Care from safety-net providers in Massachusetts, such as community health centers and public hospitals, from patient demand has increased. Despite an increasing number of patients with health insurance following the state's passage of health care reform, according to a study in the August 8 issue of Archives of Internal Medicine, one of the JAMA/Archives journals, part of the journal's Health Care Reform series.

A disproportionate amount of people without health insurance, receive care from community health centers (CHCs) and safety-net hospitals (e.g., public or charity hospitals), according to background data in the report. In Massachusetts, health care reform legislation carried out in 2006 increased insurance coverage of non-elderly adults from 87.5% in 2006 to 95.2% in 2009, also lowering the state's un-insurance rate to 1.9% by 2010. Since the state's implementation of health care reform, the researchers, who used data from Massachusetts safety-net facilities and patients, sought to evaluate changes in the demand for and use of outpatient and inpatient care.

Leighton Ku, Ph.D., M.P.H., from George Washington University, Washington, D.C., and colleagues analyzed data from several sources. From 2005 through 2009, data for CHCs were taken from the Uniform Data System for Massachusetts. Data for hospitals was collected from the Massachusetts Division of Health Care Finance and Policy from 2006 through 2009. Data about patient's perspectives was collected from the 2009 Massachusetts Health Reform Survey, a state-representative telephone survey of 3,041 non-elderly adults. Case study interviews were also conducted by the investigators from January through March 2010, with CHC and hospital administrators and medical staff in Boston, Fall River, Springfield and Pittsfield, Mass.

The total amount of patients served by CHCs rose by 31% from 2005 to 2009, also increased were the average number of patient visits. The number of patients without insurance in the CHC caseload decreased from 35.5% to 19.9% during the same timeframe. CHCs staff members told investigators that patients who were newly insured often returned because they liked the care received and the relationships they had established with center health care professionals at these sites.

Safety-net hospitals were defined by the reporters as those that, in 2009, received 20% 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. Reporters identified 17 institutions as safety-net hospitals and 48 without that designation. From 2006 to 2009 the growth levels overall were similar for both types of hospitals. Yet, non-emergency ambulatory care visits from outpatient departments and hospital's community clinics rose by 9.2% for safety-net hospitals and 4.1% for non-safety net hospitals. Newly insured patients visited safety-net facilities because they liked the care received and the accessibility of the locations, administrators and medical staff told the researchers.

Responses from patients of safety-net facilities who were non-elderly adults with incomes under 300% of the poverty line, were analyzed by the researchers. Approximately two-thirds had health coverage through a public program. In comparison to other low-income adults or all adults, safety-net patients reported seeking care at emergency departments more. Compared to 14.7% of all adults, 33.3% of lower-income safety-net patients said they had sought care for a non-emergency condition at an emergency department, most said they used safety-net facilities because the services were affordable and convenient, while one-quarter expressed difficulty in receiving care elsewhere.

The reporters said

"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.

"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

Mitchell H. Katz, M.D., from the Los Angeles County Department of Health Services, stated, that by 2014 there will be a major expansion of health insurance as part of federal health reform, providing coverage to millions of people currently without. However, it will still leave an estimated 24 million without insurance. He continued,

"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."

Katz continues that the article by Ku and colleagues, 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 states, suggesting, that this scenario however, 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,"

he highlights. With an implementation of a federal health reform, the health care system will have to increase capacity for those newly insured. According to Katz a preferred option may be to develop teams of health care providers instead of just training more primary care physicians. In a concluding statement he writes,

"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. 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."

Written by Grace Rattue