The Complexities of Coverage and Access

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 for 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.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Ramu Kharel, MD, MPH. He is an emergency medicine resident at Emory University.

Abstract

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.

PMID: 30461581

Lines, LM, et al. Med Care. 2019; 57 (2): 101-108.