News Release

Care disparities for Hispanic Medicare Advantage enrollees in Puerto Rico

Peer-Reviewed Publication

JAMA Network

Hispanic Medicare Advantage enrollees on the U.S. island territory of Puerto Rico received worse care compared with Hispanics in the United States (the 50 states and Washington, D.C.), according to a new study published online by JAMA Internal Medicine.

The Medicare program extends health insurance to older adults and people with disabilities in the U.S. territories. However, few studies include Medicare beneficiaries living in the U.S. territories. The Medicare program, in particular Medicare Advantage (MA), plays a critical role in delivering health care in Puerto Rico, the largest of the U.S. territories.

Assessing health care for Medicare beneficiaries is important for a number of reasons, including that MA plans in Puerto Rico receive lower payments than MA plans in the U.S. because of underlying differences in health care costs and payment regulations. Recent payment rates to MA plans in Puerto Rico were 40 percent lower than per-capita payments to MA plans in the United States.

Amal N. Trivedi, M.D., M.P.H., of Brown University, Providence, R.I., and coauthors compared the quality of care among whites in the United States, Hispanics in the United States and Hispanics in Puerto Rico. The authors focused on those three groups because 99 percent of Puerto Ricans self-identify as Hispanic.

The authors used the 2011 Healthcare Effectiveness Data and Information Set (HEDIS) for MA plans from the Centers for Medicare & Medicaid Services. The study used 17 performance measures related to diabetes, cardiovascular disease, cancer screening and appropriate medications.

The study included 7.35 million MA enrollees. The number of Hispanics enrolled in MA plans in the United States and Puerto Rico was 14.4 percent of the total at more than 1 million.

The authors report that for 15 of the 17 measures, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the U.S. Absolute performance differences ranged from about 2 percentage points for blood pressure control in diabetes to about 31 percentage points for the use of disease-modifying antirheumatic drug therapy.

There were three measures where performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceed 20 percentage points: use of disease-modifying antirheumatic drug therapy, use of systemic corticosteroid in chronic obstructive pulmonary disease (COPD) exacerbation and use of bronchodilator therapy in COPD exacerbation.

There were modest differences in care between white and Hispanic MA enrollees in the United States, the study notes.

The authors note study limitations include a lack of some detailed information, including on enrollees' chronic conditions and disease self-management practices. They also lacked information on the organizational characteristics of providers in Puerto Rico, which could mediate the quality of health care.

"Our study highlights significant gaps between federal goals about promoting equity in the Medicare program and the quality of care delivered to MA enrollees in Puerto Rico. Major efforts are needed to improve quality of care within MA plans on the island to a level equivalent to that of the United States," the study concludes.

(JAMA Intern Med. Published online April 25, 2016. doi:10.1001/jamainternmed.2016.0267. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: The article includes conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Commentary: Disparities in Health Care in Puerto Rico Compared with U.S.

"The stark disparities that so clearly emerge from the work of Rivera-Hernandez and colleagues contrasts with the relative invisibility of the U.S. territories in health care research, health policy discussion and national data systems. ... Territorial status presents a challenge to democracy and social fairness. Although the U.S. Constitution guarantees that states will be treated equally at the federal level, no such guarantee exists for the territories. ... Our national policies pertaining to the health of the populations in the territories, including the types of research and data systems that are required, should be examined and debated nationally to ensure optimal health for these populations and, perhaps, as importantly, to ensure that our nationally shared goals and values of equality and fairness are not threatened by the data invisibility of the territories," writes Héctor M. Colón, Ph.D., and Marizaida Sánchez-Cesareo, Ph.D., of the University of Puerto Rico, San Juan, in a related commentary.

(JAMA Intern Med. Published online April 25, 2016. doi:10.1001/jamainternmed.2016.1144. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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Media Advisory: To contact corresponding study author Amal N. Trivedi, M.D., M.P.H., call David Orenstein at 401-863-1862 or email David_Orenstein@brown.edu. To contact corresponding commentary author Héctor M. Colón, Ph.D., email hector.colon8@upr.edu


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