Associations Between Certificate of Need Policies and Hospice Quality Outcomes

BACKGROUND

Certificate of need (CON) laws are state-based regulations requiring approval of new healthcare entities and capital expenditures. Varying by state, these regulations impact hospices in 14 states and DC, with several states re-examining provisions.

AIM

This cross-sectional study examined the association of CON status on hospice quality outcomes using the hospice item set metric (HIS).

DESIGN

Data from the February 2022 Medicare Hospice Provider and General Information reports of 4870 US hospices were used to compare group means of the 8 HIS measures across CON status. Multiple regression analysis was used to predict HIS outcomes by CON status while controlling for ownership and size.

RESULTS

Approximately 86% of hospices are in states without a hospice CON provision. The unadjusted mean HIS scores for all measures were higher in CON states (M range 94.40-99.59) than Non-CON (M range 90.50-99.53) with significant differences in all except treatment preferences. In the adjusted model, linear regression analyses showed hospice CON states had significantly higher HIS ratings than those from Non-CON states for beliefs and values addressed (β = .05, P = .009), pain assessment (β = .05, P = .009), dyspnea treatment (β = .08, P < .001) and the composite measure (β = .09, P < .001). Treatment preferences, pain screening, dyspnea screening, and opioid bowel treatment were not statistically significant (P > .05).

CONCLUSION

The study suggests that CON regulations may have a modest, but beneficial impact on hospice-reported quality outcomes, particularly for small and medium-sized hospices. Further research is needed to explore other factors that contribute to HIS outcomes.

Impact of Certificate of Need on Lumbar Discectomy Reimbursement and Utilization

The Certificate of Need (CON) program was established to respond to increasing healthcare costs; however, its impact on spine surgery trends is not well understood. The purpose of this study was to evaluate the impact of CON status on utilization of single-level lumbar discectomy. A combined Medicare and private payor database was used to identify single-level lumbar discectomies performed from 2007 to 2015. Utilization and reimbursement trends were compared using the compound annual growth rate (CAGR) with reimbursement adjusted by the consumer price index. In total, 30,617 lumbar discectomies were analyzed. Procedure utilization increased across all settings. CAGR was highest in the outpatient CON group (19.7%) and lowest in the inpatient non-CON group (0.5%). Reimbursement increased in the outpatient setting (CAGR: 1.2% CON, 1.0% non-CON), but decreased in the inpatient setting (CAGR: -6.1% CON, -5.5% non-CON). These trends are important to consider in a value-based healthcare environment. (Journal of Surgical Orthopaedic Advances 31(1):026-029, 2022).

Certificate of Need and Inpatient Psychiatric Services

BACKGROUND

Certificate of need (CON) laws require would-be healthcare providers to obtain the permission of a state board before opening or expanding. 35 US states operate some type of CON program, though they vary widely in the specific services or equipment they target, with 25 states requiring CON for psychiatric services.

AIMS OF THE STUDY

We provide the first empirical estimates on how CON affects the provision of psychiatric services.

METHODS

We use Ordinary Least Squares regression to analyze 2010-2016 data on psychiatric CON from the American Health Planning Association together with data on psychiatric facilities and services from the National Mental Health Services Survey.

RESULTS

We find that CON laws targeting psychiatric services are associated with a statistically significant 0.527 fewer psychiatric hospitals per million residents (20% fewer) and 2.19 fewer inpatient psychiatric clients per ten thousand residents (56% fewer). Psychiatric CON is also associated with psychiatric hospitals being 5.35 percentage points less likely to accept Medicare. Our estimates for CON's effect on the number of inpatient psychiatric beds per ten thousand residents and the likelihood of psychiatric hospitals accepting Medicaid, private insurance, or charity care (no charge) are negative but not statistically significant.

DISCUSSION

CON laws may substantially reduce access to psychiatric care. A limitation of our study is that there is almost no variation in which states have psychiatric-related CON laws during the time period of our data (New Hampshire is the only state to change its psychiatric services CON requirement in this period, repealing its CON program entirely in 2016). This precludes the use of preferred econometric techniques such as difference-in-difference.

IMPLICATIONS FOR HEALTH POLICIES

Our results indicate that CON laws may reduce access to inpatient psychiatric care. State policymakers should consider whether CON repeal could be a simple way of enhancing access to psychiatric care.

IMPLICATIONS FOR FURTHER RESEARCH

While hundreds of articles have examined the effects of CON laws, we believe ours is the first to provide empirical estimates of their effects on mental health care specifically. We hope it is not the last.

The impact of certificate of need laws on heart attack mortality: Evidence from county borders

Certificate of need (CON) regulations requires that health care providers obtain state approval before offering a new service or expanding existing facilities. The purported goal of CON regulations is to reduce health care costs by generating regional economies of scale and reducing redundant investments resulting from excessive competition. Critics of CON regulations note that the regulatory environment increases the costs of expansion and may incentivize health care providers to forgo capital investment, which can have a negative effect on health outcomes. To estimate the net effect of CON regulations, I use a border discontinuity design to measure within-regional heart attack mortality spanning 1968 to 1982. I estimate that CON regulations led to an increase in heart attack deaths, by 6%-10%, three years after the policy was enacted.

Early Acceleration of COVID-19 in Areas with Larger Nursing Homes and Certificate of Need Laws

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have become common in large nursing homes, placing not only residents but also staff and community members at risk for infection. However, the relationship between larger nursing homes and the community spread of SARS-CoV-2 has not yet been documented.

OBJECTIVE

To examine the association between county average nursing home bed size and presence of certificate of need (CON) laws, which influence nursing home size, with county-level SARS-CoV-2 prevalence over time.

DESIGN

Cross-sectional study using county-level data from March 11 through June 12, 2020.

PARTICIPANTS

All US counties with at least one nursing home (n = 2,883).

MAIN MEASURES

The main explanatory variables were county average nursing home bed size and presence of a CON law. The main outcome was the cumulative number of SARS-CoV-2 cases on each day of the study period adjusted for county population size and density, demographic and socioeconomic characteristics, total nursing home bed supply, other health care supply measures, epidemic stage, and census region.

KEY RESULTS

By June 12, a between-county difference in average nursing home size equal to 1 bed was associated with 3.92 additional SARS-COV-2 cases (95% CI = 2.14 to 5.69; P < 0.001), on average, and counties subject to CON laws had 104.53 additional SARS-CoV-2 cases (95% CI = 7.68 to 201.38; P < 0.05), on average. Counties with larger nursing homes also demonstrated higher growth in the frequency of SARS-COV-2 throughout the study period.

CONCLUSIONS

At the county level, average nursing home size and CON law presence was associated with a greater frequency of SARS-CoV-2 cases. Controlling the impact of the coronavirus 2019 pandemic may require additional resources for communities with larger nursing homes and more attention towards long-term care policies.

The Impact of Certificate of Need Status on the Utilization and Reimbursement of Open and Endoscopic Carpal Tunnel Release

A certificate of need (CON) permits a healthcare organization to build new facilities only if significant medical needs exist. Many states have implemented CON programs to prevent procedure overutilization and price inflation. We hypothesized that there are no differences in reimbursement or utilization for open and endoscopic carpal tunnel release (CTR) when comparing states with and without CON programs. We queried a private-payer database to identify open and endoscopic CTRs performed between 2007 and 2015. In total, 82,689 CTRs were identified: 70,160 open, 12,529 endoscopic. Reimbursement increased for open procedures (compound annual growth rate [CAGR] 1.0% CON, 1.4% non-CON) but only marginally increased or decreased in the endoscopic group (CAGR -0.8% CON, 0.2% non-CON). Utilization increased across all settings, and was highest in the endoscopic CON group (CAGR 17.9%). Least growth was seen in the open non-CON group (CAGR 10.0%). Overall, CON programs may not actually decrease CTR spending or utilization. (Journal of Surgical Orthopaedic Advances 30(2):090-092, 2021).

Juggling Doctor and Patient Needs in Mental Health Record Design

Providing patients access to mental health records is a controversial topic that gains growing attention in research and practice. While it has great potential in increasing the patient engagement, skepticism is prevailing among therapists who fear detrimental effects and face a lack of feasibility when treatment notes are handwritten. We aim at empowering both therapists to new documentation approaches and patients to higher engagement, and develop the collaborative documentation system Tele-Board MED (TBM) as an adjunct to talk-based mental health interventions. We present an evaluation of TBM by comparing four prototypes and testing scenarios, reaching from early simulations to attempts of real-life implementations in clinical routines. This paper delivers a systematic need comparison of therapists as primary users and patients as secondary users, both during and beyond treatment sessions. While patient feedback is thoroughly positive, the therapist needs are only partially addressed; the benefits remain hidden behind the perceived effort.

Nursing Homes with Persistent High and Low Quality

This article examines the concentration of low- and high-quality care within particular nursing facilities over time. The authors explore three different explanations for persistent low and high quality over time including the level of public reimbursement, the presence of bed constraint policies such as certificate-of-need and construction moratoria, and the role of consumer information. Using 1991 through 1999 data from the On-Line Survey, Certification, and Reporting system, the authors show that both low- and high-quality nursing home care is concentrated in certain facilities over time. Their results further show that public reimbursement and asymmetric information are both important factors in explaining why low quality persists over time in certain facilities.

The mismatch between the health research and development (R&D) that is needed and the R&D that is undertaken: an overview of the problem, the causes, and solutions

One of the most pressing global health problems is that there is a mismatch between the health research and development (R&D) that is needed and that which is undertaken. The dependence of health R&D on market incentives in the for-profit private sector and the lack of coordination by public and philanthropic funders on global R&D priorities have resulted in a global health R&D landscape that neglects certain products and populations and is characterised, more generally, by a distribution that is not 'needs-driven'. This article provides an overview of the mismatch, its causes, and solutions.

Certificate of need programs, intensity modulated radiation therapy use and the cost of prostate cancer care

PURPOSE

Certificate of need programs are a primary mechanism to regulate the use and cost of health care services at the state level. The effect of certificate of need programs on the use of intensity modulated radiation therapy and the increasing costs of prostate cancer care is unknown. We compared the use of intensity modulated radiation therapy and change in prostate cancer health care costs in regions with vs without active certificate of need programs.

MATERIALS AND METHODS

This population based, observational study using SEER (Surveillance, Epidemiology, and End Results)-Medicare linked data from 2002 through 2009 was comprised of 13,814 men treated for prostate cancer in 3 regions with active certificate of need programs (CON Yes) vs 44,541 men treated for prostate cancer in 9 regions without active certificate of need programs (CON No). We assessed intensity modulated radiation therapy use relative to other prostate cancer definitive therapies and overall prostate cancer health care costs with respect to certificate of need status.

RESULTS

In propensity score adjusted analyses, intensity modulated radiation therapy use increased from 2.3% to 46.4% of prostate cancer definitive therapies in CON Yes regions vs 11.3% to 41.7% in CON No regions from 2002 to 2009. Furthermore, we observed greater intensity modulated radiation therapy use with time in CON Yes vs No regions (p <0.001). Annual cost growth did not differ between CON Yes vs No regions (p = 0.396).

CONCLUSIONS

Certificate of need programs were not effective in limiting intensity modulated radiation therapy use or attenuating prostate cancer health care costs. There remains an unmet need to control the rapid adoption of new, more expensive therapies for prostate cancer that have limited cost and comparative effectiveness data.

Reducing racial disparities in coronary angiography

Racial disparities in cardiac services are well documented; however, policies to close these gaps have not been studied. This paper evaluates a New Jersey certificate-of-need reform to reduce disparities in diagnostic coronary angiography. The number of angiography facilities in New Jersey doubled following reform, and a large black-white disparity was eliminated-a trend not observed in nearby states. Surprisingly, increases in service to African American patients following reform were concentrated in hospitals licensed before reform, while the newly licensed facilities contributed relatively little to reducing disparities. We hypothesize that added hospital competition contributed to the reduction in disparities.

Effects of regulation and competition on health care disparities: the case of cardiac angiography in New Jersey

This article evaluates a Certificate of Need (CON) reform in New Jersey that was designed to expand hospital capacity to provide cardiac angiography (CA) and reduce long-standing disparities in access to the procedure. Using data from 1995 to 2004, we find that expanded capacity increased CA utilization overall and did so more rapidly for blacks, leading to a large reduction in the disparity. However, this reduction was not attributable to services provided by new entrants to the CA market, since they were located in mostly white suburban areas. Instead, the new entrants cut into the incumbents' share of white CA patients who had previously traveled from the suburbs to receive the procedure at inner-city incumbent hospitals. As a result, it appears that incumbents were forced to serve more black patients in their local area to maintain their CA volume. These findings suggest that prior restrictions on CA capacity contributed to the historical disparity in access to the procedure.

When health policy is the problem: a report from the field

We often think of health policy and health services research as offering solutions to cost, quality, and access problems. Many of us see health policy as simply ineffective. But any activity that has the power to cure can also do harm. Is it possible that the health policy enterprise has contributed to the very problems it has been attempting to eliminate? We argue that it has. Reasonable assumptions have led to a series of solutions that have provided political cover for those vested in the status quo. This process is nonpartisan, with those of us on the left and the right unintentionally and inadvertently contributing to the problems we are so committed to solving.

Monopoly Is Not The Answer

Certificate-of-need (CON) regulation was originally intended to correct market failures that no longer afflict health care markets. It is ironic that Sujit Choudhry and colleagues now invoke it to deal with situations where, in their view, competition is working altogether too well. Protectionist regulation, long discredited in other areas, is particularly misguided in health care, where health insurance greatly increases the profitability of monopoly and imposes the resulting higher costs on unwilling premium payers. To use cross-subsidies to finance even worthy (let alone unworthy) health care projects is to put public burdens unfairly (regressively) on the backs of working Americans.

Market competition and quality of care in the nursing home industry

Poor quality nursing home care is a problem in the United States, a problem that threatens the lives and well-being of one of our most vulnerable populations. The competitive structure of the nursing home market may influence the strategies and behaviors nursing homes pursue to capture the resources they need to operate. The goal of this study was to determine whether nursing home quality is related to the level and type of competition present in the market. This study specifically examined whether or not a relationship exists between structural, process, and outcome quality indicators, and (1) the availability of nursing home substitutes, (2) the threat of market entry, (3) the presence of rivalry in the market, and (4) the relationship between the nursing homes and their buyers and suppliers. This study examined secondary data from the Minimum Data Set Plus (MDS +), the On-line Survey Certification of Automated Records (OSCAR), the Area Resource File (ARF), and the Medicaid Reimbursement Survey. Weighted least squares regression analysis was utilized to estimate the relationships between the quality indicators and the different aspects of competition. This study found that some forms of competition are significantly related to nursing home quality performance. The availability of nursing home substitutes, the presence of active certificate of need laws, and the level of excess demand are associated with nursing home quality.

The economic implications of case-mix Medicaid reimbursement for nursing home care

In recent years, there has been large growth in the nursing home industry in the use of case-mix adjusted Medicaid payment systems that employ resident characteristics to predict the relative use of resources in setting payment levels. Little attention has been paid to the access and quality incentives that these systems provide in the presence of excess demand conditions due to certificate-of-need (CON) and construction moratoria. Using 1991 to 1998 panel data for all certified U.S. nursing homes, a fixed-effects model indicates that adoption of a case-mix payment system led to increased access for more dependent residents, but the effect was modified in excess demand markets. Quality remained relatively stable with the introduction of case-mix reimbursement, regardless of the presence of excess demand conditions. These results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.

[What does it feel like for a physician to be a gatekeeper?]

BACKGROUND

Doctors increasingly act as gatekeepers. We have studied the effect that this function has on the doctors themselves.

MATERIAL AND METHODS

Analysis of 24 questions from large surveys of representative samples of Norwegian doctors in 1993 and 2000.

RESULTS

Six out of seven doctors sometimes or often met unrealistic demands from patients. More than one third experienced stress because of patient expectations about help for non-medical problems. Nearly 50% had adjusted medical certificates in order to help the patient. More than 50% sometimes or often gave more weight to patients' wishes than to their own medical judgement. 86% had chosen to come in for work themselves when they would have certified as sick a patient with the same symptoms and working situation. The proportions were significantly smaller among older doctors and doctors with a high level of job satisfaction.

INTERPRETATION

The gatekeeper role has important influence on doctors' job satisfaction. A possible generation effect may imply that society will meet problems more often in the future when assigning gatekeeper functions to doctors.

Navigating the niche. Three markets respond to the influx of specialty facilities--Indianapolis, Phoenix, Columbus

Specialty centers that focus on lucrative services such as cardiology and orthopedics pose a challenge to full-service hospitals in already crowded health care markets. We examine how hospitals in three markets have responded, from aggressively working to keep niche facilities from gaining a foothold to partnering with physicians on their own centers.