Smulowitz Peter B, O'Malley James, Yang Xiaowen, Landon Bruce E
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Dartmouth Institute for Health Policy and Clinical Practice Geisel School of Medicine at Dartmouth, Hanover, NH.
Ann Emerg Med. 2014 Aug;64(2):107-15, 115.e1-3. doi: 10.1016/j.annemergmed.2014.02.011. Epub 2014 Mar 20.
With implementation of the Patient Protection and Affordable Care Act, 30 million individuals are predicted to gain access to health insurance. The experience in Massachusetts, which implemented a similar reform beginning in 2006, should provide important lessons about the effect of health care reform on emergency department (ED) utilization. Our objective is to understand the extent to which Massachusetts health care reform was associated with changes in ED utilization.
We compared changes in ED utilization at the population level for individuals from areas of the state that were affected minimally by health care reform with those from areas that were affected the most, as well as for those younger than 65 years and aged 65 years or older. We used a difference-in-differences identification strategy to compare rates of ED visits in the prereform period, during the reform, and in the postreform period. Because we did not have population-level data on insurance status, we estimated area-level insurance rates by using the percentage of actual visits made during each period by individuals with insurance.
We studied 13.3 million ED visits during 2004 to 2009. Increasing insurance coverage in Massachusetts was associated with increasing use of the ED; these results were consistent across all specifications, including the younger than 65 years versus aged 65 years or older comparison. Depending on the model used, the implementation of health care reform was estimated to result in an increase in ED visits per year of between 0.2% and 1.2% within reform and 0.2% and 2.2% postreform compared with the prereform period.
The implementation of health care reform in Massachusetts was associated with a small but consistent increase in the use of the ED across the state. Whether this was due to the elimination of financial barriers to seeking care in the ED, a persistent shortage in access to primary care for those with insurance, or some other cause is not entirely clear and will need to be addressed in future research.
随着《患者保护与平价医疗法案》的实施，预计将有3000万人获得医疗保险。马萨诸塞州自2006年开始实施类似改革，其经验应能为医疗改革对急诊科（ED）利用率的影响提供重要借鉴。我们的目标是了解马萨诸塞州医疗改革与急诊科利用率变化之间的关联程度。
我们比较了该州受医疗改革影响最小地区和受影响最大地区的个人在人口层面上急诊科利用率的变化，以及65岁以下和65岁及以上人群的急诊科利用率变化。我们采用了双重差分识别策略，以比较改革前、改革期间和改革后时期的急诊就诊率。由于我们没有关于保险状况的人口层面数据，我们通过使用各时期有保险的个人实际就诊百分比来估计地区层面的保险费率。
我们研究了2004年至2009年期间的1330万次急诊就诊。马萨诸塞州保险覆盖范围的扩大与急诊科使用的增加相关；所有规格的结果都是一致的，包括65岁以下与65岁及以上人群的比较。根据所使用的模型，估计医疗改革的实施导致改革期间每年急诊就诊次数增加0.2%至1.2%，与改革前时期相比，改革后增加0.2%至2.2%。
马萨诸塞州医疗改革的实施与全州急诊科使用量的小幅但持续增加相关。这是否是由于消除了在急诊科就诊的经济障碍、有保险者获得初级医疗服务的持续短缺或其他一些原因尚不完全清楚，需要在未来的研究中加以解决。
