Tale of Three Territories

Guam, Puerto Rico and Virgin Islands Chapters Face Unique Challenges

July 31, 2014 04:16 pm Jessica Pupillo

Despite shortages in health care resources, funding inequities and high costs of living, many family physicians are passionate about practicing in the United States territories. The unique heritage and culture of Guam, Puerto Rico and the U.S. Virgin Islands, along with a commitment to their fellow islanders, keeps family physicians rooted in these unique communities.

Virgin Islands AFP delegate Cora Christian, M.D., right, poses during last September's Every Step Saves a Beat! event in St. Croix, V.I. More than 500 residents participated in various activities and educational sessions.

Still, there's no denying that these regions feel the effects of some key differences between U.S. states and territories.

Residents of Guam, Puerto Rico and the U.S. Virgin Islands are U.S. citizens, but they cannot vote for president. Territory citizens elect nonvoting delegates to the U.S. House of Representatives. Most do not pay federal income tax; however, they do pay many other federal taxes, including Social Security and Medicare.

The Patient Protection and Affordable Care Act provided little help for the territories because they did not receive the subsidies that states did, and none of them have insurance exchanges. Earlier this month, HHS announced that several of the law's mandates would not apply to the territories, including a requirement that insurance companies cover essential health benefits and spend 80 percent of premiums on the direct health care of those insured. Federal matches for the Medicaid programs in the territories are capped, and territory matches are higher than those of most states.

It's a scenario one Guam AFP member -- Walter "Chris" Perez, M.D. -- likened to that seen during an earlier period in U.S. history. "'Mandates without subsidies,' is the territories' battle cry," said Perez, "eerily similar to the colonies' '(No) taxation without representation.'"

Story highlights
  • Some of the AAFP's smaller chapters face unique challenges with often limited resources.
  • The Guam, Puerto Rico and Virgin Island AFPs struggle, to varying degrees, with delivering consistent, high-quality care while maintaining their own ranks.
  • Still, chapter members find creative ways to spread family medicine's message of the importance of prevention and patient self-management.

Guam Family Physicians Provide "High-Touch" Primary Care

Fifteen hundred miles east of the Philippines lies the roughly 210-square-mile tropical island of Guam. This westernmost U.S. territory is home to 22 Guam AFP chapter members, including Perez, a former chapter delegate, and his wife Debra Ericson, M.D. Perez and Ericson opened Family Medical Clinic in Barrigada with two internists in 1985. The four physicians still practice together, providing care to Guam residents who are known for being "very, very considerate of their doctors," Perez said. "They tend to be very appreciative of the care that we give."

The Guam AFP doesn't have the financial ability to offer its members much support, so the chapter keeps dues low, said William Weare, M.D., chapter executive and a physician in Guam's Southern Region Community Health Center in Mangilao. The chapter doesn't hold formal meetings, but members routinely rely on each other to help care for the population, often treating each other's patients during vacations and other time away.

"We don't have that sense of competition you often see. Nobody cares who has the better looking chairs in the waiting room. We're just happy we have chairs," Perez said with a laugh.

Specialty care on Guam is available, Perez noted, but there is little depth to the specialist rosters. And only one government hospital, Guam Memorial Hospital, serves Guam's civilians. A second, private hospital is expected to open in 2014. To access high-level care not available on-island, patients travel more than three hours by plane to the Philippines or 7 1/2 hours to Honolulu.

Although Guam has a shortage of health care professionals, the physicians on the island remain well-qualified, said Perez, and are known for providing "high-touch" care in their clinics and throughout the community.

Just like the other territories, Guam struggles to provide health care to the uninsured and those who receive public assistance.

Facts About the Guam AFP

Chapter executive director: William Weare, M.D.
Number of chapter members: 22
Year chapter was chartered: 1992
No website or annual meeting

Guam Memorial Hospital is broke, Perez explained, because there is no money for Medicaid. "Much of the uninsured can qualify for government insurance, but that is only (in) name." The federal match for Medicaid is capped, and Guam's government can't bear the burden of paying for coverage beyond the match. "It's one of the perennial requests by our representative in Congress ... to raise that match," he said.

"In addition, Guam has been burdened for years by the U.S. treaty obligations with the Marshall Islands, Federated States of Micronesia and Palau, which allow unrestricted immigration -- often of quite ill individuals -- which adversely impacts the financial well-being of Guam's health care system with no equitable reciprocal payment for these services from the U.S. government," said Weare. "This is also a problem for Hawaii and some other states, but at least they have some ability to respond with voting members of Congress."

Even so, Guam remains a patriotic island, grateful to the United States for liberating its residents from Japanese forces during World War II and home to two military bases. It's also a place where the economy is driven largely by tourism, and Perez wants travelers, particularly older travelers, to know that Guam's FPs are prepared to treat them if the need arises. As he put it, primary care on Guam is "just as good as any place in the states that has the same challenges we have."

Active Puerto Rico Chapter Works to Maintain FP Workforce

The Commonwealth of Puerto Rico is the largest of the U.S. territories, with 3.6 million people (that's three times the population of Hawaii), and, in many ways, the Puerto Rico AFP closely resembles state-side chapters. The academy maintains a paid executive officer, Ariel Diaz, M.D., and a secretary. The chapter's 11-member board of directors holds meetings several times each month to plan a variety of activities and initiatives.

The PR AFP's annual convention typically draws about 500 family physicians and other specialists, according to Marina Almenas, M.D., a chapter delegate and past president. The chapter also organized free health clinics in October, Puerto Rico's Month of Family Medicine, to provide diabetes and cholesterol screenings, evaluations for Alzheimer's disease and osteoporosis, mammograms, body mass index assessments, and vaccinations. In addition, the PR AFP provided two $10,000 grants to projects conducted by family medical students and residents. The chapter often consults with the commonwealth's department of health and other government organizations to evaluate health-related projects.

Still, said Almenas, one of the biggest challenges in Puerto Rico is recruiting and retaining family physicians.

"The payments of health insurance are lower in Puerto Rico than in the states," Almenas said. "For this reason and others, during the last year, many doctors moved to the United States, including prospective students of medicine."

According to an Associated Press article(bigstory.ap.org) published last year, between 2008 and 2013, the number of doctors on the island dropped by 13 percent.

"A lot of the medical organizations in Puerto Rico work on this problem during the years without much progress," Almenas said.

Still, the work continues, with the chapter just last month releasing two videos to promote the specialty with Puerto Ricans and future physicians: a 30-second video that was played on television and in movie theaters and a longer video(www.youtube.com) for use in physician offices and similar locations.

Facts About the Puerto Rico AFP

Chapter executive director: Ariel Diaz, M.D.
Number of chapter members: 396
Year chapter was chartered: 1956
Website: http://www.amfpr.org(www.amfpr.org)
Annual meeting: April 2015

Tiny Caribbean Chapter Uses Community Connections to Effect Change

With just 16 chapter members and an annual operating budget of about $150, the Virgin Islands AFP is the tiniest chapter. But what it lacks in size and resources, the chapter more than makes up for through its community collaborations.

"We feel so fortunate to be able to participate as a chapter, but we do make lots of personal sacrifices," said Cora Christian, M.D, M.P.H., chapter delegate and medical director of the Virgin Islands Medical Institute (VIMI).

To encourage participation, annual chapter dues run just $10, she said. The chapter never uses its funds for travel to local or national academy meetings, and chapter meetings, held in conjunction with the Virgin Islands Medical Society, rotate between the Virgin Island's two principal islands: St. Croix and St. Thomas. Attendees pay the $150-or-so plane tickets themselves, Christian said.

Of the 200 physicians who serve the roughly 108,000 Virgin Island residents, about 30 attend the meetings, and at least four or five are VI AFP members.

"It's not the number," Christian said, "It's the contribution of the people there. I have always held a position in office so that my voice is bigger and so I can put the issues of family physicians on the table."

Similar to the mainland, two common diseases plague Virgin Islanders: diabetes and heart disease.

About six years ago, Christian created a diabetes education program based on the Diabetes Empowerment Education Program in Chicago to help patients in her community self-manage their disease. In collaboration with VIMI, she said she convinced CMS to allow them to run the program without funding. The program was continued by the territory's department of health with a few small grants and resulted in a number of trained diabetes educators from 2008-13. Unfortunately, the formal training program was discontinued, but VIMI and some of the educators continue to work with residents living with diabetes.

In September 2013, Virgin Islands physicians also hosted Every Step Saves a Beat(www.viqio.org) to encourage residents to get active and prevent heart disease. More than 500 people attended to walk and visit health education booths.

Facts About the Virgin Islands AFP

Chapter executive director: Tom Evangelista, M.D., FAAFP
Number of chapter members: 16
Year chapter was chartered: 1969
No Website or annual meeting

Despite these and similar efforts, however, the Virgin Islands are in a dire situation, said Christian. Fifty percent of care provided in the islands' hospitals is unpaid, between 30 percent and 40 percent of the population is uninsured, and the only Medicare-certified nursing home is struggling.

The result: Rather than practicing preventive medicine, Gemaine Owen, M.D., often sees patients with advanced-stage illness. She sees patients in clinic and also in their homes, frequently stopping by during her personal time. Owen said she struggles to find resources for her patients, especially when they are discharged from the hospital, yet she finds joy in helping her fellow islanders.

She related the story of one of her patients, a U.S. veteran, who was discharged and sent home in a wheelchair. He had a caretaker who could help him only a few hours a day, Owen said. On reviewing his hospital records, she said she noted that he had a growing lung mass that had not yet been diagnosed, and she knew she had to get him to the nearest Department of Veterans Affairs (VA) hospital in Puerto Rico. Her patient had given up, but Owen had not. "I was praying: How am I going to get this guy the health care he needs before he is too debilitated to get on a commercial plane?"

After calling the VA nurse and discovered her patient had been missing appointments, Owen convinced him to go to the clinic, and a few days later, he was admitted to the VA hospital in Puerto Rico.

"He did have cancer, and as soon as he got there, his lungs filled up with fluid," she said. "To me, he got there just in the nick of time. If he was in our hospital at that more debilitated state where he was unstable, I would not have been able to get him out. But he's getting help now at the VA. That brought me satisfaction.

"When you can navigate a system or help someone navigate a system, that's fulfilling," Owen said.