Insurance Status and Emergency Department Disposition Among Psychiatric Presentations

We previously reported that emergency department (ED) length of stay for psychiatric patients was associated with insurance status. In this follow-up study, we examined whether insurance status was also associated with ED disposition among adult psychiatric presentations.

We conducted a secondary analysis of a database of psychiatric patients evaluated at an urban, teaching ED over a one-year period. The dataset included age, gender, race/ethnicity, primary and secondary psychiatric diagnoses, insurance status (private, public, or uninsured/self-pay), telepsychiatry use, number of telepsychiatry evaluations, and ED disposition (discharge, psychiatric transfer, or medical admission). Descriptive statistics were calculated, χ² tests assessed bivariate associations, and multinomial logistic regression was used to estimate adjusted relative likelihoods of each disposition category by insurance type, with discharge as the reference outcome.

Among 240 patients, 65% were male, mean age 41 ± 15 years, and 57% Hispanic. Insurance: 46% uninsured, 29% Medicare/Medicaid, 25% private. Primary diagnoses: suicidal ideation 53% and psychosis 12%. Seventy-four percent received telepsychiatry evaluation. Overall, 68% were transferred to inpatient psychiatry, 20% discharged, and 12% had other dispositions (e.g., medical admission or arrest). In bivariate analyses, insurance status (p < 0.001), telepsychiatry use (p < 0.01), and diagnosis (p = 0.02) were associated with disposition; age, gender, and race were not. After adjustment, uninsured patients had a higher predicted probability of discharge (26% vs 13%, p = 0.01) and lower probability of psychiatric transfer (65% vs 75%, p = 0.02) than privately insured. Relative likelihood for uninsured vs private was 0.36 for transfer (p = 0.01) and 0.33 for medical admission (p = 0.04). Telepsychiatry use remained independently associated with higher transfer likelihood (p = 0.01).

In this single-center cohort of psychiatric ED presentations, insurance status and telepsychiatry use were associated with disposition outcomes. Uninsured patients were more likely to be discharged and less likely to be transferred to inpatient psychiatry. These disparities warrant further investigation to determine whether they represent underlying inequities in access to psychiatric care.