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Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform

Lines, Lisa M. PhD, MPH*,†; Li, Nien-Chen MPH, MA*; Mick, Eric O. ScD*; Ash, Arlene S. PhD*

doi: 10.1097/MLR.0000000000001025
Original Article

Objective: Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees.

Population and Setting: People under age 65 in the Massachusetts All-Payer Claims Data, 2011–2012.

Study Design: Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records.

Principal Findings: Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49–2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one’s own (attributed) primary care provider (38% vs. 44%).

Conclusions: Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.

*University of Massachusetts Medical School, Worcester

RTI International, Waltham, MA

Partial support for this research was provided by the Agency for Healthcare Research and Quality (Award #1R36HS022194-01).

Portions of the analysis were presented at the American Public Health Association Annual Meeting, November 4–8, 2017, Atlanta.

The content is solely the responsibility of the authors and does not necessarily represent the official views of RTI International, the University of Massachusetts Medical School, or AHRQ.

The authors declare no conflict of interest.

Reprints: Lisa M. Lines, PhD, MPH, RTI International, 307 Waverly Oaks Road, Ste 101, Waltham, MA 02452-8413. E-mail:

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