ER visits, costs in Mass. climb

Visits to Massachusetts emergency rooms grew 7 percent between 2005 and 2007, to 2,469,295 visits. The estimated cost of treating those patients - including salaries for caregivers, tests such as X-rays and CT scans, and medicines - jumped from $826 million to $973 million, according data provided to the Globe.

The large portion of visits in which the patient didn't require immediate treatment, or could have been treated in a doctors' office, remained essentially unchanged over those years at 47 percent.

Massachusetts officials yesterday cautioned against drawing conclusions about whether the state's new insurance mandate has failed to ease overuse of the emergency room, saying more years of data are needed to measure the law's impact. But the numbers may provide an early view of how difficult it will be to meet the high expectations for the law.

The 2006 mandate requires nearly everyone to have health insurance, coverage the law's framers hoped would encourage the insured to visit primary care doctors for minor illnesses.

Several physicians and policy makers said the state information, along with other new data from Harvard researchers, suggests that emergency room crowding and rising costs will not be solved by providing people with health insurance alone, despite optimistic talk by politicians who advocated for the law.

What is needed, they said, are more primary care doctors and nurses, and a new payment system that encourages intense monitoring of patients with diabetes, asthma, and other chronic illnesses.

"Just because you have insurance doesn't mean there's a [primary care] physician who can see you," said Dr. Sandra Schneider, vice president of the American College of Emergency Physicians, which, like other national groups, is closely watching the Massachusetts experiment. "I am not surprised at all that visits went up."

During the college's annual conference in Washington, D.C., this week, Dr. Peter Smulowitz, an emergency room physician at Beth Israel Deaconess Medical Center, presented preliminary, but more recent, data showing that ER visits at six Boston-area hospitals grew between 2006 and 2008, despite a steep drop in the number of uninsured residents. As a result, Smulowitz said, he is convinced that the uninsured are not causing emergency room crowding and overuse and that the solutions are far more complicated than simply providing health insurance coverage.

"We have to pay primary care doctors what they're worth and increase the network for primary care from doctors and other providers," he said. "It's going to take a lot of money up front to change this. But do we have any other choice?"

In the emergency room where Smulowitz headed to work yesterday afternoon, for example, patients with congestive heart failure sometimes arrive with severe shortness of breath or swelling of their legs. Some of these visits could be prevented, he and others believe, if primary care doctors had time to monitor these patients more closely.

Massachusetts' pioneering experiment with near-universal healthcare is under growing scrutiny, as President Obama calls for an affordable, universal coverage plan that draws heavily from the state's law. National policy makers are eager for evidence about the law's impact and to know whether it is improving residents' health. They also want to know whether Massachusetts is able to control the cost of state-subsidized plans, a goal officials are struggling to meet.

The state's emergency room data are for the two fiscal years, ending September 2007. The state began enrolling residents in Commonwealth Care, the state-subsidized insurance plan, in October 2006; all residents were mandated to have health insurance by July 1, 2007. The state's data include ER visits for patients who were discharged from the emergency room, not patients who were admitted.

"These are very early results," said Kate Nordahl, assistant commissioner for policy and research at the state Division of Health Care Finance and Policy, which collects the data and provided the results to the Globe. "I would caution you not to make any conclusions until we have 2008 data available."

Andrew Dreyfus, a senior vice president at Blue Cross and Blue Shield of Massachusetts, the state's largest insurer, agreed more information is needed but said the state's soaring emergency room costs - and healthcare costs generally - are not going to be solved by mandatory health insurance.

Blue Cross, which estimates that half its members' 650,000 emergency room visits a year are for conditions that could have been addressed by a primary care doctor, is increasing promotion of its 24-hour nurse hotline and taking other measures to reduce emergency room overuse. But ultimately, said Dreyfus, who also is a member of the state's payment reform panel, more dramatic changes are needed.

"The most important way to change patterns of care is to change payments and encourage primary care physicians and the health system to treat conditions early and actively to prevent patients from going to the ER in the first place," he said. "That's the next important reform we need in Massachusetts. It should be part of the legacy of the health insurance law."

Liz Kowalczyk can be reached at kowalczyk@globe.com.