Presentation on theme: "Kathleen Carey* James F. Burgess Jr.* and Gary J. Young** AHRQ Annual Meeting – September 21, 2011 Research funded in part by the Robert Wood Johnson Foundation."— Presentation transcript:
Kathleen Carey* James F. Burgess Jr.* and Gary J. Young** AHRQ Annual Meeting – September 21, 2011 Research funded in part by the Robert Wood Johnson Foundation and by AHRQ *Boston University School of Public Health and Department of Veterans Affairs ** Northeastern University
Ethics in Patient Referrals Act (Stark I & II): 1989, 1993 “Whole Hospital Exception”: a fertile environment for development of new SSHs Reasons for proliferation? ◦ Distortions in the payment system ◦ Technological advances ◦ Dissatisfaction on the part of physicians with responses of hospital administrators Moratorium on new physician-owned cardiac, orthopedic, and surgical SSHs: 2003 to 2006
What were the issues? ◦ Patient selection: cherry-picking ◦ Financial impact on community hospitals ◦ Conflict of interest: self-referral, induced demand Medicare inpatient reimbursement structure reform: FY2007 Patient Protection and Affordable Care Act Section 6001 ◦ Whole hospital exception dismantled ◦ Stricter limitations on grandfathered SSHs
Efforts to remove restrictions in Section 6001 underway ◦ Lobbying efforts to persuade legislators ◦ Legal challenges around the constitutionality to persuade the courts Restrictions only relate to SSHs with respect to reimbursement under federal insurance programs (viz., Medicare) SSHs can continue to operate by relying on reimbursements from private plans and on out-of-pocket payments by patients
All SSHs are not the same Two types: Orthopedic/Surgical and Cardiac Key differentiating factors in addition to specialization: ◦ Size: Cardiac average 60 beds – OrthSurg average 20 ◦ Scope of Services: Most OrthSurg SSHs do not have Emergency Departments but most Cardiac SSHs do ◦ Payer mix: MedPAC found that ~ 2/3 of Cardiac SSH patients were reimbursed by Medicare and 1/3 by private payers; for OrthSurg SSHs just the reverse
Self-referral ◦ Mitchell, Medical Care, (2008): in referrals by orthopedic doc-owners compared to non-owners, OK SSHs Utilization ◦ Nallamothu, JAMA, (2007) : in coronary revascularization procedures, Medicare population ◦ Mitchell, Medical Care Research & Review (2007): in complex spinal fusion procedures, OK SSHs Selection ◦ GAO Report, 2003 ◦ Cram et al., NEJM, 2005 ◦ Mitchell, Health Affairs, 2005 ◦ Guterman, Health Affairs, 2006 Cost ◦ Barro et al. Journal of Health Economics (2006) ↓ spending for cardiac care in markets w/ cardiac SSHs w/o worse outcomes ◦ Schneider et al., Inquiry, 2007: ↓ in hospital level costs, national SSH study ◦ Carey et al. Health Services Research (2008): Orthopedic/Surgical SSHs cost inefficiency
The question of SSH cost efficiency is deep One economic issue is whether there is “enough scale at all of these separate institutions to allow them to operate efficiently” (Newhouse, 2004) Also, more services allow for joint costs of services Do SSHs realize economies of scale? Do SSHs realize economies of scope?
Too few observations on cardiac SSHs We focused on orthopedic and surgical SSHs These hospitals are primarily engaged in outpatient surgical services They also treat inpatients, although on a smaller scale Multiple output cost function with 2 outputs: ◦ Inpatient Discharges ◦ Outpatient Visits
Operating Costs = f (discharges, outpatient visits, average length of stay, wage index, bed size, case-mix index, outpatient case-mix index, teaching hospital indicator, ownership, SSH indicator, SSH*discharges, SSH*outpatient visits)
Medicare Cost Reports 1998-2008 American Hospital Association Annual Survey Database ~ 90% of SSHs are located in 10 states (n=405): ArizonaLouisiana CaliforniaOhio IdahoOklahoma IndianaSouth Dakota KansasTexas Competitors in same market (n=5,273) (Dartmouth Hospital Referral Regions)
Economies of Scale (EOS) Does the average cost decline as output increases? Or, is cost ↑ < output ↑(in proportional terms) EOS = [ 1/ (MC/AC) ] = [1 / cost elasticity] For multiple outputs, Ray Scale EOS assumes that all outputs increase proportionately Ray EOS = [ 1 / Σ cost elasticities ]
Marginal Cost Average Cost Medical Services Cost Range of EOS
General HospitalsSpecialty Hospitals Discharges Visits Beds EOS Discharges Visits BedsEOS Q1 1,60028,555522.702623,88292.13 Median 4,64561,4781191.114985,224141.44 Q3 10,925121,6332330.6589879,499241.05
Economies of scope (ESC): present if the cost of jointly producing a set of outputs is lower than the costs of producing those outputs separately For the 2 output case: ESC = [C(DIS, 0) + C(0,OPV) – C (DIS,OPV)] / C(DIS,OPV) ESC are present if the expression is positive ◦ Will occur if the numerator is positive ◦ Indicates it is cheaper to produce outputs DIS and OPV jointly than in separate facilities The expression rarely applied in the case of hospitals Why not? Because it is unusual that hospitals would be producing at levels of zero output
Alternative conception of economies of Scope (ESC) ESC exist if it is possible to produce outputs jointly in the same hospital cheaper than it is to produce them separately How will we measure ESC? ◦ ESC = [C(System A) + C(System B) – C(System C)] C(System C) ◦ where System A is general hospital production, System B is SSH production, and System C is a simulation of general hospital technology cost of producing (general hospital + SSH) outputs
Cost A refers to production of general hospital output using general hospital technology. Cost B refers to production of specialty hospital output using specialty hospital technology. Cost C refers to joint production of general hospital and specialty hospital output using general hospital technology.
Specialty Hospitals General Hospitals 1 st QuartileMedian3 rd Quartile 1 st Quartile (22.71+8.62- 23.95)/23.95 = 0.30 (41.12+8.62- 43.02)/43.02 = 0.16 (105.44+8.62- 108.69)/108.69 = 0.05 Median (22.71+11.76- 25.07)/25.07 = 0.38 (41.12+11.76- 44.74)/44.74 = 0.18 (105.44+11.76- 111.65)/111.65 = 0.05 3 rd Quartile (22.71+21.09- 27.62)/27.62 = 0.59 (41.12+21.09- 48.60)/48.60 = 0.28 (105.44+21.09- 118.19)/118.19 = 0.07 Costs measured in million $ Quartile values taken across distributions of discharges and outpatient visits [ESC = (Cost A + Cost B – Cost C) / Cost C]
Specialty Hospitals General Hospitals 1 st QuartileMedian3 rd Quartile 1 st Quartile 7.386.725.37 Median 9.408.145.55 3 rd Quartile 16.1813.618.34 Implicit Cost Savings (million dollars): (Cost A + Cost B – Cost C)
SSHs may lack sufficient scale to compete effectively with general hospitals on the basis of cost efficiency ◦ Yet this supply side analysis does not account for demand side price competition pressures Simulation analyses also suggest potential improvement in cost efficiency through exploitation of economies of scope by shifting SSH production to general hospitals But only one piece of evidence in understanding a very complex issue: SSHs might be able to control costs through leaner staffing, tighter inventory control and/or effective discharge planning, e.g.