More Money Is Made, But It Doesn’t Appear that More Lives Are Saved…

There’s a new trend in the delivery of medicine: Specialty hospitals that focus on a single, lucrative area of care such as cardiology or orthopedics. The idea is that a more efficient and focused health care model will enable physicians to deliver a higher standard of care that costs less. After all, it has long been recognized that the higher volume of a particular surgery performed at a medical center — whether it’s removing a gallbladder, opening a blocked artery or replacing a hip — the better outcome, on average. Using this rationale, specialty hospitals make sense, don’t they?

Well, not really. Though the argument might be made for more quality control and cost-effective care, there are other factors that can influence outcome data — for instance, heart hospitals attract patients who are healthier and wealthier. So, it’s hard to know definitively whether they achieve better results than hospitals where a comparable volume of similar procedures are performed. And now a new study demonstrates that when a specialty heart hospital is opened in a neighborhood, suddenly more heart procedures — in one case a 42% higher rate of elective heart procedures — are performed.

AT THE HEART OF THE MATTER: POLITICS AND PROFITS

To learn more about specialty hospitals in general and heart hospitals in particular, I spoke with University of Iowa researcher Peter Cram, MD, who is involved in research on the impact of specialty hospitals on the delivery of care to financially vulnerable populations. He told me that specialty hospitals are usually for-profit facilities owned at least in part by doctors who refer their own patients to them. Most that have opened since 1990 are located in states lacking a “certificate of need” permit for the construction or expansion of health care facilities (such as Texas, Arizona, California, Kansas, Louisiana, Oklahoma and South Dakota).

CLEAR CONFLICTS OF INTEREST

The conflicts of interest aren’t hard to identify. Critics instantly pointed out that when doctors share in hospital ownership, they’re more likely to refer patients for procedures there since financial incentives add to the medical considerations. This in and of itself could account for the significant rise in the volume of expensive and specialized procedures. Another problem is that these specialty facilities rapidly earned a reputation for “skimming” the healthier, better-insured patients, leaving the burden of caring for the sicker and uninsured on general hospitals.

At the VA Health Services Research and Development Center of Excellence in Ann Arbor, Michigan, researchers examined the provision of heart care for Medicare beneficiaries 65 and older in various regions around the country between 1995 and 2003. Their goal was to determine whether specialty heart hospitals were associated with an increase in volume of heart procedures to unblock clogged arteries — specifically, coronary artery bypass surgery (CABGs) and “percutaneous coronary interventions” (PCIs, which are less invasive artery-opening techniques, such as angioplasty and stenting).

The researchers found that four years after the opening of a new heart hospital in a region, the rate of heart procedures performed in that area doubled when compared with those where no new specialty hospital opened or even where heart programs were opened at a general hospital. The numbers were more dramatic when it came to post-heart attack PCI procedures (emergency) versus non-emergency (elective) PCIs — in the latter, the medical benefits are less clear-cut. When a specialty heart hospital opened in a particular community, the rate of elective PCIs jumped by 42%. This was nearly twice the rate of growth for these procedures in regions where a general hospital had recently added cardiac services (23%), or where no new cardiac care facilities opened (24.8%). These results were published in the March 7, 2007, issue of the Journal of the American Medical Association.

There is sufficient concern on this topic that the federal government put a ban on opening new specialty hospitals in 2003 (which expired in 2005) and denied Medicare coverage at these facilities as well. Now a host of new specialty hospitals for cardiac care and orthopedic care are scheduled to open around the country, sparking renewed controversy and debate.

PUT YOUR HEART IN THE RIGHT HANDS: CHOOSING YOUR HOSPITAL

Whenever you go to the hospital, whether it’s for a major or minor problem, you need to ensure you are in the best hands possible. In Dr. Cram’s opinion, that means the most experienced hands. Facilities that perform the highest volume of the particular procedure you require — whether general or specialty hospitals — remain the safest and most effective choice. Also, it’s best to get a second opinion prior to undergoing such a procedure.

Additionally, hospitals are required to be ever more transparent about reporting on quality — including medical errors, outcomes and more. Asking a physician you trust for advice always makes sense, but now you can also do your own research by going on-line to compare and contrast all types of hospitals in your area on various Web sites, including…

  • www.jointcommission.org. To see how hospitals stack up against one another, visit the free Web site of The Joint Commission and click on “Quality Check.”
  • www.leapfroggroup.org. This not-for-profit, employer-based coalition tracks data on 30 safety and quality practices at more than 1,300 hospitals around the country.
  • www.hospitalcompare.hhs.gov. A Web site of the US Department of Health and Human Services, this resource contains free performance reports on thousands of hospitals.