Massachusetts health reform didn't cut ER visits
NEW YORK (Reuters Health) - Health care reform in Massachusetts only had a small impact on the number of trips residents took to the emergency room, according to a new study.
Contrary to expectations that easier access to primary care would reduce ER use, the total number of ER visits at 11 hospitals increased slightly after reform was implemented -- a pattern similar to that seen in other states.
"There was perhaps a perception that if we could just get people insurance they won't need the ER anymore," said Dr. Peter Smulowitz, the study's lead author from Harvard Medical School in Boston. But, "you cannot ever redirect every visitor, perhaps even the majority of visitors, away from the ER," he told Reuters Health.
Estimates have shown that the state's reform was successful in cutting its number of uninsured people by about three quarters.
Supporters of the reforms hoped that insurance would allow people to see a primary care doctor before health problems get serious enough to warrant an ER trip, with the added bonus of easing pressure on crowded emergency departments.
To assume that insuring more people will drastically cut down on the need for emergency care "is a dangerous policy choice," Smulowitz said, partly because there are many different factors that influence statewide use of ERs.
Massachusetts' health care reform required everyone in the state to have health insurance and made subsidized insurance available to residents who were uninsured or had limited coverage.
The legislation was enacted in 2006, when Mitt Romney -- now an opponent of current national health reform legislation -- was governor, and fully implemented by 2008.
Smulowitz and his colleagues used hospital billing data to compare the number of ER visits at 11 Massachusetts hospitals during nine-month periods before and after the state's individual insurance mandate was implemented in January 2008.
Total visits increased from about 425,000 in the first nine months of 2006 to 442,000 over the same period in 2008 -- a four-percent rise.
When the researchers focused in on the visits that should have been most affected by reform -- visits they classified as "low severity" in people previously uninsured or underinsured -- they found a slight dip of 2.6 percent, from 186,000 visits in 2006 to 182,000 in 2008.
By definition, most people with "low severity" visits could have been treated by a primary care doctor.
The authors note in Annals of Emergency Medicine that even with insurance, some people may have trouble accessing primary care -- for example, if they work during the day and can only get medical help at night or on the weekend. Also, primary care doctors are in limited supply, and people may have trouble booking appointments, Smulowitz added.
"Access to health care is dependent on really more than switching you over to being insured," he said.
Kathy Fuda, a former state health worker who researched emergency room use but was not involved in the current study, said policymakers may have been "overly optimistic" about health care reform's impact on ER visits.
People with insurance are the ones driving increases in ER use, she said - mainly because there are many more insured than uninsured people, at least in Massachusetts.
Fuda, now at Abt Associates, a health and policy research organization in Cambridge, Massachusetts, added that it's possible people who were previously uninsured might even use the ER more after they get insurance, if they couldn't afford to pay out-of-pocket for an ER visit before.
"There are really conflicting trends there," she told Reuters Health. "It's not a completely simple picture."
The authors said that longer-term studies will be needed to see if patterns in ER use change over the years after reform. They also note that the current study couldn't look at patterns in all Massachusetts hospitals.
In terms of extrapolating to national health care reform, Smulowitz said that "the only message that one can really conclude...is that increasing access to health insurance is not going to make major changes in utilization of the emergency department."
SOURCE: bit.ly/iVH6wB Annals of Emergency Medicine, online May 12, 2011.
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