Impact of Insurance and Hospital Ownership on Hospital Length of Stay Among Patients With Ambulatory Care-Sensitive Conditions

Abstract

PURPOSE Some studies suggest proprietary (for-profi t) hospitals are maximizing fi nancial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profi t environment. METHODSWe undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratifi ed by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status.RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a signifi cantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was signifi cantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, inhospital mortality rate for individuals with either private insurance or Medicaid was not signifi cantly different from the mortality rate for those without insurance.CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely. INTRODUCTIONT he problem of health care access is one that continues to vex the United States. Recent estimates suggest that in 2009, 46 million US residents younger than 65 years (17.5%) were uninsured.1 Insurance is an indicator of access to care and is associated with getting timely care for conditions for which appropriate access can make a major difference. Past studies show that patients who do not have health insurance are less likely than those with health insurance to be seen by a physician in ambulatory care for acute conditions.2 Health care access, particularly in an ambulatory setting, for such conditions as pneumonia and asthma is important because lack of access leads to increased emergency department use, as well as what could be termed preventable hospitalizations. 490 INSUR A NCE A ND HOSPI TA L L ENG T H O F S TAYAlthough the recent passage of the Patient Protection and Affordable Care Act provides health insurance for many more Americans, it is unclear whether other factors affecting the cost of health insurance will actually increase the number of uninsured resulting from the increasing cost o...

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