The effect of insurance status on likelihood of neonatal interhospital transfer

Objective. To determine the effect of insurance status on the likelihood of in Design. Population-based retrospective cohort study. Setting. All general acute care nonpediatric hospitals in the five counties of southeastern Pennsylvania. Patients. Fifty-six thousand, seven hundred eighty-nine infants from 0 to 28 days of age admitted to or born in study hospitals between January 1 and December 31, 1991. Intervention. None. Main Outcome Measure Transfer to another general or specialty acute fare hospital. Results. The incidence (95% confidence interval) of interhospital transfer was 1.69% (1.60, 1.78). Uninsured infants were nearly twice as likely [relative risk (RR) = 1.96 (1.67, 2.31)] to be transferred as commercially insured infants, even when adjusted for the effects of prematurity, severity of illness, and the level of neonatal intensive care unit in the referring hospital. Similarly, infants with Medicaid were more likely to be transferred [RR = 1.20 (1.01, 1.43)] than similar commercially insured neonates. Uninsured and publicly insured infants were also more likely to be born premature [RR 1.49 (1.39, 1.60)] than privately insured neonates, and were more likely to have both moderate [RR 1.11 (1.04, 1.23)] and high [RR 1.21 (1.11, 1.32)] illness severity on admission to the hospital than privately insured infants. Conclusions. Neonates with no insurance and those with Medicaid coverage were more likely to be transferred than infants with private insurance. These results are consistent with those of other investigators who have studied financially motivated patient transfers-so-called patient dumping-in nonpediatric populations of patients. Our study may represent the first documentation of this phenomenon in a pediatric population. Our results are also consistent with those,of other investigators who have examined the effect of insurance status an maternal interhospital transfer, thus providing further evidence for the existence of financially motivated transfers within regional systems of perinatal fare. Future investigation into the effect of economic factors on variation in the utilization of transport services, and on how transfer influences ultimate patient outcome, is needed as managed care health systems become more widespread.