13. The impact of government regulation of ambulatory surgical facilities on access to elective surgical procedures

Abstract

Advances in medical technology have made free-standing ambulatory surgery centres a cost-effective method of delivering health care in the United States. One: Rapid expansion of such centres and duplication of services have raised concerns over rising health care costs, two: leading to government regulation of facilities via a Certificate of Need (CON) law in many states. Three: Such regulation may decrease access to elective procedures.
 This study investigates access to elective surgical procedures in selected states with and without CON laws. Results of the Health Care Utilization Project were analyzed. Per capita rates of elective carpal tunnel release (CTR) and lumbar discectomy were evaluated in 16 states with CON laws and 5 states without CON laws over the years 2004-2005. Distribution of CTR and lumbar discectomy were analyzed by facility ownership and teaching status, using rates of emergent procedures as a control. Student’s t-tests compared rates of CTR and discectomy as a function of CON legislation. Two-factor ANOVA extended this analysis to account for teaching environment and facility ownership. 
 Fewer CTR cases were performed in states with CON laws (p=0.014), specifically in government-owned (p=0.012) and non-teaching facilities (p=0.01). No difference was observed in lumbar discectomy rates in states with respect to CON regulation. Distribution of both procedures among teaching and non-teaching centers was independent of CON laws. Facility ownership predicts fraction of these cases performed at an institution,(p < 0.01) and this distribution is influenced by CON regulation, increasing fractions of both types of procedures performed at private, not-for-profit centers (p=0.001, p=0.003 respectively).
 We conclude that CON laws restrict access to certain procedures, specifically in government-owned and non-teaching facilities. These laws may limit the supply of surgical care, notably by redistributing away from government and for-profit centres. Potential solutions include reinvestigating the need for CON laws, or examining the CON methodology to accurately reflect need.
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