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Insurance Status of Patients Admitted to Specialty Cardiac and Competing General Hospitals: Are Accusations of Cherry Picking Justified?

Cram, Peter MD, MBA*; Pham, Hoangmai H. MD, MPH; Bayman, Levent MS*; Vaughan-Sarrazin, Mary S. PhD*‡†

doi: 10.1097/MLR.0b013e31816c43d9
Original Article

Background: There has been widespread concern that procedurally oriented specialty hospitals select well-insured patients for admission, while avoiding the underinsured, but data are limited.

Objective: To determine if specialty cardiac hospitals admit a higher proportion of well-insured patients than general hospitals and/or preferentially transfer patients with less generous insurance to other acute care hospitals.

Design, Setting, and Participants: A retrospective study of patients admitted to specialty cardiac and general hospitals with acute myocardial infarction (AMI; N = 41,863), congestive heart failure (CHF; N = 51,696), percutaneous coronary intervention (PCI; N = 73,966), and coronary artery bypass grafting (CABG; N = 33,327) using 2000–2004 all-payor data from Arizona, California, and Texas.

Main Outcome Measures: Proportion of all admissions in specialty and general hospitals with more generous insurance (Medicare or private insurance), interhospital transfer patterns of patients with less generous insurance by specialty and general hospitals.

Results: Specialty hospitals admitted a higher proportion of patients with more generous insurance for both the medical cohort (AMI and CHF) (92.4% vs. 89.0%; P < 0.0001) and revascularization cohort (PCI and CABG) (94.3% vs. 90.6%; P < 0.0001). After adjustment for patient demographics, comorbidity, and the distance that each patient lived from the nearest specialty and general hospital, odds of admission to specialty hospitals were significantly higher for patients with more generous insurance compared to patients with less generous insurance for the medical cohort [odds ratio (OR), 1.16; 95% confidence interval (CI), 1.07–1.27; P < 0.001] and revascularization cohort (OR, 1.17; 95% CI, 1.08–1.27; P < 0.001). In Cox proportional hazards models, there was no evidence that specialty hospitals were more or less likely to transfer patients with more or less generous insurance to another hospital.

Limitations: The analysis was limited to 3 states and we were unable to track the care of patients after transfer.

Conclusions: Patients with more generous insurance are significantly more likely to gain admission to specialty hospitals. Alternatively, we found no evidence that specialty hospitals preferentially transfer patients with less generous insurance who are admitted. Overall, these findings suggest that specialty hospitals may contribute to segregation of the healthcare system along socioeconomic lines.

From the *Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; †Center for Studying Health System Change, Washington, Washington DC; and ‡Center for Research in the Implementation of Innovative Strategies for Practice, Iowa City Veterans Administration Medical Center, Iowa City, Iowa.

Supported by R01 HL085347-01A1 from NHLBI at the National Institutes of Health and the Robert Wood Johnson Foundation Physician Faculty Scholars Program (to P.C.).

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The funding sources had no role in the analyses or drafting of this manuscript.

Reprints: Peter Cram, MD, MBA, Division of General Medicine, University of Iowa Carver College of Medicine, Iowa City VA Medical Center, Mail Stop 152, Iowa City, IA 52242. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.