ONE OF THE hopes of healthcare reformers in Massachusetts has been that extending insurance to nearly all residents would cause the previously uninsured to seek treatment with primary care physicians and rely less on hospital emergency rooms for routine problems. Unfortunately, early indications are that the success of the state’s three-year-old universal coverage program has not led to reduced dependence on emergency rooms. For that to happen, the state will need to provide more primary care physicians.
Care in a doctor’s office provides greater continuity and costs less than visits to the emergency room. But new data shows that emergency room visits in Massachusetts rose 7 percent between 2005 and 2007. Analysts caution against drawing conclusions from those numbers, since many of the uninsured did not actually get coverage until late 2007 and early 2008. But the same trend emerged in a 2006-2008 study of six Boston-area hospitals.
With or without insurance, the public will continue to overuse emergency rooms as long as there aren’t enough primary care doctors to see them. According to two 2008 studies, most state residents have a primary care physician, but the wait for new patients to get an appointment averages 50 days and can be as long as 100 days, especially in Western Massachusetts and on the Cape. A 2008 survey in the Journal of the American Medical Association showed that just 2 percent of graduating medical students planned to go into primary care, preferring specialists’ higher pay and more congenial hours.
In 2007, Bank of America started a tuition loan repayment program for medical graduates who agreed to work two to three years as primary care physicians or nurse practitioners in community health centers. The state added $1.7 million to the effort, which was also supported by Partners Healthcare, the Blue Cross Blue Shield Foundation of Massachusetts, and Neighborhood Health Plan. But the state’s contribution could be in jeopardy in an extraordinarily tight budget year.
The state could also make primary care more attractive by changing the payment system for providers, with greater rewards for the work done in doctors’ offices. A payment commission created by the Legislature is expected to report by the end of May.
The inability of universal coverage to reduce overuse of emergency rooms is evidence that increasing access to care isn’t enough. A primary goal now must be expanding primary care.