Transfer of emergency general surgery patients. Could the role of insurance status be underestimated?

To the Editors:

We applaud Bruenderman et al¹ for their excellent article. The authors found that the common reasons for emergency general surgery transfers were lack of adequate surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). Surprisingly, more than half of the transfers did not require any urgent surgical intervention and, of those that do, the most common procedures performed were the “bread and butter” (ie, laparoscopic cholecystectomy, small bowel resection, and drainage/debridement of skin and soft tissue infections).

Although a small bowel resection may require a higher level of acuity, we wondered why the other 2 operations, which are quite ubiquitous among most general surgeons, would require tertiary care. What were the detailed reasons behind such a transfer, given that 75% of all patients did not require emergent surgical intervention? Could it be that the transfer was done because of some other pernicious factor such as the patient’s insurance status?

Although Bruenderman et al¹ did not find insurance status to be associated with the likelihood of hospital transfer, this could represent a type II statistical error. In their study, Medicaid represented 21% and self-pay was 9%. In a safety-net institution such as ours, these combined rates can be as high as 60%.² We have personally found that one of the reasons for the transfer of patients from a private hospital to our hospital was patients’ lack of adequate insurance coverage. Patients were often told that they could either be treated at the current hospital and pay the full bill out of pocket or be transferred to our safety-net hospital where the state will cover their medical bills. The reason for such a transfer was often cited as attributable to “patient preference.”

In a landmark study published in 1984, Himmelstein and Woolhandler³ reported that the preponderance of transferred patients were uninsured. More recently, Venkatesh et al⁴ reported that uninsured patients had a 2.41-fold higher odds of being transferred to another facility than privately insured patients.

Bruenderman et al¹ speaks to the ongoing perniciousness of legitimate/undisputable versus questionable/disputable transfers. Cherry-picking of the “ideal patients” has been a long-term concern within the medical community. Perhaps, the introduction of risk adjustment indices may allow us to codify these high-need transfer populations. This has the potential to move us in the direction of comparing “apples with apples.”⁵

In their report, Bruenderman et al¹ describe some interesting points surrounding the need for transparency and a system approach. An area that remains unclear involves longer distance transfers, transfers that at times bypass nearby available hospitals. Given the current atmosphere of value-based care delivery and payment models, Bruenderman et al¹ underscore the need for us to police ourselves or be subjected to external actors.

Again, we commend the authors for adding another dimension to this complex issue and have no criticism of their excellent analysis of a vexing problem, but we would like to bring to focus the possibility of economics playing an insidious role.

Funding/Support

The authors have no funding sources to report.

Conflict of interest/Disclosure

None of the authors have financial interests or potential conflicts of interest to disclose.