The Effects of Health Reform
on the Safety
y Net:
Preliminary Findings from
Massachusetts
AcademyHealth Boston
AcademyHealth,
Boston, June 2010
Emily Jones, Leighton Ku,
P t Shin,
Peter
Shi and
dF
Fraser B
Byrne
George Washington University
Thanks to the
Blue Cross Blue Shield
of Massachusetts Foundation
Overview
• Health reform a success in expanding coverage
andd access to care, particularly
i l l for
f previously
i l
underserved communities
• But coverage ≠ access
• Safety
S f t net:
t community
it health
h lth centers,
t
key
k
hospitals & clinics, community mental health
• Contrary to expectations, though uninsured
fell safety net continues to have a major role,
fell,
role
serving both insured & uninsured
Mixed Methods
• Health center administrative data: UDS
• 2009 Massachusetts Health Reform Survey
• MA Division of Health Care Finance and
Policy
y data
• 4 case studies, 8 focus groups
–
–
–
–
Boston
B
Fall River
Springfield
Pittsfield
Background
• Chapter 58 passed 2006, began 2007
• Insurance and access expansion
• Both before and after reform:
– Limited capacity/maldistribution of
providers
– Costs rising
i i more than
h expectedd
• Recession began 2008. State budget cuts
followed
Wh Are
Who
A Safety
S f t N
Nett U
Users?
? Ad
Adults
lt
Have usual source of care
Usual source is CHC
Usual source provides
free/low cost care
Received care at place w/
f /l cost care
free/low
Used HSN program
Source: 2009 Mass Health Reform Survey
Among
Among
Insured Uninsured
92%
57%
8%
9%
28%
13%
24%
21%
3%
8%
Reasons for Using Safety Net Provider
Provider,
Adults
Of Users
Convenient
74%
Affordable
57%
Problem Getting Appt Elsewhere
16%
Spoke Same Language
34%
Other Services Available at Site
3%
Source: 2009 Mass Health Reform Survey
Effects of Reform on Safety Net
Providers
• Continued demand among existing patients,
pplus
us newly
ew y insured
su ed
• Changing payer mix: fewer uninsured
• Changes in payment methods, e.g., UCP to
HSN
• Increased role in outreach and enrollment
• Increased
I
d insurance
i
helps
h l link
li k primary
i
care
to specialty, behavioral health, pharmacy
and hospitals
Uncompensated
U
co pe sated Ca
Care
e Pool
oo Becomes
eco es
Health Safety Net (HSN) Program
Volume (1,000s)
1526
Health
Centers
342
$661
41
-35%
1184
Hospitals,
Inpt &
outpt
Payments, $ Mil.
-38%
987
986
272
280
715
620
$409
$414
37
42
706
372
PFY07
HSN08
HSN09
PFY07
HSN08
Source: Massachusetts Division of Health Care Finance and Policy, Key Indicators Report
3 2
372
HSN09
Health Center Caseloads Rose,,
While Percent Uninsured
Fell
535,255
Number of
Patients
482,503
446,559
431,005
+4%
%
19%
7%
38%
+11%
+8%
18%
19%
20%
8%
8%
7%
42%
42%
5%
Medicare
42%
M di id/CHIP
Medicaid/CHIP
9%
Comm Care &
Oth Public
Uninsured
36%
33%
26%
21%
2005
2006
2007
2008
Note: Comm Care and Other Public served 1% in 2005 and <1% in 2006
Source: GW analysis of Massachusetts Uniform Data System data
Private
Increasing Percent of Statewide
Uninsured Served by Health Centers
657,157
P
a
t
i
e
n
t
s
339,744
145,964
% Statewide Uninsured Served by Health Centers
22.2%
Source: # uninsured based on March CPS data
123,388
36.3%
352,230
114,609
32.5%
Massachusetts Safety Net Hospitals
Massachusetts Safety Net Hospitals
• No reduction in ED usage
• MassHealth reimbursement rates and transition
payments:
• Limited inpatient rates, based on historical
costs
• Recession led to budget
g cuts,, esp.
p MassHealth
payments beginning FY 09. Reduced
MassHealth for legal immigrants
• In 2009, BMC sues state over MassHealth
rates then 6 others sue
rates,
Mass Hospital Total Margins 2005 9
Mass. Hospital Total Margins 2005‐9
5%
Total Marrgin
4%
3%
Median Non-DSH
2%
Median DSH
1%
0%
-1%
2005
2006
2007
Fiscal Year
Source: Mass Div. of Health Care Finance & Policy
2008
2009
Community Mental Health
•
•
•
•
•
•
Parity since 2000
Largely left out of reform
Not part of HSN for outpatient
Aff
Affected
d bby state bbudget
d cuts
Provider shortage
Lack of integration with medical
care
Lessons for Providers
• Coverage
g expansions
p
increase demand
• Base and supplemental payment policies affect
providers
• Health centers doing well, largely because of
f d l policies
federal
li i
• Hospital finances more dependent on state
policies and budgets. More affected by
recession, as was behavioral health
• Massachusetts now discussing cost
containment
Further Questions?
Please contact Emily Jones:
(202) 994-4240
or
emjones@gwu edu
emjones@gwu.edu