Physician-Owned Specialty Hospitals and Coronary Revascularization Utilization

Abstract

THE EMERGENCE OF SPECIALTY HOSPITALS THAT FOcus on lucrative procedural aspects of medicine has generated a heated debate among policy makers that largely involves 4 issues: patient selection (ie, “cherry-picking” of healthier and wealthier patients by specialty hospitals); quality of care in specialty and general hospitals; impact of specialty hospitals on the financial health of general hospitals; and influence of specialty hospitals on utilization and health care costs. The debate intensified in 2003 with the passage of a temporary congressional moratorium (allowed to expire in 2005) on new specialty hospital construction. However, empirical data addressing the 4 issues remain limited. Consistent evidence suggests that specialty hospitals admit patients with lower acuity and fewer comorbidities than general hospitals. Studies assessing quality have found that riskadjusted rates of adverse outcomes in specialty hospitals are similar or somewhat lower (perhaps 10%-20%) compared with general hospitals. While anecdotal reports about the negative influence of specialty hospitals on the financial health of general hospitals abound, limited data suggest that, thus far, the impact has been small. In this issue of JAMA, Nallamothu and colleagues provide intriguing new data suggesting that increases in the use of coronary revascularization were 2.5 to 3 times higher in health care markets that experienced entry of a new physician-owned specialty hospital compared with markets without specialty hospitals, including those markets in which new revascularization programs were established at general hospitals. The differences reflected a much lower decline in use of coronary artery bypass graft surgery and a larger increase in use of percutaneous coronary intervention (PCI). The increase in PCI was particularly striking among patients without acute myocardial infarction, a group for whom PCI may provide less benefit, but that accounted for more than two thirds of all PCI procedures. One potential explanation for these findings is that utilization in markets with specialty cardiac hospitals reflects that astute investors chose to open specialty hospitals in markets that were already experiencing rapid growth in demand for revascularization. However, additional analyses conducted by the authors provided little support for this possibility. Alternatively, the growth in utilization in markets with new specialty hospitals may be directly attributable to procedures performed in the new specialty hospitals. Indeed, at the end of the observation period, in the study by Nallamothu et al, specialty hospitals had approximately twice the volume as new cardiac programs in general hospitals and accounted for more than a third of all revascularization procedures performed in their markets. The current study would seem to support the hypothesis that specialty hospitals directly drive utilization of coronary revascularization. However, immediately drawing such a conclusion requires careful consideration and caution, particularly given the lack of direct information in the current study about the clinical appropriateness of procedures. Although new specialty hospitals may directly increase utilization by performing procedures for patients who might receive only marginal benefit from having interventions, it is also possible that specialty hospitals indirectly increase utilization by drawing patients away from existing general hospitals through competition. In turn, existing revascularization programs may respond to losses in patient volume with their own efforts to generate new business, further fueling utilization. Even though it is not possible to dissect the fundamental drivers of utilization from the study by Nallamothu et al, or the influence of increased utilization on patient outcomes, the results need to be considered in light of 3 important issues currently confronting the US health care system. First, and perhaps most important, increasing evidence suggests a general lack of association between more aggressive management practices and greater health care expenditures and better patient outcomes at a population level. At the individualpatient level, the recently published Occluded Artery Trial (OAT) found that PCI performed more than 3 days following an acute myocardial infarction provided no benefits relative to medical therapy. Yet payment policies promoted by Medicare and other third-party payers have created large fi-