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ER study undercuts conventional wisdom on health reform

A central hypothesis underlying the case for health reform's insurance expansion is being challenged by new evidence, as the quest to reduce emergency visits and spending continues. The research also highlights ongoing concerns about primary care access.

From Massachusetts' experience with near-universal coverage comes new data showing that emergency room use increased in tandem with insurance expansion -- contrary to the goals of bringing more insured patients primary care access to reduce emergency care use.

A research team led by Beth Israel Deaconess Medical Center emergency care physician Peter Smulowitz, MD, found a "small but consistent increase" in emergency room use following Massachusetts' individual mandate and insurance subsidy system.

From fall 2006 to fall 2007, after the law took effect, ER visits increased by 1.2 percent and then increased by 2.2 percent between 2007 and September 2009, Smulowitz and colleagues found, in a study published in the Annals of Emergency Medicine.

"This obviously has implications about what we can expect to see nationally as the roll-out of the Affordable Care Act continues," Smulowitz, also a Harvard Medical School instructor, said in an accompanying media release.

"We cannot say for sure why more people came to the ER -- whether it's a lack of access to primary care or the result of pent-up demand -- but we need to be ready. Other states should be prepared for equal or greater influxes of patients into the ER after reform is fully implemented."

The study, described as the first of its kind, examined data from 13 million emergency department visits in Massachusetts between 2004 and September 2009 at 69 acute care hospitals.

Among other things, Smulowitz and colleagues argued, the findings should "further weaken the long-held notion that high use of the ED is being driven mainly by the uninsured."

ER visits by uninsured Massachusetts residents declined from 9.5 percent of all ER visits among the pre-65-year-old population in the two years leading up to the new law to 5.7 percent afterwards. The rate of ER visits by commercially insured residents also declined, from 54 percent of all pre-65-yearold ER visits before reform, in 2006, to 49 percent afterwards.

Those with the largest increase in ER utilization (in the pre-65 population) were Medicaid-covered residents, whose ER use increased from 23.6 percent of all ER visits pre-reform to 29.7 percent post-reform.

Residents covered by the new state-supported Commonwealth Care program accounted to 2.8 percent of ER visits post-reform, while those in the uncompensated care population declined from 6.7 percent to 4.9 percent of ER visits.

Multiple factors seem to be driving those trends, Smulowitz and his fellow researchers wrote, including "pent-up demand," "decreased economic barriers to seeking emergency care," and a lack of easy access to primary care.

The primary care problem

The primary care access factor especially is a big one, portending potential ER utilization in the coming years nationally, as anywhere from 10 million to 20 million previously uninsured (or even eventually 30 or 40 million) gain insurance through subsidized private coverage or Medicaid.

"The reality is that primary care access remains limited in Massachusetts and across the United States, and in most states the problem is far grimmer than in Massachusetts," Smulowitz and colleagues wrote.

One hypothesis they offer is that previously-insured patients may have seen their access to primary care limited slightly -- as in longer appointment wait times -- due to newly-insured patients coming into the primary care system, and as a result they may be turning more to the ER.

At the same time primary care access may be limited, the ER has a certain draw to individuals, Smulowitz and colleagues noted: 24-hour availability (compared to the usual 9-5, Monday to Friday schedule of many primary care services); the "perceived efficiency, technologic expertise, and quality of ED care"; and "increasing awareness of emergency conditions."

There's also a body of economic theory and evidence -- mostly recently expanded with data from the Oregon Medicaid experiment -- suggesting that having health insurance may "increase use of certain healthcare resources, including the ED," while "greater financial barriers such as increased copayments may result in reduced use of both necessary and unnecessary care," Smulowitz and colleagues wrote.

"It appears that when people have health insurance, they will seek medical care wherever they can get it, which is sometimes only the ER," he added.

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