ED Discharge, Transfer Rates Tied to Patients' Ability to Pay

Diana Phillips

April 01, 2019

Decisions about hospital admissions and transfers from the emergency department (ED) continue to be associated with patient insurance status despite decades-old federal legislation mandating a payment-blind care access, a study has shown.

The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 requires all US hospitals that accept Medicare to provide ED care to all patients regardless of their ability to pay. In particular, the legislation requires that hospitals with capacity to do so must stabilize patients prior to transfer to another facility, unless patients have requested immediate transfer.

To assess the effectiveness of the EMTALA in ensuring appropriate patient stabilization, Arjun K. Venkatesh, MD, of Yale University School of Medicine in New Haven, Connecticut, and colleagues analyzed data from a national all-payer administrative claims database of ED visits in the United States, looking specifically at transfer and discharge patterns for patients with common medical conditions at hospitals with critical care capabilities.

"[W]e 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," the authors write in an article published online today in JAMA Internal Medicine. "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."

The researchers conducted a cross-sectional analysis of the 2015 National Emergency Department Sample (NEDS), which included ED visits between January 2015 and December 2015, focusing specifically on ED visits for pneumonia, asthma, and chronic obstructive pulmonary disease. The outcomes of interest included risk-adjusted ED discharge, ED transfer, and hospital admission rates based on patient insurance status at both the hospital level and the patient level.

The full 2015 NEDs sample included 30,542,691 ED visits to 953 hospitals, of which 215,028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care–capable hospitals that were predominantly metropolitan-based nonteaching hospitals located in urban areas.

Of the pulmonary-related ED visits, 142,900 (66.5%) resulted in ED discharge, 3210 (1.5%) resulted in ED transfer to another hospital, and 68,918 (32.1%) led to hospital admission. Approximately 35% of the visits were made by uninsured (9.4%) and Medicaid insured (25.5%) patients. The majority of patients (65.1) had Medicare or private insurance.

At the hospital level, the risk-standardized ED discharge, ED transfer, and hospital admissions rates were, respectively, 66.2% (60.2% - 71.9%), 1.3% (1.0% - 1.9%), and 32.3% (26.6% - 37.7%). In the patient-level analysis, after adjusting for age, sex, income, and comorbidities, the ED transfer rates were greater for uninsured (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 2.08 - 2.79 ) and Medicaid patients (aOR, 1.19; 95% CI, 1.05 - 1.33), compared with privately insured patients. Further, uninsured patients were more likely to be discharged (OR, 1.66; 95% CI, 1.57 - 1.76) than privately insured patients, while Medicaid beneficiaries had similar odds of discharge (aOR, 1.00; 95% CI, 0.97 - 1.04).

A secondary analysis looking at ED patient dispensation by hospital ownership status showed that uninsured patients were less likely to be transferred than privately insured patients in nonprofit hospitals (aOR, 0.70; 95% CI, 0.47 - 1.05), but they were more likely to be transferred in for-profit hospitals (aOR, 1.64; 95% CI, 0.97 - 2.76). The authors note, however, that the wide confidence intervals "preclude statements of association."

In both nonprofit and for-profit hospitals, respectively, Medicaid beneficiaries had lower odds of ED transfer, with adjusted odds ratios of 0.74 (95% CI, 0.58 - 0.96) and 0.43 (95% CI, 0.27 - 0.68).

The study "confirms the hypotheses of previous research, indicating that hospital transfer patterns are associated with patient insurance status despite accounting for the usual caveats, namely, interhospital transfer was necessary for specialty or critical care services unavailable at the index hospital," the authors write. The findings pertaining to discharge patterns are also consistent with previous research linking lack of insurance with an increased likelihood of ED discharge, they note.

The comparative admission rate from the ED of uninsured vs privately insured patients was unexpected, according to the authors. "That the uninsured had nearly half of the admission rate of the privately insured in this study, even after risk adjustment, was an unanticipated finding, given the relatively standard clinical guidelines used for hospitalization decisions for the common pulmonary conditions studied," they write. "These findings may be explained by a higher threshold for inpatient admission from the perspective of the patients, the physicians, or both for financial reasons."

The authors hypothesize that transferring uninsured or Medicaid patients may be the equivalent of an EMTALA loophole. "Traditional EMTALA violations, such as refusing to provide or providing inadequate medical screening examinations in the ED are rare; however, our findings suggest that financial incentives may be associated with access to inpatient hospital care," they write.

Noting that "the discharge of patients after ED evaluation is entirely ignored by the law, despite concerns that interpretation of the stabilization requirements of the EMTALA may allow for unstable patients to be discharged with only instructions to seek care elsewhere," the authors call for policymakers to acknowledge these hospitalization patterns and develop financing policies to bridge the access gaps for uninsured patients.

In an accompanying commentary, Mitchell H. Katz, MD, and Eric K. Wei, MD, of NYC Health and Hospitals in New York City, note the findings of this study highlight flaws of the EMTALA, including the fact that the legislation does not guarantee free or low-cost care. "It only guarantees that the ability to pay cannot be used as a reason for denying emergency care. After an ED visit and potential hospitalization, a patient can be sent a full charge bill," they explain.

This consideration could be a factor in the payment-based transfer disparities, the editorialists write, noting that uninsured or Medicaid patients may prefer to be transferred to a Veterans Affairs or public hospital. "Unfortunately, we do not know why patients were transferred, but one possibility is that those who were privately insured were less likely to be transferred because their insurance would cover their bill."

In addition to ED dispensation-related flaws, the EMTALA has no provision or equivalent legislation for medically necessary nonemergency care. "In extreme cases, patients with chronic diseases may be forced to wait to seek care until their conditions become emergencies," the commentary authors write.

The lack of funding associated with the EMTALA means that hospitals must shift costs to cover unpaid care, typically by charging more for insured patients, according to the commentary. "Hospitals located in very-low-income areas may find it especially difficult to cross-subsidize the care they provide because of large volumes of uninsured patients, whereas hospitals in wealthy areas may have little burden as patients tend to go to the nearest hospital," the authors state.

Finally, the commentary authors describe the EMTALA as a political weapon of sorts, noting that politicians use it to justify lack of universal health insurance for all US residents "because patients can always go to the ED and receive care under EMTALA."  

The study received funding support from an Emergency Medicine Foundation Health Policy Scholar Award, a Yale Center for Clinical Investigation grant from the National Center for Advancing Translational Science of the NIH, a Paul B. Beeson Career Development Award grant from the National Institute on Aging and the American Federation for Aging Research, and a Yale Claude D. Pepper Older Americans Independence Center grant.

The study authors report financial relationships with multiple organizations, including the Centers for Medicare & Medicaid Services (CMS), the US Food and Drug Administration, Medtronic, Johnson & Johnson, and the National Heart, Lung, and Blood Institute of the National Institutes of Health. A complete list is available on the journal's website. The editorialists have disclosed no relevant financial relationships.

JAMA Int Med. Published online April 1, 2019. Full text, Editorial

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