Shorter hospital stays tied to lack of coverage

Washington -- Uninsured patients stay in hospitals for consistently shorter periods than do patients covered by private insurance or Medicaid, according to an analysis of nearly 850,000 hospitalizations of working-age adults.

Self-pay patients with health conditions deemed avoidable stayed in hospitals for an average of 2.77 days, compared with 3.19 days for Medicaid patients and 2.89 days for all other payment types. That's according to a study in the November/December Annals of Family Medicine.

The length-of-stay differences between the uninsured and other patients were not very large, but they were consistent, according to the study's lead author, Arch Mainous III, PhD, a professor of family medicine at the Medical University of South Carolina.

"Self-pay tends to be shorter over and over again," Mainous said. Other studies of hospital stays that focused on specific diagnoses did not find this pattern by type of health insurance, he said.

The shorter stay pattern for the uninsured did not change significantly between patients with health conditions considered preventable, such as asthma, and patients with unavoidable problems, such as injuries from car accidents. Also, mortality rates did not vary significantly among patients with different insurance statuses.

There are several possible explanations for the earlier discharge pattern for the uninsured, Mainous said, but he hasn't concluded that any particular one is true. The uninsured had their shortest stays at for-profit hospitals, which led Dr. Mainous to wonder if administrators or physicians at these hospitals might be under pressure to limit uninsured patients' length of stays.

But physicians usually aren't aware of their patients' insurance status, said Beth Feldpush, DrPH, vice president for policy and advocacy for the National Assn. of Public Hospitals and Health Systems. And hospital administrators rarely intervene directly in patient care, she said. "I don't see hospital administrators playing into those discussions at all."

However, the uninsured might choose to leave hospitals earlier than other patients to save money, Feldpush said. "There is a lot of room for a discussion and a dialogue between a patient and their care providers."

Mainous agreed: "There could be some sort of informal negotiation going on."

The study attempted to reduce the impact of outliers by excluding patients who stayed in hospitals for unusually long periods and patients who left against medical advice, Mainous said.

Feldpush said the study raises interesting questions about patterns in hospital care. "It's an area where more work should be done," she said. The next step would be to interview patients and physicians to find out why these patterns exist.

Patients' health status may be a factor as well, said Renee Hsia, MD, MSc, assistant professor in the Dept. of Emergency Medicine at the University of California San Francisco. Although the study's authors attempt to control for comorbidities, researchers can't account completely for patients' health status in administrative data, Dr. Hsia said. Therefore, Medicaid patients, who generally are sicker than the overall population, could have longer stays than self-pay patients for good reasons, she said. Feldpush did not take issue with the authors' efforts to control for health status.

Another possibility is that Medicaid or privately insured patients stay longer than necessary because they can afford to, Dr. Hsia said. Also, geographic patterns could skew the results. For example, self-pay patients might go to hospitals that tend to provide shorter stays, and Medicaid patients might favor hospitals that provide longer stays.