Health Policy Journal Club, Health Policy

Health Policy Journal Club: The Complexities of Coverage and Access

Public insurance must be expanded, but coverage does not equal accessibility

In 2006, Massachusetts became the first state to pioneer a system of health reforms which ultimately paved the way for the Affordable Care Act (ACA) in 2010. It was thought that emergency department (ED) visits would decrease with the rise of insured populations. Researchers performed a retrospective observational analysis to evaluate primary care sensitive (PCS) ED visits. They analyzed the Massachusetts all payer claims database from 2011-2012 comparing PCS ED use based on insurance category: private or  public (Medicaid) coverage, excluding patients age over 65. The uninsured were excluded from the study.

The analysis found that PCS ED use was significantly higher in the publicly insured group compared to the privately insured by as much as 4 times. Patients with public insurance were less likely to have any primary care visit. The pool of patients with public insurance who utilized primary care visits, however, were using it more frequently than the private group. Along with insurance type, higher morbidity conditions like heart failure were also associated with higher PCS ED.

Higher PCS ED use among people with public insurance is likely multifactorial but are likely related to barriers to access. For example, having public insurance is associated increased wait times or appointments. There are also concerns about a lower than needed provider pool due to relatively low reimbursement rates with public insurance. The publicly insured are also likely to have lower health literacy, which could lead to increased PCS ED visits. 

Massachusetts, one of the wealthiest states, has many innovative models for primary care access including community health centers. Although Massachusetts is not representative of the entire country, this analysis does provide evidence that having public insurance is associated with higher PCS ED visits compared having private insurance. Massachusetts’ 40% who were publicly insured is similar to the overall U.S. rate of 36% with either Medicare or Medicaid.  

The public insurance sector must have incentives and mechanisms in place to focus on the root drivers of higher PCS ED use. Some examples include expanding the provider pool and reimbursing providers competitively. Further partnerships with private sector accountable care organizations (ACO) might help lower PCS ED use as well. Incorporation of tele-health might play a big role in lowering PCS ED use of patients with high co-morbid conditions. Public insurance must be expanded, but mere coverage with insurance does not equal accessibility to primary care

PMID: 30461581

Lines LM, Li NC, Mick EO, Ash AS. Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform. Current neurology and neuroscience reports. 


OBJECTIVE: Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees.
POPULATION AND SETTING: People under age 65 in the Massachusetts All-Payer Claims Data, 2011-2012.
STUDY DESIGN: Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records.
PRINCIPAL FINDINGS: Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49-2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one's own (attributed) primary care provider (38% vs. 44%).
CONCLUSIONS: Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.


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