Dr-Lisa M. Lines

Despite More Insurance, Medicaid Recipients Still Use ER Over Primary Care

MedicalResearch.comInterview with:
Lisa M. Lines, PhD, MPH
University ofMassachusetts Medical School
RTI International,Waltham, MA

MedicalResearch.com:  What is the background for this study?  What are the main findings?

Response: The problem of potentially avoidable emergency department (ED) visits has been linked to barriers in access to high-quality, timely primary care. In Massachusetts ,about half of all ED visits were considered potentially avoidable, or primary-care sensitive (PCS), in the mid-2000s. Indeed, improving access to primary care was a prime motive for the state’s – and the nation’s – first universal coverage health insurance program in 2006. Now, the state has the highest coverage rate in the country.

We used Massachusetts All-Payer Claims Data to study characteristics of insured Massachusetts residents associated with primary-care sensitive ED use and compared such use among people under age 65 with public (Medicaid[MassHealth]) versus private insurance. We studied more than 2.2 million individuals in 2011-12; about 40% had public insurance in 2011, and the rest had private insurance. Our PCS ED measure included nonurgent, urgent but primary care treatable, and urgent but potentially avoidable ED visits.

We found that primary-care sensitive ED use was more than 4 times higher among the publicly insured (public insurees: 36.5 PCS ED visits per 100 person-years; private insurees: 9.0). After adjusting for a range of potential confounders, such as the vastly different morbidity burden of the two groups, public insurance in2011 was associated with about 150% more primary-care sensitive ED use. We also found that 70% of people with public insurance had at least 1 primary care visit, compared with 80% of those with private insurance. The public group also had fewer visits to their PCP of record, even though nearly all of them had an officially designated PCP.

MedicalResearch.com: What should readers take away from your report?

Response: Five years after passage of major health reforms intended to improve access to care, our study found that Massachusetts faces continued insurance-based disparities in potentially avoidable ED use and underuse of primary care by people with the greatest potential to benefit from it. The underlying reasons may include continued barriers to access for people with public insurance, including long wait times for new appointments. With low reimbursement rates for providers that accept MassHealth patients and an already inadequate supply of PCPs, improved access to public insurance may not have actually improved access to primary care.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Our work suggests that ED utilization measures could be more useful if they focused on potentially avoidable (PCS) visits and were risk-adjusted to avoid punishing providers who care for the kinds of patients whose ED use is predictably high.The PCS ED measure used in this study could help measure and reduce dysfunctional ED use.

MedicalResearch.com: Is there anything else you would like to add?

Response: The author team was Lisa M. Lines, PhD, MPH; Nien-Chen Li, MPH, MA; Eric O. Mick, ScD; and Arlene S. Ash, PhD; all are affiliated with University of Massachusetts Medical School. Dr. Lines is employed by RTI International. Partial support for this research was provided by the Agency for Healthcare Research and Quality (Award #1R36HS022194-01). Views expressed are those of the authors and do not necessarily reflect those of University of Massachusetts or RTI International. The co-authors gratefully acknowledge the following additional University of Massachusetts Medical School staff for data management, programming, and analysis assistance: Nisha Kini, MBBS, MPH; Peter Lazar, BS; and Jianying Zhang, MD, MPH.


Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform

Lines, Lisa M., PhD, MPH*,†; Li, Nien-Chen, MPH, MA*; Mick, Eric O., ScD*; Ash, Arlene S., PhD*

Medical Care: November 19, 2018 – Volume Publish Ahead of Print – Issue- p


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Last Updated on December 11, 2018 by Marie Benz MD FAAD