Dumping Uninsured Patients - We All Know It's Happening

Written by Clay Smith

Spoon Feed
Uninsured patients had 66% greater odds of ED discharge and 241% greater odds of ED transfer than similar privately insured patients in hospitals that had capacity to care for them in-house.

Why does this matter?
EMTALA was designed to prevent dumping of uninsured patients with emergencies or who are in labor. The wording of the law says, “If the hospital determines that an emergency medical condition exists, the hospital must provide for further medical examination and treatment as required to stabilize the individual. If the hospital does not have the capabilities to stabilize the individual, an appropriate transfer to another facility is permitted.” Are otherwise similar uninsured patients being treated differently than privately insured patients when seen in hospitals with equal capacity to take care of them?

Uninsured patients never get transferred when they can be cared for locally, right?
Wrong. This was a retrospective look at the 2015 National ED Sample (NEDS) database to determine if patients without insurance were more likely to be discharged from the ED or to be transferred when the referring hospital was capable of taking care of equally sick patients in-house. They looked at patients with three diagnoses - pneumonia, COPD, and asthma - only in hospitals with advanced critical care capabilities for pulmonary patients. When adjustments were made for age, sex, income, and comorbidity, odds of ED discharge were 66% higher in uninsured patients (aOR 1.66, 95%CI, 1.57-1.76) and odds of transfer to another hospital 241% greater than privately insured patients (aOR 2.41; 95%CI, 2.08-2.79). Medicaid patients had a comparable adjusted ED discharge rate to privately insured patients (aOR = 1) but a 19% greater odds of transfer (aOR 1.19; 95% CI, 1.05-1.33).

Let’s just call this what it is — dumping. We all know it happens, especially those of us at hospitals who primarily receive patients. If your hospital can handle privately insured patients with high acuity illness but can’t seem to handle uninsured patients with the same, you may want to consider why that is.

Another Spoonful

  • Ever wondered what EMTALA actually says? Go straight to the source.

  • The Centers for Medicare & Medicaid Services (CMS) has issued multiple guidelines and rules on how it believes EMTALA should be interpreted.

  • Still, there is controversy on the application of EMTALA. Check out this Health Affairs article that succinctly explores how Circuit Courts have offered differing interpretations of EMTALA.

Source
Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition. JAMA Intern Med. 2019 Apr 1. doi: 10.1001/jamainternmed.2019.0037. [Epub ahead of print]

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Reviewed by Thomas Davis

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