Trends during 1993-2004 in the availability and use of revascularization after acute myocardial infarction in markets affected by certificate of need regulations

The Economics of a Bed Shortage: Certificate-of-Need Regulation and Hospital Bed Utilization during the COVID-19 Pandemic

Certificate-of-need (CON) laws are intended to restrain health care spending by limiting the acquisition of duplicative capital and the initiation of unnecessary services. Critics contend that need is difficult to objectively assess, especially considering the risks and uncertainty inherent in health care. We compare statewide bed utilization rates and hospital-level bed utilization rates in bed CON and non-bed CON states during the COVID-19 pandemic. Controlling for other possibly confounding factors, we find that states with bed CONs had 12 percent higher bed utilization rates and 58 percent more days in which more than 70 percent of their beds were used. Individual hospitals in bed CON states were 27 percent more likely to utilize all of their beds. States that relaxed CON requirements to make it easier for hospitals to meet the surge in demand did not experience any statistically significant decreases in bed utilization or number of days above 70 percent of capacity. Nor were hospitals in states that relaxed their CON requirements any less likely to use all their beds. Certificate-of-need laws seem to have exacerbated the risk of running out of beds during the COVID-19 pandemic. State efforts to relax these rules had little immediate effect on reducing this risk.

Certificate-of-Need Programs Are Associated with a Reduced Incidence, Expenditure, and Rate of Complications with Respect to Knee Arthroscopy in the Medicare Population

BACKGROUND

To curb costs at the state level, improve care quality, and promote access to care, certificate-of-need (CON) laws were established in many states in 1974. It is not known how CON regulations have affected the provision of knee arthroscopy, one of the most common orthopedic procedures performed in the USA.

QUESTIONS/PURPOSES

We sought to characterize the effects of CON regulations on knee arthroscopy in the national Medicare population by examining trends in procedure volumes, comparing trends in procedure charges, evaluating distribution of procedure volumes between high-, mid-, and low-volume facilities, and comparing adverse event and complication rates after knee arthroscopy between states with and without CON regulations.

METHODS

States with CON regulations covering both inpatient and outpatient operating rooms formed the study group (n = 25 states) and were compared with states without CON laws or laws that did not cover operating rooms during the study period (n = 20 states). The 100% Medicare Standard Analytical Files from 2005 through 2014 were used to compare knee arthroscopy procedure volumes, charges, reimbursements, distribution of procedures based on facility volumes and adverse events between the two groups.

RESULTS

The rate of decrease in the incidence of knee arthroscopy was significantly greater in CON states than that in non-CON states. CON states also had significantly lower charges at all time points, and overall, compared with non-CON states. There were significantly more high- and mid-volume facilities in CON states than in non-CON states, and there were significantly more low-volume facilities in non-CON states than in CON states. Finally, there were significantly higher rates of emergency room visits within 30 days and infection within 6 months in non-CON states than in CON states.

CONCLUSIONS

CON regulations appear to have achieved several of their intended goals for knee arthroscopy. Further research is needed to determine if CON regulations affect the quality and sustainability of care provided to patients undergoing knee arthroscopy.

Do certificate of need regulations impact total shoulder arthroplasty volumes and associated complication rates?

Objectives: Certificates of Need (CON) laws were introduced to improve resource utilization and reduce unnecessary health-care expansion. While many states have repealed their use, the debate continues as to their efficacy in achieving these goals. As such, we asked: 1) Are there differences in TSA incidence in CON/non-CON states? 2) Are there differences in procedural charges or reimbursement between CON/non-CON states? 3) Are there differences in the proportion of cases treated in high-, mid- or low-volume facilities between groups? 4) Are there differences in complications and length-of-stay (LOS) between high-volume and low-volume facilities? Methods: The 100% Medicare Standard Analytic files were queried for all TSA between 2005 and 2013, with minimum 1-year follow-up. Publically available data was used to identify states that upheld or repealed CON regulations, and comparisons were subsequently made between groups for normalized incidence of TSA per year and procedural charges and reimbursement rates. Comparisons were then made regarding the distribution of high-, mid- and low volume facilities, post-operative complication rates, and length-of-stay (LOS) between the different volume centers. Results: 167,288 patients undergoing TSA were identified. Normalized rates of TSA increased in both groups. Non-CON states had higher per-patient reimbursement, but paradoxically lower reimbursement rates compared with CON states. CON regulations lead to a greater proportion of procedures being performed in high-volume facilities compared with non-CON (p = 0.002). Finally, 30-day and 1-year complications, and length-of-stay, were significantly lower in high-volume facilities versus low-volume facilities (p ≤ 0.016). Conclusions: Where upheld, CON regulations contributed to a notable increase in the percentage of procedures performed in high-volume facilities, which in turn lead to a significant reduction in post-operative complications and LOS. Further study is necessary to definitely establish this relationship and the utility of CON regulations for the delivery of TSA care, particularly as it relates to clinical outcomes.

Certificate-of-Need State Laws and Total Hip Arthroplasty

BACKGROUND

Many states have certificate-of-need (CON) programs requiring governmental approval to open or expand healthcare services, with the goal of limiting cost and coordinating utilization of healthcare resources. The purpose of the present study was to evaluate the associations between these state-level CON regulations and total hip arthroplasty (THA).

METHODS

States were designated as CON or non-CON based on existing laws. The 100% Medicare Standard Analytic Files from 2005 to 2014 were used to compare THA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the CON and non-CON states. Adverse postoperative outcomes were also analyzed.

RESULTS

The per capita incidence of THA was higher in non-CON states than CON states at each time period and overall (P < .0001). However, the rate of change in THA incidence over the time period was higher in CON states (1.0 per 10,000 per year) compared to non-CON states (0.68 per 10,000 per year) although not statistically significant. Length of stay was higher and a higher percentage of patients received care in high-volume hospitals in CON states (both P < .0001). No meaningful differences in postoperative complications were found.

CONCLUSION

CON laws did not appear to have limited the growth in incidence of THA nor improved quality of care or outcomes during the study time period. It does appear that CON laws are associated with increased concentration of THA procedures at higher volume facilities. Given the inherent potential confounding population and geographic factors, additional research is needed to confirm these findings.

Appropriateness of Percutaneous Coronary Intervention: Appropriate Use Criteria Outperform Certificate of Need

See Article by Chui et al.

Certificate-of-Need State Laws and Total Knee Arthroplasty

BACKGROUND

Many states in the United States have certificate-of-need (CON) programs designed to restrain health care costs and prevent overutilization of health care resources. The goal of this study was to characterize the associations between CON regulations and total knee arthroplasty (TKA) by comparing states with and without CON programs.

METHODS

Publicly available data were used to classify states in to CON or non-CON categories. The 100% Medicare Standard Analytical Files from 2005 through 2014 were then used to compare primary TKA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the groups. Adverse events such as infection and emergency room visits after TKA were also evaluated.

RESULTS

Although CON status was associated with lower per capita utilization of TKA, the annual incidence of TKA appears to have increased over time more rapidly in states with CON laws compared with non-CON states (overall increase of 5.6% vs 2.3%, P < .01). When normalized to the Medicare population, the incidence of TKA increased 2.0% in CON states, whereas it actually decreased 7.2% in states without CON regulations (P = .011). Average reimbursement (and thus Medicare spend) was 5% to 10% lower in non-CON states at all time points (P < .0001). In non-CON states, relatively more TKAs appear to be performed in lower volume hospitals. Examination of adverse events rates did not reveal any strong associations between any adverse outcome and CON status.

CONCLUSION

CON programs appear to have influenced the delivery of care for TKA. Although our data suggest that these laws are associated with lower per capita utilization of TKA and the use of higher-volume facilities, we were unable to detect any strong evidence that CON regulations have been associated with improved quality of care or have limited growth in the utilization of this procedure over time. Confounding population and geographic factors may influence these findings and further study is needed to determine whether or not these programs have served their purpose and should be retained.

Characteristics of Early and Late Adopting Hospitals Providing Percutaneous Coronary Intervention in Taiwan

BACKGROUND

Studies in the United States suggested that the characteristics of hospitals providing percutaneous coronary intervention (PCI) differed from those not providing PCI. However, little is known on the differences between the characteristics of early-adopting hospitals and those of late-adopting hospitals, and on their potential impacts on PCI volume and access.

METHODS AND RESULTS

We used inpatient claims data from 1997 to 2012 from the Taiwan National Health Insurance program to identify the hospitals offering PCI. Geographic information systems (GIS) were used to determine the population access to PCI hospital. As of 2012, 88 hospitals were capable of providing PCI. On the basis of the year that the hospitals started providing PCI, 32 hospitals were designated as early adopters (before 1998), 23 as early majority (1998-2002), 24 as late majority (2003-2007), and 16 as laggards (2008-2012). Hospitals that adopted PCI later were smaller in size and closer to an existing PCI hospital and had lower PCI volumes performed and less bypass surgery support. The median PCI volumes in 2012 were n=706, 330, 138, and 81 in early adopters, early majority, late majority, and laggards, respectively. Despite the low volume of PCI performed in laggard hospitals, the percentage with ST-elevation myocardial infarction and acute myocardial infarction as principal discharge diagnosis was higher than their early-adopting hospital counterparts. The percentage of the Taiwanese population living within 40 km of PCI hospitals (appropriate access defined in this study) was 95.7% in 1997 and 98.0% in 2002, and this has remained unchanged since 2002.

CONCLUSIONS

The characteristics of early-adopting hospitals differed from those of late-adopting hospitals. Despite lower PCI volume performed in late-adopting hospitals, many of them are in remote areas and provide needed and timely services for patients with acute myocardial infarction.

Association of various risk factors with prognosis and hospitalization cost in Chinese patients with acute myocardial infarction: A clinical analysis of 627 cases

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality in the developed world and is becoming increasingly more common in developing countries. The risk factors affecting the prognosis of Chinese patients may differ from those in other populations. This study was conducted to investigate the potential risk factors that may correlate with prognosis and hospitalization costs of Chinese AMI patients. A total of 627 hospitalized AMI patients were recruited and their general information and relevant laboratory parameters were collected. Accordingly, the patients were grouped into different subgroups and potential risk factors and their correlations with prognosis and hospitalization costs were analyzed. Age, high blood pressure, infarct location and percutaneous coronary intervention (PCI) were the variables significantly associated with the differences in the prognosis of AMI patients (P<0.05), whereas times and duration of hospitalization, high blood pressure, infarct location and PCI treatment were found to be significantly associated with the cost of hospitalization (P<0.05). However, the AMI patients enrolled in this study may not be representative of all AMI patients in China. In addition, the prognosis of these patients was limited to their hospital stay. Therefore, long-term follow-up requires careful assessment.

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.