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Massachusetts offers a warning about universal coverage and hospitalizations

New evidence from Massachusetts suggests that expanded health insurance may not bring the needed benefits of reduced hospitalization, and could spur a rethinking of cost-sharing for valuable primary care.

Even though the rate of uninsurance was cut in half to 6 percent, Massachusetts's 2006 health reform has not really helped improve preventable hospital admissions for chronic conditions that can be well treated with primary care, nor ethnic and racial disparities in those hospitalizations, according to a new study in the BMJ, formerly the British Medical Journal.

Harvard Medical School's Danny McCormick, MD, and researchers at Boston University School of Medicine examined hospital admissions in Massachusetts in the two years before and after the healthcare law, using control data from New Jersey, New York and Pennsylvania.

They tracked the rates of hospitalizations for 12 conditions that can be treated effectively with primary care, including short- and long-term diabetes complications, COPD, hypertension, congestive heart failure, chest pain and urinary tract infection.

In Massachusetts, the admission rate per 100,000 before the law was at 667 for whites, 1,258 for Hispanics and 1,713 African Americans. After the law, the researchers found almost no changes in admission rates for those diseases--known as ambulatory care sensitive conditions--nor any evidence of major changes for a composite measure of the conditions across ethnic/racial demographics, with admissions actually increasing for caucasians.

Also, they found no changes in admission rates for those conditions in Massachusetts counties with higher uninsurance rates before 2006, in areas where the previously uninsured could have benefited from robust primary care following health plan coverage, nor any changes in wealthy counties where most were already insured.

"The fact that we found no evidence that the Massachusetts reform diminished either preventable admissions or disparities in such admissions, suggests that particular features of the Massachusetts reform might need to be optimized to realize improvements in access to outpatient care that can prevent admissions," write McCormick, an internist at the Cambridge Health Alliance, and colleagues. "In addition to being a key measure of access, preventable admissions represent a clinical failure for patients and a needless expenditure of scarce healthcare resources."

Since Massachusetts' law was a major inspiration for the core insurance reforms and programs of the Affordable Care Act, it's possible a similar trend may play out in parts of the population for Americans covered in exchange plans.

Among the policy and health insurance practice ideas that could be considered are a "reduction in cost related barriers to outpatient care among those with insurance, and more comprehensive outreach efforts to the insured and uninsured to ensure adequate knowledge of the processes for applying for and effectively utilizing insurance."

While a sizable amount of evidence shows that insurance coverage correlates with more and better access to healthcare, health reform policies may "need to go beyond simply expanding insurance coverage" to "reduce preventable admissions and disparities," McCormick and colleagues write.

Whether or not ever-more-common high deductibles are a factor in preventable hospitalization rates, there is a movement afoot for value-based insurance design that makes evidence-based high value primary and preventive care and medications as easy for high-risk patients to access as possible.

"I would like a HDHP that makes bad stuff high deductible and good stuff low," said Mark Fendrick, MD, an internist and University of Michigan medical professor who helped develop the value-based insurance design framework. For the most part, "people pay the same out-of-pocket for high-value services as low-value services," he said. "Currently, Americans are neither incented nor disincented on the value proposition."

One avenue Fenrick is pushing for change: HSAs as a way for consumers to pay for secondary preventive care.