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Does Insurance Status Affect Hospital Care for Pulmonary Patients?


Insurance status was found to potentially affect whether patients who used emergency department services were transferred to other hospitals, discharged, or admitted to hospitals.

Medicaid recipients and uninsured patients seeking emergency department (ED) services had higher rates of being transferred between hospitals than patients insured by Medicare or private plans, according to a new study in JAMA Internal Medicine.

Researchers performed a cross-section analysis of the 2015 National Emergency Department (NED) sample that included ED visits from January to December 2015. Data were gathered from hospital visits with intensive care capabilities regarding cases of pneumonia, chronic obstructive pulmonary disease (COPD), and asthma. Only data from hospitals with advanced critical care capabilities for pulmonary care were included. The purpose of the study was to determine whether insurance status had any effect on rates of transfer between hospitals visits resulting from common medical conditions.

In 1986, the United States Congress enacted the Emergency Medical Treatment and Active Labor Act, which required all hospitals that accepted Medicare to provide emergency department care to all patients regardless of whether they could afford treatment. While the act addressed disparities in access to emergency care, some discrepancies in treatment continue.

The primary outcomes in the study were patient-level and hospital-level risk-adjusted ED discharges, ED transfers between hospitals, and hospital admissions. Researchers included both hospital-level and patient-level analyses.

Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare recipients, and privately insured patients were reported. Hospital ownership status, regarding whether they were for-profit or not-for-profit, was used for secondary analysis.

Of the total NED sample, 215,028 ED visits were for acute pulmonary diseases to 160 intensive care-capable hospitals. Patients whose visits were included in the study had a median age of 55 years and 58.1% were women. Researchers found that:

  • 66.5% of visits resulted in ED discharge
  • 1.5% of visits resulted in ED transfer to another hospital
  • 32.1% of visits resulted in hospital admission
  • 9.4% of visits were made by uninsured individuals
  • 25.5% of visits were made by Medicaid beneficiaries
  • 65.1% of visits were made by patients with Medicare or those who were privately insured

Researchers constructed regression models at the patient-level to determine the chances ED patients would be transferred or discharged as opposed to admitted to hospitals based on whether they were uninsured, underinsured Medicaid beneficiaries, or insured with Medicare or private plans. Researchers used multinomial logistic regression models to calculate the adjusted odds ratio of ED transfer and discharge in comparison to rates of hospital admission. They also used multinomial regression modelling to align their statistical approach with ED decision-making where physicians decide whether patients should be discharged, transferred, or admitted. Regression models were adjusted for patient age, sex, income, and Charlson comorbitiy index to account for differences in patient case mix.

The study found discrepancies between insurance status and rates of ED transfer between hospitals, rates of patient discharge, and rates of hospital admission.

Transfer Rates

  • 1.6% among uninsured
  • 1.3% among Medicaid beneficiaries
  • 1.2% among privately insured

Discharge Rates

  • 88.8% among uninsured
  • 80.2% amond Medicaid beneficiaries
  • 78.5% among privately insured

Uninsured and underinsured Medicaid recipients were transferred between hospitals more frequently than privately insured patients. Uninsured patients were also found to be the most likely to be discharged from an ED.

Ownership data was available for 44.4% of hospitals in the study. The majority, or 30.0% of the hospitals were nonprofit while 14.4% were for-profit. Secondary outcome analysis found that uninsured patients had lower rates of ED transfer than privately insured patients in nonprofit hospitals but higher rates in for-profit hospitals. Uninsured patients also had higher rates of ED discharge regardless of whether the hospital was nonprofit or for-profit.

“Among a national sample of ED visits for common medical conditions at hospitals with critical care capabilities, we found that, after accounting for patient characteristics, both uninsured patients and Medicaid beneficiaries were more likely to be transferred to another hospital compared with those with private insurance. 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,” researchers stated.2

An unanticipated finding in the study was that uninsured patients had nearly half of the admission rates of the privately insured, considering clinical guidelines used for hospitalization decisions regarding asthma, COPD, pneumonia are relatively standardized.

Researchers suggested that policymakers should seek to correct disparities in access to hospital care by acknowledging hospitalization patterns and developing policies capable of fully supporting the hospitalization needs of uninsured patients.

“All things being equal, if hospitals are stabilizing patients without regard to their ability to pay, one would expect no association between insurance status and disposition from the ED. Instead, Venkatesh and colleagues found that compared with privately insured patients, uninsured patients were more likely to be discharged or transferred and Medicaid beneficiaries were more likely to be transferred to another hospital. Of course, in the real world, all things are never equal. In particular, if uninsured patients are more likely to present to the ED with low-acuity illness, owing to a lack of a regular source of care, it could explain why they are more likely to be discharged,” said the authors of an accompanying editorial.1


1. Katz MH, Wei EK. EMTALA - a noble policy that needs improvement [published online April 1, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.0026

2. Venkatesh AK, Chou SC, Li SX, et al. Association between insurance status and access

to hospital care in emergency department disposition [published online April 1, 2019]. JAMA Intern Med. doi: 10.1001/jamainternmed.2019.0037.

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