Uninsured patients and those with Medicaid are more likely to be transferred from an emergency department to another hospital, researchers report.

EMTALA, passed in 1986, created a federal mandate to provide medical screening examinations and essential universal access to acute emergency care to any patient presenting to an emergency department.

Dr. Arjun K. Venkatesh from Yale University School of Medicine, in New Haven, Connecticut, and colleagues wanted to find out if patients who were either uninsured or insured by Medicaid were more likely than insured patients to be transferred despite a hospital’s ability to care for them.

The team used data from the 2015 National Emergency Department Sample and focused on one of three common pulmonary conditions: pneumonia, chronic obstructive pulmonary disease (COPD), and asthma.

Their study included 20,228 visits by uninsured patients, 54,817 visits by Medicaid beneficiaries and nearly 140,000 visits by patients insured by Medicare or a private plan.

ED discharge, ED transfer, and hospital admission rates varied widely across hospitals, the researchers report in JAMA Internal Medicine, online April 1. For example, the risk-standardized ED-transfer rate ranged from 0.8 percent at the 5th percentile to 4.6 percent at the 95th percentile, representing a coefficient of variation of 120.4.

Transfer rates were higher among uninsured patients (1.6 percent) and Medicaid beneficiaries (1.3 percent) than among privately insured patients (1.2 percent).

In adjusted analyses, uninsured patients had 2.41-fold higher odds and Medicaid beneficiaries had 19 percent higher odds of being transferred than privately insured patients—both significant results.

Uninsured patients also had significantly higher odds of being discharged from the ED (odds ratio, 1.66), compared with privately insured patients, whereas Medicaid beneficiaries and privately insured patients had similar odds of discharge.

In a secondary analysis based on hospital ownership status, compared to insured patients, uninsured patients had 30 percent lower odds of ED transfer out of nonprofit hospitals but 64 percent higher odds of transfer out of for-profit hospitals.

Uninsured patients had higher odds of ED discharge in both nonprofit and for-profit hospitals, while Medicaid beneficiaries had lower odds of ED transfer in both nonprofit and for-profit hospitals.

“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 conclude. “Policymakers should broaden the scope of hospital quality, payment, and certification initiatives to reduce these disparities and improve access to hospital-based care.”