Massachusetts Health Reform and 30 Day Hospital Readmissions
Massachusetts Health Reform and 30 Day Hospital Readmissions
Objectives To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey).
Design Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform.
Setting US hospitals in Massachusetts, New York, and New Jersey.
Participants Adults aged 18-64 admitted for any cause, excluding obstetrical.
Main outcome measure Readmissions at 30 days after an index admission.
Results After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates.
Conclusions In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome.
Thirty day hospital readmissions are common and costly and because they may signal an unnecessary use of resources have been the focus of health policy interventions to reduce cost. In March 2010, President Obama signed a comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The law established a program for reduction in hospital readmissions, which requires the US Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions, effective for discharges beginning on 1 October 2012. Uninsured patients are at increased risk for readmission, and there are well documented racial disparities in this outcome. Prior studies suggest that when people have insurance, they are more likely to have a usual source of care and to utilize medical care. Receipt of such care can prevent unnecessary and costly hospital admissions. However, it is unknown whether expanding health insurance coverage can reduce the risk of readmissions in the overall population, specifically among minority populations, or whether an insurance expansion might have differential effects related to variation in baseline uninsurance rates. One mechanism by which such effects might occur is that previously uninsured people who gain insurance could also gain improved access to outpatient primary and specialty care. Such access, in turn, could enable outpatient follow-up after hospital discharge, which may prevent readmission. Patients could also gain coverage for medications and for treatment of comorbid conditions, which could further reduce the risk of readmission. Insurance expansion might have the greatest effects on those least likely to have been insured prior to reform, including racial and ethnic minority groups, or people residing in areas with higher pre-reform uninsurance rates.
Since 2006 Massachusetts has been the setting of a landmark experiment in healthcare reform. The principal aim of the reform was to achieve near universal health insurance coverage. The Massachusetts reform also aimed to decrease racial and ethnic disparities in both coverage and access. The expansion of coverage has been accomplished in three ways. The first approach is an individual mandate for coverage. The Massachusetts Health Care Reform Law requires most Massachusetts adults who can afford health insurance to have coverage or pay a penalty. In 2013 the penalties ranged from $240 (£145; €174) to $1272 per year, depending on an individual’s income, age, and family size. The second approach to increasing coverage was an expansion of public coverage. This was accomplished through an extension of Medicaid (health insurance for Massachusetts residents with the lowest income), and the creation of Commonwealth Care, a publicly subsidized plan for people with incomes below 300% of the poverty line. Prior to these changes, Massachusetts Medicaid (MassHealth) covered families with income up to 133% of the federal poverty line. Finally, the reform created a health insurance exchange, "the Massachusetts Health Connector," for more affordable private insurance. The Health Connector is a health insurance marketplace that enables those who are not eligible for public coverage to purchase insurance offered by private health plans. The Health Connector requires health insurance carriers to meet certain requirements such as participation in all Commonwealth Choice offerings and coverage of standardized benefit packages. All forms of health insurance must meet standards for "minimal creditable coverage," including coverage for preventive and primary care, emergency services, hospital stays, outpatient services, prescription drugs, and mental health services. The number of uninsured Massachusetts residents fell substantially after the reform was implemented. Among adults aged 18 to 64—the population targeted by the reform—uninsurance rates declined from 8.4% (2006) to 3.4% (2009) overall, but from 15% to 5% among black people and 20% to 13% among Hispanic people, compared with 7% to 2% among white people. Massachusetts reform also impacted the numbers of people insured through Medicaid and private insurance. In 2005, 72% of insurance coverage in Massachusetts was private and 11% was Medicaid, whereas in 2011, 79% of insurance coverage in Massachusetts was private and 16% was Medicaid. Massachusetts therefore provides a unique opportunity to evaluate whether an expansion in coverage can impact 30 day readmissions. In addition, analyzing the effects of healthcare reform in Massachusetts may provide insight into the possible effects of the Affordable Care Act as it is implemented nationwide. Modeled on the Massachusetts experience, the Affordable Care Act similarly requires that most US citizens have health insurance. The Federal law also expands Medicaid and enables people who do not qualify for Medicaid to purchase coverage through state based health benefit exchanges. The Affordable Care Act requires that health insurance covers a range of services similar to those covered by Massachusetts reform. Some details differ between the two insurance reforms, such as the extent of the Medicaid expansion and the proposed penalty for those who do not obtain coverage.
We examined readmission rates among patients aged 18-64; we did not include patients aged 65 and older since most are covered by Medicare, and hence are unlikely to have been affected by Massachusetts health reform. We sought to determine whether readmission rates changed differentially in Massachusetts compared with two control states, New York and New Jersey, which did not expand coverage during the study period. We also examined whether disparities in readmission rates changed subsequent to reform, hypothesizing that minority groups in Massachusetts might stand to benefit the most, as they are at increased risk for readmissions and made the most gains in terms of insurance coverage. Finally, we evaluated whether the insurance expansion had differential effects on readmissions related to geographically varying baseline uninsurance rates, within Massachusetts only since the other states had no similar reform.
Abstract and Introduction
Abstract
Objectives To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey).
Design Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform.
Setting US hospitals in Massachusetts, New York, and New Jersey.
Participants Adults aged 18-64 admitted for any cause, excluding obstetrical.
Main outcome measure Readmissions at 30 days after an index admission.
Results After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates.
Conclusions In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome.
Introduction
Thirty day hospital readmissions are common and costly and because they may signal an unnecessary use of resources have been the focus of health policy interventions to reduce cost. In March 2010, President Obama signed a comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The law established a program for reduction in hospital readmissions, which requires the US Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions, effective for discharges beginning on 1 October 2012. Uninsured patients are at increased risk for readmission, and there are well documented racial disparities in this outcome. Prior studies suggest that when people have insurance, they are more likely to have a usual source of care and to utilize medical care. Receipt of such care can prevent unnecessary and costly hospital admissions. However, it is unknown whether expanding health insurance coverage can reduce the risk of readmissions in the overall population, specifically among minority populations, or whether an insurance expansion might have differential effects related to variation in baseline uninsurance rates. One mechanism by which such effects might occur is that previously uninsured people who gain insurance could also gain improved access to outpatient primary and specialty care. Such access, in turn, could enable outpatient follow-up after hospital discharge, which may prevent readmission. Patients could also gain coverage for medications and for treatment of comorbid conditions, which could further reduce the risk of readmission. Insurance expansion might have the greatest effects on those least likely to have been insured prior to reform, including racial and ethnic minority groups, or people residing in areas with higher pre-reform uninsurance rates.
Since 2006 Massachusetts has been the setting of a landmark experiment in healthcare reform. The principal aim of the reform was to achieve near universal health insurance coverage. The Massachusetts reform also aimed to decrease racial and ethnic disparities in both coverage and access. The expansion of coverage has been accomplished in three ways. The first approach is an individual mandate for coverage. The Massachusetts Health Care Reform Law requires most Massachusetts adults who can afford health insurance to have coverage or pay a penalty. In 2013 the penalties ranged from $240 (£145; €174) to $1272 per year, depending on an individual’s income, age, and family size. The second approach to increasing coverage was an expansion of public coverage. This was accomplished through an extension of Medicaid (health insurance for Massachusetts residents with the lowest income), and the creation of Commonwealth Care, a publicly subsidized plan for people with incomes below 300% of the poverty line. Prior to these changes, Massachusetts Medicaid (MassHealth) covered families with income up to 133% of the federal poverty line. Finally, the reform created a health insurance exchange, "the Massachusetts Health Connector," for more affordable private insurance. The Health Connector is a health insurance marketplace that enables those who are not eligible for public coverage to purchase insurance offered by private health plans. The Health Connector requires health insurance carriers to meet certain requirements such as participation in all Commonwealth Choice offerings and coverage of standardized benefit packages. All forms of health insurance must meet standards for "minimal creditable coverage," including coverage for preventive and primary care, emergency services, hospital stays, outpatient services, prescription drugs, and mental health services. The number of uninsured Massachusetts residents fell substantially after the reform was implemented. Among adults aged 18 to 64—the population targeted by the reform—uninsurance rates declined from 8.4% (2006) to 3.4% (2009) overall, but from 15% to 5% among black people and 20% to 13% among Hispanic people, compared with 7% to 2% among white people. Massachusetts reform also impacted the numbers of people insured through Medicaid and private insurance. In 2005, 72% of insurance coverage in Massachusetts was private and 11% was Medicaid, whereas in 2011, 79% of insurance coverage in Massachusetts was private and 16% was Medicaid. Massachusetts therefore provides a unique opportunity to evaluate whether an expansion in coverage can impact 30 day readmissions. In addition, analyzing the effects of healthcare reform in Massachusetts may provide insight into the possible effects of the Affordable Care Act as it is implemented nationwide. Modeled on the Massachusetts experience, the Affordable Care Act similarly requires that most US citizens have health insurance. The Federal law also expands Medicaid and enables people who do not qualify for Medicaid to purchase coverage through state based health benefit exchanges. The Affordable Care Act requires that health insurance covers a range of services similar to those covered by Massachusetts reform. Some details differ between the two insurance reforms, such as the extent of the Medicaid expansion and the proposed penalty for those who do not obtain coverage.
We examined readmission rates among patients aged 18-64; we did not include patients aged 65 and older since most are covered by Medicare, and hence are unlikely to have been affected by Massachusetts health reform. We sought to determine whether readmission rates changed differentially in Massachusetts compared with two control states, New York and New Jersey, which did not expand coverage during the study period. We also examined whether disparities in readmission rates changed subsequent to reform, hypothesizing that minority groups in Massachusetts might stand to benefit the most, as they are at increased risk for readmissions and made the most gains in terms of insurance coverage. Finally, we evaluated whether the insurance expansion had differential effects on readmissions related to geographically varying baseline uninsurance rates, within Massachusetts only since the other states had no similar reform.