Does procedure profitability impact whether an outpatient surgery is performed at an ambulatory surgery center or hospital?

Ambulatory surgery centers (ASCs) are small (typically physician owned) healthcare facilities that specialize in performing outpatient surgeries and therefore compete against hospitals for patients. Physicians who own ASCs could treat their most profitable patients at their ASCs and less profitable patients at hospitals. This paper asks if the profitability of an outpatient surgery impacts where a physician performs the surgery. Using a sample of Medicare patients from the National Survey of Ambulatory Surgery, we find that higher profit surgeries do have a higher probability of being performed at an ASC compared to a hospital. After controlling for surgery type, a 10% increase in a surgery's profitability is associated with a 1.2 to 1.4 percentage point increase in the probability the surgery is performed at an ASC. Copyright © 2010 John Wiley & Sons, Ltd.     

Patient switching in general practice

Patients switching physicians involves costs to the patients because of less continuity of care. From a theoretical model we derive that inferior physician quality as perceived by patients, implies patient shortage for the physician and more patients switching physicians. By means of a unique panel data set covering the entire population of Norwegian general practitioners (GPs) and estimation methods that adjust for potential endogeneities, we find that the occurrence of patient shortage increases the proportion of patients switching physicians by 50%. A competing hypothesis that GPs with a shortage of patients experience less switching because of superior access is rejected by data. To assist patients in making informed decisions, we suggest that the number of switches a physician experiences should be made public.     

Physician office space in an ambulatory surgical center

Medicare requires that ambulatory surgical centers (ASCs) be operated exclusively for the purpose of providing surgical services to patients who do not require hospitalization. As a result, ASCs have been reluctant to establish physician office space within their facilities for non-surgical procedures due to fear of losing their Medicare certification for failure to satisfy the exclusivity requirement. Recently, however, the Centers for Medicare and Medicaid Services (CMS) clarified its position on the exclusivity issue, stating that if an ASC follows certain criteria, it can establish physician office space within its facility without violating the exclusivity requirement or jeopardizing its Medicare certification.     

Urologist Ownership of Ambulatory Surgery Centers and Urinary Stone Surgery Use

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.     

Uncompensated care provided by emergency physicians in Florida emergency departments

Uncompensated emergency department (ED) visits can negatively affect patients, clinicians, and hospitals, particularly as overcrowding occurs. Florida provides a unique market to analyze uncompensated ED care due to the high percent of for-profit hospitals, which typically provide significantly less uncompensated care, coupled with the older population that is more likely to be insured through Medicare. A survey of 188 Florida hospital emergency physician groups was conducted to estimate the level of uncompensated care provided by each ED physician group in 1998. The response rate was 44 percent (eighty-three ED physician groups). All ED physician groups provided substantial uncompensated care regardless of hospital ownership type. Uncompensated care averaged 46.8 percent and ranged from 25.8 to 79.4 percent. A model was developed to predict the amount of uncompensated care using ED volume and payer mix. A rise in the percent of self-pay patients causes a disproportionate increase in uncompensated care, such that EDs with high levels of self-pay visits have markedly higher uncompensated care rates. The results suggest the need for a uniform reporting method of ED physician uncompensated care cost.     

Bypassing the Local Rural Hospital for Outpatient Procedures

ABSTRACT:  Purpose: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. Methods: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. Findings: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. Conclusions: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations .     

Determinants of ambulatory physician utilization among adults with chronic diseases in Quebec

OBJECTIVES: To test the explanatory power of a model of ambulatory service use and to determine the relative roles of the main determinants of physician utilization for two chronic medical conditions in adults in Quebec. METHODS: A behavioral model based on Andersen's model was developed and tested by linking two databases: the Quebec health survey as regards patient characteristics, and the Quebec health insurance board data on physician characteristics and service use. Path analysis was used for data analysis. RESULTS: The model explained a little less than 20% of the variation in service use. The number of hospitalizations, physician's specialty and perceived health were the most important predictors of the volume of visits. CONCLUSION: Further specification of utilization, relating it to a particular medical condition, does not necessarily lead to an increase in the explanatory power of the model. We recommend that future research should put more emphasis on provider-related determinants rather than focusing on the type and purpose of utilization.     

Hospital board effectiveness: relationships between board training and hospital financial viability.

This study examined whether hospital governing boards that invest in board education and training are more informed and effective decision-making bodies. Measures of hospital financial viability (i.e., selected financial ratios and outcomes) are used as indicators of hospital board effectiveness. Board participation in educational programs was significantly associated with improved profitability, liquidity, and occupancy levels, suggesting that investment in the education of directors is likely to enhance hospital viability and thus increase board effectiveness.     

Hospital competition and financial performance: the effects of ambulatory surgery centers

Ambulatory surgery centers (ASCs), limited-service alternatives for treating surgery patients not requiring an overnight stay, are a health-care service innovation that has proliferated in the U.S. and other countries in recent years. This paper examines the effects of ASC competition on revenues, costs, and profit margins of hospitals that also provided these services as a subset of their general services in Arizona, California, and Texas during the period 1997-2004. We identified all ASCs operating during the period in the 49 Dartmouth Hospital Referral Regions in the three states. The results of fixed effects models suggested that ASCs are meaningful competitors to general hospitals. We found downward pressure on revenues, costs, and profits in general hospitals associated with ASC presence.     

Ambulatory Surgery Centers and Their Intended Effects on Outpatient Surgery

Objectives

To assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events.

Data Sources

Twenty percent national sample of Medicare beneficiaries.

Study Design

A retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups—those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission.

Principal Findings

Adjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p < .001 for test between slopes). Within these markets, procedure use at ASCs outpaced the decline observed in the hospital setting. Perioperative mortality and admission rates remained flat after ASC opening (both p > .4 for test between slopes).

Conclusions

The opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals.     

(Re)disclosing physician financial interests: rebuilding trust or making unreasonable burdens on physicians?

Recent professional guidelines published by the General Medical Council instruct physicians in the UK to be honest and open in any financial agreements they have with their patients and third parties. These guidelines are in addition to a European policy addressing disclosure of physician financial interests in the industry. Similarly, In the US, a national open payments program as well as Federal regulations under the Affordable Care Act re-address the issue of disclosure of physician financial interests in America. These new professional and legal changes make us rethink the fiduciary duties of providers working under new organizational and financial schemes, specifically their clinical fidelity and their moral and professional obligations to act in the best interests of patients. The article describes the legal changes providing the background for such proposals and offers a prima facie ethical analysis of these evolving issues. It is argued that although disclosure of conflicting interest may increase trust it may not necessarily be beneficial to patients nor accord with their expectations and needs. Due to the extra burden associated with disclosure as well as its implications on the medical profession and the therapeutic relationship, it should be held that transparency of physician financial interest should not result in mandatory disclosure of such interest by physicians. It could lead, as some initiatives in Europe and the US already demonstrate, to voluntary or mandatory disclosure schemes carried out by the industry itself. Such schemes should be in addition to medical education and the address of the more general phenomenon of physician conflict of interest in ethical codes and ethical training of the parties involved.     

Pour l’implantation des équipes transversales de nutrition clinique à l’hôpital : le plaidoyer du pédiatreNutrition support teams in the hospitals: why and how?

Despite major advances in the quality of care in many other areas, the prevalence of malnutrition in hospitals is high and has not decreased over the last 20 years. Young children are especially threatened. Malnutrition is associated with an increase in morbidity and mortality in hospitalized patients, induces an increase in length of stay and thus, in hospital costs. The nutritional risk in hospitalized patients is related to the underlying disease and to the organization of feeding and nutrition in the hospitals. Moreover, most of the physicians and other professionals do not have enough knowledge in the area of nutrition. Therefore, the intervention of professionals specialized in nutrition is needed. These professionals must be well organized and coordinated. Two different kinds of nutritional support boards exist in hospitals. Nutrition advisory (steering) boards which include all categories of professionals involved in feeding and nutrition, set broad policies about patients’ meal service and nutrition, but do not envisage patients on an individual basis. By contrast, nutrition (support) teams (NT) are little clinical units (even without devoted beds), involving a small number of nutrition specialists including at least one senior physician, to which patients should be referred individually. The main objective of the NT is to set up optimum nutrition according to each individual situation, especially in case of need for artificial nutrition. The impact of NT intervention, in terms of patients’ outcome as well as financial benefits, has been shown for long.     

Impact of the Rural Health Clinics Services Bill: A projection

A survey of directors of midlevel practitioner training programs was conducted to analyze the projected impact of the Rural Health Clinics Services Bill (PL95-210). Sixty-eight percent of the directors responded. The majority of the respondents agreed that the bill would have a positive impact on accessibility and continuity of care and would increase the number of practitioners in rural areas. The directors of nurse practitioner programs disagreed with the directors of physician assistant programs over the issue of physician supervision and midlevel practitioner responsibility for care. Almost half of the respondents believed that the legislated method of reimbursment was not optimal, and 58% felt that financial abuses of the bill may occur. The legal implications of the bill and its impact on cost of care are discussed.     

Does better disease management in primary care reduce hospital costs? Evidence from English primary care

We apply cross-sectional and panel data methods to a database of 5 million patients in 8000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.     

The effects of hospital-physician integration strategies on hospital financial performance.

STUDY QUESTION. This study investigated the longitudinal relations between hospital financial performance outcomes and three hospital-physician integration strategies: physician involvement in hospital governance, hospital ownership by physicians, and the integration of hospital-physician financial relationships. DATA SOURCES AND STUDY SETTING. Using secondary data from the State of California, integration strategies in approximately 300 California short-term acute care hospitals were tracked over a ten-year period (1981-1990). STUDY DESIGN. The study used an archival design. Hospital performance was measured on three dimensions: operational profitability, occupancy, and costs. Thirteen control variables were used in the analyses: market competition, affluence, and rurality; hospital ownership; teaching costs and intensity; multihospital system membership; hospital size; outpatient service mix; patient volume case mix; Medicare and Medicaid intensity; and managed care intensity. DATA COLLECTION/EXTRACTION. Financial and utilization data were obtained from the State of California, which requires annual hospital reports. A series of longitudinal regressions tested the hypotheses. PRINCIPAL FINDINGS. Considerable variation was found in the popularity of the three strategies and their ability to predict hospital performance outcomes. Physician involvement in hospital governance increased modestly from 1981-1990, while ownership and financial integration declined significantly. Physician governance was associated with greater occupancy and higher operating margins, while financial integration was related to lower hospital operating costs. Direct physician ownership, particularly in small hospitals, was associated with lower operating margins and higher costs. Subsample analyses indicate that implementation of the Medicare prospective payment system in 1983 had a major impact on these relationships, especially on the benefits of financial integration. CONCLUSIONS. The findings support the validity of hospital-physician financial integration efforts, and to a lesser extent the involvement of physicians in hospital governance. The results lend considerably less support for strategies built around direct physician ownership in hospitals, particularly since PPS implementation. RELEVANCE/IMPACT. These findings challenge prior studies that found few financial benefits to hospital-physician integration prior to PPS implementation in 1983. The results imply that financial benefits of integration may take several years after implementation to emerge, are most salient in a managed care or managed competition environment, and vary by hospital size and multihospital system membership.     

Rural and Urban Physicians' Perceptions Regarding the Role and Practice of the Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife

ABSTRACT: Context: There is a dearth of literature citing the differences in rural and urban physicians' perceptions of the role and practice of nurse practitioners, physician assistants, and certified nurse midwives (nonphysician providers). Purpose: The purpose of this study was to investigate and compare differences, if any, between rural and urban primary care physicians' perceptions of the role and practice of nonphysician providers. Results: Despite a 15.55% response rate using a mail-out survey in South Carolina, data from 681 rural and urban primary care physicians indicated that they perceived that nonphysician providers possess the necessary skills and knowledge to provide primay care to patients, are an asset to a physician's practice, free the physician's time to handle more critically ill patients, and increase revenue for the practice, but increase the risk of patient care mistakes and a physician's time in administrative duties. Urban physicians' mean scores were higher for perceiving that nonphysician providers are able to see as many patients in a given day as a physician but experience impediments in the delivery of patient care. Conclusions: Results will be used to clarify physicians' perceptions regarding the role and practice of nonphysician providers to reduce impediments to patient care access.     

Monitoring access following Medicare price changes: physician perspective

In this article, the author examines changes in Medicare beneficiaries' access to services following the Omnibus Budget Reconciliation Act of 1987 "overpriced" procedure price reductions from the physician perspective. Three measures of physician availability remained essentially constant: number of physicians treating beneficiaries or performing overpriced procedures; average Medicare caseload; and average share of a physician's Medicare practice comprised of those who are poor and not white. Physician practice characteristics were examined and provided evidence of continuing participation in Medicare: Average Medicare revenue increased 10 percent, and average volume of all services increased. However, physicians with the largest fee reductions or who were the most financially dependent on the procedures did not change overpriced procedure volume.