By Charleen Hsuan, JD, PhD; Renee Y. Hsia, MD, MSc; Jill R. Horwitz, PhD, JD, MPP; Ninez A. Ponce, MPP, PhD; Thomas Rice, PhD; Jack Needleman, PhD, FAAN
HSR – Health Services Research, April 2, 2019
To examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private.
Data Sources/Study Setting
Ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California’s Office of Statewide Health Planning and Development and the American Hospital Association (2007).
We match public and private (nonprofit or for‐profit) hospitals by distance and size. We use random‐effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals.
Hospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P < 0.001). Hospitals declaring diversions have lower ED occupancy (P < 0.001) after neighboring public (vs private) hospitals divert. Hospitals have 4.2 percent shorter diversions if neighboring diverting hospitals are public vs private (P < 0.001). When the neighboring hospital ends its diversion first, hospitals terminate diversions 4.2 percent sooner if the neighboring hospital is public vs private (P = 0.022).
Sample hospitals respond differently to diversions by neighboring public (vs private) hospitals, suggesting that these hospitals might be strategically declaring ambulance diversions to avoid treating low‐paying patients served by public hospitals.
By Don McCanne, M.D.
When a neighboring hospital places its Emergency Department (ED) on ambulance diversion (presumably because it is exceeding capacity), the hospital to which the ambulances are diverted is more likely to place its own ED on ambulance diversion if the neighboring hospital is a public hospital than if it is a private hospital. That is true even if they have lower ED occupancy (suggesting that ambulance diversion is declared for reasons other than exceeding capacity). Further, the diversions are shorter and are ended sooner if the neighboring hospital is public and ends its diversion first (both suggesting that there was no occupancy crisis in the hospital to which the ambulances were diverted).
Private hospital patients are more likely to be insured, paying patients, whereas public hospital patients are more likely to be uninsured or medically indigent patients, or enrolled in the underfunded Medicaid program. This study, which reaches a high degree of statistical significance, demonstrates that hospitals close their EDs when it may not be necessary if a neighboring public hospital with indigent patients has placed their ED on ambulance diversion thus potentially resulting in an influx of non-paying patients.
This suggests that hospitals give a higher priority to business success than they do to patient service in a system in which there is great variability in the patients’ ability to pay for services. But what if every patient was fully covered for health care services? Obviously, a single payer Medicare for All program would eliminate the concern over whether or not the patient has adequate insurance coverage.
If there is truly inadequate capacity in the system, that could be adjusted through regional planning, hospital budgeting with capacity adjustments, and applying the science of queue management. If sloth is the reason for ambulance diversion then, at worst, that might warrant disciplinary action. But getting rid of sorting patients based on ability to pay would be an important step towards moving us closer to a high performance health care system that takes good care of all of us.
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