Clinical Rheumatology

, Volume 32, Issue 6, pp 763–769

Impact of managed care health insurance system for indigent patients with rheumatoid arthritis in Puerto Rico

  • Yesenia Santiago-Casas
  • Tania González-Rivera
  • Lesliane Castro-Santana
  • Grissel Ríos
  • David Martínez
  • Vanessa Rodríguez
  • Rafael González-Alcover
  • Ángel M. Mayor
  • Luis M. Vilá
Original Article

Abstract

The aim of this study was to determine the clinical outcome among indigent patients with rheumatoid arthritis (RA) in Puerto Rico receiving their healthcare in a managed care system, as compared with non-indigent patients treated in fee-for-service settings. A cross-sectional study was conducted in 214 Puerto Ricans with RA (per American College of Rheumatology classification criteria). Demographic features, health-related behaviors, cumulative clinical manifestations, disease activity (per disease activity score 28), comorbid conditions, functional status (per Health Assessment Questionnaire), and pharmacologic profile were determined. Data were examined using uni- and multivariable (logistic regression) analyses. The mean (standard deviation (SD)) age of the study population was 56.6 (13.5) years; 180 (84.1 %) were women. The mean (SD) disease duration was 10.8 (9.6) years. Sixty-seven patients were treated in the managed care setting, and 147 patients received their healthcare in fee-for-service settings. In the multivariable analyses, RA patients treated in the managed care setting had more joint deformities, extra-articular manifestations, arterial hypertension, type 2 diabetes mellitus, cardiovascular events, fibromyalgia syndrome, and poorer functional status while having a lower exposure to biological agents than those treated in fee-for-service settings. Efforts should be undertaken to curtail the gap of health disparities among these Hispanic patients in order to improve their long-term outcomes.

Keywords

Fee-for-service system Healthcare Hispanics Managed care system Medically indigent patients Puerto Ricans Rheumatoid arthritis 

References

  1. 1.
    Weissman JS, Stern R, Fielding SL, Epstein AM (1991) Delayed access to health care: risk factors, reasons, consequences. Ann Intern Med 114:325–331PubMedCrossRefGoogle Scholar
  2. 2.
    Pappas G, Queen S, Hadden W, Fisher G (1993) The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 329:103–109PubMedCrossRefGoogle Scholar
  3. 3.
    Brekke M, Hjortdahl P, Thelle DS, Kvien TK (1999) Disease activity and severity in patients with rheumatoid arthritis: relations to socioeconomic inequality. Soc Sci Med 48:1743–1750PubMedCrossRefGoogle Scholar
  4. 4.
    McEntegart A, Morrison E, Capell HA et al (1997) Effect of social deprivation on disease severity and outcome in patients with rheumatoid arthritis. Ann Rheum Dis 56:410–413PubMedCrossRefGoogle Scholar
  5. 5.
    Harrison MJ, Tricker KJ, Davies L et al (2005) The relationship between social deprivation, disease outcome measures, and response to treatment in patients with stable, long-standing rheumatoid arthritis. J Rheumatol 32:2330–2336PubMedGoogle Scholar
  6. 6.
    Maiden N, Capell HA, Madhok R, Hampson R, Thomson EA (1999) Does social disadvantage contribute to the excess mortality in rheumatoid arthritis patients? Ann Rheum Dis 58:525–529PubMedCrossRefGoogle Scholar
  7. 7.
    Alegría M, McGuire T, Vera M, et al (2001–2002) The impact of managed care on the use of outpatient mental health and substance abuse services in Puerto Rico. Inquiry 38:381–95.Google Scholar
  8. 8.
    Hulme PA, Rios H (1998) Healthcare reform in Puerto Rico. Managed care in a unique environment. J Nurs Adm 28:44–49PubMedGoogle Scholar
  9. 9.
    Marín HA, Ramírez R, Wise PH, Peña M, Sánchez Y, Torres R (2009) The effect of Medicaid managed care on prenatal care: the case of Puerto Rico. Matern Child Health J 13:187–197PubMedCrossRefGoogle Scholar
  10. 10.
    Arnett FC, Edworthy SM, Bloch DA et al (1988) The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 31:315–324PubMedCrossRefGoogle Scholar
  11. 11.
    Grundy SM, Cleeman JI, Daniels SR et al (2005) American Heart Association/National Heart, Lung, and Blood Institute. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 112:2735–2752PubMedCrossRefGoogle Scholar
  12. 12.
    Fransen J, van Riel PL (2005) The Disease Activity Score and the EULAR response criteria. Clin Exp Rheumatol 23:S93–A99PubMedGoogle Scholar
  13. 13.
    Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus T, Wolfe F (1992) The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthritis Rheum 35:498–502PubMedCrossRefGoogle Scholar
  14. 14.
    Yelin EH, Shearn MA, Epstein WV (1986) Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis. Med Care 24:236–247PubMedCrossRefGoogle Scholar
  15. 15.
    Ward MM, Lubeck D, Leigh JP (1998) Longterm health outcomes of patients with rheumatoid arthritis treated in managed care and fee-for-service practice settings. J Rheumatol 25:641–649PubMedGoogle Scholar
  16. 16.
    Solomon A, Christian BF, Dessein PH, Stanwix AE (2005) The need for tighter rheumatoid arthritis control in a South African public health care center. Semin Arthritis Rheum 35:122–131PubMedCrossRefGoogle Scholar
  17. 17.
    Dessein PH, Christian BF, Woodiwiss AJ, Norton GR, Solomon A (2010) Public healthcare attendance associates with enhanced conventional and non-conventional atherosclerotic cardiovascular disease risk burdens in established rheumatoid arthritis. Clin Exp Rheumatol 28:230–237PubMedGoogle Scholar
  18. 18.
    Yazici Y, Kautiainen H, Sokka T (2007) Differences in clinical status measures in different ethnic/racial groups with early rheumatoid arthritis: implications for interpretation of clinical trial data. J Rheumatol 34:311–315PubMedGoogle Scholar
  19. 19.
    Bruce B, Fries JF, Murtagh KN (2007) Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study. J Rheumatol 34:1475–1479PubMedGoogle Scholar
  20. 20.
    Young A, Koduri G (2007) Extra-articular manifestations and complications of rheumatoid arthritis. Best Pract Res Clin Rheumatol 21:907–927PubMedCrossRefGoogle Scholar
  21. 21.
    Turesson C, McClelland RL, Christianson TJ, Matteson EL (2006) Multiple extra-articular manifestations are associated with poor survival in patients with rheumatoid arthritis. Ann Rheum Dis 65:1533–1534PubMedCrossRefGoogle Scholar
  22. 22.
    Ruiz-Esquide V, Gómez-Puerta JA, Cañete JD et al (2011) Effects of smoking on disease activity and radiographic progression in early rheumatoid arthritis. J Rheumatol 38:2536–2539PubMedCrossRefGoogle Scholar
  23. 23.
    Saevarsdottir S, Wedrén S, Seddighzadeh M (2011) Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: observations from the Epidemiological Investigation of Rheumatoid Arthritis and the Swedish Rheumatology Register cohorts. Arthritis Rheum 63:26–36PubMedCrossRefGoogle Scholar
  24. 24.
    Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D (2012) Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis 71:1524–1529PubMedCrossRefGoogle Scholar
  25. 25.
    Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S (1997) Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 350:235–239PubMedCrossRefGoogle Scholar
  26. 26.
    Rose G, Marmot MG (1981) Social class and coronary heart disease. Br Heart J 45:13–19PubMedCrossRefGoogle Scholar
  27. 27.
    Karpouzas GA, Dolatabadi S, Moran R, Li N, Nicassio PM, Weisman MH (2012) Correlates and predictors of disability in vulnerable US Hispanics with rheumatoid arthritis. Arthritis Care Res 64:1274–1281CrossRefGoogle Scholar
  28. 28.
    Wolfe F, Cathey MA, Kleinheksel SM (1984) Fibrositis (Fibromyalgia) in rheumatoid arthritis. J Rheumatol 11:814–818PubMedGoogle Scholar
  29. 29.
    Yelin EH, Trupin LS, Katz PP (2005) Impact of managed care on the use of biologic agents for rheumatoid arthritis. Arthritis Rheum 53:423–430PubMedCrossRefGoogle Scholar
  30. 30.
    Quinn MA, Conaghan PG, O'Connor PJ et al (2005) Very early treatment with infliximab in addition to methotrexate in early, poor-prognosis rheumatoid arthritis reduces magnetic resonance imaging evidence of synovitis and damage, with sustained benefit after infliximab withdrawal: results from a twelve-month randomized, double-blind, placebo-controlled trial. Arthritis Rheum 52:27–35PubMedCrossRefGoogle Scholar
  31. 31.
    Fajardo Hermosillo LD, Mayor AM, Franco AE MD, Morell CA, Román YM, Vilá LM (2010) Malignancy in a Hispanic population with rheumatoid arthritis. Ann Rheum Dis 69(Suppl3):370Google Scholar
  32. 32.
    Lubeck DP (2001) A review of the direct costs of rheumatoid arthritis: managed care versus fee-for-service settings. PharmacoEconomics 19:811–818PubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2013

Authors and Affiliations

  • Yesenia Santiago-Casas
    • 1
  • Tania González-Rivera
    • 2
  • Lesliane Castro-Santana
    • 1
  • Grissel Ríos
    • 1
  • David Martínez
    • 1
  • Vanessa Rodríguez
    • 1
  • Rafael González-Alcover
    • 1
  • Ángel M. Mayor
    • 1
  • Luis M. Vilá
    • 1
  1. 1.Division of Rheumatology, Department of MedicineUniversity of Puerto Rico Medical Sciences CampusSan JuanPuerto Rico
  2. 2.Division of Rheumatology, Department of MedicineUniversity of Michigan School of MedicineAnn ArborUSA

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