The data on combined inpatient and outpatient ED use (top graph) suggest that the Massachusetts reform did not change the state's trend in total ED utilization relative to that in states where no such reform was enacted. The continuous upward trend in ED utilization throughout the three periods is remarkably consistent from state to state; if we didn't know which state had implemented the reform law, we could not guess on the basis of these data. Although the majority of ED visits are outpatient visits, inpatient ED visits account for a large fraction of total ED costs (approximately 65% in our data set). To clarify the trends in such visits, we show in the bottom graph inpatient visits only. Here, too, we find no evidence that the Massachusetts reform significantly increased hospitalizations from the ED relative to those in other states that did not pass reforms. We also examined ED use in safety-net hospitals, which were disproportionately affected by the insurance expansion, but did not find evidence that ED utilization in these hospitals was different from that in similar hospitals in other states. In summary, ED use increased in Massachusetts after reform but also increased by similar amounts in New Hampshire and Vermont, states that did not implement insurance expansions.
On the basis of these findings, we conclude that Massachusetts' health care reform law has thus far neither increased nor decreased ED utilization relative to that in other states. The similarity among states is to be expected if the level of ED visits is dominated by broader trends in population health, such as health status or accidents that are not affected by a health insurance expansion. Alternatively, it is possible that this null result arises from two equal forces pushing in opposite directions — that the Massachusetts insurance expansion increased prevention, thereby reducing ED use, but that this effect has been offset by the reduced out-of-pocket cost of using the ED or difficulties in finding primary care physicians.
MMS: Error
Objective: There is widespread concern that large-scale insurance expansion - such as that anticipated from the Affordable Care Act - has the potential to cause sharp increases in health care utilization and costs. In the setting of Massachusetts’ landmark 2006 health care reform, we estimated pre-reform to post-reform changes in inpatient care volumes and costs, contrasting the experience of safety-net hospitals (SNH) as the predominant providers of care for targeted reform beneficiaries, with that of non-SNH.
Study Design: We analyzed MA inpatient discharge on all discharges from 2004-2010 for 2,636,326 non-elderly patients (age 18-64) across all 66 short-term acute care hospitals. Safety-net hospitals were identified as those in the top quartile of hospitals in the proportion of hospital admissions with Medicaid, Free Care and self-pay as the primary payer. Using linear regression models we estimated hospital-level post-reform changes in (a) # admissions, (b) length of stay (LOS; days), (c) charge per day ($) and (d) charge per stay ($), separately for SNH and non-SNH, adjusting for patient demographics and comorbidities. We also examined changes for subpopulations by race/ethnicity and socioeconomic status (SES; defined using patient zip code median income). To isolate the impact of reform from secular trends, we treated the elderly as the "control" population.
Findings: There was no significant post-reform change in the number of admissions; average quarterly number of admissions per hospital were 1,480 pre-reform and 1,520 post-reform (p=0.68). A similar pattern was found for admissions by SNH status, and for minority and low-income subpopulations. Average LOS increased by a smaller amount among SNH (0.20 days; 95% CI=[0.15, 0.25]) than among non-SNH (0.30 days; 95% CI=[0.27, 0.33]). Average charges per day decreased among SNH ($-198; 95%=[$-251, $-145]) and increased among non-SNH ($249; 95%=[$215, $284]). A similar trend with a larger difference was found for average charges per stay (SNH=$-477; 95%CI=[$-768, $-187] and non-SNH=$1,442; 95%CI=[$1,248, $1,635]). Similar trends were found for both acute and non-acute admissions. Among blacks, Hispanics and low-income patients, none of the measures indicated larger increase in SNH compared to that in non-SNH.
Conclusion: Following MA health reform, utilization of inpatient care did not increase at SNH, the predominant providers of inpatient care for populations targeted by the reform, compared to non-SNH. A similar trend was found for acute and non-acute admissions, and for minority and low-income subpopulations. Future analyses in the coming months will test robustness of these findings using the non-elderly patients from comparison states as the control population.
Abstract 23: Impact of Massachusetts Health Reform on Hospitalizations, Length of Stay and Costs of Inpatient Care: Does Safety-Net Status Matter? -- Hanchate et al. 6 (1003): A23 -- Circulation: Cardiovascular Quality and Outcomes
