RESUMO
BACKGROUND: While Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria's impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York. CASE PRESENTATION: A 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient's treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines. CONCLUSIONS: We employ this patient's narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.
Assuntos
Tempestades Ciclônicas , Atenção à Saúde/normas , Desastres , Medicare/normas , Múltiplas Afecções Crônicas/terapia , Hispânico ou Latino , Humanos , Seguro Saúde , Masculino , Turismo Médico , Pessoa de Meia-Idade , Múltiplas Afecções Crônicas/etnologia , Cidade de Nova Iorque , Aceitação pelo Paciente de Cuidados de Saúde , Porto Rico/etnologia , Refugiados , Diálise Renal , Estados UnidosRESUMO
Background: The 6-minute walk test (6MWT) and the Glittre ADL-test (GT) are used to assess functional capacity and exercise tolerance; however, the reproducibility of these tests needs further study in patients with acute lung diseases. Objectives: The aim of this study was to investigate the reproducibility of the 6MWT and GT performed in patients hospitalized for acute and exacerbated chronic lung diseases. Method: 48 h after hospitalization, 81 patients (50 males, age: 52±18 years, FEV1: 58±20% of the predicted value) performed two 6MWTs and two GTs in random order on different days. Results: There was no difference between the first and second 6MWT (median 349 m [284-419] and 363 m [288-432], respectively) (ICC: 0.97; P<0.0001). A difference between the first and second tests was found in GT (median 286 s [220-378] and 244 s [197-323] respectively; P<0.001) (ICC: 0.91; P<0.0001). Conclusion: Although both the 6MWT and GT were reproducible, the best results occurred in the second test, demonstrating a learning effect. These results indicate that at least two tests are necessary to obtain reliable assessments. .
Assuntos
Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Assistência ao Convalescente/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Medicare/economia , Readmissão do Paciente/estatística & dados numéricos , Centros de Reabilitação/estatística & dados numéricos , Artroplastia de Substituição/reabilitação , Estudos de Coortes , Fraturas Ósseas/reabilitação , Pacientes Internados , Medicare/normas , Doenças do Sistema Nervoso/reabilitação , Alta do Paciente , Indicadores de Qualidade em Assistência à Saúde , Valores de Referência , Estudos Retrospectivos , Acidente Vascular Cerebral/reabilitação , Estados Unidos/epidemiologiaRESUMO
Gubernatorial administrations in New Mexico have initiated four overhauls of the publicly funded behavioral health care system over the past two decades. The most recent effort, Centennial Care, was implemented under a Section 1115 Medicaid waiver in January 2014. The authors describe Centennial Care, which closely resembles the now defunct restructuring of the public system that introduced Medicaid managed behavioral health care to the state in 1997. They also note disruptions in services to clients and hardships for providers, described locally as a "behavioral health crisis," that resulted from actions taken in 2013 by the current gubernatorial administration to force the takeover of 15 nonprofit service delivery agencies by five Arizona companies. These actions led to an onsite investigation by the Centers for Medicare and Medicaid Services.
Assuntos
Política de Saúde , Programas de Assistência Gerenciada/organização & administração , Medicaid/organização & administração , Serviços de Saúde Mental/organização & administração , Humanos , Programas de Assistência Gerenciada/normas , Medicaid/normas , Medicare/organização & administração , Medicare/normas , Serviços de Saúde Mental/normas , New Mexico , Estados UnidosRESUMO
BACKGROUND: Little is known about the healthcare experiences of Medicare beneficiaries in Puerto Rico. OBJECTIVES: We compare the experiences of elderly Medicare beneficiaries in Puerto Rico with their English-preferring and Spanish-preferring Medicare counterparts in the U.S. mainland. RESEARCH DESIGN: Linear regression models compared mean Consumer Assessment of Healthcare Providers and Systems scores for these groups, using cross-sectional data from the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems survey. SUBJECTS: Medicare beneficiaries aged 65 years and older (6733 in Puerto Rico, 282,654 in the U.S. mainland) who completed the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems survey. MEASURES: Six composite measures of beneficiary reports and two measures of beneficiary-reported immunization. RESULTS: Beneficiaries in Puerto Rico reported less positive experiences than both English-preferring and Spanish-preferring U.S. mainland beneficiaries for getting needed care, getting care quickly, and immunization (P<0.05 in all cases). Beneficiaries in Puerto Rico reported better customer service than Spanish-preferring U.S. mainland beneficiaries and better doctor communication experiences than English-preferring U.S. mainland beneficiaries. Additional analyses find little variation in care experiences within Puerto Rico by region, plan type, or specific plan. CONCLUSIONS: Medicare beneficiaries in Puerto Rico report generally worse healthcare experiences than beneficiaries in the U.S. mainland for several Consumer Assessment of Healthcare Providers and Systems outcomes and lower immunization rates. Lower funding of healthcare services in Puerto Rico relative to the U.S. mainland may affect healthcare. Strategies such as patient and provider education, provider financial incentives, and increased use of information technologies may improve adherence to the recommended preventive care practices.
Assuntos
Medicare , Idoso , Idoso de 80 Anos ou mais , Feminino , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Imunização/normas , Imunização/estatística & dados numéricos , Masculino , Medicare/normas , Medicare/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Porto Rico , Estados UnidosRESUMO
The importance of immunization in protecting seniors against influenza and pneumonia has long been recognized. Nevertheless, immunization rates among Medicare beneficiaries continue to fall short of what is both desirable and achievable. The problem is even more acute among certain racial and ethnic groups in the United States within which rates are below the rate for the country as a whole. This is true in New Mexico where 40 percent of the population is estimated to be Hispanic. As part of its work on behalf of the Centers for Medicare & Medicaid Services (CMS), the New Mexico Medical Review Association (NMMRA) undertook a project aimed both at reducing the disparities that exist in immunization status between the Hispanic and non-Hispanic population in the state and attempting to increase overall rates in the state for all groups. Developing interventions to reduce disparaties in immunization rates between Hispanic seniors and the rest of the senior population requires more than a straightforward review of the literature and must take into account not only the cultural differences that exist between Hispanics and non-Hispanics but, certainly, in the case of New Mexico, it must attempt to understand the richness and diversity that exists within the Hispanic communities across the state. To do otherwise runs the risk of designing interventions that are at best ineffective and at worst culturally insensitive and potentially damaging to future efforts to improve health status. This article describes the process undertaken by NMMRA, a Medicare Quality Improvement Organization (QIO), to collect qualitative data from three culturally different groups of Hispanics in New Mexico. The data are used to design interventions that will increase immunization rates for all Hispanics in New Mexico.
Assuntos
Características Culturais , Hispânico ou Latino/psicologia , Programas de Imunização/estatística & dados numéricos , Vacinas contra Influenza/administração & dosagem , Influenza Humana/prevenção & controle , Medicare/normas , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Vacinas Pneumocócicas/administração & dosagem , Pneumonia Pneumocócica/prevenção & controle , Idoso , Centers for Medicare and Medicaid Services, U.S. , Acessibilidade aos Serviços de Saúde , Humanos , Influenza Humana/etnologia , Entrevistas como Assunto , Medicare/organização & administração , New Mexico/epidemiologia , Pneumonia Pneumocócica/etnologia , Marketing Social , Estados UnidosRESUMO
The accuracy, reliability, and validity of the Medicare Peer Review Organization (PRO) review process have all been questioned. Evidence concerning the PRO program's effect on cost and quality of care remains lacking. The Health Care Financing Administration has thus committed itself to reform, and the Uniform Clinical Data Set (UCDS) has been proposed as the national database for Medicare's quality review program. The UCDS is an automated, computerized data set designed to standardize the evaluation of quality. It should allow an objective, consistent, and efficient process for peer review, based on explicit decision criteria and on aggregated information about patterns of care and quality. But is this truly so? We review the existing evidence on the UCDS and compare it with the current PRO reviews of quality, concluding that although the UCDS can potentially improve the accuracy and the reliability of data abstraction and the validity of reviews, this remains to be shown. Preliminary data on the UCDS suggest that work is needed before it can meet appropriate expectations for a national database for quality assessments. We also propose a model for reviews of quality in which we show that reviews of care done in the context of internal quality improvement programs will differ in goals and intensity from reviews of care done at the national level. We suggest that the UCDS has a unique, but limited role--that of national surveillance of practice patterns. Detailed assessments of quality are more appropriately done at local or institutional levels.