Demand for medical care at 'safety-net facilities' appears to have increased since Massachusetts enacted its health care reform law

According to background information in the article, a disproportionate share of patients who do not have health insurance obtain care from community health centers (CHCs) and safety-net hospitals (e.g., public or charity hospitals). In Massachusetts, health care reform legislation implemented in 2006 expanded insurance coverage of nonelderly adults from 87.5 percent in 2006 to 95.2 percent in 2009, and lowered the state's uninsurance rate to 1.9 percent by 2010. Using data from Massachusetts safety net facilities and patients, the researchers sought to assess changes in the demand for and use of outpatient and inpatient care since the state's implementation of health care reform.

Leighton Ku, Ph.D., M.P.H., from George Washington University, Washington, D.C., and colleagues examined data from multiple sources. Data for CHCs were obtained from the Uniform Data System for Massachusetts for 2005 through 2009. Data for hospitals were obtained from the Massachusetts Division of Health Care Finance and Policy for calendar years 2006 through 2009. Data regarding patients' perspectives were obtained from the 2009 Massachusetts Health Reform Survey, a state-representative telephone survey of 3,041 nonelderly adults. The researchers also conducted case study interviews from January through March 2010 with CHC and hospital administrators and medical staff in Boston, Fall River, Springfield and Pittsfield, Mass.

The total number of patients served by CHCs increased by 31 percent from 2005 to 2009 and the average number of patient visits also increased. During the same period, the number of patients without insurance in the CHC caseload decreased from 35.5 percent to 19.9 percent. Staff members at CHCs told researchers that newly insured patients returned because they like the care received at these sites and the relationships they had developed with center health care professionals.

The authors defined safety-net hospitals as those that, in 2009, received 20 percent or more of their net patient service revenue from Medicaid or two Massachusetts programs for low-income patients: Commonwealth Care and the Health Safety Net program. They identified 17 institutions as safety-net hospitals and 48 without that designation. Overall growth levels from 2006 to 2009 were similar for both types of hospitals. However, nonemergency ambulatory care visits from outpatient departments and hospitals' community clinics increased 9.2 percent for safety-net hospitals and 4.1 percent for non-safety net hospitals. Administrators and medical staff at safety-net hospitals told researchers that newly insured patients visited their facilities because they liked the care received at these sites and the convenience of the locations.

The researchers analyzed responses from patients of safety-net facilities who were nonelderly adults with incomes below 300 percent of the poverty line. Roughly two-thirds had health coverage through a public program. Safety-net patients reported seeking care at emergency departments more than other low-income adults or all adults. Of lower-income safety-net patients, 33.3 percent said they had sought care for a nonemergency condition at an emergency department, compared with 14.7 percent of all adults. Most reported that they used safety-net facilities because these services were convenient and affordable, with one-quarter reporting difficulty in obtaining care elsewhere.

"Despite the significant reduction in uninsurance levels in Massachusetts that occurred with health care reform, the demand for care at safety-net facilities continues to rise," the authors write. "Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after health care reform programs are established."

Editorial: Safety-Net Providers and Preparation for Health Reform

Major expansion of health insurance as part of federal health reform will occur by 2014, providing coverage to millions of individuals who currently lack it, but still leaving an estimated 24 million without insurance, according to an editorial by Mitchell H. Katz, M.D., from the Los Angeles County Department of Health Services. "Of the various health care providers, safety-net providers will be the most affected by the health coverage expansion because they are the major providers of care for the uninsured," he writes. The article by Ku and colleagues, Katz notes, may help dispel conventional wisdom that demand for safety-net services would decrease once individuals obtain insurance coverage.

"The important lesson from Massachusetts is that the newly insured continued to seek care in the safety net," he comments. However, this scenario may differ in other parts of the country, depending on perceived quality and convenience of safety-net providers and the degree of competition from other providers. "How much competition there will be for the newly insured is unknown," points out Katz.

As federal health reform is implemented, the health care system will likely have to increase capacity to care for newly insured patients. Katz writes that instead of just training more primary care physicians, a better option may be to develop teams of health care providers. "Ironically, safety-net providers have more experience working in teams than most commercial providers because low reimbursement rates have forced them to learn to be more cost-efficient," he concludes. "The challenge will be proving that they can also be a system of choice for their patients, not just in Massachusetts, but across the country."