Puerto Rico hospitals show, in general, higher readmission and mortality rates than their peers in the U.S. mainland, as well as longer emergency room stays for patient, a study by San Juan-based V2A Consulting firm.
In general, Puerto Rico hospitals score lower than the national average in quality metrics, based on reports from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database, the study showed.
“Several factors that are external to hospitals, including a shortage of qualified professionals and of other resources, the particular Medicare and Medicaid reimbursement guidelines for Puerto Rico, and the limited care coordination between the health sector participants are contributing to poor quality results,” the study concluded, among other things.
The healthcare industry is generally in pursuit of three goals — access, quality and cost.
The study cites “The Hospital Compare” database published by the Centers for Medicare & Medical Services (CMS), which provides a detailed description of the performance of hospitals according to defined quality criteria.
“Compared to the rest of the United States, Puerto Rico’s hospitals, when grouped together, rank last in most quality measures,” V2A concluded in its study. “We have conducted an analysis at a national, state, and local level, aiming to quantify the disparity between the quality of Puerto Rican hospital care with that of the rest of the country, with a special focus on readmission, mortality, and emergency room care.”
The readmission rate measures the percentage of patients who had an unplanned readmission to the hospital within 30 days of discharge — 35 out 41 Puerto Rico hospitals show readmission rates above the U.S. average of 15.3%.
Meanwhile, the biggest gap between local and U.S.-mainland hospitals is reflected in emergency room-related metrics. The average amount of time a patient spends in the emergency room before being admitted as an inpatient is roughly 4 hours and 18 minutes at the national level.
In Puerto Rico, a patient waits approximately 14 hours and 30 minutes on average, almost three times the national average, the study concluded.
The 26 Puerto Rico hospitals that report this metric show longer waiting times than the US average, with a lot of variability among Puerto Rico hospitals.
“There are six hospitals in which patients wait less than six hours while, on the opposite side, there are eight hospitals where patients wait, on average, more than 16 hours. Additionally, we see no correlation between the island’s hospital management groups and emergency department performances,” the firm concluded.
The firm attributed the disparities to several factors: Excessive or unnecessary treatment at the emergency room level; Lack of qualified professionals and/or resources available to hospitals; and, overall system deficiencies in coordination of care.
V2A cited the 2017 American Hospital Association Survey, which showed that the number of emergency department visits per 1,000 population was 445 in the U.S. mainland, ranging between 317 and 698 depending on the state.
Puerto Ricans use ER room more often
Puerto Rico’s Fiscal Plan as certified by the Financial Oversight and Management Board for Puerto Rico states that “Puerto Rican’s utilize the emergency room three times as often as peers on the U.S. mainland, with estimates as high as 90% of ER visits occurring for nonemergency care that could be treated in lower cost settings.”
“The quality metrics of local hospitals seem to be impacted by the scarcity of various types of specialists, particularly emergency physicians, as well as nursing staff. Hurricane María has probably worsened this situation further,” the firm stated, citing Puerto Rico Institute of Statistics estimates that establish that between 2005 and 2013, more than 1,200 physicians and surgeons left Puerto Rico to live in the U.S. mainland.
Looking ahead, hospitals are likely to feel more pressure to improve their quality results from the patient community and from the CMS itself, the study showed.
“CMS is pushing for greater visibility in terms of hospital performance across the United States through a star rating system where quality is a key component.
Furthermore, through the Quality Payment Program that started in January 1st of 2017, CMS is moving payment to physicians and other eligible clinicians away from fee-for-service reimbursement, and instead pay them based on the quality and cost of care,” the study showed.
“It is not clear whether doctors and doctor groups in Puerto Rico are prepared for the gradual but imminent compliance with those guidelines and avoid lower reimbursement levels. If they are not, hospitals will also suffer the consequences,” it concluded.