Uninsured patients spend less time in the hospital than insured patients, according to a study that suggests that ability to pay plays a greater role than medical need when determining length of stay.
"The only two explanations we could come up with are either people without insurance are being discharged prematurely or hospitals are keeping people who can pay longer to increase revenue," Arch G. Mainous, III, the author of the study, told HealthLeaders Media.
The study, published in the December issue of Annals of Family Medicine, examined nearly 850,000 adult discharges between 2003 and 2007, at for-profit, non-profit, and government hospitals nationwide. The findings show that in hospitalizations for ambulatory care-sensitive conditions – which should have been avoidable through disease management and preventive care -- uninsured patients stayed an average of 2.8 days.
Privately insured patients stayed an average of 2.9 days, and Medicaid patients averaged 3.2 days. For patients hospitalized with non-ACSCs, the average length of stay averaged 2.7 days for the uninsured, compared with 2.8 days for the privately insured, and 3.1 days for Medicaid patients.
"We have relatively robust findings that appear over and over that people without insurance, regardless of what they come in for, stay a shorter period of time, even on things where they might be sicker," says Mainous, a researcher with the Department of Family Medicine at the Medical University of South Carolina, in Charleston.
"We controlled for how sick they were. We controlled for people who left the hospital early against medical advice. It still shows up," he says.
The study found that in-hospital mortality for uninsured patients with non-ACSCs was higher than at both nonprofit and for-profit hospitals, while there was little difference in mortality among patients hospitalized for ACSCs.
Mainous says the findings "are not completely surprising but very distressing."
"Healthcare businesses providing uncompensated care would be like providing uncompensated hamburgers at McDonald's. There is only so much you can do in terms of supplying free stuff," he says. "As we see the proportion of people without insurance continuing to rise, it is a wake-up call. Are we going to have a two-tiered system where there is going to be a small proportion of people who get a level of care and others who don't?"
Mainous says the study isn't about a chasm between rich and poor so much as it is about the insured and the uninsured. "If you look at the Medicaid group, they did actually well," he says. "Those folks seem to stay in as long as the privately insured, or ever longer. The cut point for access to care is insurance."
Mainous says he hopes the study will help policymakers as they try to determine how this nation will pay for healthcare. "We are probably going to move more and more away from employer-based health insurance. As we do that and more people become uninsured it is going to be a big issue. If you go from 46 million without insurance to 100 million people without insurance I don't think it is sustainable," he says.
"This boils down to the final ethical issue: Do we consider healthcare a business? That is the take home question. If you consider it a business then you let in people who can pay your fees and you try to make money," he says. "If you don't consider it a business, then we need to look at it in a different way."
John Commins is the news editor for HealthLeaders.
