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Massachusetts Reform and Disparities in Inpatient Care Utilization

Hanchate, Amresh D. PhD*,†; Lasser, Karen E. MD, MPH†,‡; Kapoor, Alok MD, MSc; Rosen, Jennifer MD§; McCormick, Danny MD, MPH; D’Amore, Meredith M. MPH; Kressin, Nancy R. PhD*,†

doi: 10.1097/MLR.0b013e31824e319f
Original Articles

Background: The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform’s impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral.

Methods: Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006–12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ≥70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40–64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform.

Results: Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [−3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [−20%, 30%]), and whites=7% (95% CI [5%, 10%]).

Conclusions: Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Supplemental Digital Content is available in the text.

*VA Boston Healthcare System

Section of General Internal Medicine, Boston University School of Medicine

Department of Community Health Sciences, Boston University School of Public Health

§Department of Surgery, Boston University School of Medicine, Boston

Harvard Medical School, Department of Medicine, Cambridge Health Alliance, Cambridge, MA

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The authors declare no conflict of interest.

Supported by NIH grants (1R21NS062677, A.D.H., PI and 1U01HL105342-01, N.R.K., PI). N.R.K. is supported in part by a Research Career Scientist award from the Department of Veterans Affairs, Health Services Research and Development Service (RCS 02-066-1). A.D.H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Presented at: Plenary session—oral presentation at the Society of General Internal Medicine, Minneapolis, MN, April 29, 2010; poster presentation at AcademyHealth, Boston, MA, June 29, 2010 and American Heart Association Quality of Care and Outcomes Research, Scientific Sessions, Washington, DC, May 13, 2011; oral presentation at the Society of General Internal Medicine, Phoenix, AZ, May 5, 2011.

The views expressed in this article are those of the authors and do not necessarily represent the views of the National Institutes of Health, Boston University or Department of Veterans Affairs.

Reprints: Amresh D. Hanchate, PhD, Health/Care Disparities Research Program, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Ave, #2092, Boston, MA 02118. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.