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Tang MC. A structural analysis of physician agency and pharmaceutical demand. HEALTH ECONOMICS 2023; 32:1453-1477. [PMID: 36965114 DOI: 10.1002/hec.4674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/17/2023] [Accepted: 03/03/2023] [Indexed: 06/04/2023]
Abstract
This paper examines the significance of physician agency in medical providers' prescription choices. Physician agency is considered as medical providers' responses to the price and markup percentage of prescription drugs. Their preferences are allowed to be heterogeneous using a random coefficient logit model. Using a sample of anti-diabetic prescriptions with metformin from a population-based database in Taiwan, empirical results reveal that physician owners, privately-owned medical providers, small medical providers and the medical providers facing less competition are more likely to prescribe drugs with higher profit margins. The aggregate pharmaceutical demand is also found to increase with the markup, which is allowed to be endogenous in the estimation. Price elasticity estimates suggest medical providers are quite responsive to pharmaceutical price changes in Taiwan. Counterfactual analysis reveals the potential impact of physician agency is economically significant. Removing markups and lowering pharmaceutical prices are found to be more welfare enhancing than restricting physicians' dispensing services.
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Affiliation(s)
- Meng-Chi Tang
- Department of Economics, National Chung Cheng University, Min-Hsiung, Chiayi, Taiwan
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2
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Bian J, Morrisey MA. Free-Standing Ambulatory Surgery Centers and Hospital Surgery Volume. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2016; 44:200-10. [PMID: 17850045 DOI: 10.5034/inquiryjrnl_44.2.200] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper examines the association of free-standing ambulatory surgery centers (ASCs) with hospital surgery volume, using data from the 2002 Medicare Online Survey Certification and Reporting System and the American Hospital Association Annual Surveys of Hospitals. From 1993 to 2001, the number of ASCs per 100,000 population in metropolitan statistical areas (MSAs) increased by 150%. During the same period, hospital outpatient surgeries increased 28%, while inpatient surgeries decreased by 4.5%. MSA and year fixed-effects regression analyses suggest that an increase of one ASC per 100,000 people was associated with a 4.3% reduction in hospital outpatient surgical volume, but was not associated with inpatient surgical volume.
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Affiliation(s)
- John Bian
- Atlanta Veterans Affairs Medical Center, USA
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3
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Yi PH, Cross MB, Johnson SR, Rasinski KA, Nunley RM, Della Valle CJ. Patient Attitudes Toward Orthopedic Surgeon Ownership of Related Ancillary Businesses. J Arthroplasty 2016; 31:1635-1640.e4. [PMID: 26897493 DOI: 10.1016/j.arth.2016.01.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 01/17/2016] [Accepted: 01/20/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Physician ownership of businesses related to orthopedic surgery, such as surgery centers, has been criticized as potentially leading to misuse of health care resources. The purpose of this study was to determine patients' attitudes toward surgeon ownership of orthopedic-related businesses. METHODS We surveyed 280 consecutive patients at 2 centers regarding their attitudes toward surgeon ownership of orthopedic-related businesses using an anonymous questionnaire. Three surgeon ownership scenarios were presented: (1) owning a surgery center, (2) physical therapy (PT), and (3) imaging facilities (eg, Magnetic Resonance Imaging scanner). RESULTS Two hundred fourteen patients (76%) completed the questionnaire. The majority agreed that it is ethical for a surgeon to own a surgery center (73%), PT practice (77%), or imaging facility (77%). Most (>67%) indicated that their surgeon owning such a business would have no effect on the trust they have in their surgeon. Although >70% agreed that a surgeon in all 3 scenarios would make the same treatment decisions, many agreed that such surgeons might perform more surgery (47%), refer more patients to PT (61%), or order more imaging (58%). Patients favored surgeon autonomy, however, believing that surgeons should be allowed to own such businesses (78%). Eighty-five percent agreed that patients should be informed if their surgeon owns an orthopedic-related business. CONCLUSION Although patients express concern over and desire disclosure of surgeon ownership of orthopedic-related businesses, the majority believes that it is an ethical practice and feel comfortable receiving care at such a facility.
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Affiliation(s)
- Paul H Yi
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Ryan M Nunley
- Washington University in St. Louis, St. Louis, Missouri
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4
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Blumenthal DM, Orav EJ, Jena AB, Dudzinski DM, Le ST, Jha AK. Access, quality, and costs of care at physician owned hospitals in the United States: observational study. BMJ 2015; 351:h4466. [PMID: 26333819 PMCID: PMC4558297 DOI: 10.1136/bmj.h4466] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare physician owned hospitals (POHs) with non-POHs on metrics around patient populations, quality of care, costs, and payments. DESIGN Observational study. SETTING Acute care hospitals in 95 hospital referral regions in the United States, 2010. PARTICIPANTS 2186 US acute care hospitals (219 POHs and 1967 non-POHs). MAIN OUTCOME MEASURES Proportions of patients using Medicaid and those from ethnic and racial minority groups; hospital performance on patient experience metrics, care processes, risk adjusted 30 day mortality, and readmission rates; costs of care; care payments; and Medicare market share. RESULTS The 219 POHs were more often small (<100 beds), for profit, and in urban areas. 120 of these POHs were general (non-specialty) hospitals. Compared with patients from non-POHs, those from POHs were younger (77.4 v 78.4 years, P<0.001), less likely to be admitted through an emergency department (23.2% v. 29.0%, P<0.001), equally likely to be black (5.1% v 5.5%, P=0.85) or to use Medicaid (14.9% v 15.4%, P=0.75), and had similar numbers of chronic diseases and predicted mortality scores. POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30 day mortality, 30 day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia. CONCLUSION Although POHs may treat slightly healthier patients, they do not seem to systematically select more profitable or less disadvantaged patients or to provide lower value care.
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Affiliation(s)
- Daniel M Blumenthal
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - E John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - David M Dudzinski
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sidney T Le
- University of California, San Francisco, San Francisco, CA, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
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5
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Trybou J, De Regge M, Gemmel P, Duyck P, Annemans L. Effects of physician-owned specialized facilities in health care: a systematic review. Health Policy 2014; 118:316-40. [PMID: 25305719 DOI: 10.1016/j.healthpol.2014.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 09/17/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple studies have investigated physician-owned specialized facilities (specialized hospitals and ambulatory surgery centres). However, the evidence is fragmented and the literature lacks cohesion. OBJECTIVES To provide a comprehensive overview of the effects of physician-owned specialized facilities by synthesizing the findings of published empirical studies. METHODS Two reviewers independently researched relevant studies using a standardized search strategy. The Institute of Medicine's quality framework (safe, effective, equitable, efficient, patient-centred, and accessible care) was applied in order to evaluate the performance of such facilities. In addition, the impact on the performance of full-service general hospitals was assessed. RESULTS Forty-six studies were included in the systematic review. Overall, the quality of the included studies was satisfactory. Our results show that little evidence exists to confirm the advantages attributed to physician-owned specialized facilities, and their impact on full-service general hospitals remains limited. CONCLUSION Although data is available on a wide variety of effects, the evidence base is surprisingly thin. There is no compelling evidence available demonstrating the added value of physician-owned specialized facilities in terms of quality or cost of the delivered care. More research is necessary on the relative merits of physician-owned specialized facilities. In addition, their corresponding impact on full-service general hospitals remains unclear. The development of physician-owned specialized facilities should thus be monitored carefully.
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Affiliation(s)
- Jeroen Trybou
- Department of Public Health, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Melissa De Regge
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, B-9000 Gent, Belgium.
| | - Paul Gemmel
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, B-9000 Gent, Belgium.
| | - Philippe Duyck
- Faculty of Medicine and Health Science, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Lieven Annemans
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Elsene, Brussels, Belgium.
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Hollingsworth JM, Ye Z, Strope SA, Krein SL, Hollenbeck AT, Hollenbeck BK. Physician-ownership of ambulatory surgery centers linked to higher volume of surgeries. Health Aff (Millwood) 2012; 29:683-9. [PMID: 20368599 DOI: 10.1377/hlthaff.2008.0567] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Many physicians confronting declining reimbursement from insurers have invested in ambulatory surgery centers, where they perform outpatient surgical and diagnostic procedures. An ownership stake entitles physicians to a share of the facility's profits from self-referrals. This arrangement can create a potential conflict of interest between physicians' financial incentives and patients' clinical needs. Our analysis of Florida data for five common procedures revealed a significant association between physician-ownership and higher surgical volume. Possible remedies include revising federal law to require disclosure of investment arrangements; reducing facility payments to dilute ownership incentives; and reforms (such as accountable care organizations) that discourage an excessive rate of procedures.
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Affiliation(s)
- John M Hollingsworth
- Robert Wood Johnson Foundation Clinical Scholar at University of Michigan in Ann Arbor, USA
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Dubois JM, Carroll K, Gibb T, Kraus E, Rubbelke T, Vasher M, Anderson EE. Environmental Factors Contributing to Wrongdoing in Medicine: A Criterion-Based Review of Studies and Cases. ETHICS & BEHAVIOR 2012; 22:163-188. [PMID: 23226933 PMCID: PMC3515073 DOI: 10.1080/10508422.2011.641832] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In this paper we describe our approach to understanding wrongdoing in medical research and practice, which involves the statistical analysis of coded data from a large set of published cases. We focus on understanding the environmental factors that predict the kind and the severity of wrongdoing in medicine. Through review of empirical and theoretical literature, consultation with experts, the application of criminological theory, and ongoing analysis of our first 60 cases, we hypothesize that 10 contextual features of the medical environment (including financial rewards, oversight failures, and patients belonging to vulnerable groups) may contribute to professional wrongdoing. We define each variable, examine data supporting our hypothesis, and present a brief case synopsis from our study that illustrates the potential influence of the variable. Finally, we discuss limitations of the resulting framework and directions for future research.
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Affiliation(s)
- James M Dubois
- Bander Center for Medical Business Ethics, Saint Louis University
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O’Neill L, Hartz AJ. Lower Mortality Rates At Cardiac Specialty Hospitals Traceable To Healthier Patients And To Doctors’ Performing More Procedures. Health Aff (Millwood) 2012; 31:806-15. [DOI: 10.1377/hlthaff.2011.0624] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Liam O’Neill
- Liam O’Neill ( ) is an associate professor in the School of Public Health at the University of North Texas Health Science Center, in Fort Worth
| | - Arthur J. Hartz
- Arthur J. Hartz is a professor in the Department of Internal Medicine and director of the Health Services Research Program at the Huntsman Center Institute, both at the University of Utah, in Salt Lake City
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Landon BE, Reschovsky JD, Pham HH, Kitsantas P, Wojtuskiak J, Hadley J. Creating a parsimonious typology of physician financial incentives. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2010; 9:213-233. [PMID: 20976118 DOI: 10.1007/s10742-010-0057-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In order to create an empirically derived parsimonious typology of physician financial incentives that will be useful for future research, we used data from the nationally representative 2004-2005 Community Tracking Study Physician Survey (N = 6,628). Linear regression analyses informed by economic theory were used to identify the combinations of incentives associated with an overall financial incentive to expand services to individual patients. The approach was validated using two nonparametric methods (CART analysis and data mining techniques) and by examining the relationship between the resulting typology and other measures of physician behavior including hours worked, visit volume, and specialty-adjusted income. Of the 6,628 physicians surveyed, approximately 25% (1,605) reported an overall incentive to increase services and 75% (5,023) reported either neutral incentives or incentives to decrease services. Men, who were approximately 75% of respondents, were slightly more likely to report incentives to increase services (P < 0.05). There were no differences in reported incentives according to specialty. We created two typologies (one with eleven categories and the other with a collapsed set of six categories) based on combinations of variables measuring ownership, base compensation methods, and financial incentives. The percentage with an overall incentive to increase services ranges from 6% for employed physicians compensated via fixed salary to 36.7% for owners in low capitation environments with either individual or practice level productivity incentives. The criterion validity of the typology was established by examining the relationship with adjusted physician income, hours worked, and visit volume, which showed generally consistent relationships in the expected direction. A parsimonious typology consisting of six mutually exclusive groups reasonably captures the continuum of incentives to increase service delivery experienced by physicians.
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Affiliation(s)
- Bruce E Landon
- Department Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA
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10
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Lu X, Hagen TP, Vaughan-Sarrazin MS, Cram P. The impact of new hospital orthopaedic surgery programs on total joint arthroplasty utilization. J Bone Joint Surg Am 2010; 92:1353-61. [PMID: 20516310 PMCID: PMC2874670 DOI: 10.2106/jbjs.i.00833] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Utilization of arthroplasty is increasing, but there are little data exploring the causes of this increase. The objective of this study was to examine the relationship between new programs for arthroplasty of the lower extremity joints and the utilization of arthroplasty. METHODS We identified twenty-four markets (hospital referral regions) that experienced the entry of new physician-owned specialty hospitals, using 1991 to 2005 Medicare data. We matched each market with a new specialty hospital to two different control markets (one market with a new arthroplasty program in a general hospital and one market without a new arthroplasty program), using a propensity score that accounted for market supply and demand for orthopaedic surgery and the regulatory environment. We compared the utilization of arthroplasty of the lower extremity joints (total hip arthroplasty and total knee arthroplasty) in each group of markets over a five-year window, extending from two years before to three years after the entry of new orthopaedic surgery programs. RESULTS The twenty-four markets with new specialty orthopaedic hospitals had higher utilization of arthroplasty at baseline (10.9 arthroplasties per 1000 Medicare beneficiaries per year) and follow-up (12.7 per 1000 beneficiaries) compared with the twenty-four markets with new arthroplasty programs in general hospitals (9.7 and 11.4, respectively) and the twenty-four markets with no new programs (9.9 and 11.3), although the differences were not significant (p > 0.05). Growth in the utilization of arthroplasty was similar in markets with new specialty hospitals before (an increase of 0.63 procedure per 1000 beneficiaries per year) and after the entry of new specialty hospitals (an increase of 0.39) compared with markets with new surgery programs in general hospitals (an increase of 0.24 before and 0.43 after) and markets with no new programs (an increase of 0.38 before and 0.33 after the entry of new specialty hospitals) (p > 0.05 for all comparisons). CONCLUSIONS The utilization of arthroplasty is increasing at similar rates in markets with and without new arthroplasty programs.
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Affiliation(s)
- Xin Lu
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52246.E-mail address for P. Cram:
| | - Tyson P. Hagen
- Center for Research in the Implementation of Innovative Strategies for Practice (CRIISP), Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246
| | - Mary S. Vaughan-Sarrazin
- Center for Research in the Implementation of Innovative Strategies for Practice (CRIISP), Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246
| | - Peter Cram
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52246.E-mail address for P. Cram:
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11
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Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: evidence from the state of Florida. Med Care 2009; 47:403-10. [PMID: 19330889 DOI: 10.1097/mlr.0b013e31818af92e] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the relationship between ownership and use of ambulatory surgical centers (ASCs). METHODS From 1998 through 2002, ambulatory surgical discharges for procedures within the genitourinary system were abstracted from the Florida State Ambulatory Surgery Database. State-wide utilization rates for ambulatory surgery were calculated by physician-level ownership (using an empirically-derived, externally-validated method) and financial incentives. A surgeon-level Poisson regression model was fit to compare the rates of surgery by year, ownership, and their interaction. RESULTS Rates of ambulatory surgery increased from 607 per 100,000 in 1998 to 702 per 100,000 in 2002 (P < 0.01 for trend). Although rates at the hospital increased only slightly (0.9%), those at the ASC were up by 53% (P < 0.01). Physician ownership was associated with this greater utilization as new owners increased their use from 9 per 100,000 to 94 per 100,000 (P < 0.01) in the first full year as owners. In the first year of ownership, the proportion of a new owner's surgeries comprising of financially lucrative procedures increased to 61% compared with 50% in the year preceding ownership (P < 0.01). CONCLUSIONS Physician ownership is associated with the increasing use of ASCs, although the extent to which this is attributable to previously unmet demand is unclear. However, new owners seem to alter their procedure mix after establishing ownership to include a greater share of financially lucrative procedures.
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Hollingsworth JM, Ye Z, Strope SA, Krein SL, Hollenbeck AT, Hollenbeck BK. Urologist ownership of ambulatory surgery centers and urinary stone surgery use. Health Serv Res 2009; 44:1370-84. [PMID: 19490161 DOI: 10.1111/j.1475-6773.2009.00966.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To understand how physician ownership of ambulatory surgery centers (ASCs) relates to surgery use. DATA SOURCE Using the State Ambulatory Surgery Databases, we identified patients undergoing outpatient surgery for urinary stone disease in Florida (1998-2002). STUDY DESIGN We empirically derived a measure of physician ownership and externally validated it through public data. We employed linear mixed models to examine the relationship between ownership status and surgery use. We measured how a urologist's surgery use varied by the penetration of owners within his local health care market. PRINCIPAL FINDINGS Owners performed a greater proportion of their surgeries in ASCs than nonowners (39.6 percent versus 8.0 percent, p<.001), and their utilization rates were over twofold higher ( p<.001). After controlling for patient differences, an owner averaged 16.32 (95 percent confidence interval [CI], 10.98-21.67; p<.001) more cases annually than did a nonowner. Further, for every 10 percent increase in the penetration of owners within a urologist's local health care market, his annual caseload increased by 3.32 (95 percent CI, 2.17-4.46; p<.001). CONCLUSIONS These data demonstrate a significant association between physician ownership of ASCs and increased surgery use. While its interpretation is open to debate, one possibility relates to the financial incentives of ownership. Additional work is necessary to see if this is a specialty-specific phenomenon.
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Affiliation(s)
- John M Hollingsworth
- RWJ Clinical Scholars Program, The University of Michigan, Ann Arbor, MI 48105-2967, USA.
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13
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Abstract
OBJECTIVE To compare the costs of physician-owned cardiac, orthopedic, and surgical single specialty hospitals with those of full-service hospital competitors. DATA SOURCES The primary data sources are the Medicare Cost Reports for 1998-2004 and hospital inpatient discharge data for three of the states where single specialty hospitals are most prevalent, Texas, California, and Arizona. The latter were obtained from the Texas Department of State Health Services, the California Office of Statewide Health Planning and Development, and the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Additional data comes from the American Hospital Association Annual Survey Database. STUDY DESIGN We identified all physician-owned cardiac, orthopedic, and surgical specialty hospitals in these three states as well as all full-service acute care hospitals serving the same market areas, defined using Dartmouth Hospital Referral Regions. We estimated a hospital cost function using stochastic frontier regression analysis, and generated hospital specific inefficiency measures. Application of t-tests of significance compared the inefficiency measures of specialty hospitals with those of full-service hospitals to make general comparisons between these classes of hospitals. PRINCIPAL FINDINGS Results do not provide evidence that specialty hospitals are more efficient than the full-service hospitals with whom they compete. In particular, orthopedic and surgical specialty hospitals appear to have significantly higher levels of cost inefficiency. Cardiac hospitals, however, do not appear to be different from competitors in this respect. CONCLUSIONS Policymakers should not embrace the assumption that physician-owned specialty hospitals produce patient care more efficiently than their full-service hospital competitors.
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MESH Headings
- Arizona
- California
- Cardiac Care Facilities/economics
- Cardiac Care Facilities/standards
- Catchment Area, Health
- Costs and Cost Analysis
- Diagnosis-Related Groups
- Economic Competition
- Efficiency, Organizational/economics
- Efficiency, Organizational/statistics & numerical data
- Empirical Research
- Health Services Research
- Hospital Costs/classification
- Hospital Costs/statistics & numerical data
- Hospitals, Community/economics
- Hospitals, Community/standards
- Hospitals, Community/statistics & numerical data
- Hospitals, Proprietary/economics
- Hospitals, Proprietary/standards
- Hospitals, Proprietary/statistics & numerical data
- Hospitals, Special/economics
- Hospitals, Special/standards
- Hospitals, Special/statistics & numerical data
- Humans
- Iatrogenic Disease
- Models, Econometric
- Orthopedics/economics
- Orthopedics/standards
- Ownership/classification
- Ownership/economics
- Quality Indicators, Health Care
- Specialties, Surgical/economics
- Specialties, Surgical/standards
- Stochastic Processes
- Texas
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Affiliation(s)
- Kathleen Carey
- VA Center for Health Quality, Outcomes and Economic Research and Boston University School of Public Health, 200 Springs Road, Bedford, MA 01730, USA.
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14
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Burns LR, Muller RW. Hospital-physician collaboration: landscape of economic integration and impact on clinical integration. Milbank Q 2008; 86:375-434. [PMID: 18798884 PMCID: PMC2690342 DOI: 10.1111/j.1468-0009.2008.00527.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). METHODS This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration. FINDINGS The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. CONCLUSIONS Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.
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Affiliation(s)
- Lawton Robert Burns
- Wharton Center for Health Management and Economics, Wharton School, University of Pennsylvania, Philadelphia, PA 19104-6218, USA.
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15
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Abstract
Why do we need “public policy” regarding specialty hospitals? What is the rationale for government involvement in decisions by the private sector to invest in specialty hospitals? Two possibilities are reduced access to services primarily by the uninsured (a fairness concern) and changes in the types of patients receiving care resulting from poor consumer information (an efficiency concern). The fairness argument faces logical and empirical difficulties, and even if it proved to be true, it is not clear that limiting the growth of specialty hospitals would be an efficient way to address the problem. However, there is some empirical evidence to support the efficiency concern, and if specialty hospitals result in the treatment of patients with lower expected net benefits from treatment, then it is possible that physician-owned facilities could result in an increasingly inefficient allocation of health care resources, higher insurance premiums, and higher rates of uninsurance.
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16
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Gabel JR, Fahlman C, Kang R, Wozniak G, Kletke P, Hay JW. Where do I send thee? Does physician-ownership affect referral patterns to ambulatory surgery centers? Health Aff (Millwood) 2008; 27:w165-74. [PMID: 18349040 DOI: 10.1377/hlthaff.27.3.w165] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
For more than three decades, Congress has struggled with potential financial conflicts of interest when physicians share in financial gain from nonprofessional services. This study asks the question: Are physicians who are leading referrers to physician-owned ambulatory surgery centers (ASCs) more likely to send Medicaid patients to hospital outpatient clinics than other patients? The comparison group is physicians who are leading referrers to non-physician-owned ASCs, using data from two metropolitan areas. Findings indicate that physicians at physician-owned facilities are more likely than other physicians to refer well-insured patients to their facilities and route Medicaid patients to hospital outpatient clinics.
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Affiliation(s)
- Jon R Gabel
- University of Chicago in Washington, DC, USA.
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Hadley J, Zuckerman S. Physician-owned specialty hospitals: a market signal for Medicare payment revisions. Health Aff (Millwood) 2007; Suppl Web Exclusives:W5-491-3. [PMID: 16249248 DOI: 10.1377/hlthaff.w5.491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Jean Mitchell's findings show that physician-entrepreneurs respond to financial incentives and take advantage of variations in profitability within Medicare's hospital payment system. The growth of physician-owned specialty hospitals can be seen as the reflection of parallel growth in profit opportunities. As Medicare plans to do, payments should be revised to squeeze out excess profits. Prohibiting physicians' use of hospitals they own might be unnecessary and could make it harder to identify future distortions in Medicare prices. If squeezing out excess profits threatens general hospitals' social missions, then new and explicit ways of identifying and funding social missions must be found.
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Welton JM, Zone-Smith L, Fischer MH. Adjustment of inpatient care reimbursement for nursing intensity. Policy Polit Nurs Pract 2006; 7:270-80. [PMID: 17242392 DOI: 10.1177/1527154406297510] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.
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Affiliation(s)
- John M Welton
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Millard WB. Too POSH for the public: are physician-owned hospitals a drain on emergency care? (Part II). Ann Emerg Med 2006; 48:144-8. [PMID: 16953528 DOI: 10.1016/j.annemergmed.2006.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kahn CN. Intolerable risk, irreparable harm: the legacy of physician-owned specialty hospitals. Health Aff (Millwood) 2006; 25:130-3. [PMID: 16403752 DOI: 10.1377/hlthaff.25.1.130] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Issues of physician ownership and referral could cause major shifts in the structure of medical care and make the financing of U.S. hospital services problematic. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 mandated research on this matter and applied an eighteen-month moratorium against self-referral to allow policymakers to consider the issue. Research findings thus far confirm that physicians' ownership and referral present conflicts of interest through medical and economic patient selection and potentially excessive utilization. The policy response must prevent these results and preserve fair competition among hospitals.
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