Alvaro Montealegre: How I patched up American healthcare

Years spent working for a Texas-based health insurer prompted Alvaro Montealegre an exile from the Nicaraguan Sandinista revolution to buy a medical clinic in America. "Health-care providers were too focused on the insurance companies. Because we paid the bills, we were their priority. Not the patients." The healthcare crisis that dogged Bill Clinton's presidency gave Montealegre his opportunity. In 1996, with its owners looking for a way out, he was able to buy his first clinic.

"My idea was that instead of looking to maximise the cash I could get from insurers I would try to offer great patient care and pick up more clients." Convinced, for example, that most hip fractures are caused by bad eyesight, Montealegre offered free glasses to his patients. "They cost me very little but my patients loved it." His timing proved spot on as health spending picked up. He soon bought another clinic and then a pharmacy. With more clients and scale, he set up a special customer care team to manage the treatment of patients. "Many treatments were not successful because people forgot to take their pills or didn't understand the instructions. By spending small amounts of money on customer care we were able to prevent big bills later on." This in turn gave him expertise in the growing field of health management services.

Noticing the growing demand for medical business process outsourcing, in 2003 Montealegre decided to sell his clinics and start providing administration and customer care services for insurance companies and health clinics. "There were already lots of similar firms. I decided the best way to win business would be to have better staff at a lower cost."

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So, 25 years after he had left the country, Montealegre returned to Nicaragua. "I knew from my contacts in the country that there were lots of bright, bilingual candidates who didn't have a job. There were graduates who were grateful to work in my call centres." Nicaraguans could also connect with America's growing Hispanic market.

His firm, Almori, was the first foreign-focused call centre in the country. But insurers were initially unwilling to be its customers. Luckily, "I was able to persuade firms I knew to let us process some of their administration and deal with their customers and gradually we convinced people that we could do a great job". For example, in one deal, doctors in a clinic in the US would send Almori scan results. The firm would then process them, fill in the necessary paperwork and make a claim to an insurance company.

For five years the firm grew steadily. The breakthrough came in 2008 when business process outsourcing giant eTelecare agreed to come to Nicaragua and work with Almori through a joint venture. "Overnight we went from 300 staff to 800 staff." Now mainstream medical groups and health plans would happily work with Almori. "The eTelecare deal gave us a lot of credibility." Another boost came from the US recession. It put greater pressure on companies to cut costs and led to a slew of new contracts. Almori diversified into other areas, such as payment collection and basic software tasks. By 2010 sales hit $35m, with Montealegre confident of more growth.