Rullan plans to work closely with the Health Insurance Administration (known as ASES for its Spanish initials). "ASES has to make available all the information health insurers have submitted to it," he said, adding that health insurers have done a great job of documenting the population’s diseases, conditions, and use of medications. "The only problem is that the state agency has not provided that information."

    In addition, Rullan already has plans to develop statistical activities to obtain information on the population’s health, especially regarding cancer and AIDS. "The cancer cases have not been registered appropriately, even though there is a legal obligation to report every case," he said.

    Because the cancer register depended on reports from hospitals, control over this information was lost once the government hospitals were sold to private companies as part of the health reformand the government never demanded that the register be continued. "We will now have to rebuild a registration system that took years to implement," he said.

    In response to that situation, Rullan said he will work on studying the incidence of cancer, especially in Vieques. Once that is done, he will implement a plan to find out what is the trend regarding this disease.

    This is also more or less the same situation with the HIV and AIDS epidemic, Rullan said . "We have no idea of what is going on with HIV. We don’t know if it is really controlled. All we know is that the medications are working effectively."

    To gather data concerning HIV and AIDS, Rullan proposes to make HIV a reportable disease by law, always keeping the information confidential to protect those suffering from the disease.

    c. Regional medical webs

    Another strategy that will help contain costs and prevent outbreaks will be the creation of effective regional medical webs. For one, he said there are regional medical directors who have little if any contact with the physicians, laboratories, and other health providers of their region.

    "Before the reform, health providers were pretty much homogeneous in nature, but now, after the sale of many facilities, each region has a mix of providers," Rullan said. While some facilities are owned by the central government, others are owned by private medical groups, medicine schools, hospital-based corporations, or municipalities, he added, noting that medical directors can’t effectively communicate with all these groups.

    To solve this, he proposes the creation of regional medical webs headed by a medical director and comprised by a board with members of each medical management group existing in the specific region.

    Said Rullan: "For example, if a certain region is comprised of facilities owned by private medical groups and municipalities, then both groups should have representation in the web."

This Caribbean Business article appears courtesy of Casiano Communications.
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