Where do uninsured patients go? The paradox of collaborative network dynamics in interhospital transfers

Interhospital patient transfers have gained attention as a form of interorganizational collaboration that enhances care quality and hospitals' organizational efficiency, increasing care capacity and sustainability at the community level. The healthcare literature has emphasized the importance of relational mechanisms, such as trust and solidarity, in fostering collaborative social capital in hospital networks. However, social science researchers have highlighted the adverse effects of these mechanisms, including exclusion that exacerbates societal disparities in service access and use. Using relational event models to analyze the temporal dynamics of daily patient transfers among 159 hospitals in Florida from 2018 to 2021, this study examines collaborative dynamics in hospital transfer networks and how these dynamics contribute to transfer disparities based on patient insurance status. Findings show that network dynamics crucial for establishing and maintaining collaborative interorganizational ties-inertia (repeated transfers from a hospital to another), reciprocity (mutual transfers between hospitals), and triadic closure (transfers between hospitals with a common partner)-generally operate differently based on patient insurance status, disadvantaging uninsured patients across emergency and nonemergency care, with more profound disparities in emergency transfers. Results of this study also demonstrate that such network-driven disparities persist rather than being resolved during public health crises, such as the COVID-19 pandemic. This study discusses the implications of these findings from theoretical and policy perspectives.