In an exclusive interview with the Daily Sun, Dr. Nuñez-Smith said the statistical data was significant. Other health officials consulted in Puerto Rico concurred with her assessment.
“Virtually all of the territorial hospitals performed below the U.S. national averages,” read the study which was conducted from July 2005 to June 2008 and included 53 territorial hospitals and 4,595 stateside hospitals with data provided by the Centers for Medicare and Medicaid Services.
“Mortality rates were significantly higher in the territories … For acute myocardial infarction (AMI) it was 18.8 percent in the territories versus 16 percent in the states; for heart failure (HF) 12.3 percent versus 10.8 percent; and for pneumonia (PNE) 14.9 percent versus 11.4.
“The study cohort included hospitals in the U.S. territories and in the U.S. states, inclusive of the District of Columbia, that discharged at least one Medicare fee-for-service (FFS) adult patient with a primary diagnosis of AMI, HF, or PNE between July 2005 and June 2008. Additional patient inclusion criteria included at least 12 months of continuous Medicare FFS coverage prior to the index admission in order to accurately capture patient comorbidity.”
For the study, Puerto Rico’s population was estimated at 3.9 million, American Samoa at 57,000, Northern Mariana at 69,000, Guam with 155,000, and the U.S. Virgin Islands at 108,000.
The author’s grandfather emigrated through Puerto Rico and settled in the U.S. Virgin Islands. Nuñez-Smith was born in St. Thomas, part of the U.S. Virgin Islands and has visited Puerto Rico many times. Calie Santana, M.D., MHS, a Puerto Rican physician also participated in the study.
Asked whether the populations of the territories were sicker than those in the states, Dr. Nuñez-Smith answered in the negative. “We are not sure why more people are dying in territories hospitals than in the states. There are differences but the variances are small,” she said. “The study suggests we should look into other variances such as access to medical providers, how soon patients get to a hospital, timely treatment, and how funding streams affect federal, state, and insurance reimbursements to medical providers,” said Dr. Nuñez.
Another fact noted in the study was the percentage of hospitals that were privately owned versus those who were publicly owned or managed by a not-for-profit organization. In the case of Puerto Rico, many more hospitals were privately owned in comparison to the states, where most hospitals are publicly owned or are managed by not-for-profit organizations. Hospital characteristics were derived from the 2007 American Hospital Association Survey.
Dr. Nuñez-Smith said that she could not make an assumption, but that it should be studied whether a for-profit hospital thinks and responds to patients in the same manner as a not-for-profit hospital would.
“Our findings reveal a marked geographic disparity that affects a subset of racial/ethnic minority populations in the United States. Hospitals in the U.S. territories, on average, have significantly higher RSMRs [Risk-Standardized Mortality Rate] than hospitals in the U.S. states. The magnitude of differences across these rates raises concerns about differences in the quality of care … We also found that risk-standardized readmission rates were higher in the U.S. territories for AMI and PNE prior to adjustment. Again, almost all of the hospitals in the territories performed worse than the average in the U.S. states, although these associations were not significant after adjusting for hospital characteristics and core process measure performance. Still, readmission rates for all the hospitals were high, and although the disparity was not as prominent as with the mortality measure, the need for improvement is clear.”
The conclusion of the study reads “Compared with hospitals in the U.S. states, hospitals in the U.S. territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF, and PNE. Eliminating the substantial quality gap in the U.S. territories should be a national priority.”
Puerto Rico’s Health Secretary
Earlier on Wednesday, The Daily Sun requested Puerto Rico Health Secretary, Lorenzo González’s reaction to the study.
González noted that “the article recognized the disparities in funds awarded to territories in comparison to those granted to states to address healthcare services.” He also stated the article “acknowledges how our territorial status limits our participation in any public policy discussion regarding the limited funds Puerto Rico receives in terms of healthcare.”
The article also mentioned a General Accounting Office study of 2003 which indicated that Medicare beneficiaries in the Continental U.S. receive an average of $6,300 per patient compared to $2,800 for U.S. citizens living on the island.
González, however, stated that “hospitals in the U.S. territories have to meet quality healthcare standards and be certified by the Joint Commission as well as CMS just like hospitals in the continental U.S.,” and argued that “the doctors working in these facilities around the island are as competitive as any you can find in other institutions abroad. We guarantee that Puerto Rico has a professional medical class dedicated to the well being of our patients and many of our professionals working in hospitals on the island are Board Certified,” said González.
González also noted that the study cited in the article had some limitations since it only analyzed Medicare patients, excluding the younger and healthier populations. He added that the study was also based on claims data and didn’t include a clinical review of the patients’ medical records to identify any other factors that could impact the findings described in the study.
Other experts comment
The Archives of Internal Medicine also published an accompanying commentary written by Nilsa Gutiérrez, M.D., MPH, in which she provides her opinion on Dr. Nuñez’s study. Dr. Gutiérrez document is titled, “Understanding Health Care Disparities in the US Territories.”
In her commentary Dr. Gutiérrez says: “Congress has played a major role in shaping the financing of health care services since the passage of the Social Security Act of 1965. Laws involving Medicare and icaid often include language about application in the U.S. territories. Typically, formulas used for territorial Medicaid allocations direct most funding to Puerto Rico, the largest territory. With a population of 4 million, Puerto Rico accounts for 90 percent of the total territorial population and has a larger population than 26 U.S. states and Washington, D.C. This leads the U.S. Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands, with population sizes between 70,000 and 170,000 people, to raise concerns about the impact of the current allocation methodology on their ability to strengthen a fragile health care infrastructure and respond to the changing demands of medical practice and service delivery.”
A health care industry expert who has worked in Puerto Rico for many years, but asked to remain anonymous, spoke about Dr. Nuñez-Smith study.
“The numbers in the study point out that the results are significant: that is, that we are worse than in the U.S. with respect to complications — mortality and readmission — after the person leaves the hospital. Complications can occur for several reasons: first, the patient had problems accessing services and the doctor was late in treating the patient; second, the service provider is giving a poor quality of care; and third, the patients did not have enough resources to control their condition and the condition itself worsened (lack of health education, lack of medicines, lack of a physician’s follow-up).”
The physician also said: “Any of these complications may be due to the financing of the health system (public and private) where the patient has a hard time accessing the services they need. Taking into account that the study is not just Reforma or Mi Salud (government health plans), but that it includes the entire population of Puerto Rico, one cannot rule that we are not doing good medicine on the island.”
Regarding the streams of health funds, the expert said: “It is important to know the source of fee payment for the patients, if it is Medicaid or a private plan. One has too see how they are distributed according to each health plan. A study on diabetics conducted in 2003-2004 showed that the drugs that are prescribed to patients [in Puerto Rico] were worse than those prescribed to diabetics in the U.S. The question then arises, what do doctors on the island prescribe to patients who have a good health plan? We never received an answer. For me the issue of quality of care, which demonstrates that there is poor quality medical care, has to do with the patterns of medical practice and not the health plan that the person has. There is a lot of pre-authorization and people get tired of the bureaucracy, arriving late [for treatment]. I think the government is second guessing what is really going on in Puerto Rico because they lack clinical information and feedback on the treatment of patients. This may be because physicians shy away from treating new patients because there are no guarantees that the insurers will pay them, or because there are insufficient resources for the patients to take adequate medicines to stay as healthy as possible, or because there is no tradition of visiting the doctor and maintaining a therapeutic engagement.”
