Interhospital Transfers Occur Less Frequently for Uninsured Patients

Patients without insurance experienced significantly higher odds of mortality among hospital admissions of critically ill patients with acute respiratory failure on a mechanical ventilator, a new study in JAMA Network Open reported.¹

High-volume care centers—or medical facilities that cater to a large number of patients with a specific condition, procedure, or specialty—are associated with a lower risk of mortality, especially for patients who are placed on a mechanical ventilator. This is likely due to the specialized nature of said facilities, which are often equipped with intensive care unit (ICU) protocols or clinicians with experience managing critically ill patients.

Patients who are uninsured are less likely to be transfered to high-volume care centers despite their critical condition. | Image Credit: Eakrin - stock.adobe.com

The authors of the new study suggest that moving critically ill patients, specifically those on a mechanical ventilator, to a high-volume center may improve their outcomes. While the impact of schematics involved in transferring patients has yet to be investigated, there is prior evidence that being uninsured is associated with lower odds of interhospital transfer for patients with acute coronary syndrome, earlier withdrawal of life-sustaining therapies for patients with traumatic brain or spinal cord injury, and increased mortality among critically ill patients. While there have been policy implementations to ensure emergency care is provided regardless of a patient’s ability to pay under the Emergency Medical Treatment & Labor Act, these regulations do not protect patients after they have been deemed medically stable—often after admission.

Using data from the Premier Healthcare Database, which includes nearly 25% of all inpatient hospitalizations in the US, researchers sought to determine the association between insurance status and interhospital transfer for critically ill patients admitted with acute respiratory failure who were placed on a mechanical ventilator. Patients included were hospitalized between January 1, 2017, and September 30, 2021.

Among the 703,392 admissions included in the retrospective cohort study, the mean age was 60.5 years, and the majority of patients were either admitted into a general or medical ICU. Of the total patients, 43.1% were female, 2.19% were Asian, 16.4% were Black, 69.35% were White, 8.85% were of other races, and 3.2% had unknown race; and relating to ethnicity, 8.39% were Hispanic. Among the 824 hospitals included, about one-third were teaching hospitals, and 812 transferred at least 1 patient.

Interhospital Transfers

A total of 30,613 admissions led to interhospital transfer, while the remaining 95.65% did not. The patients who were transferred were younger (mean [SD] age, 56.82 [16.56] years) when compared with those who were not transferred (60.68 [17.04] years) and were also more likely to have commercial insurance (8013 [26.18%] vs 116,955 [17.38%]) despite both groups having similar severity of illness and chronic comorbidities. Furthermore, 37.43% (n = 263,261) of patients either died or were discharged to hospice. The most frequent discharge diagnoses were infectious (216,874 [30.83%]), respiratory (140,744 [20.01%]), neurologic (104,021 [14.79%]), and cardiac (90,810 [12.91%]).

After adjusting for patient characteristics, the adjusted odds ratio for the probability of interhospital transfers for patients with vs without insurance was 3.2% vs 5.59%, respectively. The odds of transfer were also significantly lower for patients with Medicare (AOR, 0.72; 95% CI, 0.68-0.76; P < .001) or Medicaid (AOR, 0.69; 95% CI, 0.64-0.74; P < .001) when compared with patients with commercial insurance. The estimated probability of mortality for those without insurance was 42% compared to the 37% for patients with commercial insurance. There was also a noticeable difference in time to interhospital transfers, which showed that not having insurance, Medicare, or Medicaid was associated with a slower time to transfer when compared to having insurance.

On the other hand, the study authors also acknowledge the barrier clinicians sometimes face regarding transfers, which may account for slower times regardless of whether a patient has insurance or not.

“Clinicians attempting to transfer patients to other hospitals have described barriers, such as a lack of guidance to identify patients who should be transferred and to where they should be transferred,” the study authors explained. “Clinicians receiving transferred patients have reported uncertainty about which patients to prioritize for acceptance. Additionally, the extent to which patient and family preferences also might play a role in the decision for interhospital transfer is incompletely understood, with existing evidence signaling a lack of patient and family involvement in the process.”

New eligibility requirements and cuts to Medicaid may also affect families with low income, older adults, individuals with disabilities, and immigrant communities. These requirements pertaining to work, which may reduce retroactive coverage and stricter documentation, will also affect patient access and hospital operations and finances.² Moreover, the insurance review process between patient transfer, referral, and acceptance has limited evidence to describe the process, thus creating gaps that may disenfranchise patients without insurance.¹

“To better evaluate how insurance plays a role in the transfer process, data sources that capture more granular transfer data are crucial,” the study authors suggested. “For example, being able to identify patients for whom transfer was requested (not just those who were transferred) as well as reasons for requested transfer would enable a better assessment of outcomes of transferred patients and identification of potential targets for interventions to reduce disparities.”

The study limitations included its reliance on administrative data, which may lack clinical detail and risk misclassification of conditions like respiratory failure. Transfer decisions and patient outcomes could not be fully captured, as the data excluded certain influencing factors—such as illness severity, patient or family preferences, and hospital capacity—and did not track patients across hospitals after transfer. The analysis may also reflect selection bias, since only successfully transferred patients were included, potentially underestimating the role of insurance or other barriers. Finally, the study could not assess the appropriateness of transfers or the broader decision-making processes underlying them.

“Our results signal that health insurance may play an important yet underrecognized role in the care of critically ill patients,” the study authors concluded. “There is a need to examine the role of insurance in the care of the critically ill and better define how interhospital transfers occur to ensure that interhospital transfer practices occur equitably.”

References

1. Harlan EA, Ghous M, Cortinas N, et al. Health insurance and interhospital transfer for critically ill patients with respiratory failure. JAMA Netw Open. 2025;8(8):e2528889. doi:10.1001/jamanetworkopen.2025.28889

2. Klein HE, Patel L. 5 key takeaways on Medicaid policy changes from Savista’s chief strategy officer. AJMC. August 15, 2025. Accessed August 26, 2025. https://www.ajmc.com/view/5-key-takeaways-on-medicaid-policy-changes-from-savista-s-chief-strategy-officer