Admit or Transfer? The Role of Insurance in High-Transfer-Rate Medical Conditions in the Emergency Department

Kindermann, Dana; Mutter, Ryan; Cartwright-Smith, Lara; Rosenbaum, Sara; Pines, Jesse M.

doi:10.1016/j.annemergmed.2013.11.019

Cited by 59 publications

(57 citation statements)

References 27 publications

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“…21 Our findings suggest that payer status, particularly lack of insurance, is likely to affect the care that pediatric patients receive in EDs and inpatient units. Similar findings have been documented among infants (aged 0 to 28 days) 12 and adults 8,10 : patients without insurance have been shown to have approximately 2 times the odds of transfer relative to patients with private insurance. Consistent with our results, those of a study of children with psychiatric-related ED visits demonstrated that patients with Medicaid were 10% more likely to be transferred compared with those with private insurance.…”

Section: Discussionsupporting

confidence: 76%

“…Consistent with our results, those of a study of children with psychiatric-related ED visits demonstrated that patients with Medicaid were 10% more likely to be transferred compared with those with private insurance. 13 Patients without insurance, with Medicaid, and with other government insurance receive lower physician and hospital payments relative to those with private insurance, 8,[22][23][24] and it is likely for this reason that we observe a similar phenomenon in EDs caring for pediatric patients. This finding is consistent with those of studies demonstrating that physicians are often reluctant to accept or provide care to patients with insurance plans providing lower reimbursement.…”

Section: Discussionmentioning

confidence: 66%

“…However, patterns observed in the medical literature evaluating adult patients have suggested that factors other than medical need are associated with decisions to admit locally or transfer a patient to another hospital for admission. [8][9][10] For example, Volume -, no.…”

Section: Importancementioning

confidence: 99%

See 2 more Smart Citations

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

Huang

Natale

Kissee

et al. 2017

Annals of Emergency Medicine

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Study objective: Among children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital.Methods: This cross-sectional study used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in emergency departments (EDs) who were either admitted or transferred were included. Clinical Classifications Software was used to categorize patients into noninjury diagnostic cohorts. Multivariable logistic regression models adjusting for potential confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission.Results: A total of 240,620 noninjury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and nonteaching hospitals, were associated with greater odds of transfer relative to admission. Patients who were uninsured or had self-pay had higher odds of transfer (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.08 to 7.09) relative to admission compared with those with private insurance. Uninsured and self-pay patients also had higher odds of transfer across all 13 diagnostic categories, with ORs ranging from 2.96 to 12.00. Patients with Medicaid (OR 1.05; 95% CI 0.90 to 1.22) and other insurances (OR 1.14; 95% CI 0.87 to 1.48) had similar odds of transfer compared with patients with private insurance. Conclusion:Children without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

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Section: Discussionsupporting

confidence: 76%

Section: Discussionmentioning

confidence: 66%

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The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

Huang

Natale

Kissee

et al. 2017

Annals of Emergency Medicine

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“…Of note, these estimates were adjusted for comorbidity burden of the population, but not for acute illness severity. [8] A similar study specific to major trauma patients who initially presented to non-trauma emergency departments found that after adjustment for mechanism of injury and injury severity score, uninsured patients were more likely to be transferred to a trauma center whereas insured patients were more likely to be admitted to the non-trauma center. [6] This finding among trauma transfers was corroborated by evaluations of payer mix among head-injured patients using the National Trauma Data Bank (NTDB) and regional studies of trauma patients.…”

Section: Discussionmentioning

confidence: 99%

Insurance status influences emergent designation in surgical transfers

Broman

Phillips

Hayes

et al. 2016

Journal of Surgical Research

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Background There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency Medical Condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs. Materials and Methods A retrospective cohort study was performed of patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only. Results There were 1,295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer non-white, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% vs 84%, p<0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (OR 1.61, 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR 2.27, 1.08-4.77) Conclusions The finding that uninsured patients were more likely to be designated as EMCs suggests non-clinical variation that may be mitigated by clearer definitions and increased inter-facility coordination to identify patients requiring transfer for emergency medical conditions.

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“…It is notable that other studies have shown that Medicaid patients presenting to the emergency department are more likely to be transferred; however, this relationship may be influenced by the Emergency Medical Treatment and Labor Act, which mandates that acute care hospitals accept patients in transfer from emergency departments when a request has been issued for a higher level of care (38).…”

Section: Original Researchmentioning

confidence: 99%

Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure

et al. 2017

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Rationale: Patients with ventilator-dependent respiratory failure have improved outcomes at centers with greater expertise; yet, most patients are not treated in such facilities. Efforts to align care for respiratory failure and hospital capability would necessarily require interhospital transfer.Objectives: To characterize the prevalence and the patient and hospital factors associated with interhospital transfer of adults residing in Florida with ventilator-dependent respiratory failure.Methods: We performed a retrospective, observational study using Florida Healthcare Cost and Utilization Project data. We selected patients 18 years of age and older with International Classification of Diseases, Ninth Revision, codes of respiratory failure and mechanical ventilation during 2012 and 2013, and we identified cohorts of patients that did and did not undergo interhospital transfer. We obtained patient sociodemographic and clinical variables and categorized hospitals into subtypes on the basis of patient volume and services provided: large, medium (nonprofit or for-profit), and small.Results: Interhospital transfer was our primary outcome measure. Patient sociodemographics, clinical variables, and hospital types were used as covariates. We identified 2,580 patients with ventilatordependent respiratory failure who underwent interhospital transfer. Overall, transfer was uncommon, with only 2.9% of patients being transferred. In a hierarchical model, age less than 65 years (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.77-2.45) and tracheostomy (OR, 3.19; 95% CI, 2.80-3.65) were associated with higher odds of transfer, whereas having Medicaid was associated with lower odds of transfer than having commercial insurance (OR, 0.65; 95% CI, 0.56-0.75). Additionally, care in medium-sized for-profit hospitals was associated with lower odds of transfer (OR, 1.37 vs. 2.70) than care in medium nonprofit hospitals, despite similar hospital characteristics. Conclusions:In Florida, interhospital transfer of patients with ventilator-dependent respiratory failure is uncommon and more likely among younger, commercially insured, medically resourceintensive patients. For-profit hospitals are less likely to transfer than nonprofit hospitals. In future studies, researchers should test for geographic variations and examine the clinical implications of selectivity in interhospital transfer of patients with ventilatordependent respiratory failure.

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Admit or Transfer? The Role of Insurance in High-Transfer-Rate Medical Conditions in the Emergency Department

Abstract: Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

Cited by 59 publications

References 27 publications

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

Insurance status influences emergent designation in surgical transfers

Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure

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