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  • Radiology Struggles to Weather the Devastation from Hurricane Maria 

    More than seven weeks after Maria, scores of outpatient imaging centers are still not up and running. By Stephan Benzkofer

    November 16, 2017

    The day before Hurricane Maria pummeled Puerto Rico, diagnostic radiologist Dennis Pérez, MD, sent his employees home to their families and closed up the imaging center located just west of San Juan.

    Expecting the worst, Dr.  Pérez , who operates Vega Alta Radiology, paid his staff the day before the Sept. 20 storm made landfall.

    What happened that day was something Puerto Rico has not experienced in more than a century.

    The storm was a 50-mile-wide hammer that pounded homes, hospitals, roads, and the power and communications systems with sustained 155 miles per hour winds, devastating flooding and torrential rain.  More than 50 people were killed by the storm or in the aftermath. The entire island, home to 3.4 million people, lost power.

    And Maria hit just two weeks after Hurricane Irma lashed the northeast corner of Puerto Rico.

    “It was very, very stressful,” said Dr.Pérez, who spent the following weeks cleaning up the flood damage and repainting and sanitizing the 6,000-square-foot facility. “There was no communication with the southern part of the island. The highway was closed. The system had collapsed.”

    More than seven weeks later, more than two million people on the island still wait for electricity, while tens of thousands wait for cell phone service and clean water.

    And the worst could be yet to come, said Fernando Zalduondo, MD, a neuroradiologist whose imaging practice, San Patricio MEDFLIX, in Guaynabo near San Juan, sustained major structural and water damage in the storm.

    “Right now we have a healthcare access crisis that will only exacerbate in the coming months,” said Dr. Zalduondo, a past president of the Sociedad Radiologica de Puerto Rico (SOCRAD), American College of Radiology (ACR) Chapter.

    Scores of Outpatient Imaging Centers Still Closed

    Maria was just one in a string of catastrophic hurricanes that churned through the Atlantic Ocean in September — one of the deadliest, and costliest, hurricane seasons on record. Hurricane Harvey killed 75 people, mostly in Texas, while Hurricane Irma caused more than 80 deaths in Florida and the surrounding areas including Puerto Rico, according to news reports.

    Hurricanes Harvey and Irma alone were expected to cost the U.S. between $150 and $200 billion in combined property damage, while damage from Hurricane Maria is expected to top $72 billion.

    But recovery efforts in Puerto Rico have been considerably more challenging.

    In an email from Puerto Rico last week, U.S. Rep. Luis Gutiérrez (D-Illinois) said the situation needs to be stabilized quickly to save lives.

    “It is much more dire than most people on the mainland think and almost no progress has been made since the storms hit,” said Gutiérrez, whose parents moved to Chicago from Puerto Rico in the 1950s.

    While the main hospitals are operating normally, scores of outpatient imaging centers remain closed or are lacking necessary generators and fuel to reopen.

    Dr. Zalduondo struggled to reopen his 55-member practice with a skeleton crew of staff who stayed in Puerto Rico through both hurricanes. Power was not restored to San Patricio MEDFLIX until late October, he said.

    Dr. Pérez was not able to re-open his practice until Oct. 31. At that time, just six of his 20 employees were on staff to handle about 26 patients, about a third of his daily pre-storm schedule, said Dr.Pérez, also a past SOCRAD president.

    His Vega Alta clinic has been powered with a temperamental, diesel-fueled generator that runs the lights and air conditioning and allows him to perform x-rays and ultrasound. But he must power down another piece of equipment before operating a CT or an MRI machine.

    The need for diesel fuel has spiked the already exorbitant cost of electricity, attributed partially to an already-failing electrical grid. Before Irma and Maria eliminated the power grid, electricity averaged about 20 cents per kilowatt-hour (kWh), double the U.S. average cost, according to government data.

    After the storms, with diesel-fueled generators delivering power at closer to 75 cents/kWh, many outpatient radiology practices cannot afford to reopen. Restarting a flooded MRI machine, of which there are dozens, could set a practice back $30,000.

    Reimbursement Cuts Contribute to Devastation

    But the two storms may not have been the worst things that happened to radiologists in September, said Jorge Vidal, MD, the current SOCRAD president.

    The more devastating, long-term blow may have been the implementation of sharp reimbursement cuts by the local health agency effective Sept. 1.

    “Maria was terrible, but it came and went,” Dr. Vidal said. “But it is the inequities in reimbursement that is killing medical radiology practices in Puerto Rico — not Maria.”

    For years, radiologists on the island have been fighting against the head winds of a bureaucratic and economic perfect storm. Because of a longstanding federal law, Puerto Rico’s Medicare funding is capped, limiting the effective reimbursement rate to 15-20 percent compared with a 55 percent rate for the U.S., according to a September 2016 report by the nonpartisan Center on Budget and Policy Priorities.

    More than half of Puerto Rico’s residents are on Medicaid. The territory’s government tries to make up the difference, which adds to the island’s debilitating debt.

    After a fierce, years-long lobbying effort, local ACR officials last year persuaded the Centers for Medicare & Medicaid Services (CMS) to increase reimbursement rates for radiological services.

    “We lobbied hard and presented our case and said, ‘Look, this isn’t sustainable,’” Dr. Vidal said. “Finally, CMS said, ‘The evidence is here, we are going to give you more funding.’”

    But this summer, the battle shifted to the local level when the Puerto Rican Secretary of Health and other officials proposed cuts that would more than erase the CMS gains.

    All that went by the wayside when Irma hit, Dr. Vidal said.

    “Now we were in catastrophe mode,” he said. “Reimbursements were no longer the main focus — the priority was the people.”

    Keeping Puerto Rico in the Conversation

    Patients continue to be the focus of radiologists, who are working to ensure the catastrophe in Puerto Rico does not fall off the world’s radar.

    The most important contribution supporters can make is to help keep Puerto Rico in the conversation, they said. “This isn’t even close to being over,” Dr. Zalduondo said.

    Dr. Pérez agreed.

    “Press your congressman to pay attention to the healthcare situation in Puerto Rico,” he said. “The situation is likely to get worse in coming days and months. If something is not done, radiologists will basically disappear.”