Lacking health insurance usually means getting worse health care, but that may not be true when it comes to a traumatic injury, a new study suggests.
The study, published Wednesday in JAMA Surgery, found that uninsured patients with severe injuries – the kind commonly associated with car crashes, serious falls and gunshots – were significantly more likely than insured patients to be transferred out of hospitals not specializing in trauma care.
It's most likely that those patients made their way to trauma centers, hospitals set up to handle such cases and proved to save more lives, researchers say.
"This is one scenario where the uninsured may not be worse off," says lead author M. Kit Delgado, a specialist in emergency medicine at the University of Pennsylvania.
Some other experts question the study's suggestion that hospitals choose to admit or transfer trauma patients based on insurance coverage. They agree that it illustrates a broader problem: Many people with traumatic injuries are treated at community hospitals rather than regional trauma centers, despite research showing a 25% survival advantage at such centers.
For the study, Delgado and colleagues reviewed records from more than 4,000 adult trauma patients under age 65 initially treated at 636 non-trauma hospitals in 2009. About 75% of U.S. hospitals are non-trauma hospitals, and about one-third of trauma patients get initial treatment in them, Delgado says.
Guidelines from the federal Centers for Disease Control and Prevention call for most of those patients to be transferred to trauma centers after they are stabilized.
In the study, transfers occurred 45% of the time. Transfers were 14% less likely in patients with Medicaid and 11% less likely in those with private insurance than in otherwise similar patients with no insurance.
Delgado says the study does not mean hospitals used "wallet biopsies" to pick patients, though he says it is possible case managers discouraged doctors from admitting uninsured patients who could get better care elsewhere – but failed to give the same appropriate scrutiny to insured patients doctors felt they could handle.
Howard Mell, an emergency physician based in Cleveland who works at seven hospitals in four states, says he never knows a patient's insurance status and never has such conversations with case managers. That's how it's supposed to work, he says, under a law that prohibits "dumping" of uninsured patients on other hospitals.
"I have to make the decision based on whether I have the capacity to care for the patient," says Mell, a spokesman for the American College of Emergency Physicians.
Mell says the study found transfer differences based on injury and hospital types: More head injuries than abdominal injuries were transferred, and more rural hospitals than urban teaching hospitals did the transferring. He says it's likely those factors or others not picked up in the study drove decisions that might appear linked to insurance.
Delgado says he can't rule out effects of unreported differences in patients. One possibility, he says, is that insured patients are more likely to insist upon staying at familiar hospitals. He says he does believe insurance coverage sometimes steers decisions not fully explained by the hospital and injury differences picked up in the study.
Insurance status may "be of trifling interest" as the Affordable Care Act kicks in and fewer people are uninsured, says an editorial accompanying the study, written by Charles Mabry, a surgeon at the University of Arkansas. A shortage of surgeons at many hospitals will probably mean more patients will be transferred, he says.
Most decisions "in the heat of battle" are made by doctors trying to "do their best for the patient," he wrote.
Delgado says the study did not show whether the patients kept at non-trauma hospitals actually suffered as a result, but previous research suggests some did.