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Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

ABSTRACT: OBJECTIVE:Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis). DATA SOURCES/STUDY SETTING:Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004-2010. STUDY DESIGN:Using a difference-in-differences design, we compared pre-/post-reform changes in safety-net and non-safety-net hospital discharge outcomes in Massachusetts among adults 18-64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations. PRINCIPAL FINDINGS:Reform was not associated with changes in inpatient care use at safety-net and non-safety-net hospitals across all discharges or in most subpopulations examined. CONCLUSIONS:Demand for inpatient care at safety-net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.

SUBMITTER: Hanchate AD

PROVIDER: S-EPMC5583295 | biostudies-other | 2017 Oct

REPOSITORIES: biostudies-other

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Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

Hanchate Amresh D AD McCormick Danny D Lasser Karen E KE Feng Chen C Manze Meredith G MG Kressin Nancy R NR

Health services research 20160808 5

<h4>Objective</h4>Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical s ...[more]

PMID: 27500666

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Project description:Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

Project description:The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform's impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral.Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006-12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ?70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40-64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform.Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [-3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [-20%, 30%]), and whites=7% (95% CI [5%, 10%]).Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Project description:Racial disparities in receipt of minimally invasive surgery (MIS) persist in the United States and have been shown to also be associated with a number of driving factors, including insurance status. However, little is known as to how expanding insurance coverage across a population influences disparities in surgical care.To evaluate the impact of Massachusetts health care reform on racial disparities in MIS.A retrospective cohort study assessed the probability of undergoing MIS vs an open operation for nonwhite patients in Massachusetts compared with 6 control states. All discharges (n?=?167,560) of nonelderly white, black, or Latino patients with government insurance (Medicaid or Commonwealth Care insurance) or no insurance who underwent a procedure for acute appendicitis or acute cholecystitis at inpatient hospitals between January 1, 2001, and December 31, 2009, were assessed. Data are from the Hospital Cost and Utilization Project State Inpatient Databases.The 2006 Massachusetts health care reform, which expanded insurance coverage for government-subsidized, self-pay, and uninsured individuals in Massachusetts.Adjusted probability of undergoing MIS and difference-in-difference estimates.Prior to the 2006 reform, Massachusetts nonwhite patients had a 5.21-percentage point lower probability of MIS relative to white patients (P?<?.001). Nonwhite patients in control states had a 1.39-percentage point lower probability of MIS (P?=?.007). After reform, nonwhite patients in Massachusetts had a 3.71-percentage point increase in the probability of MIS relative to concurrent trends in control states (P?=?.01). After 2006, measured racial disparities in MIS resolved in Massachusetts, with nonwhite patients having equal probability of MIS relative to white patients (0.06 percentage point greater; P?=?.96). However, nonwhite patients in control states without health care reform have a persistently lower probability of MIS relative to white patients (3.19 percentage points lower; P?<?.001).The 2006 Massachusetts insurance expansion was associated with an increased probability of nonwhite patients undergoing MIS and resolution of measured racial disparities in MIS.

Dataset Information

Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

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Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

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