Insurance Status and the Transfer of Hospitalized Patients

Abstract

Background There is little objective evidence to support concerns that patients are transferred between hospitals based upon insurance status. Objective To examine the relationship between patients’ insurance coverage and inter-hospital transfer. Design We analyzed data from the 2010 National Inpatient Sample. Patients All patients aged 18-64 years discharged alive from U.S. acute care hospitals with one of five common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, skin or subcutaneous infection). Measurements For each diagnosis, we compared the proportion of hospitalized patients who were transferred to another acute-care hospital based upon insurance coverage (private, Medicare, Medicaid, and uninsured). We used logistic regression to estimate the odds of transfer for uninsured patients (reference category- privately insured) while adjusting for patient and hospital level factors. All analyses incorporated sampling and post-stratification weights. Results Among 315,748 patients discharged from 1051 hospitals with our five diagnoses, the percentage of patients transferred to another acute-care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses uninsured patients were significantly less likely to be transferred for three diagnoses (p<.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for the four diagnoses: biliary tract disease (Odds Ratio (OR) 0.73 (95% Confidence interval (CI) 0.55-0.96)); chest pain (OR 0.63 (CI 0.44-0.89)); septicemia (OR 0.76 (CI 0.64-0.91)); and skin infections (OR 0.64 (CI 0.46-0.89)). Women were significantly less likely to be transferred than men for all diagnoses. Limitations This analysis relied on administrative data and lacked clinical detail. Conclusions Uninsured patients (and women) were significantly less likely to undergo inter-hospital transfer. Differences in transfer rates may contribute to healthcare disparities.

Interhospital transfer patients discharged by academic hospitalists and general internists: Characteristics and outcomes

“…Our analysis does not explain why the outcomes of IHTs are worse, but plausible contributing factors include that (1) patients chosen for IHT are at higher risk of death in ways uncaptured by established mortality risk scores, (2) referring, transferring, or accepting providers and institutions have provided inadequate care, (3) the transfer process itself involves harm, (4) socioeconomic bias in selection for IHT, or (5) some combination of the above. Regardless of the causes of the worse outcomes observed in these “outside‐hospital transfers,” as these patients are colloquially known at accepting hospitals, they present challenges to everyone involved.…”

Disproportionate effects of dementia on hospital discharge disposition in common hospitalization categories

“…Also tabulated were Alzheimer's disease (ICD‐9 331.0) and falls (E880–E888) . The primary reimbursement status coded as Medicaid or self‐pay was considered a field of interest, as it reflects socioeconomic status . Medicare as the sole reimbursement source was also considered a field of interest, as this influences the hospital LOS requirement prior to reimbursable skilled nursing facilities (SNF) transfer .…”

Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction

“…In some settings, patients without health insurance are transferred more frequently, 8–10 and in others, less frequently. 11 These previous studies suggest that compared to patients with health insurance, uninsured patients are more likely to be transferred for an emergent condition, but are less likely to be transferred after hospitalization; when a patient’s clinical status becomes more stable. 8–12 These previous studies combined with our findings suggest that acuity of the clinical condition and location of care may not be the only factors affecting the transfer decision, but insurance status may also influence this as well.…”

“…This is consistent with previous studies showing higher transfer rates among males compared to females for a wide range of conditions, including trauma, and hospitalized patients. 11,13 Potential reasons for this difference between the sexes include different perceived severity of illness, and atypical presentations among women with suspected acute myocardial infarction. 13,14 …”