Quality of Care in the United States Territories, 1999-2012

Abstract

Background: Millions of Americans live in the US territories, but health outcomes and payments among Medicare beneficiaries in these territories are not well characterized.

Methods: Among Fee-for-Service Medicare beneficiaries aged 65 years and older hospitalized between 1999 and 2012 for acute myocardial infarction (AMI), heart failure (HF), and pneumonia, we compared hospitalization rates, patient outcomes, and inpatient payments in the territories and states.

Results: Over 14 years, there were 4,350,813 unique beneficiaries in the territories and 402,902,615 in the states. Hospitalization rates for AMI, HF, and pneumonia declined overall and did not differ significantly. However, 30-day mortality rates were higher in the territories for all 3 conditions: in the most recent time period (2008-2012), the adjusted odds of 30-day mortality were 1.34 [95% confidence interval (CI), 1.21-1.48], 1.24 (95% CI, 1.12-1.37), and 1.85 (95% CI, 1.71-2.00) for AMI, HF, and pneumonia, respectively; adjusted odds of 1-year mortality were also higher. In the most recent study period, inflation-adjusted Medicare in-patient payments, in 2012 dollars, were lower in the territories than the states, at $9234 less (61% lower than states), $4479 less (50% lower), and $4403 less (39% lower) for AMI, HF, and pneumonia hospitalizations, respectively (P<0.001 for all).

Conclusions and relevance: Among Medicare Fee-for-Service beneficiaries, in 2008-2012 mortality rates were higher, or not significantly different, and hospital reimbursements were lower for patients hospitalized with AMI, HF, and pneumonia in the territories. Improvement of health care and policies in the territories is critical to ensure health equity for all Americans.

Figure 1.

Observed All-cause Mortality Rates Among Medicare Fee-for-Service and Medicare Advantage Beneficiaries Age ≥65 Years in the Territories and States, 1999–2012. Medicare beneficiaries aged ≥65 years enrolled in the Fee-for-Service plan for ≥1 month and Medicare beneficiaries aged ≥65 years enrolled in a Medicare Advantage program for the full duration for a given year are shown. The blue line represents mortality among Fee-for-Service beneficiaries in the territories, the yellow line represents mortality among Medicare Advantage beneficiaries in the territories, the green line represents mortality among Fee-for-Service beneficiaries in the states, and the orange line represents mortality among Medicare Advantage beneficiaries in the states.

Figure 2.

Risk of Hospitalization for Medicare Fee-for-Service Beneficiaries from the Territories Compared with Beneficiaries from the States for Acute Myocardial Infarction, Heart Failure, or Pneumonia, 1999–2012. Adjusted incidence risk ratios for hospitalization for Medicare Fee-for-Service beneficiaries from the territories compared with those from the states (referent) for each of the 3 conditions (acute myocardial infarction, heart failure, and pneumonia) in each study period (1999–2003, 2004–2007, 2008–2012).

Figure 3.

Odds of 30-day Mortality, 30-day Readmission, and 1-year Mortality for Medicare Fee-for-Service Beneficiaries Hospitalized with Acute Myocardial Infarction, Heart Failure, or Pneumonia in the Territories Compared with the States, 1999–2012. Adjusted odds ratios for 30-day mortality, 30-day readmission, and 1-year mortality for Medicare Fee-for-Service beneficiaries hospitalized in the territories compared with those hospitalized in the states (referent) for each of the 3 conditions (acute myocardial infarction, heart failure, and pneumonia) in each study period (1999–2003, 2004–2007, 2008–2012).