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Uninsured Get Short Shrift on Hospital Stays
  • Posted April 1, 2019

Uninsured Get Short Shrift on Hospital Stays

Folks who aren't covered by private insurance are much more likely to get booted out of the hospital early, a new study finds.

Uninsured patients were also more than twice as likely to be transferred to another hospital and 66% more likely to be discharged outright, compared with people with private insurance, the findings showed.

People on Medicaid had nearly 20% increased odds of being transferred, but about the same odds of being discharged as those covered by private insurance, the researchers said.

"It suggests there is a disparity in access to hospital care. Based on the insurance card in your pocket, you may have different access to different hospitals for the most standard inpatient care they offer," said lead researcher Dr. Arjun Venkatesh. He is director of Emergency Department Quality and Safety Research and Strategy with the Yale School of Medicine.

Since 1986, federal law has required hospitals to treat anyone who shows up at an emergency room for treatment, regardless of insurance status.

But experts have been hearing anecdotes for some time suggesting that hospital patients with no or low-quality insurance tend to get "dumped," either through discharge or transfer to another hospital, Venkatesh said.

However, it's tough to pin this down because many transfers that occur really are needed to make sure people get the care they require, he noted.

"You really do need to get transferred if, say, you have an injury to a hand and you need a hand surgeon at another hospital," Venkatesh said.

So he and his research team picked pneumonia, chronic obstructive pulmonary disease (COPD) and asthma as three common conditions that any hospital could treat, and made their analysis even more conservative by only including hospitals that had intensive care units.

The researchers then examined more than 215,000 emergency department visits for those lung conditions that occurred in 2015 and were logged as part of a federal database used to track emergency department care in the United States.

The investigators found that people with private insurance had a much better chance of remaining as long as necessary in the hospital, compared with the uninsured and Medicaid patients. The association held even after the research team took into account other factors, such as patient income and the hospital's ability to provide critical care.

"The insurance type they had was still very predictive of whether they would be transferred to another hospital," Venkatesh said. "That's just not really explicable."

The concern is that patients who are transferred or discharged early might not be fully healed, and their condition might suffer as a result of leaving the hospital, he explained.

While the study did not examine the cause of these disparities, financial incentives for hospitals could play a role, said Venkatesh. Hospitals are not reimbursed for admitting uninsured patients and they receive lower payments for Medicaid, he noted.

Eliot Fishman, senior director of health policy for Families USA, called the findings "upsetting," and places the study in the context of the ongoing national debate over health care coverage for everyone. Families USA is a consumer health care advocacy group.

"I think there's a broader conversation that is starting to happen in the country about moving toward a more universal, more equal system of health insurance coverage," Fishman said.

"As inappropriate as the behavior described in this article is, I think that does feed into the conversation around moving towards a more universal platform of payment, not just for hospital services, but for medical services in general," Fishman added.

Venkatesh suggested that policy makers who want to change this practice could look at amending federal health care law to better structure emergency care in the United States.

"We haven't really said what is the kind of universal access to hospital-based care that everybody in the country should get, and how we should finance and pay for that," Venkatesh said.

In the meantime, federal agencies like the U.S. Centers for Medicare and Medicaid Services could develop regulations aimed at preventing such disparities in care, he added. These disparities also could be weighed as a factor when hospitals apply for accreditation or certification.

The new study was published online April 1 in JAMA Internal Medicine.

More information

The Kaiser Family Foundation has more about the uninsured in America.

SOURCES: Arjun Venkatesh, M.D., director, Emergency Department Quality and Safety Research and Strategy, Yale School of Medicine, New Haven, Conn.; Eliot Fishman, Ph.D., senior director, health policy, Families USA; April 1, 2019, JAMA Internal Medicine, online
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