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Original Investigation
Health Care Reform
April 1, 2019

Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition

Author Affiliations
  • 1Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 2Yale New Haven Hospital–Center for Outcomes Research and Evaluation, New Haven, Connecticut
  • 3Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
  • 4Yale University School of Medicine, New Haven, Connecticut
  • 5Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
  • 6Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 7Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 8Clover Health, Jersey City, New Jersey
JAMA Intern Med. 2019;179(5):686-693. doi:10.1001/jamainternmed.2019.0037
Key Points

Question  Are emergency department patients more likely to be transferred to another hospital after stabilization for common medical conditions on the basis of insurance status?

Findings  In this cross-sectional analysis of 215 028 emergency department visits to 160 US hospitals, uninsured patients and Medicaid beneficiaries were more likely to be transferred for pneumonia, chronic obstructive pulmonary disease, or asthma despite hospital capabilities to provide advanced pulmonary or critical care.

Meaning  After accounting for differences in hospital capabilities, the study found that uninsured patients who were discharged or transferred from an emergency department with pulmonary disease appeared to not have access to the same level of hospital care as was available to privately insured patients.


Importance  Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives.

Objective  To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care.

Design, Setting, and Participants  A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included.

Main Outcomes and Measures  The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis.

Results  Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care–capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33).

Conclusions and Relevance  After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.

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