Insurance Coverage Factors into ER Care of Pulmonary Patients

Arjun Venkatesh, MD, MBA, MHS

Insurance coverage can influence whether emergency departments (ED) transfer or discharge patients rather than admit them for necessary inpatient care, according to a study of ED disposition of pulmonary patients presenting to the EDs of hospitals with intensive care capabilities.

Arjun Venkatesh, MD, MBA, MHS, an assistant professor in the Department of Emergency Medicine and Scientist at the Center for Outcomes Research and Evaluation, Yale University School of Medicine, and colleagues noted that previous analyses of investigations of compliance with the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) were limited to extreme cases. This means they were not subjected to the more subtle refusals of acute care access that can occur after an EMTALA-mandated medical screening examination.

They also pointed out that that previous assessments were based on a binary decision between transfer and hospital admissions, and that neither the EMTALA nor the analyses of compliance consider inappropriate discharge from the ED. Further, Venkatesh and colleagues found that these studies did not account for differences in hospitals' capability to care for patients with severe illness.

"Our study sought to address limitations in prior research in 2 ways: first, we limited our study to patients with common medical conditions that would not need transfer to see a specialist; and second, we limited our study to hospitals likely capable of providing intensive care," Venkatesh told MD Magazine^®.

The investigators accessed the 2015 National Emergency Department Sample (NEDS), the largest, all-payer administrative claims data set of ED visits in the US. They selected pulmonary patients with pneumonia, chronic obstructive pulmonary disease (COPD) or asthma, as conditions that are commonly evaluated in the ED, have well-defined treatment, and—if severe—can be treated in hospitals with standard intensive care.

The 160 hospitals included in the study were confirmed to have critical care capabilities for pulmonary care. A secondary analysis by nonprofit or for-profit status included the 71 of the 160 hospitals for which that category was available from the Agency for Healthcare Research and Quality. They assessed 215,028 ED visits at the 160 hospitals in the study primary analysis; 81,447 ED visits at the 71 hospitals were included in the secondary analysis.

Venkatesh and colleagues reported substantial variation in unadjusted and risk-standardized ED discharge, ED transfer and hospital admission rates. Compared with privately insured patients, those without insurance were more likely to be discharged (OR 1.66; 95% CI: 1.57-1.76); and transferred (aOR 2.41; 95% CI: 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge, but higher odds of transfer.

In the secondary analysis, while acknowledging limited availability of hospital ownership data, the investigators found that for-profit ownership status appeared more likely to be associated with ED transfers for uninsured patients. Visits to nonprofit-owned hospitals by the uninsured were less likely to result in transfer.

"The financial rationale for this situation is clear but requires further study using more complete data sets before any specific conclusions based on hospital governance and financial structure can be drawn," Venkatesh and colleagues indicated.

The investigators are confident, however, that their data indicate that financial incentives can influence patterns of acute care access. Venkatesh offered several possible measures to rectify this relation, in discussion with MD Magazine^®.

"There are numerous policy levers to address this issue, some of which are more readily implemented than others," Venkatesh said. "In the short term, public and private payers seeking to improve access to care could support quality measures that capture these disparities.”

He added that certification and accreditation organizations could include transfer policies and practices in their assessment of hospital community benefit programs.

"Congress could revisit the EMTALA law to consider opportunities for improving access to hospital care," Venkatesh indicated, "given the numerous changes to our healthcare system and the importance of time-sensitive emergency care since passage of the original law."

The study, “Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition,” was published online in JAMA Internal Medicine.