Emergency Department Utilization After the Implementation of Massachusetts Health Reform - 24/08/11

Doi : 10.1016/j.annemergmed.2011.02.020

Peter B. Smulowitz, MD, MPH ^a,^⁎ , Robert Lipton, PhD ^a, J. Frank Wharam, MB, MPH ^c, Leon Adelman, MD ^b, Scott G. Weiner, MD, MPH ^d, Laura Burke, MD ^a, Christopher W. Baugh, MD, MBA ^e, Jeremiah D. Schuur, MD, MHS ^e, Shan W. Liu, MD, MPH ^f, Meghan E. McGrath, MD ⁱ, Bella Liu, BA ^h, Assaad Sayah, MD ^j, Mary C. Burke, MD, MHA ^k, J. Hector Pope, MD ^l, Bruce E. Landon, MD, MBA ^g
^a Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
^b Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
^c Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
^d Department of Emergency Medicine, Tufts Medical Center, and Tufts University School of Medicine, Boston, MA
^e Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
^f Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
^g Department of Health Care Policy, Harvard Medical School, Boston, MA
^h Harvard Medical School, Boston, MA
ⁱ Department of Emergency Medicine, Boston Medical Center, and the Boston University School of Medicine, Boston, MA
^j Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, MA
^k Department of Emergency Medicine, Milford Regional Medical Center, and the Department of Emergency Medicine, University of Massachusetts Medical Center, Worcester, MA
^l Department of Emergency Medicine, Baystate Medical Center, Springfield, MA

Address for correspondence: Peter B. Smulowitz, MD, MPH, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, WCC 2, Boston, MA 02215; 617-667-1708, fax 617-754-2350

Résumé

Study objective

Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions.

Methods

We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation.

Results

Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%).

Conclusion

Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

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Plan

Introduction

Background and Importance

Goals of This Investigation

Materials and Methods

Study Design

Setting

Selection of Participants

Methods of Measurement

Primary Data Analysis

Results

Characteristics of Study Subjects

Limitations

Discussion

	Please see page 226 for the Editor's Capsule Summary of this article.
	Supervising editor: Donald M. Yealy, MD
	Author contributions: PBS, RL, JFW, CWB, SGW, JDS, SWL, and BEL conceived and designed the study. PBS, SGW, LB, CWB, MEM, AS, MCB, and JHP undertook recruitment of participating centers and data collection. PBS, RL, LA, SGW, LB, CWB, JDS, SWL, and BL managed the data, including quality control. PBS, RL, JFW, and BEL provided statistical advice on study design and analyzed the data. PBS drafted the article, and all authors contributed substantially to its revision. PBS takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
	Publication date: Available online May 12, 2011.
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