Emergency room visits grow in Mass.

New insurance law did not reduce number of users

By Liz Kowalczyk
Globe Staff / July 4, 2010

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The number of people visiting hospital emergency rooms has climbed in Massachusetts, despite the enactment of nearly universal health insurance that some hoped would reduce expensive emergency department use.

According to state data released last week, emergency room visits rose by 9 percent from 2004 to 2008, to about 3 million visits a year.

When the Legislature passed the insurance law in 2006, officials hoped it would increase access to primary care doctors for the uninsured, which would improve their health and lessen their reliance on emergency rooms for the flu, sprains, and other urgent care. Residents began enrolling in state-subsidized insurance plans in October 2006; everyone was required to have coverage by July 1, 2007.

But, according to a report from the Division of Health Care Finance and Policy, expanded coverage may have contributed to the rise in emergency room visits, as newly insured residents entered the health care system and could not find a primary care doctor or get a last-minute appointment with their physician.

David Morales, commissioner of the division, said several national and statewide studies have shown that expanding insurance coverage does not reduce emergency room visits. This is because the uninsured “are not really responsible for significant ER use’’ he said.

The growth in emergency room use predates the health insurance law and mirrors national trends, according to Nancy Turnbull, a senior lecturer at the Harvard School of Public Health.

“I don’t think the increase has anything to do with health care reform,’’ she said. “It’s much more reflective of [primary care] access problems.’’

Sarah Iselin, president of the Blue Cross Blue Shield of Massachusetts Foundation and a former commissioner of the Division of Health Care Finance and Policy, said that even before the state enacted universal health insurance, the uninsured made up only about 10 percent of the state’s population. As a result, she said, “you’d have to see an enormous decrease in their ER use’’ to affect the overall trend. “ER use has been going up every single year for time eternal,’’ she said.

The state report found that the number of emergency room visits climbed at about the same rate in community hospitals and teaching hospitals.

But, the report found, the growth in emergency room use varied widely across the state, for reasons unknown. Emergency room visits at hospitals in Western Massachusetts soared 20 percent over the four-year period, but grew by just 3 percent at hospitals in the northeastern part of the state.

The state said the growing use of emergency rooms has significant cost implications, because private insurers and government programs pay substantially more for a visit to the emergency room than for a doctor’s appointment. Morales said the state needs “to change our payment system to encourage the use of primary care.’’ Better payment for primary care physicians would encourage more doctors to enter the field, he said.

Andrew Dreyfus, executive vice president for health care services at Blue Cross, said changing how doctors are paid could create incentives for them to expand office hours and keep patients out of emergency rooms. Global payments, for example, in which doctors are paid a fixed annual fee intended to cover all of a patient’s care, discourage use of unnecessarily expensive care, he said.

Blue Cross, the state’s largest insurer, has seen a slight decrease in emergency room use among its members over the past year, Dreyfus said. He said that trend could be related to growing use of limited-service clinics, such as CVS MinuteClinics.

Liz Kowalczyk can be reached at

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