Insured children who show up in the emergency department are more likely to be admitted to the hospital than those covered by Medicaid and CHIP. But they don't fare any better than those sent home.
Much of healthcare reform is about matching patients to the most appropriate care. Recent studies looking at emergency department admissions offer evidence of how hard that can be.
In New Jersey, an analysis of more than 3 million ED cases found that children with public insurance were less likely to be admitted to hospital, especially during flu season when beds tend to be full.
However, based on data including readmission rates, those who did not stay overnight suffered no bad health outcomes, according to research published in Economics and Human Biology.
The patients who were not admitted via the ED had the same rate of future visits and subsequent admissions as those who were hospitalized. Since the hospitalized patient got no benefit, the authors suggest the finding could be evidence of unnecessary care.
To establish whether unnecessary care is occurring, researchers would have to look at clinical data rather than the claims data used in this study, said Princeton University health economist Janet Currie, a coauthor of the study.
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If patients did need additional care, it would show up in the data on subsequent admission and ED visits, Currie said. "If I am really sick and I get sent home, I should end up coming back," she said. "But they're not coming back… What we infer from that is they don't really need to be hospitalized."
While the publicly insured have less access to after-hours and specialist care, once admitted, they receive the same care as privately insured children. However, little research has been done on access to hospital care for publicly insured children, the researchers noted.
The statewide data used in the study covered 2006 through 2012 and looked at claims data for more than 3 million patients. They found the widest difference in admission probability (4.4 versus 4.7) during flu season—or 9,700 more publicly insured children who were not hospitalized.
A Different Twist
A slightly different twist on the impact of insurance in emergency care come from a 2014 study which found that insured patients with severe injuries who were initially evaluated at non-trauma center EDs were less likely to be transferred to trauma centers.
These patients were at risk of receiving suboptimal trauma care because they might not be transferred to Level 1 trauma centers, which are equipped to deal with the most serious cases, the study concluded.
A more recent (2016) study in JAMA Surgery suggests that only one in five patients meeting American College of Surgeon transfer criteria were transferred. "Further study is necessary to critically evaluate whether these ACS criteria identify patients who require transfer," the researchers wrote.
ED Experts Question Findings
Howard Mell, MD, an Illinois emergency medicine physician and a spokesman for the American College of Emergency Physicians, questioned the suggestion that ED clinicians would be less likely to admit publicly insured patients.
ED physicians are blind to a patient's coverage, said Mell. Furthermore, "it is very tough to look at data that is designed for billing and make a good determination as to where this is coming from," Mell said.
The huge volume of data in the Princeton study means the study finding doesn't reflect "the individual thought processes" of physicians, said Karin Rhodes, MD, emergency medicine physician and head of care management design for Northwell Health in New York City.
That there was no benefit to the hospital stay made sense to Rhodes based on her work with the frail elderly.
"The people I work with—geriatricians and palliative care doctors—strongly feel that hospital admissions that are unnecessary increase suffering and cause many adverse consequences." Unnecessary admissions could be harmful for children as well, said Rhodes.
Hospitals could use their in-house clinical data to explore links between insurance status and admissions, Currie said.
"You certainly want to make sure you are admitting the right people," she said.
Tinker Ready is a contributing writer at HealthLeaders Media.