Table Of Content

COORDINATINGHEALTHCAREREFORM WITHTHEU.S. TERRITORIESANDPOSSESIONS: THECASEOFPUERTORICO RobertoRamirez,Ph.D.,PrincipalInvestigator WilliamRodriguezGonzalez,M.S.,ProjectDirector MariaE.Velazquez,M.P.H.,DataAnalyst IrisAnetteFigueroaRivera,AssistantInvestigator MariaA.HennquezMontes,Secretary ProjectConsultants AllenDobson,Ph.D. ThisreportpreparedwiththesupportoftheHealthCareFinancingAdministration,OfficeofResearchand Demonstrations,undercooperativeagreementNo.18-C-90240/2-01toInstitutedeAdministrationyPoliticade SaluddePuertoRico,Inc.Theopinionsexpressedaresolelythoseoftheauthors,anddonot necessarilyrepresentthoseoftheHealthCareFinancingAdministration. PROJECT: COORDINATING HEALTHCAREREFORM WITHTHETERRITORIES: THECASEOFPUERTORICO GRANTNUMBER:18-C-90240/201 WORK PLAN InthefirstyearoftheProjectwewillgatherandanalyzedataonhealthstatusofthe populationofPuertoRico,andonutilizationofhealthservicesandexpenditures. The analyseswillidentifythemajorproblemsofourhealthcaresystemanditsuniquecauses. Oncethisinformationisavailable,theeffortsofthesecondyearwillbedirectedtoanalyze healthcarereformsinitiativesatthestateandfederallevelandproposespecificpolicies forhealthcarereform. Aspartofthisendeavor,wewillidentifywhichhealthcarereform conceptscouldbeappliedtoPuertoRicoandareasofhealthpolicyinteresttodevelop futureresearch. DuringthefirstyearoftheProjectwewillachievethefollowingobjectives: Objective1 GatherandanalyzedataonhealthstatusofthepopulationofPuertoRico. Thisobjectiveisgearedtoprovideadetaileddescriptionofthehealthstatusofthe population in Puerto Ricoand identifythemostpressing healthcareproblems according to mortality and morbidity data. This objectivewill beachieved by performingthefollowingspecifictasks. a. Gatherdataoninfantmortalityrates(neonatalandpostneonatal). b. CompareinfantmortalityratestothemainlandUnitedStates. c. Analyzeinfantmortalityrateswithacrosssectionalmodeltoestablishthe relationship between infant mortality rates in each town with system variables,likemedianincome,totalemployment,medianyearsofeducation, hospitalbedsper1,000population,expenditurespercapitainprimarycare servicesandnumberofprimarycarephysiciansper1,000population. d. Gatherdataonmortalityratesforthepopulation. e. ComparemortalityrateswithmainlandUnitedStates. f. EstablishthemaincausesofdeathandcomparethemwithmainlandUnited States. g. Analyze the trends on AIDS related mortality and compare them with mainlandUnitedStates. h. EstablishthemostfrequentDRGdistributionofcasesfortheMedicareand Medicaidpopulation. i. ComparetheDRGdistributionwiththatofthemainlandUnitedStates. Thefollowingdatasourceshavebeenidentifiedwiththetasksofthefirstobjective: 1. PuertoRicoDepartmentofHealthVitalStatistics1980-1990. 2. PuertoRicoDepartmentofHealthQuarterlyHealthSurvey1980-1990. 3. 1990U.S. CensusforPuertoRicoand1990U.S.CensusSocioeconomic SurveyofPuertoRicoanditsMunicipalities. 4. U.S.StatisticalAbstracts. 5. PuertoRicoPeerReviewOrganization(PRO). Objective2 ExplainlevelsofhealthexpendituresandgrowthinPuertoRico. Thefollowingtaskswillbeexecutedtoachievethissecondobjective: a. Gatherandanalyzetimeseriesdataonutilizationtrendsfordifferenttypes ofhealthcareservicessuchas,admissions,lengthofstay,andoutpatient visits. Comparisonbetweentheutilizationratesinthepublicandtheprivate sectors will be essential to understand structural differenceswithin the healthcaresystem. b. Analyzeexpendituresaccordingtotypeofservice. Thedifferenttypeof servicesthatwillbeconsideredare:Hospitalcare,physicianservices,dental services, other professional services, medical durable, program administration, government public health activities and research and construction. c. Analyzeexpendituresaccordingtosourcesoffunds, thefollowingsources offundshavebeenidentified: Privateinsurance,outofpocket,Federaland Stateandlocal. d. ComparewiththemainlandUnitedStatestotal healthexpendituresasa percentofgrossdomesticproduct. e. Compare with the mainland United States the level of public health expendituresasapercentoftotalhealthexpenditures. f. ComparewiththemainlandUnitedStatesthepercapitahealthspending. g. Compare with the mainland United States the rate ofgrowth in health spending usingthe GDP deflatorandthehealth deflator. This analysis enableustocomparetheimportanceofvolumeandhealthservicesinflation inexplaininggrowthinexpenditures, betweenPuertoRicoandmainland UnitedStates. h. Estimatetheelasticityofpercapitahealthspendingrelativetopercapita grossdomesticproductfrom19851990andcompareitwitbtheestimated elasticityforthemainlandUnitedStates. Thefollowingdatasourceshavebeenidentified: 1. Healthexpenditures:PuertoRicoPlanningBoard1980-1990. 2. Healthexpenditures:OfficeofInsuranceCommissioner;AnnualReport. 3. Healthexpenditures:CooperativadeSegurosdeVida(COSVI),Medicare PartACarrier. 4. Healthexpenditures:TripleS;MedicatePartBIntermediary. 5. Healthexpenditures:PuertoRicoOfficeofBudgetandManagement. 6. Health and GDPdeflators: Puerto Rico DepartmentofLabor; Bureauof- Statistics. 7. VitalStatistics,PuertoRicoDepartmentofHealth. 8. NationalHealthExpenditures,HCFA. Objective3 Establishtherelationshipbetweenhealthandhealthfinancingproblemwiththeunique structuralcharacteristicsofthePuertoRicohealthsystem. In conjunctionwiththeexecution ofthefirsttwo objectives, wewill beableto correlatetheidentifiedprincipalproblemswithcharacteristicsofthehealthcare systeminPuertoRicothatcouldbesubjecttohealthpolicyreforms. Theexecution ofthisobjectivewillsetthebaselinewhichwillbeusedtoevaluatehealthcare reformsinitiativesatthestateandfederallevel. Thefollowingtaskswillbeperformedtoattainthisthirdobjective: a. Analyzehealthcareexpendituresgrowthbysector(publicandprivate)and type ofservice. Thiswill enable usto identifythe services that are in competitionforresourcesineachsectorandexplainitsuniquecausesof growthinthePuertoRicohealthsystem. b. Comparegrowthinhealthcareexpenditureswiththegrowthoffundsused tofinancetheseexpenditures. Thisanalysiswillbeperformedforthepublic andprivatehealthcaresectorsinPuertoRico. c. Correlatehealthcareexpendituresgrowthtomorbidityandmortalityindices. d. Establishtherelationshipbetweenmortalityandmorbidityindicesandthe availabilityofhealthcareresources. Forexample,infantmortalityratesand lowbirthweightineachtownwillbecorrelatedwiththesupplyofprimary care physicians practicing in each town, numberoffull time equivalent physiciansandalliedpersonnelworkingingovernmentprimarycarecenters, andtheavailabilityofbackupfacilitiestoprimarycarecenters. e. Appraisebowthenumberofinsuredbyprivatehealthinsurancecompanies, numberofpersonscertifiedasMedicaidrecipientsandnumberofMedicate beneficiariesexplainthegrowthinhealthcareexpendituresinthepublicand privatesectors. Datasourcestobeusedinexecutingthesetasksrelatedtothethirdobjective. 1. Healthexpenditures:PuertoRicoPlanningBoard1980-1990. 2. Healthexpenditures:OfficeofInsuranceCommissioner;AnnualReport. 3. Healthexpenditures:CooperativedeSegurosdeVida(COSVI),Medicare PartACarrier. 4. Healthexpenditures:TripleS;MedicarePartBIntermediary. 5. Healthexpenditures:PuertoRicoOfficeofBudgetandManagement. 6. Insuredpersons:OfficeofInsuranceCommissionerAnnualReport. 7. Medicaidrecipients:OfficeofServicestotheMedicallyIndigent;PuertoRico HealthDepartment. ThefollowingobjectiveswillbeachievedduringthesecondyearoftheProject. In thesecondyearwewillevaluatereformsinitiativesattheStateandFederallevel tounderstandwhatspecificproblemsgearedthemanditsapplicationtoPuerto Ricouniquesystem. Objective4 Evaluatehealthcarereformsinitiativesatthestateleveltoestablishitsapplicabilityto PuertoRico. Themajorstrategiesemployedbythestatestoexpandaccesstohealthcarefall intothefollowingbroadcategories: I. comprehensivereforms ii. smallgroupmarketreforms iii. expandingcoverageforspecapopulations;and, iv. pooling risk to improve access to individuals who have difficulty findinginsurance. Giventhedualnatureofourhealthcaresystem,eachofthesecategoriesofreform initiativeswillbeanalyzedtoassessitsapplicabilitytoPuertoRico. Webelieve that any health care reform initiative in Puerto Ricowill haveto address both sectors,thepublicandtheprivate. Thefollowingspecifictaskswillbeexecutedas partofthisobjective: a. StudylegislationpassedinFlorida,VermontandMinnesotaasinitiativesof comprehensivereforms. Instudyingtheseinitiativeswewillestablishto what specific problems they intent to respond and the differences and similaritieswiththeproblemsidentifiedinouranalysisofthehealthsystem inPuertoRico. b. AnalyzereformsofpubliclyfinancedprogramsliketheOregonHealthPlan, andtheArizonaHealthCareCostContainmentAct(AHCC)gearedmainly toservetheMedicaidpopulation. Objective5 AnalyzeproposedhealthcarereformsinitiativesattheFederallevelanditsfeasibilityin PuertoRico. Atthistimethereisuncertaintyregardingthespecificproposalsforhealthcare reformthatwillbesenttoCongressbytheTaskForce. However,therearesome generaltasksthatinwhichwewillbeengage. a. Studyproposedlegislationandestablishbowitsmainpolicymeasurescan beappliedtoPuertoRico. b. Recommend specific policies geared to coordinate health care reforms initiativesinU.S.mainlandwithreformsinitiativesinPuertoRico. ProgressReport I FilesandDataBanks FILE DESCRIPTION LOCALIZATION EV-PRUS.WK3 GeneralMortalityRatebySex;PRvs.USA;Rateby C:/123W/PRES (DATABANK) 1,000population;1950-91 GeneralMortalityRatebySex;USA;Rateby100,000 population;1950-91 PuertoRicopopulationinmillions;1950-90 SpecificMortalityRatesbyHeartConditons,HIV, CardiovascularDiseasesandAccidentsRatesby 100,000population;1980-93 DeathsbyAgeGroups;PR;1950-91 DeathsbySpecificsCausesbySex;USA;1950-91 DeathsbySpecificsCausesbySex;USA;Ratesby 100,000population;1950-91 DeathsbyAgeGroups;USA;1950-91 DeathsbyExternalCauses;PRvs.USA Ratesby100,000population;1950-91 MortalityRatesbyExternalCausesbySex;PRvs. USA;Ratesby100,000population;1950-91 MortalityRatesbyExternalCausesbyAgeGroups;PR vs.USA;Ratesby100,000population;1950-91 DeathsbyExternalCausesbySexandAgeGroups; PRvs.USA;Ratesby100,000;1951-90 NeonatalandPostneonatalbyYear,SexandCause; PRvs.USA;Ratesby1,000population InfantMortalityRatebyHealthRegions;PR;1977-91 InfantMortalityRatesbyMunicipalities;PR;1977-91 C:/123W/WILLIAM EV.PRU2.WK3 MortalityRatesbySpecificCauses;PRvs.USA;1950- C:/123W/WILLIAM 91 NumberandDeathsRatesbyExternalCausesand Sex;PRvs.USA;Accidents,HomicidesandSuicides SASANA.WK3 Municipality,Income,UnemploymentRate,Bedsby C:/123WAA/ILLIAM 1,000population,Physiciansby1,000population, OBGYNby1,000population;PR;1990 MEDIC0.WK3 PrimaryCarePhysiciansbySpecialtiesand C7123VV/WILLIAM Municipality;PR P0BLACI0.WK3 PopulationbyMunicipalityandDemographicData; C:/123W/WILLIAM (DATABANK) 1980-90 Page1of4 ProgressReport I FilesandDataBanks FILE DESCRIPTION LOCALIZATION SIDA.WK3 ConfirmedAIDSCasesinPuertoRico;1992 C:/123WAA/ILLIAM SIDAPM.WK3 AIDSbyMunicipality;PR;Ratesper1,000 C:/123WAA/ILLIAM C.PRIMA.WK3 CostbyPatientsServicesinCDT,CSF,Areaand C:/123WAA/ILLIAM RegionalHospitals;PR;1981-92 SALUD.WK3 HospitalizationbySexandAgeGroups;PR;1973-88 C:/123W/WILLIAM (DATABANK) HospitalizationbyServiceSectorandAeGroups;PR; 1973-88 DischargesbySexandAgeGroups;PR;1973-88 DischargesbyServiceSectorandAgeGroups;PR; 1973-88 PhysiciansVisitsbySex,AgeGroupsandTypeof Hospital;PR DentistVisitbySex,AgeGroups,andTypeofHospital; PR SIDAEUII.WK3 ConfirmedAIDSCases:USA;1992 C:/123WAVILLIAM GRAPHHOM.PRS MortalityRatebyHomicide;PR C:/HGW/PRES GRAPHS1.PRS TotalAIDSConfirmedCasesByRace/Ethnicity;PR C7HGW/PRES GRAPHS2.PRS TotalAIDSConfirmedCasesByRace/Ethnicityand C:/HGW/PRES Sex;PR GRAPHS4.PRS TotalAIDSConfirmedCasesbyPatientGroups;PR C:/HGW/PRES GRAPHS5.PRS TotalAIDSConfirmedPediatric MaleCasesbyPatient C:/HGW/PRES Groups;PR GRAPHS6.PRS TotalAIDSConfirmedPediatric FemaleCasesby C:/HGW/PRES PatientGroups;PR GRAPHS7.PRS TotalAIDSConfirmedPediatric CasesbyPatient C:/HGW/PRES Groups;PR GRAPHSUI.PRS MortalityRatesbySuicide;PRvs.USA;1975-91 C:/HGW/PRES GRAPHVIH.PRS MortalityRatesbyVIH;PRvs.USA;1981-91 C:/HGW/PRES RIC.PRS LeadingCausesofDeath;PRvs.USA;1950-91 C:/HGW/PRES SIDAG1.PRS AIDSinAdults/AdolescentsCasesReported;PR C:/HGW/PRES SIDAG2.PRS AIDSinPediatricCasesReported;PR C:/HGW/PRES Page2of4 ProgressReport I FilesandDataBanks FILE DESCRIPTION LOCALIZATION bcilnUAAGr*o*>.nPnKoS AIDSinTotalCasesReported;PR C:/HGW/PRES olUAG4.PKb AIDSDeathsinAdult/AdolescentsCasesReported; C7HGW/PRES PR QinAPX:nnc AIDbDeathsinPediatricsCasesReported;PR C:/HGW/PRES SlUAoD.rKo AlUbDeathsinlotalCasesReported;PR C7HGW/PRES olUArul.rKb AIDbConfirmedCasesbyAge;PR C:/HGW/PRES QinAD^'iridoc AIDbinAdults/AdolescentsFemalesbyPatientGroup; C:/HGW/PRES PR bCllUnAAPDlPjildi.DPDKCb TotalConfirmedAIDSCasesinAdults/Adolescentsby C7HGW/PRES PatientGroups;PR trTiV\WAr/D.rDKObC FirstYearWork Plan C:/HGW/PRES (jKAPHI.PKb MortalityRatesbyYear;PRvs.USA;1962-90 C:/HGW/PRES GKAPH2.PRS MortalityRatesbySex;PRvs.USA;1962-90 C7HGW/PRES pGKdAaPnHu3i.PnRooS MortalityRates;PRvs.USA;1962-90 C:/HGW/PRES <jKAPH4.PKb InfantMortalityRates;PRvs.USA;1955-90 C:/HGW/PRES GKAAPDrUlEo.OPOKCb InfantMortalityRates;PRvs.USAWhiteandBlacks; C:/HGW/PRES 1955-90 rCjDKAADPUnCb.DPDKCb NeonatalMortalityRates,PRvs.USA;1971-90 C./HGW/PRES ^uKDAArDnU/7.rDKOCb NeonatalMortalityRates,PRvs.USAWhiteand C./HGW/PRtb Blacks;1971-90 GRAPH8.PRS PosneonatalMortalityRates;PRvs.USA;1971-90 C:/HGW/PRES GRAPH9.PRS PostneonatalMortalityRates;PRvs.USAWhiteand C:/HGW/PRES Blacks;1971-90 GRAPHCAN.PRS MortalityRatesbyCancer;PRvs.USA;1975-91 C:/HGW/PRES GRAPHCUA.PRS MortalityRatesbyCerebrovascularDisease;PRvs. C:/HGW/PRES USA;1975-91 /G"*Rr>AaPrH>iI_iiAa.dPoRcS MortalityRatesbyDiabetesMellitus,PRvs.USA,1975 C./HGW/PKbb 91 GRAPHMDI.PRS MortalityRatesbyHeartDisease;PRvs.USa;1975-91 C:/HGW/PRES GPC1.PRS ChangeintheRateofDeathbyAccidentandAge C:/HGW/PRES Groups;PR Page3of4 o ProgressReport I FilesandDataBanks FILE DESCRIPTION LOCALIZATION t^jorCiii.nroKb ChangeintheRateofDeathbyHomicideandAge C:/HGW/PRES Groups;PR brOJ.HKo ChangeintheRateofDeathbySuicideandAge C:/HGW/PRES Groups;PR JUotl.rKo AIDSCasesbyRace/Ethnicityper100,000population; C:/HGW/PRES PRvs.USA JOSE2PRS A"IiDuSoPwad<a;pc<o;huyvrR\saropc//Ff-hnIIiIrIiUIhL/y-,PrrR\\V/oc.IUIOQnA L/./noVv/rKto PEDIATEP.PRS AIDSPediatricCasesby100,000population;PR C:/HGW/PRES DRG's.PRS OperationalCostperPatientbyHospitalandBeds;PR C:/HGW/PRES Page4of4