Some hospitals turn away ambulances when the patients are more likely to be poor, study finds
MILWAUKEE – Hospitals that temporarily shut their doors to ambulances have long argued the decision is driven purely by volume, so sick patients don't have to endure long waits for care in crowded emergency rooms.
But a new study has uncovered evidence of another motive for the practice: Hospitals may be turning away ambulances for financial reasons by avoiding treating patients with government health insurance or no coverage at all.
Using data from California, the study found evidence that suggests private hospitals are more likely to go on what is known as "ambulance diversion" if a nearby public hospital, which treats more indigent patients, is already turning away ambulances.
In other words, researchers found private hospitals acted differently – by three separate measurements – depending on whether the nearby hospital turning away ambulances was public or private.
The researchers termed this behavior "strategic diversion."
Earlier studies have documented "defensive diversions," where a hospital will close because its ER is being overrun with patients after nearby hospitals also have closed.
The new study found private hospitals may have used "diversion as a way to avoid treating Medicaid and uninsured patients. Strategic diversions of this kind delay access to emergency care for particularly vulnerable populations – delays that may increase mortality."
Lead author Charleen Hsuan, an assistant professor of health policy and administration at Penn State University, said if a public "safety-net" hospital is on diversion first, it may change the kind of patients going elsewhere.
"If the first hospital that goes on diversion is public, then the patients that are floating around in ambulances are more likely to be uninsured, have Medicaid – the patients that hospitals do not necessarily want in a financial sense.
"This paper suggests it is not just a defensive maneuver ... It's also potentially a payer type issue."
The practice hits poor patients especially hard and can impact anyone who happens to be in an ambulance at the time of the diversions.
Read the investigation: Wisconsin woman dies after an ambulance was turned away from best, closest hospital
A Milwaukee Journal Sentinel investigation published in January revealed that in 2014 a Milwaukee woman, Tiffany Tate, suffered a stroke while she was working at the cafeteria at the Medical College of Wisconsin.
The 37-year-old mother of two was 350 yards from Froedtert Hospital, the highest-rated stroke center in the area, when she had the stroke, but that hospital was on diversion at the time.
Tate was taken by ambulance to a hospital with a lower level of stroke care. Tate later died. Experts couldn't say if quicker care would have saved her, but they agreed she would have had a better chance.
At the time of Tate’s stroke, Milwaukee County was in the process of ending ambulance diversion, joining a growing number of places across the country to do so. The state of Massachusetts outlawed the practice 10 years ago.
Studies have found emergency room overcrowding is not only caused by the number of patients coming into an ER but rather by bottlenecks elsewhere in the hospital and longtime practices such as scheduling elective surgeries early in the week.
For years, hospitals would refuse to care for uninsured patients and those with Medicaid, which pays hospitals for the care at a lower rate. The practice, called "patient dumping," became illegal under a 1986 federal law that forbids hospitals from denying treatment to patients based on their insurance.
However, federal regulators have allowed hospitals to turn away ambulances as long as they are not turning away specific indigent patients.
Diversions began decades ago as a desperate attempt to lessen hospital overcrowding. The practice has become common across the country, despite evidence it can endanger patients and doesn’t solve crowding long term.
No federal agency tracks diversion, so it’s unclear exactly how many places allow it, but it is common in urban areas. Two-thirds of the nation's largest 25 cities allow diversion or practices similar to it, including nine of the top 10, the Journal Sentinel found.
The practice of diversion is largely unknown to the public. People assume they will be taken to the closest hospital with the best care and the one they want to go to. But that may not be true if the hospital is on diversion.
Turning away ambulances has a minimal effect on the volume of people coming into an emergency room because roughly three-quarters of patients arrive on foot or by car and – under the federal law – cannot be turned away.
At a conference earlier this year, paramedics from New Jersey, Chicago, suburban Philadelphia, New York and London, England, told the Journal Sentinel of daily frustration with ambulance diversion.
Tip from ER doctor
The practice of hospitals temporarily closing to ambulances has been studied for years. Researchers found diversions delay care and they have been associated with increased death rates, in particular, among African American patients who suffered heart attacks and strokes.
Some studies have documented that hospitals lose money during times of diversion, but a 2008 study found hospitals may actually make more money during diversions. That’s because there are often higher profits on scheduled surgeries. And those surgeries may be canceled when beds are filled by patients coming from the emergency room.
Hsuan got the idea for her study when an emergency room doctor at a public hospital told her something surprising: Every time we declare an ambulance diversion, everyone around us goes diversion, too.
"I thought, 'Huh? I wonder if I can measure that?"' Hsuan told the Journal Sentinel.
Hsuan looked for data in a half-dozen states and cities, including the city where she got the tip, but she found none of those places collected the data or – if they did – would provide it.
She then found researcher Renee Hsia, an emergency medicine doctor and a professor at the University of California at San Francisco, who has studied the issue of diversion for years.
Their study, which became public last month, examined 2007 data from California – the most recent year statewide data was available. While the data is relatively old and from just one state, Hsuan said the comment from her source and other doctors suggests the practice continues.
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Lack of available data has been a persistent problem in studying diversions, despite calls from academic researchers for years to better track the practice and publicly disclose it. In many areas of the country, hospitals have taken steps to ensure diversion data is not publicly released.
"We really do need more data about ambulance diversion," Hsuan said. "It’s obviously an important thing that happens that influences a lot of people’s access to emergency care and could have very negative consequences but we really don’t know much about it.”
A complex issue to study
For her study, Hsuan said she wanted to be sure other factors were not the reason for the differences they were seeing in how the 28 private hospitals examined acted during diversions.
Hsuan, Hsia and the other researchers considered if the size of the hospitals or the severity of patients' illnesses was affecting outcomes but determined they were not.
The data showed private hospitals, including nonprofit and for-profit institutions, went on diversion more quickly when a neighboring, similar-size public hospital was diverting. Those private hospitals were on diversion even though the number of patients in their ERs was not as high as at other times they used the strategy, the study says.
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Also, the private hospitals quickly came off diversion once the public hospitals opened, suggesting they wanted to be open for patients once the chance of getting indigent patients dropped.
The study is set to be published in the Health Services Research Journal later this year.
Hsuan said she has presented the paper several times and each time ER doctors came up to her after, but with different experiences. One would say her findings are false, that kind of diversion doesn't ever happen. But another doctor would be right there saying, "Are you kidding? This happens all the time."
Hsuan said the differing viewpoints indicate a need for more study to help state and federal authorities consider if oversight is warranted. But first researchers need better understanding of an issue that is invisible to most people.
"It all happens behind the scenes. If you are in an ambulance being diverted, you likely don’t even know you have been diverted," she said. "We know a bit about how it influences patient outcomes but we really need more data. That is the first step."
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The Milwaukee Journal Sentinel is investigating the issue of ambulance diversion, including the consequences when people don't get timely care from hospitals. We are looking for information from patients, paramedics and other health providers across the country.
This article originally appeared on Milwaukee Journal Sentinel: Some hospitals turn away ambulances when the patients are more likely to be poor, study finds