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.”

“The secondary analyses, which were based on hospital ownership, should only be hypothesis-generating in nature as they are both underpowered and prone to selection bias because of limited data availability,” the researchers note.

Dr. Eric K. Wei from NYC Health and Hospitals, in New York, who co-authored a linked commentary, told Reuters Health by email, “Despite our best intentions and without consciously trying to have two standards of care, the data shows that these disparities in care exist. We cannot continue the status quo and expect different results.”

He offered three suggestions that might reduce or eliminate these disparities: “provide EMTALA-like protections to preventative and outpatient care; level the financial playing field for hospitals that provide care to a larger proportion of uninsured and Medicaid patients; [and] create programs that provide universal access to preventative and outpatient care.”

“Public health systems play an important role in providing health care to patients who would otherwise be marginalized in the U.S. health care system,” Dr. Wei concluded.

Dr. Scott M. Dresden from Northwestern University’s Department of Emergency Medicine, in Chicago, who has studied ED use for the uninsured before and after Affordable Care Act Insurance expansion, told Reuters Health by email, “Despite EMTALA, it appears that preferential transfer of ‘lower paying’ patients still happens.”

“I was surprised that after eliminating hospitals without critical care capacities, uninsured and Medicaid patients were still more likely to be transferred,” said Dr. Dresden, who was not involved in the new work. “It could be that these were the more complex patients rather than evidence that hospitals are doing a wallet biopsy prior to admission or transfer decisions; however, these were only hospitals with critical care capacities included in the study.”

“The first step (to addressing these disparities) would be to continue to reduce the number of patients who are uninsured and to increase the Medicaid reimbursement to be equivalent to private insurance,” Dr. Dresden said. “This would take away any financial incentive to diverting patients to different hospitals. Short of that, transfer rates at hospitals should be compared against peer institutions, and those with higher transfer rates for patients who are uninsured or on Medicaid should be investigated.”

Dr. Venkatesh did not respond to a request for comments.