Date of Award

January 2019

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Harlan M. Krumholz


Millions of Americans live in United States territories, but health outcomes and payments among Medicare beneficiaries in these territories are not well characterized. We sought to assess and compare hospitalization rates, outcomes, and Medicare payments between Medicare Fee-for-Service beneficiaries in the territories and the 50 states and District of Columbia (hereafter called “states”) for common medical conditions. Utilizing the Medicare denominator and inpatient files, we conducted a serial cross-sectional analysis of Fee-for-Service Medicare beneficiaries 65 years of age or older hospitalized between 1999 and 2012 for acute myocardial infarction (AMI), heart failure (HF), and pneumonia in the territories and states. Over 14 years, there were 4,350,813 unique beneficiaries in the territories and 402,902,615 in the states. Hospitalization rates for AMI, HF, and pneumonia declined overall and did not differ significantly. However, 30-day mortality rates were higher in the territories for all three conditions: in the most recent time period (2008-2012), the adjusted odds of 30-day mortality were 1.34 (95% CI, 1.21 to 1.48), 1.24 (95% CI, 1.12 to 1.37), and 1.85 (95% CI, 1.71 to 2.00) for AMI, HF, and pneumonia, respectively; adjusted odds of 1-year mortality were also higher. In the most recent study period, inflation-adjusted Medicare in-patient payments, in 2012 dollars, were lower in the territories than the states, at $9234 less (61% lower than states), $4479 less (50% lower), and $4403 less (39% lower) for AMI, HF, and pneumonia hospitalizations, respectively (p<0.001 for all). In conclusion, among Medicare Fee-for-Service beneficiaries, mortality rates were significantly higher, and hospital reimbursements were substantially lower, for patients hospitalized with AMI, HF, and pneumonia in the territories. Improvement of healthcare in the territories and the policies that govern them is needed to ensure health equity for all Americans.


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