Study: Medicaid, uninsured more likely for ED discharge than privately insured

Hospital safety
Private hospitals are more likely to discharge or transfer uninsured patients than those with insurance. (Moment/Getty Images)

When it comes either being directly discharged from the emergency department or transferred to another hospital after being stabilized, patients who are uninsured or on Medicaid are more likely to be discharged than privately insured patients are, a recently published JAMA International Medicine study found.

The study, which analyzed 215,000 ED visits at 160 U.S. hospitals, was conducted to determine whether insurance status seemed to affect where patients were sent following their visit to an ED. Although current policy from 1986 mandates that all patients be seen and treated for an emergency in an ED, there is no mandate against transfers once the patient is stable.

Previously collected data showed that uninsured and underinsured patients, such as Medicaid beneficiaries—particularly those requiring specialized care for severe trauma or psychiatric and renal emergencies—were more likely to be transferred than admitted compared with patients who have private insurance or Medicare coverage. However, these studies did not take into account the capabilities of the individual hospital. This most recent JAMA report limited its findings to traditional intensive care needs that don’t usually require a specialty such as ED visits for pneumonia, asthma and chronic obstructive pulmonary disease.

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The study was set up to make conservative estimates and yet still found a sizable difference in ED transfers for uninsured and insured patients, said Arjun Venkatesh, M.D., assistant professor of emergency medicine at Yale University School of Medicine and a co-author of the report. Plus, he was surprised that this unique look at discharges also proved to be disproportionate among insured and uninsured patients. 

“The stark differences based on insurance differences makes us ask, ‘Is it time to start thinking about access to healthcare?'" Venkatesh told FierceHealthcare. While he notes there has been a lot of talk and research around the cost and quality of healthcare in the U.S. over the past decade, there has been a lot less concern around access. 

Looking at the results from a hospital level, there was a substantial variation found in ED transfers and hospital admission rates. The median ED discharge rates were around 66.2%, the transfer rate was 1.3% and the hospital admission rate was 32.3%. Therefore, discharge rates were significantly higher than admissions or transfers. The odds of an ED transfer for uninsured patients was lower than that for privately insured patients in nonprofit hospitals.

When insurance came into play, 88.8% of uninsured patients and 80.2% of Medicaid patients were more often discharged compared to 78.5% of privately insured patients. 

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“These findings are consistent with studies conducted over the past decade and confirm the belief that financial incentives, or a patient’s ability to pay, may be associated with hospitalization decisions,” the study concluded. 

Also, data reveal that uninsured patients were more likely to be discharged from the ED, even though this population is more likely to have a serious illness. In essence, although EDs can no longer turn away the uninsured or underinsured, it seems this discrimination has just been moved to the admission stage of the process. 

Given the results, Venkatesh believes that policymakers need to start putting more of a focus on access to care. 

“In the past 30 years, health systems have evolved and we’ve made important strides in acute emergent care,” he said. “Now it’s probably time to think about disparities and access to healthcare.”