Research Magazine 2010

Massachusetts: Health Care Reform’s Guinea Pig?


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Ever since Massachusetts became the first state to mandate health insurance in 2006, the nation has been watching to see how the reforms would impact patients and hospitals. A recent study conducted by School of Medicine faculty members Amresh Hanchate and Nancy Kressin may offer some clues.

The study has caught the attention of policymakers, researchers, and others across the country who are interested in how previously uninsured and underinsured individuals may be benefiting from health care legislation. In particular, Hanchate and Kressin are investigating whether minority populations that did not have access to affordable health insurance before 2006 have started to seek medical attention for referral-sensitive procedures. Hanchate defines these as “inpatient surgical procedures for which most admissions are scheduled by physician referral and not via the Emergency Department or transferred from other inpatient facilities,” and which are therefore likely to be sensitive to insurance status. Such procedures are traditionally underutilized by minorities.

For their study, Hanchate and Kressin focused on a range of cardiovascular, cancer, and musculoskeletal procedures. They began, says Kressin, with a fundamental question: “If somebody now has an insurance card that they could take to a primary care provider, would they be more likely to get care (e.g., a procedure) that requires the provider’s referral?”

To ascertain whether access to health insurance had made an impact, Hanchate and Kressin analyzed data collected from Massachusetts hospitals on referral-sensitive procedures performed between 2004 and 2008—two years before and two years after the health care legislation passed. They used inpatient discharge data on 2,656,554 white patients, 195,481 African American patients, and 172,852 Hispanic patients.

Amresh Hanchate

Amresh Hanchate

The results were staggering. The data showed a marked increase in the use of these procedures across the board, but especially among the minority groups. African American patients, for instance, had a 25 percent increase in heart surgeries after the passage of health care reform. For knee replacement surgeries, there was a 17 percent increase among African Americans, and a 9 percent increase among Hispanics. “We have shown that health care reform has positively impacted minority patients in Massachusetts,” says Hanchate.

In addition to referral-sensitive procedures, Hanchate and Kressin are also interested in examining the impact of health reform on the use of emergency admissions. Without insurance, patients with nonemergency conditions tend to wait until their health deteriorates to the point where they cannot continue without medical care. Then they go to the emergency room. As a result, says Hanchate, “Any time a patient comes into the ER because of complications of asthma or diabetes, we say it’s in some sense a failure of proper care.”

There are several problems with this strategy. Emergency room visits are expensive, for one thing, and patients who cannot afford health insurance can rarely afford to pay thousands of dollars for emergency care. There is a human cost, too, for the lack of health insurance that goes far beyond the price of a trip to the ER. “One response from the patient would be just to delay, and people can delay to some extent things like knee replacements,” says Hanchate. “The way some people cope is just by cutting down on their activity level and postponing.” In many cases, the decision to postpone can be life-threatening.

Nancy Kressin

Nancy Kressin

Yet another step in their research will involve taking a closer look at what hospitals are doing to reduce the rate of readmission. “If people have better access to outpatient care when they come home from the hospital,” says Kressin, “that may prevent them from needing to be quickly readmitted for something that didn’t get resolved once they were discharged from the hospital.” Currently, 20 percent of people who are hospitalized return to a hospital within a month, which could mean that hospitals need to do a better job of explaining to patients when and how they need to follow up with their primary care physician for treatment and medication.

Last year Hanchate and Kressin were selected to share their early findings in a plenary talk at the Society of General Internal Medicine’s annual meeting, reflecting the wide appeal and interest of their work.

“The national health reform law that passed earlier in the year is very similar, in many respects, to the Massachusetts reform law,” says Hanchate. “The entire nation is going to be watching how Massachusetts turns out, and any effects that we see here are going to directly get the attention in Washington, DC.”