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Safety Nets Remain Key Access Point for Minority Patients

By John Commins  
   June 22, 2016

Data suggests that minorities continue to seek inpatient care at safety net hospitals, even as access options at other hospitals expand under Massachusetts' universal healthcare reforms.

Assumptions that newly insured minorities under the Patient Protection and Affordable Care Act would expand their traditional inpatient care options beyond the nearest safety-net hospital are being challenged by a report published in the journal Medical Care.

Boston University researchers found that the proportion of discharges among minority patients receiving inpatient care at minority-serving safety net hospitals in Massachusetts increased, even after the reforms expanded access to non-safety net hospitals.

They used 2004 –2009 data reflecting Massachusetts' expanded health insurance coverage under its sweeping healthcare reforms.

Study lead author Karen Lasser, MD, a primary care internist at Boston Medical Center, a 496-bed academic medical center and the largest safety net hospital in New England, says the findings bolster the claim that minority-serving hospitals remain a vital component of healthcare delivery that could be helped by raising or restoring Medicaid reimbursements.

"We made a hypothesis that some minorities would move," Lasser says.

"Was I surprised? Not so much. I've been working in the safety nets in Massachusetts for many years and the feeling is that things haven't changed that much. There hasn't been that migration."

According to the study, funded by the National Institutes of Health, researchers compared inpatient discharge data from Massachusetts, New York, and New Jersey between 2004 and 2009 and identified minority-serving hospitals and safety-net hospitals in each state.

Researchers examined the change in concentrations of minority discharges at minority-serving hospitals and tracked the movement of safety-net hospital users, or patients with at least four hospitalizations within the study period.

The results showed that Massachusetts' minority-serving hospitals saw an increase of 5.8% in minority discharges compared to New Jersey, and a non-significant 2.1% increase compared to New York.

Of those patients identified as "safety-net hospital users" in all three states, 62% continued to receive care at safety-net hospitals in the post-reform period.

Patient movement from safety-net to non-safety-net hospitals was slightly greater in Massachusetts than New York and New Jersey.

"We do need to compensate these hospitals that are doing disproportionate care for poor and minority patients," Lasser says.

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"We have another study we are working on right now looking at segregation of hospitals by payer and race and there are certain hospitals that are taking care of less-affluent patients who may have more psycho-social needs and we may need to fund social workers at those hospitals."

Lasser offered several potential explanations for the findings, including the brand loyalty of minority patients to hospitals that are close by and have served them before they had insurance.

Other reasons could include interpretation services for non-English-speaking patients, intensive case management, and a lack of primary care physicians in Massachusetts.  

"There are also some providers who aren't accepting new patients or patients with these public forms of insurance that don't reimburse well," she says.

The data is limited to the three-state area, but the Affordable Care Act is modelled on Massachusetts' healthcare reforms, so it would be reasonable to assume that these findings are playing out in other parts of the country since 2014.

 "As we expand health insurance, there is this idea that patients can now go anywhere, that they aren't necessarily going to go to safety net hospitals, so those safety net hospitals don't need additional funding for uncompensated care or for all of the special programs the safety nets hospitals take on," Lasser says.

"Safety net hospitals still need those added resources."

John Commins is a senior editor at HealthLeaders.

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