Program in Health Services Research

Major Goals: To measure changes in indicators of health care access, utilization of care and continuity of care among underserved users of safety-net providers following the Medicaid transition to manage care.

The Affordable Care Act (ACA) insurance coverage expansions beginning in 2014 resulted in historic reductions in uninsurance rates among working-age adults in the states that expanded Medicaid and in the other states. An estimated 26.7 million gained either Medicaid or subsidized private insurance by 2017. This study examines the impact of ACA on racial/ethnic disparities on access to healthcare and patient outcomes. We have assembled a large database of the near-universe of individual discharge and ED records of all patients (all ages, race/ethnicity and payers) from all hospitals in 22 states from 2010 to 2017. In collaboration with researchers at Boston University School of Medicine, our agenda is to study the utilization of a wide range of inpatient and ED services – preventable hospitalizations and ED visits, cardiac procedures, knee replacement, bariatric surgery, heart transplant, LVAD use, safety-net hospital use, inpatient deaths – to add to the evidence base on ACA's longer term impact on access to healthcare, with a particular focus on Hispanics and other racial/ethnic minorities. Given their comprehensive coverage of all inpatient care, these data are suitable for studying a broad range of topics: adoption of new therapies; rare diseases and treatments; geographic variations; proximity to providers; costs; risk prediction.

The Institute of Medicine (IOM) characterized ambulance diversion (AD), the practice by which Emergency Departments (EDs) are temporarily closed, as “antithetical to quality medical care” and called for its “elimination”. Massachusetts is the only state to ban AD, effective 1/1/2009. Using a novel data of ambulance use developed from administrative data from Medicare and Boston Emergency Medical Services, this study uses quasi-experimental methods to estimate the causal impact of AD on ambulance travel, type of destination ED, patient mortality, length of stay, and costs.

In 2012, as mandated by the Patient Protection and Affordable Care Act, Medicare began implementation of two programs – the Hospital Readmissions Reduction Program and the Value-Based Purchasing (VBP) program – that reward/penalize hospitals based on performance on process of care, patient experience, and outcomes. This has raised concern for hospitals that serve a larger share of racial/ethnic minority and low income patients, due to the higher associated risk of poor patient outcomes and lower compensation for patient care. Using data on rewards and penalties following the implementation of the two programs, this study aims to measure the program impact (a) on the quality of care in minority-serving and safety-net hospitals, and (b) on patient outcomes by race/ethnicity and socioeconomic status.