Primary Care Transformation in Puerto Rico's Physician Organizations Following Hurricane Maria

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Project Summary/Abstract In September 2017, Hurricane Maria brought unprecedented devastation to Puerto Rico. The Hurricane’s impact was disproportionately borne by elderly patients and residents of remote areas of Puerto Rico who were vulnerable to disruptions in health care services. Providers and policymakers are currently seeking to make major investments in Puerto Rico’s primary care delivery system that were outlined in Puerto Rico’s recovery plan. However, the ability of Puerto Rico’s physician organizations (POs) to undertake large-scale primary care transformation remains unclear. In particular, POs might differ widely in both their existing primary care infrastructure as well as the level of technical or financial support they typically receive to implement new infrastructure from the health systems or independent physicians associations with which they are affiliated, from the Medicare Advantage plans and Medicaid managed care organizations with which they contract, or from the federal government. The proposed study, which builds on an existing collaboration between RAND and the University of Puerto Rico, will examine four models of physician organization in Puerto Rico: federally qualified health centers, small independent medical groups, large independent medical groups, and vertically- integrated medical groups. We will use Medicare fee-for-service claims and Medicare Advantage encounter data to assess trends in the physician workforce providing care through these four delivery models, the Medicare beneficiaries who receive care through each model, and changes in both trends following Hurricane Maria. We will then assess changes in access, quality of care, and care coordination before and after Hurricane Maria to measure differences in performance across PO models and to identify high-performing POs and low-performing POs in each model. We will conduct interviews with leaders of 32 of the highest-performing POs and lowest-performing POs in each model to identify the advanced primary care infrastructure they have sought to implement as well as implementation barriers. Finally, we will interview Medicare beneficiaries living with Alzheimer’s disease (or Alzheimer’s disease related dementias) and their caregivers to better understand their unmet care needs and how these needs differ across the four PO models. The research will be guided and supported by an Advisory Committee comprising representatives of two local provider associations and two local patient advocacy groups that represent older adults and people living with Alzheimer’s disease and Alzheimer’s disease related dementias. The study will help to identify specific models of physician organization that are associated with higher performance that could help guide Puerto Rico’s Hurricane Maria recovery effort. Our findings could also help stakeholders prioritize the expansion of specific services that could most directly improve the lives of patients with Alzheimer’s disease or Alzheimer’s disease related dementias and their caregivers and identify the types of POs that might need greater support to address current gaps.