How Physician—Insurance Contracting Contributes to the Medical Exodus and Access to Ophthalmic Care in Puerto Rico

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper is well-written and presents important findings on the medical exodus, particularly among ophthalmologists in Puerto Rico. I have only one minor suggestion regarding potential future studies. The authors could also consider collecting information from physicians who have chosen to remain in Puerto Rico, focusing on the key factors that influenced their decision to stay. This information could be used to promote these reasons, if applicable, to attract more physicians to Puerto Rico and improve access to ophthalmic care.

Author Response

Comment #1

The paper is well-written and presents important findings on the medical exodus, particularly among ophthalmologists in Puerto Rico. I have only one minor suggestion regarding potential future studies. The authors could also consider collecting information from physicians who have chosen to remain in Puerto Rico, focusing on the key factors that influenced their decision to stay. This information could be used to promote these reasons, if applicable, to attract more physicians to Puerto Rico and improve access to ophthalmic care.

Response 1:

We thank the reviewer for their feedback. We agree that insights from physicians who have chosen to remain in Puerto Rico would be invaluable to our study. In fact, we are in the process of conducting a qualitative study to supplement this current study. To address the reviewer’s concern, we modified the following sentence to add their suggestions (lines 384-387).:

Future research efforts could collect data from ophthalmologists and other physicians who have left PR to gain a deeper understanding of the medical exodus. Qualitative interviews with ophthalmologists who stayed in PR could also identify factors that influenced their decision to stay to potentially attract more physicians to PR.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Very Respected Authors,

After carefull reading your manuscript I have few suggestions. The abstract is well-written, and the introduction is also clear. The aim of the study is clear, and the methodology can be improved. Could you clarify the criteria for selecting the sample of ophthalmologists? The conclusion section is missing. Please added this part to the paper.

 

Author Response

Comments 1:

Could you clarify the criteria for selecting the sample of ophthalmologists? 

Response 1:

We thank the reviewer for this question. All ophthalmologists practicing in Puerto Rico were eligible to participate in the study. In an attempt to reach as many ophthalmologists across the island as possible, we recruited through various avenues including conferences, WhatsApp chats, and listservs. We added the following sentence to clarify the inclusion criteria.

New (lines 110-112 in revised manuscript):

This study recruited a convenient sample of all ophthalmologists practicing in PR via outreach in person and online communities.

 

Comments 2:

The conclusion section is missing. Please added this part to the paper.

Response 2:

We thank the reviewer for noticing this detail. We added the following conclusion.

New (lines 401-406 in revised manuscript):

Insurance/billing issues were a pervasive concern faced by ophthalmologists in PR. New ophthalmologists were disproportionately affected by these challenges, potentially leading some to find employment opportunities outside of PR. There is a need for targeted policies-regulation of insurance company contracting, and increased reimbursement from private insurance plans-to reduce insurance contracting barriers for keeping a sustainable physician workforce in PR.  

Reviewer 3 Report

Comments and Suggestions for Authors

This is a well-written article that provides some insights on the challenges faced by ophthalmologists in PR. In the introduction, the authors provided background information about the problem to the readers. The implications of the problem, knowledge gaps, and the aim of the study were clearly stated. The methodology was also discussed while the results were properly presented. The authors compared their results with previous literature and the possible reasons for their results. The limitations of the study were also discussed. However, there was no stand-alone conclusion to the manuscript.

MAJOR REVISIONS

Abstract

1. The sampling method used in the study should be stated.

2. The software used for data analysis should be mentioned.

3. In line 17, the authors state, ‘Descriptive analyses were performed, …..’ They should also mention inferential statistics used.

Materials and Methods

4. This section should be divided into subsections foe easy readability. The subsections can be study setting and period, study design, study population, sample size, inclusion and exclusion criteria, sampling method, data collection, reliability and validity of the instrument, data analysis, and ethical considerations.

5. The authors should explain how they made sure the questionnaire was valid and how its reliability was tested. What were the results of the reliability test?

Results

6. Provide subsections for the results. For example, the first subsection can be ‘Characteristics of participants’ and the second ‘Insurance/Billing Challenges’

Conclusion

7. A conclusion section should be on its own.

References

 

8. Format all references according to journal guidelines. Pay particular attention to references 21, 22, 23, and 26.

Author Response

Comments 1:

Abstract

The sampling method used in the study should be stated.

Response 1:

Thank you for your comment. We clarified that we obtained a convenient sample of ophthalmologists practicing in Puerto Rico.

New (lines 16-17 in revised manuscript):

This study recruited a convenient sample of all ophthalmologists practicing in PR  via outreach in person and online communities.

Comments 2:

Abstract, The software used for data analysis should be mentioned.

Response 2:

We clarified the use of STATA/BE 18 to conduct all analyses.

New (line 18 in revised manuscript):

STATA/BE  18 statistical software was used for data analysis.

Comments 3:

In line 17, the authors state, ‘Descriptive analyses were performed, …..’ They should also mention inferential statistics used.

Response 3:

We modified this line to include some of the statistical tests that were performed.

New (line 19 in revised manuscript):

Statistical tests, such as chi-square and proportion tests, were performed, stratifying results by age, gender, subspecialty, geographic health districts, experience, and practice type.

Comments 4:

Materials and Methods:

This section should be divided into subsections foe easy readability. The subsections can be study setting and period, study design, study population, sample size, inclusion and exclusion criteria, sampling method, data collection, reliability and validity of the instrument, data analysis, and ethical considerations.

Response 4:

We thank the reviewer for this comment. We divided parts of manuscript into subsections, including the Methods, Results, and Discussion.

Comments 5:

The authors should explain how they made sure the questionnaire was valid and how its reliability was tested. What were the results of the reliability test?

Response 5:

Two authors (LA, ROD) developed the study survey based on their experiences. A small pilot of a few ophthalmologists tested the survey before it was distributed to study participants. We understand the reviewer’s concerns about reliability and validity as these factors affect the strength of the study’s methods. We were unable to formally test the reliability or validity of the study survey as the project was intended to address information-sharing gaps within the ophthalmology community. We will keep this feedback in mind for our separate qualitative study that will complement findings from this study.

Comments 6:

Results:

Provide subsections for the results. For example, the first subsection can be ‘Characteristics of participants’ and the second ‘Insurance/Billing Challenges’

Response 6: 

We adopted the reviewer’s suggestions and added the aforementioned subsections.

Comments 7:

A conclusion section should be on its own.

Response 7:

We added the following conclusion.

New (lines 401-406 in revised manuscript):

Insurance/billing issues were a pervasive concern faced by ophthalmologists in PR. New ophthalmologists were disproportionately affected by these challenges, potentially leading some to find employment opportunities outside of PR. There is a need for targeted policies-regulation of insurance company contracting, and increased reimbursement from private insurance plans-to reduce insurance contracting barriers for keeping a sustainable physician workforce in PR.  

Comments 8 :

References

Format all references according to journal guidelines. Pay particular attention to references 21, 22, 23, and 26.

Response 8:

We thank the reviewer and have reformatted the references according to journal guidelines.

Reviewer 4 Report

Comments and Suggestions for Authors

Background:  Overall, the introduction serves as a broad overview of insurance coverage, major payors, and some of the issues physicians face when billing insurance in Puerto Rico. While well-written, the background has some information which could be reorganized and moved to the discussion section.

-Lines 63-69: Suggest incorporating these sentences into the discussion section to explain some of the factors causing physicians to move to the mainland.

-Lines 75-81:  Suggest incorporating these sentences into the discussion section to provide further context to what disparities physicians are facing and the difference between the Puerto Rico and mainland United State insurance issues.

 

Methods:  This section is well-written and could be improved by providing further context on the convenience sampling frame used.

-Line 151-153: Suggest providing further information on why 16 years of experience or less was used as an identifier for “new” physicians.  16 years of practice experience seems like a lot of experience for someone to be identified as a new provider.  Further context would help with this delineation.

 

Results: 

-Line 170 + 175 + 176 + 216 + 220: Suggest replacing “#1” with number one.

-Line 195-197: This is an interesting point and should be further expanded on in the discussion section.

-Table 1, Table 2, and Table 3: The key at the bottom of the tables could be resized and made smaller to improve readability for the rest of the table.  Suggest removing “.”  at the end of each of the sentences.

 

Discussion: Suggest removing “#1” throughout this section and replacing with number one. Also, Hurricane Maria and it’s impact on the insurance industry and physician reimbursement could be describe more in the introduction section. 

-Line 256:  Suggest inserting the information moved from the introduction section to here.

-Lines 342-349: This paragraph doesn’t fit in with the rest of the discussion.  It could possibly be moved to the results section or removed.

 

Conclusion:  As is, this section doesn’t exist.  Lines 362 through 371 could be condensed and focused on reviewing the major findings of the study, its implications for ophthalmology, and the brief call to action for changes in legislation and policy, as well as continued research surrounding this issue.

Acknowledgement:  This section could be removed as no acknowledgements were provided.

 

References: Suggest reviewing references for formatting, including DOIs for all applicable sources.

 

Author Response

Comments 1:

Background:  Overall, the introduction serves as a broad overview of insurance coverage, major payors, and some of the issues physicians face when billing insurance in Puerto Rico. While well-written, the background has some information which could be reorganized and moved to the discussion section.

-Lines 63-69: Suggest incorporating these sentences into the discussion section to explain some of the factors causing physicians to move to the mainland.

-Lines 75-81:  Suggest incorporating these sentences into the discussion section to provide further context to what disparities physicians are facing and the difference between the Puerto Rico and mainland United State insurance issues.

 

I agree that 63-69 can stay in the Background.

This sentence though could be moved to the discussion, especially when you’re using typical discussion words such as “highlight the need for policy change”

Lines 79-83:

These disparities in reimbursement rates and the challenges faced by physicians highlight the need for policy changes and interventions to address the inequities in reimbursement between PR and the mainland US. Fear of legal retaliation from insurance plans and government agencies, such as the Federal Trade Commission (FTC), provides another hurdle for physicians in PR.

Response 1:

We thank the reviewer for their recommendation. We moved lines 63-78 (original manuscript) from the introduction to line 256 (original manuscript, line 249 in revised manuscript) as per the recommendation.

Comments 2:

Methods:  This section is well-written and could be improved by providing further context on the convenience sampling frame used.

Response 2:

We clarified that we obtained a convenient sample of ophthalmologists practicing in Puerto Rico.

New (lines 110-112 in revised manuscript):

This study recruited a convenient sample of all ophthalmologists practicing in PR through via outreach in person and online communities.

Comments 3:

-Line 151-153: Suggest providing further information on why 16 years of experience or less was used as an identifier for “new” physicians.  16 years of practice experience seems like a lot of experience for someone to be identified as a new provider.  Further context would help with this delineation.

Response 3:

We thank the reviewer for this question. We defined the cutoff of 15 years of experience based on findings from our literature review. One study found that 52% of ophthalmologists planned on retiring after the age of 65. Additionally, the AAMC reports that approximately half of ophthalmologists in the U.S. are older than age 55 (46.4% less than 55 vs. 53.6% age 55 and older).⁶ Based on common knowledge among the ophthalmology community, most enter the workforce at the age of 30-35, suggesting that the average ophthalmology career lasts at least 30-35 years. We clarified the basis of determining the cutoff in the Methods.

We added the following text to lines 148-153:

Previous studies have found that 52% of ophthalmologists in the US in 2003 planned to retire after the age of 65 and 54% in 2021 were at least 55 years old. Additionally, based on common knowledge among the ophthalmology community, most enter the workforce at the age of 30-35. This observation and aforementioned findings from the literature suggests that the average ophthalmology career lasts at least 30-35 years, providing the basis of the 15-year cutoff.

Comments 4:

Results: 

-Line 170 + 175 + 176 + 216 + 220: Suggest replacing “#1” with number one.

Response 4:

Response:

We agree with the reviewer’s feedback. These changes were made on the respective lines.

Comments 5:

-Line 195-197: This is an interesting point and should be further expanded on in the discussion section. “Ophthalmologists who had considered leaving PR were more likely to have their insurance contract 196 cancelled than those that had not considered leaving PR (p<0.05).”

Response 5:

We thank the reviewer for their input. This point  was discussed in lines 304-311 of the original manuscript (lines 326-335 revised manuscript). This paragraph in the discussion was expanded further and we added this sentence to the end of the paragraph (line 335-337 revised manuscript):

These factors may explain the observation that ophthalmologists who had experienced an unjust contract cancellation were more likely to report considering leaving PR.

Comments 6:

-Table 1, Table 2, and Table 3: The key at the bottom of the tables could be resized and made smaller to improve readability for the rest of the table.  Suggest removing “.”  at the end of each of the sentences.

Response 6:

We agree with the reviewer’s feedback and have reduced the font size on the tables and removed “.” at the end of each sentence.

Comments 7:

Discussion: Suggest removing “#1” throughout this section and replacing with number one. 

Response 7:

We replaced the “#1” with “number one” throughout the manuscript.

Comments 8:

Also, Hurricane Maria and it’s impact on the insurance industry and physician reimbursement could be describe more in the introduction section. 

Response 8:

We added some additional information about the impact of Hurricane Maria on the health system: on Lines 83-87

After Hurricane Maria in 2017 there was an increased exodus of PR residents⁸ and damage to the healthcare infrastructure.⁹ It also exposed the vulnerability of the healthcare system given the medical exodus and led the PR government to institute the tax incentive for specialty physicians in an attempt to retain them.

Comments 9:

-Line 256:  Suggest inserting the information moved from the introduction section to here.

Response 9:

We thank the reviewer for their recommendation. We moved lines 63-77 (original manuscript) from the introduction to line 256 (original manuscript) as per the recommendation.

Comments 10:

-Lines 342-349: This paragraph doesn’t fit in with the rest of the discussion.  It could possibly be moved to the results section or removed.

Response 10:

We thank the reviewer for their recommendation. These results about the tax incentive policy were introduced in the results section (original manuscript  lines 216-220, new manuscript 231-237) and then discussed in this discussion paragraph (original manuscript lines 342-349, new manuscript lines 368-375). We feel that this income tax policy should be discussed as it is the only current policy in place addressing the medical exodus and, to our knowledge, our survey was the first study to evaluate how many physicians participate in the tax incentive and if they felt it was effective.

Comments 11:

Conclusion:  As is, this section doesn’t exist.  Lines 362 through 371 could be condensed and focused on reviewing the major findings of the study, its implications for ophthalmology, and the brief call to action for changes in legislation and policy, as well as continued research surrounding this issue.

Response 11:

We added the following conclusion (lines 401-406).

Insurance/billing issues were a pervasive concern faced by ophthalmologists in PR. New ophthalmologists were disproportionately affected by these challenges, potentially leading some to find employment opportunities outside of PR. There is a need for targeted policies-regulation of insurance company contracting, and increased reimbursement from private insurance plans-to reduce insurance contracting barriers for keeping a sustainable physician workforce in PR. 

Comments 12:

Acknowledgement:  This section could be removed as no acknowledgements were provided.

Response 12:

We removed the Acknowledgement section per the reviewer’s recommendation.

Comments 13:

References: Suggest reviewing references for formatting, including DOIs for all applicable sources.

Response 13:

We reviewed the references and added DOIs for all applicable sources.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Respected Authors,

Thank you for accepting my suggestions and revising the manuscript.

Author Response

Comments 1:

Thank you for accepting my suggestions and revising the manuscript.

Response 1:

Thank  you for your kind suggestions.

Reviewer 3 Report

Comments and Suggestions for Authors

1. The authors have addressed most of my concerns. They stated that 'A small pilot of a few ophthalmologists tested the survey before it was distributed to study participants. We understand the reviewer’s concerns about reliability and validity as these factors affect the strength of the study’s methods. We were unable to formally test the reliability or validity of the study survey as the project was intended to address information-sharing gaps within the ophthalmology community.'  The sample size of the participants in the pilot study should be stated.

2. Furthermore, if they have the data for the pilot study, they can use it to calculate the reliability of the questionnaire.

3. The authors should also state explicitly their exclusion criteria for participation in the study.  

4. Since this is a quantitative study, the readers will be interested in knowing how the sample size was calculated.

Author Response

Comment #1: The authors have addressed most of my concerns. They stated that 'A small pilot of a few ophthalmologists tested the survey before it was distributed to study participants. We understand the reviewer’s concerns about reliability and validity as these factors affect the strength of the study’s methods. We were unable to formally test the reliability or validity of the study survey as the project was intended to address information-sharing gaps within the ophthalmology community.'  The sample size of the participants in the pilot study should be stated.

 

Response#1:

Thank you for your recommendation. We added the sample size to the paper on line 134.

We have copied it here:

 

“A pilot survey was sent out to six ophthalmologists of varying specialties, ages, and geographic health districts for feedback. Their comments were incorporated into the final survey, and they later completed the survey as study participants.”

 

 

Comment #2: Furthermore, if they have the data for the pilot study, they can use it to calculate the reliability of the questionnaire.

 

Response#2:

Thank you for the recommendation. We calculated the reliability of the questionnaire as recommended and added a sentence to the methods section on line 136.

 

We copied it here:

“Using data from six pilot participants, the reliability of questions was assessed and yielded a Cronbach's alpha coefficient of 0.78.” 

 

Comment #3:The authors should also state explicitly their exclusion criteria for participation in the study.  

Response#3:

We thank the reviewer for the recommendation. We described the exclusion criteria on line 113 and copied it here:

“The inclusion criteria included all ophthalmologists actively practicing in PR and the exclusion criteria included non-ophthalmologists, any ophthalmologist not actively practicing in PR and ophthalmologists in PR who were still in residency or fellowship training programs.” 

Comment #4:Since this is a quantitative study, the readers will be interested in knowing how the sample size was calculated.

Response #4:

We thank the reviewer for the recommendation. We added the following sentence to the paper on line 117.

 

We copied it here:

Using the Cochran formula with α=0.05 (95% CI and β=0.8 (power), and by considering 41% of the physicians have left the workforce in PR [1], we computed the 147 sample size.  We distributed the survey to 218 ophthalmologists in PR and we received 130 completed surveys.

 

Reference

 

1. Penchi L. Colegio Medicos anticipa fuga de galenos luego de la pandemia en Puerto Rico. 2021. Noticias/Salud Publica. December 14. 2021. Accessed August 1, 2024. https://medicinaysaludpublica.com/noticias/salud-publica/colegio-medicos-anticipa-fuga-de-galenos-luego-de-la-pandemia-en-puerto-rico/12017

 

Author Response File: Author Response.docx