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Study Examines Impact of Massachusetts Health Law on Emergency Department Visits

Insurance only one factor affecting ED utilization

BOSTON - While overall emergency department use in Massachusetts continues to rise, the number of low-severity visits dropped slightly since the implementation of the state's health care reform law, according to an Annals of Emergency Medicine study published online.

"Our study suggests other factors play a role in determining access to care and use of the ED in addition to one's insurance status," writes Peter Smulowitz, MD, MPH, the study's lead author and an emergency physician at Beth Israel Deaconess Medical Center.

"These likely include availability of primary care, convenience of ED hours, the ability to obtain a comprehensive evaluation and testing at one time in the ED," says Smulowitz, adding other factors may also include cultural views about seeking care through primary care or the ED, patient perceptions about the severity of illness and other financial factors, such as co-payments.

The study examined administrative billing data from 11 hospitals between Jan. 1, 2006 and 2008, during the year before and two years after implementation of the Massachusetts law providing health care access. The hospitals included four tertiary academic medical center, two community hospitals, three safety net/community hospitals and two safety net/tertiary academic medical centers. The combined ED volume of approximately 587,000 visits accounts for about 20 percent of all emergency visits in Massachusetts.

Smulowitz, who is also an Instructor in Medicine at Harvard Medical School, says the study focused on three groups most likely to be affected by the reform law: the uninsured, enrollees in the MassHealth Medicaid program and those whose costs were covered by the state's uncompensated care pool. After reform, the target group also included those covered by the new Commonwealth Care program and the smaller health safety net group.

Researchers found a 4.1 percent increase in overall ED visits from 2006 to 2008 - 3.4 percent from 2006 to 2007 and 0.7 percent the following year. In comparison, there was a 4.6 percent increase in ED visits statewide according to data from the Massachusetts Division of Health Care Finance and Policy. They found a 1.8 percent decrease in low-severity visits for the group affected by the reform law versus the comparison group.

This small decrease in low-severity visits was somewhat contradictory to expectations prior to the implementation of reform, Smulowitz wrote.

"To the extent that policymakers expected a substantial decrease in overall and low-severity ED visits, this study does not support those expectations."

The authors suggest limitations on the availability of primary care in Massachusetts may be a key reason in the limited effect of health reform in ED utilization. Low or non-existent co-payments for MassHealth and Commonwealth Care may also be factors.
"In addition, even with adequate coverage, it might take time and effort to alter care-seeking patterns that have become ingrained in some communities," Smulowitz wrote. "Many of these patients had never had insurance before, so they may have been relying on the ED instead of other care settings."

In addition to Smulowitz, study co-authors include: Robert Lipton PhD and Laura Burke, MD, BIDMC; Leon Adelman, MD, Harvard Affiliated Emergency Residency at BIDMC; J. Frank Wharam, MB, MPH, Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute; Scott G. Weiner, MD, MPH, Department of Emergency Medicine at Tufts Medical Center and Tufts University School of Medicine; Christopher W. Baugh MD, MBA and Jeremiah D. Schuur, MD, MHS, Department of Emergency Medicine at Brigham and Women's Hospital; Shan W. Liu, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital.

Also, Bella Liu, BA, Harvard Medical School; Meghan E. McGrath, MD, Department of Emergency Medicine, Boston medical Center and Boston University School of Medicine; Assaad Sayeh, MD, Department of Emergency Medicine, Cambridge Health Alliance; Mary C. Burke, MD, MHA, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Mass.; J. Hector Pope, MD, Department of Emergency Medicine, Baystate Medical Center, Springfield, Mass.; and Bruce Landon, MD, MBA, Department of Health Care Policy, Harvard Medical School.

No potential conflicts of interest were reported.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.