SAN JUAN, Puerto Rico — Puerto Rico's struggling financial crisis has set off an exodus of medical personnel, leaving physicians with unmanageable patient loads and triggering a cascade of problems for patients and hospitals. The government, some hospitals and non-profits are offering incentives to try to keep or attract doctors to Puerto Rico as the situation worsens.

In the eight years between 2005 and 2013, 1,200 physicians and surgeons left Puerto Rico to live on the U.S. mainland, according to the Puerto Rico Statistics Institute. That amounts to 12 percent of the more than 10,000 medics and surgeons who worked on the island during that time. The exodus is still continuing now, with doctors often leaving better salaries, working conditions and resources.

In 2016, physicians and surgeons practicing in Puerto Rico earned a median hourly salary of $41.45 per hour, less than half of the median hourly wage of $99.48 for those working in the U.S., according to the U.S. Bureau Labor of Statistics.

While patients contend with an overburdened medical system that may not get to them in time, the financial crisis also means doctors at times struggle with getting paid for services. Some hospitals, meanwhile, have turned to nonprofits to find doctors.

For Angel Irizarry that's made caring for his father, who has senile schizophrenia, and his mother, who has Alzheimer’s, a greater challenge.

A scheduled 10 a.m. appointment can mean waiting all day before seeing a doctor at 4 p.m. Irizarry said doctors sometimes arrive late because they are working in other, more distant locations. He has waited months for his mother to see a specialist.

"The medical system here is really, really bad," said Irizarry, who applied to Veterans Affairs a year ago for at-home help for his father, who served in the Korean War.

Puerto Rico’s debt crisis has caused insurance companies to delay doctors’ paychecks and to supersede doctors' medical decisions, exchanging expensive treatments for less costly ones. Frustrated with the situation, the doctors board a plane and leave.

A surgical bed at the Puerto Rico Medical Center where surgeons operate on trauma patients. Mariela Patron

A U.S. Department of Health study on Puerto Rico's health system, released this year, reported the median wait time between arrival and admission to a hospital was 13 hours and a patient could wait up to nine months to see certain specialists. Puerto Rican physicians say medical specialists that are most needed are neurologists, cardiologists and surgeons.

Certain specialists, such as trauma surgeons, are located in San Juan at the Puerto Rico Medical Center, which houses a consortium of public hospitals. As a consequence, patients often travel to the capital to seek medical attention. The shortage of specialists has increased demand for the doctors who have remained — and public hospitals have become overwhelmed with patients.

In the continental U.S. in 2015, there was one vascular surgeon for every 95,717 people. Using this ratio, Puerto Rico should have about 36 vascular surgeons for its population 3.47 million. Instead, there are 15 doctors specializing in cardiovascular and thoracic surgery in all of Puerto Rico. Eight of them work in San Juan.

The Puerto Rico Medical Center is the only trauma center on the island and also serves other islands in the Caribbean. In the last 10 years, only three vascular surgeons have returned to the trauma center after training on the mainland. Two of the remaining trauma surgeons are expected to retire in the next couple of years.

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Puerto Rico’s debt crisis has strained Puerto Rico’s revenue for public programs, including health care. Congress has appointed a financial oversight board that is working out a fiscal plan for Puerto Rico and it includes many austerity measures.

Experts also cite the inequity in how the federal government reimburses physicians and hospitals in Puerto Rico for patients with Medicaid and Medicare. Puerto Rico gets a significantly lower percentage of federal funds than the rest of the 50 states.

40 percent of Puerto Ricans who were born on the island said they moved to the mainland for job-related reasons, according to the Pew Research Center. Mariela Patron

Puerto Rico is creeping close to what has been dubbed the “Medicaid cliff.” Money for the territory’s Medicaid program is on track to be depleted by March 2018. Once that happens, it will only receive its capped Medicaid allotment, which is lower, and it will be up to Puerto Rico to pay for any shortfalls.

These issues cascade down as insurance companies struggle to reimburse doctors.

Luis Flores is a gynecology surgeon and the director of robotics at Bella Vista Hospital located in Mayaguez, a municipality in the western part of Puerto Rico. It once took an insurance company more than a year to reimburse him for a procedure.

Dr. Pablo Rodriguez, director of the trauma center at the Puerto Rico Medical Center, makes way to his office with a long day of work ahead. Mariela Patron

Flores, who once worked in Atlanta, Georgia, said he earns 60 percent less in Puerto Rico than in the states.

“I came to Puerto Rico knowing that there was going to be a difference of pay, but what has happened is that the payment does not come fast enough. So the procedure I did today won’t be paid until two or three months from now. It is extremely unfair,” Flores said.

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The doctor exodus is part of a larger migration trend. Puerto Rico's population of 3.47 million makes it about the size of Connecticut. According the Puerto Rico Statistics Institute, 445,000 Puerto Ricans migrated to the United States between 2006 and 2015.

Among the Puerto Ricans who have left the island is Irizarry’s sister, Dr. Maritza Irizarry, a pediatrician who completed medical school in Puerto Rico. She now owns a practice in Arizona and has no plans to return.

Instead, she and Angel say they plan to move their parents to Arizona.

“I’m bringing them over,” she said. “That’s the only solution I think I should take at this point.”

In February, Puerto Rico Gov. Ricardo Roselló signed the Incentives for the Retention and Return of Medical Professionals Act. It lowers the income tax rate of Puerto Rican physicians from 33 percent to 4 percent. To qualify, doctors must complete 180 hours of community service annually.

But the tax break may not be enough to keep doctors on the island, or slow their migration, so other efforts are being made to lure doctors to Puerto Rico.

A helicopter lands on the roof of Puerto Rico Medical Center in San Juan. Mariela Patron

ConPRmetidos, a nonprofit that connects Puerto Ricans abroad with those living in the territory to address social need, has sent out a call for doctors on behalf of the Hospital Damas in southern Puerto Rico. The hospital is experiencing a shortage of physicians at the same time it's preparing for the retirement of many of its doctors.

ConPRmetidos is publicly seeking medical doctors and specialists looking for new opportunities or people who know medical doctors interested in working there.

Isabel Rullán, the managing director of ConPRmetidos, said Hospital Damas reached out to her group after ConPRmetidos made a presentation to the fiscal control board overseeing Puerto Rico's attempt to repay its debt holders and fix its economy.

The hospital has come up with an incentives package that includes helping jump start the practices of doctors seeking to create their own offices, a guaranteed salary, personnel and utilities. It also includes a reminder of the tax deductions from the government.

ConPRmetidos is sending out the information to U.S. universities. Spanish-speaking ability is a preference, though not a requirement, so they also are reaching out to schools in the Caribbean — including the Dominican Republic, Antigua and Saint Kitts.

The nonprofit has assembled its own database of Puerto Ricans abroad and is contacting them as well to help get out the word, Rullán said.

"This is very important to us because we are talking about the health of our people," Rullán said. She said the five- or six-month wait people are enduring for a procedure could mean "a health situation gets worse and it's too late for the patient to have an adequate procedure to save their life. So, this is urgent."

In the meantime, there are doctors like Fernando Joglar, the only surgeon in Puerto Rico who specializes in repairing trauma to the aorta, who have chosen to stay. When Joglar went for advanced training in Boston, people asked him why he was returning to the island.

He said he came back because he had a mission, which he has been accomplishing.

"I have saved 38 lives in 5 years," said Joglar. "if I leave, what will happen to these patients?"

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