It's no secret that health care in the U.S. is not as good as that in many other developed countries. And a new report finds that hospitals in U.S. territories—including Puerto Rico, Guam, the U.S. Virgin Islands and the Northern Mariana Islands—are even further behind. "Virtually all of the territorial hospitals performed below the U.S. national averages," noted the authors of the study.

To assess the quality of hospital care in U.S. territories, a team of researchers tabulated patients' risk of dying or being readmitted a month after being hospitalized for cardiac arrest, heart failure or pneumonia between 2005 and 2008. All rates were "significantly higher" (except for readmission proceeding heart failure) in territories versus in states, according to the report.

"Despite a national commitment to eliminate health disparities, the territories are largely absent in national reports of health care equity and quality," pointed out the authors of the new report, which was published online June 27 in Archives of Internal Medicine and was led by Marcella Nunez-Smith, an assistant professor of general medicine at Yale School of Medicine.

Previously, territory-wide health statistics have been difficult to come by. "I applaud Nunez-Smith and colleagues for embarking on an effort to assess the quality of care in the U.S. territories despite limited data," Nilsa Gutierrez, of the Centers for Medicare & Medicaid in New York City, wrote in an essay also published online by Archives of Internal Medicine.

For the study, the Nunez-Smith and her colleagues compared the records of Medicare patients visiting 57 hospitals in various U.S. territories with those from 4,799 hospitals in the 50 states and District of Columbia. They found, for example, that patients admitted to a territory hospital for pneumonia had a 14.9 percent chance of dying within a month, whereas in the states, that chance was 11.4 percent. And for every 100 heart attack hospital admissions, two more people die in the territories than in the states (18.8 percent risk of dying within a month in the territories versus 16 percent stateside).

"Eliminating the substantial quality gap in the U.S. territories should be a national priority," the researchers asserted in their report. But improving care for the nearly 5 million people who live in the territories likely means adjustment of the way federal funds are distributed.

U.S. states receive federal Medicare and Medicaid funds to help them cover residents who need it. Territories get this government aid, too, but policy has limited it to 50 percent of territory contribution—and places a cap on the overall dollar amount given to each territory. For territories, this "makes it unfeasible to cover all eligibility groups and Medicaid services as required of states," said Gutierrez, who calls the impact of these caps "considerable."

For example: Of Puerto Rico's four million residents, Medicaid programs cover about 900,000—about the same number as in New Jersey. In 2008 the federal government gave New Jersey about $4.5 billion to cover its Medicaid recipients; Puerto Rico got $26 million, Gutierrez noted. And across all of the territories, in 2003 the federal government chipped in 44 percent of an average stateside Medicare enrollee's benefits for each enrollee in the territories ($6,300 versus $2,800, respectively)—even though shipping costs there often make medical treatments pricey for the providers.

There is some hope for improvement, however. The American Recovery and Reinvestment Act boosted funding of U.S. territorial Medicaid, and starting July 1, federal Medicaid contributions will increase from 50 to 55 percent, courtesy of the Affordable Care Act.

But the medical systems in U.S. territories will likely need more than just financial assistance. American Samoa, for example, has just four registered doctors who qualify as physicians able to bill independently for Medicare services—and they also have to sign off on all Medicare work done by the territory's other docs.

Going forward, the report authors concluded, "the nation has a great responsibility to guarantee that residents on these islands have access to care that is at least of the same quality as care in the U.S. states"

Image courtesy of iStockphoto/plherrera