Health reform review: The Massachusetts experience

The state's universal insurance program has solved some access issues, but it's not a panacea.

By — Posted Nov. 2, 2009

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Hugh Taylor, MD, might be living in the future. The family physician uses a tablet PC to track appointments and write prescriptions. His practice has used an electronic medical records system for years, and his waiting room has a wide-screen TV. But that's not why he might be a few years ahead of the rest of the country.

Dr. Taylor practices in Massachusetts, home of the leading model for national health system reform legislation. Since 2006, the state has had a health insurance exchange offering coverage to the uninsured, with subsidies based on income. The state requires individuals to have a minimum level of health insurance and requires employers to offer it. There are penalties for noncompliance.

Reform legislation pending on Capitol Hill would attempt to take the Massachusetts framework nationwide. Although many elements of the federal measures have sparked heated debate, the health insurance exchange concept at the heart of the state initiative has not proven controversial.

Some Massachusetts physicians say the Commonwealth Connector improved access to and continuity of care for many. "It's taken away some of the anxiety people have about losing jobs and being between jobs. That was always an issue before," said Dr. Taylor, part of the nine-doctor Family Medicine Associates in Hamilton.

Despite practicing in a moderately prosperous coastal town north of Boston, Dr. Taylor saw a few uninsured patients a week before the reforms began. Now he sees only a few a month.

In a survey of more than 2,000 physicians released Oct. 21 by the Harvard School of Public Health, 70% of respondents said they supported the Connector reforms, with only 13% opposing them and 16% saying they didn't know or refusing to answer.

But the state's reforms haven't solved other problems. Some practices in 2006 were already at capacity and turning away new patients. Since then, overextended community health centers have seen an influx of tens of thousands of new patients, not all of them insured. And hiring primary care physicians in Massachusetts is just as difficult today, if not more so, doctors said.

Half as many uninsured

The Connector reforms both halved the state's already-low uninsured population and increased the percentage of employers offering health insurance -- two numbers headed in the opposite direction for most of the rest of the country.

The new system is an attempt to better coordinate health care for the underserved by getting them insured and helping them establish a relationship with a primary care physician. About 400,000 people gained coverage since 2006, according to the Connector Authority, the state-contracted organization that oversees the exchange. Massachusetts had the lowest percentage of uninsured people in the nation in 2008 -- 5.5%, down from an average of 10.7% between 2003 and 2005, according to U.S. Census Bureau estimates.

The increase in coverage is likely why Dr. Taylor is seeing more patients who needed care but had been putting it off. One 28-year-old man had a neck mass that had been growing for six months. Dr. Taylor was able to get the patient treatment and the man is healthy now.

Jeffrey Kaufman, MD, of Baystate Vascular Services in Springfield, said his patient population was about 2% uninsured. "The Connector filled in that other 2%. To me, it's been a boon."

The steps Massachusetts took are an improvement on the status quo, said Massachusetts Medical Society President Mario Motta, MD. "It's better that they have access and can at least get in line to get primary care than have them continue to have no access and be treated late in the stage in an emergency room."

Persistent problems

But some doctors said the Connector reforms have been a wash. Peter Smulowitz, MD, MPH, hasn't seen a substantial difference in patient volume or acuity in the two Boston-area emergency departments where he works. He is, however, seeing fewer people delaying care for insurance reasons. "Or at least they haven't worried about the cost being an issue," said Dr. Smulowitz, chair of the governmental affairs committee for the Massachusetts College of Emergency Physicians.

Jane Albert, a spokeswoman for Baystate Health System in Springfield, said families still visit its hospitals' EDs for urgent care and chronic conditions. "They're just choosing to go to the ED ... as a one-stop shopping opportunity." They probably could be seen by a primary care physician, but that would take longer, she said.

The state's 52 community health centers may be seeing a disproportionate share of the 400,000 newly insured, according to James W. Hunt Jr., president and CEO of the Massachusetts League of Community Health Centers. Health centers saw 800,000 unique patients last year, up from 700,000 before the reforms took effect.

Some people are still falling through the system's cracks, said Frances M. Anthes, president and CEO of the Family Health Center of Worcester, a community health center. There are two primary reasons: people who have employer-sponsored insurance and lose it may go weeks or months before they are officially enrolled in Connector coverage. And some people don't respond to state letters because they can't understand them due to language barriers.

It's been a tough couple of years for the Worcester clinic. About a year ago the facility closed to new patients for the first time since it was founded in 1972, said Jeffrey Baxter, MD, who works there part time. A decline in charitable funding and state program cuts led to a $1 million to $2 million decline in revenues this year, Anthes said.

The reforms have also given the Worcester health center more administrative work -- billing private insurance plans. "It turned this place from a granted clinic that didn't really pay much attention to prices and fees and so on to a business that has to do all that stuff," said George Maxted, MD, the center's medical director. Private plans are much more likely to reject poorly coded claims than the state was, he said.

Dr. Taylor's practice has been seeing more patients with high-deductible plans, a trend researchers have seen throughout the state. This can put a strain on both patients and doctors. The physicians, for instance, say they need to pay attention to the cost of prescribed medications because co-payments can be very high.

"There's getting people insured. And there's getting people insured well. And they're two different things," said Steve Barrett, MD, who works with Dr. Taylor.

Next steps

Physicians and other experts in Massachusetts said the 2006 reforms are just one step in a long-term effort to improve the state's health system.

In the Harvard survey, only 29% of physicians said they wanted the program to continue as is. Nearly half would like it to continue with changes, such as expanded coverage and greater attention to costs.

"You have to look at it as an investment," said William Medwid, MD, who works with Drs. Taylor and Barrett. He estimated that 10 or 20 years might pass before the state sees the full impact.

"If demand [for physicians] goes up, supply needs to go up," said Dr. Baxter of Worcester. More funding for health centers alone isn't going to be enough to expand the work force.

The state's system reform has accomplished the primary goal of increasing coverage, Dr. Taylor said. "What it hasn't done is controlled costs."

Anthes agreed. "The assumption always has been in the system: Increasing access only works if you have payment reform, too."

A commission recommended in July that the state adopt a global payment system within five years using set payment per patient, not per service, similar to the way capitation worked. The Legislature is expected to debate recommendations over the next year.

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ED volume hasn't slowed

Although Massachusetts health reforms have increased access to care, many patients are still turning to hospital emergency departments.

A recent survey of ED doctors found:

Patient volume in the ED has

Significantly increased: 22%
Somewhat increased: 42%
Neither increased nor decreased: 32%
Somewhat decreased: 4%

Fewer patients are uninsured

Yes: 34%
No: 33%
Don't know: 33%

EDs seeing more patients who can't access a primary care physician

Yes: 66%
No: 23%
Don't know: 11%

Uncompensated care for emergency patients reduced

Yes: 33%
No: 43%
Don't know: 23%

Should Massachusetts model be blueprint for national reform?

Yes: 26%
No: 53%
Don't know: 21%

Source: American College of Emergency Physicians, survey of Massachusetts Emergency Physicians, October (link)

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Severity of shortages

Massachusetts is experiencing shortages of family doctors and internists for the fourth consecutive year, according to a recent poll. Shortages are defined from severe to critical, based on majority responses to questions about the work force.

Source: "Physician Workforce study," Massachusetts Medical Society, September (link)

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Massachusetts doctors like model

Primary care physicians and specialists widely support the Commonwealth Connector health system reform program, according to a recent Harvard School of Public Health poll.

Views on reforms
All physiciansPrimary care
Don't know/refused to answer16%18%16%
Reforms should continue as is29%30%30%
Continue with changes46%48%45%
Be repealed7%6%7%
Don't know/refused to answer18%17%17%

Source: "Physicians' Views of the Massachusetts Health Care Reform Law -- A Poll," New England Journal of Medicine, October (link)

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