The Perfect Prescription: Puerto Rico Delivered Better Results, but Washington Wants a Second Opinion.
Show notes
Puerto Rico runs one of the most efficient pharmacy systems in the country - and Washington still treats it like an exception instead of a model.
In Medicare Advantage, federal funding follows the star ratings, and the stars are driven by medication adherence: are patients actually taking their prescriptions for chronic conditions like hypertension, diabetes, and high cholesterol? In 2013, the Asociación de Farmacias de Comunidad de Puerto Rico (AFCPR), under the presidency of Elliot Pacheco, built a unified adherence program and took it straight to the Medicare Advantage plans - shifting community pharmacies from simply dispensing pills to actively managing patient care (medication synchronization, reconciliation, interaction checks). Think of it as a racing pit crew tuning the engine, not just handing the driver spare parts.
The federal data from 2020-2023 tells the story:
📊 Explore the data yourself. Every number in this episode comes straight from the federal figures — Puerto Rico's Medicare Advantage star ratings, prescription utilization, and gross drug-cost rankings against the national benchmark. See it all in the live CMS Console.
- Ranked #1 of all 56 U.S. jurisdictions for both highest utilization and lowest gross drug costs
- ~19% more prescriptions filled per year than the national benchmark
- ~30% less per fill - about $63 vs. $89 nationally
- A deliberate, generics-first culture of high adherence for chronic conditions
The paradox: despite delivering five-star performance, Puerto Rico is statutorily boxed out of the low-income subsidies residents of the 50 states receive automatically - an estimated $250 million in foregone assistance each year, and up to $2 billion under full parity. If it runs this well on empty, imagine what it could do with a full tank.
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Transcript
Full transcript
Welcome back to our deep dive.
So today we're digging into a pretty massive paradox in the U.S. healthcare system.
Yeah, it's a huge one.
Right, because our mission today is to figure out how Puerto Rico built this, like, high-performance
pharmacy engine that completely beats the national average, and, you know, why the
federal government is basically forcing them to drive it on an empty tank.
Well, to really understand that paradox, we have to look at how Medicare Advantage
plan funding actually works, you know, under the hood.
Which comes down to the star ratings, right?
Exactly.
Those stars dictate how much federal funding a plan gets, and they are heavily, heavily
based on patient medication adherence.
Meaning are people actually taking their meds?
Right.
If patients aren't consistently taking their prescriptions for chronic issues, things
like hypertension, diabetes, or high cholesterol, well, the plan on a star rating drops,
and then the funding just dries up.
Wow, okay.
To jump back to 2013, the community pharmacies in Puerto Rico, they actually saw this
tension early on.
They did.
It was really visionary.
Yeah, specifically the asociación de farmacías de comunidad de Puerto Rico, or
AFCPR.
Under the presidency of Elliot Pacheco, their board of directors realized they
needed a real systemic fix.
And that's where the adherence program was born.
I mean, the clinical protocol itself was elaborated by doctors of pharmacy
Nuri Echeveria and Vixima Rodriguez, along with Elto Ricardo-Cintron.
Right.
And the crazy part is they didn't just keep it to themselves.
No, they took this unified model straight to the Medicare Advantage plans
to implement, which is a massive achievement.
They identified the gap and completely shifted the focus from, you know, just
handing over pills to actively managing the patient's care.
I actually like to think of it like a racing pit crew.
Oh, well, that's a good way to put it.
Right.
Like instead of a patient making five different trips a month and
inevitably forgetting a pill, these pharmacists act like the pit crew.
They do medication synchronization.
They do reconciliation, making sure there are no bad drug interactions.
Exactly.
They get recognized and paid for clinically tuning the engine, not just
handing the driver a box of spare parts.
And the federal health data from 2020 to 2023 shows us exactly how well
that pit crew approach actually works in practice.
The numbers are pretty wild.
They really are.
Island residents fill about 19% more prescriptions annually than
the national benchmark.
Which, you know, you'd assume that kind of intensive care would
drive costs through the roof.
But it doesn't.
They're paying roughly 30% less per fill than the national average.
We are talking about $63 per prescription versus $89 nationally.
Wait, so they are ranked first among all 56 U.S.
jurisdictions for highest utilization and lowest gross drug costs.
Yes, exactly.
Number one out of all 56.
It's a staggering dual achievement.
And, you know, we have to be really precise here.
This isn't just patients buying meds because they have a lower price tag.
Not at all.
Right.
It's highly deliberate.
Yeah.
The pharmacy profile there focuses heavily on generic treatments for
chronic conditions like thyroid and heart health.
It is fundamentally a culture of high medical adherence.
Which brings us right back to the paradox you mentioned at the start.
The empty tank.
Exactly.
You had the most efficient, highly adherent jurisdiction in the country
hitting these five star performance levels.
But because of statutory limitations,
Puerto Rico is legally boxed out of the low income subsidies
that residents in the other 50 states just get automatically.
Hold on.
I mean, if they are ranked number one for keeping costs low and adherence high,
shouldn't they be drowning in federal support?
You would think so.
But it's a statutory blind spot.
The irony is sharp, honestly.
The actual foregone assistance, meaning the money denied to these
low-income patients is estimated at $250 million annually.
$250 million?
Wow.
Yeah.
And if you look at potential parity funding,
treating them exactly like a state that a figure could reach up to $2 billion.
So what does this mean for you listening, right?
As someone navigating the health care system,
it proves that this proactive community level care works.
It gives us a clear blueprint.
It does.
And honestly, it serves as a firm recommendation to the federal government.
They need to acknowledge how local providers in Puerto Rico
successfully work together for the benefit of the patients to reach those five stars.
Absolutely.
It shouldn't be some underfunded anomaly.
It needs to be used as a national model.
And it's a strong recommendation to health plans,
to other health care providers and to patients to continue this proactive collaboration.
Yeah, you have to keep the pit crew talking to the driver.
So I will leave you with this final thought to mull over.
Consider what staggering heights of health care efficiency
could be reached nationwide if local on the ground innovation
was actually matched by equitable federal funding.
If it runs this well on empty, imagine what it could do with a full tank.
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