Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department.

STUDY OBJECTIVE: We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers. METHODS: This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs). RESULTS: Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28). CONCLUSION: Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

Show Us the Data: The Critical Role Health Information Plays in Health System Transformation.

Truly transforming the healthcare delivery and payment system turns on the ability to engage in the interoperable electronic exchange of patient health information across and beyond the care continuum. Achieving transformation requires a legal framework that supports information sharing with appropriate privacy and security protections and a trusted governance structure.

Case studies at Denver Health: 'patient dumping' in the emergency department despite EMTALA, the law that banned it.

The Emergency Medical Treatment and Labor Act was enacted in 1986 to prevent hospitals from turning away patients with emergency medical conditions, often because they were uninsured--a practice commonly known as "patient dumping." Twenty-five years later, Denver Health--a large, urban, safety-net hospital--continues to experience instances in which people with emergency conditions, many of whom are uninsured, end up in the safety-net setting after having been denied care or receiving incomplete care elsewhere. We present five case studies and discuss potential limitations in the oversight and enforcement of the 1986 law. We advocate for a more effective system for reporting and acting on potential violations, as well as clearer standards governing compliance with the law.