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- Richard J. Kovacs, MD, MACC, American College of Cardiology, Immediate Past President∗ ( and )
- Orlando Rodríguez-Vilá, MD, FACC, Past President, ACC’s Puerto Rico Chapter
- ↵∗Address for correspondence:
Dr. Richard Kovacs, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
It has been my privilege to visit Puerto Rico on several occasions, attend the American College of Cardiology (ACC) Puerto Rico Chapter meeting, and witness firsthand the dedication of the cardiovascular care teams of the island to high-quality, equitable cardiovascular care. During those visits, I became aware of health care disparities affecting my fellow U.S. citizens living on the island. The ACC Strategic Plan for 2019 to 2023 calls for us all to advance the quality, equity, and value of cardiovascular care. To further that strategic aim, and to inform JACC readers of the issues and proposed solutions, I invited Dr. Orlando Rodriguez Vila to join me as coauthor on this Leadership Page.
—Richard J. Kovacs
The World Health Organization (WHO) defines a disparity as “differences in health, which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust” (1). This definition could not be more clearly illustrated than in the case of Puerto Rico, where the clear-cut differences in federal health care funding and resources compared with the 50 U.S. states are unjustly, unfairly, and more importantly, unnecessarily impacting the lives of Puerto Rican patients.
In an editorial published in JAMA Internal Medicine in 2016, Héctor M. Colón, PhD, and Marizaida Sánchez-Cesareo, PhD, wrote that Puerto Rico’s “territorial status presents a challenge to democracy and social fairness” (2). They note that while the U.S. Constitution guarantees states equal treatment at the federal level, no such guarantee exists for U.S. territories. The U.S. Supreme Court, as far back as 1901, has held that the Territory Clause of the U.S. Constitution (Article IV, Section 3, Clause 2) allows Congress to treat territories differently than states under federal laws and programs as long as there is a “rational basis” for the differential treatment (3).
To date, residents of Puerto Rico pay Medicare and Federal Insurance Contributions Act taxes at the same rate as residents in the 50 U.S. states, but the Medicare Advantage (MA) program is paid at 60% of the average rate in the states, and Puerto Rico receives the least amount of Medicaid funds per resident compared with all 50 states (2). It is worth noting that more than 75% of Medicare-eligible residents of Puerto Rico enroll in MA. The projected Medicaid benefit spending per full-year enrollee is $2,144 in Puerto Rico, compared with $3,342 in the lowest-spending states and $6,763 in median states (4).
This disproportionate allocation of funds to a territory that has the highest poverty rate of all states is not surprisingly having a disproportionate effect on patients and access to care. A 2016 study by Maricruz Rivera-Hernandez et al. (5) found “substantially worse care” for MA enrollees in Puerto Rico compared with their U.S. counterparts. The study of 7.35 million MA enrollees found that Hispanic MA enrollees in Puerto Rico received far worse care than Hispanics in the United States on 15 of the 17 performance measures related to diabetes mellitus, cardiovascular disease, cancer screening, and appropriate medications (5).
Similarly, a 2017 study by Nuti et al. (6) found higher 30-day and 1-year mortality rates among Medicare Fee-for-Service beneficiaries hospitalized in Puerto Rico, with large absolute differences for acute myocardial infarction, heart failure, and pneumonia. They noted that these rates have increased over time, “with most mortality rates for the territories in 2008–2012 at the same level of those in the states during 1999–2003” (6).
Workforce issues also pose significant limitations to patient access to care, especially in poorer, rural communities with high Medicaid populations. Puerto Rican physicians are reimbursed for services at rates 40% lower than their stateside counterparts (2). The average annual earnings of family physicians and general practitioners in Puerto Rico are $86,970, compared with $211,780 nationally, according to 2018 statistics from the Bureau of Labor (4). The considerably lower payment rates to providers no doubt contribute to a shortage of providers.
A 2014 American College of Emergency Physicians state-by-state report card showed tremendous difference in number of registered nurses (494 vs. 941), neurosurgeons (0.8 vs. 2.0), and emergency room physicians (5.4 vs. 13.5) per 100,000 population in Puerto Rico and the United States, respectively (7). As a result, Puerto Rico as compared with U.S. states has far fewer staffed inpatient and intensive care unit beds, fewer skilled nursing facilities, and longer emergency department wait times (13 h vs. 4.5 h) for every 100,000 people (7). These data do not include the devastating effect of Hurricane Maria on the workforce.
So, how do we address these disparities and improve heart health given the current obstacles? The answers may lie with the “ABCDs”: Advocacy, Barrier Breaking, Community Programs, and Data. On the advocacy front, continuing to educate lawmakers about the disparities in care that currently exist, as well as using the annual budget appropriations process to advocate for increased funding for Medicare and Medicaid programs in Puerto Rico is crucial—and is a priority of the College’s Puerto Rico Chapter.
Addressing barriers to care like workforce issues is also important. Identifying and growing the next generation of cardiovascular clinicians from physicians to nurses is needed. Only 4% of Puerto Rican physicians are 35 years of age or younger, compared with 24% in the U.S. states (4). Helping hospitals and institutions with best practices for building an effective cardiovascular care team can also help with management and treatment of cardiovascular disease and related risk factors.
Community programs can also help with breaking down barriers and access to care challenges. A 2017 paper by Enid J. García-Rivera et al. (8) provides an overview of the “Salud para Piñones” project between the University of Puerto Rico School of Medicines and the community of Piñones, which brought community members and leaders together with researchers in a process that supported mutual learning and empowered the community to take a leadership role in its own health and well-being. Community-based programming has the potential to reach a broad group of people with prevention measures and education, with the goal of improving outcomes and mitigating cardiovascular risk factors.
The use of data to identify gaps and measure progress toward care improvement is another important tool for reducing disparities. Puerto Rican populations have been excluded from national databases like the Dartmouth Atlas of Health Care and the National Healthcare Quality and Disparities Reports from the Agency for Healthcare Research and Quality (9). Exclusions from these studies has had an impact on available disparities data and ultimately quality improvement. It also distorts the complete picture of health care disparities in the U.S. system. Registries like those that fall under the ACC’s National Cardiovascular Data Registry umbrella are starting to help with this, but challenges remain as under-reimbursed hospitals struggle to cope with the recurring staff and operational costs associated with the proper implementation of clinical registries. Identifying ways for Puerto Rican hospitals to participate in and take advantage of registry data could help not only reduce disparities and ensure guideline-driven care, but it can also help with benchmarking and quantifying value in a system where value, not fee-for-service, is the name of the game.
As we enter a new decade, it is clearly time for a change. The stark disparities in care between the United States and its territories like Puerto Rico are 100% unnecessary and 100% avoidable. The U.S. cardiovascular community has a unique opportunity to come together as a profession and transform cardiovascular care and improve heart health for ALL.
- 2020 American College of Cardiology Foundation
- World Health Organization
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- Sánchez-Cesareo M.
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- Colby T.
- ↵Solomon J. Puerto Rico’s Medicaid program needs an ongoing commitment of federal funds. April 22, 2019. Center on Budget and Policy Priorities. Available at: https://www.cbpp.org/research/health/puerto-ricos-medicaid-program-needs-an-ongoing-commitment-of-federal-funds. Accessed March 11, 2020.
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