اثرات بیمارستان تخصصی قلب در هزینه و کیفیت مراقبت های پزشکی

The recent rise of specialty hospitals – typically for-profit firms that are at least partially owned by physicians – has led to substantial debate about their effects on the cost and quality of care. Advocates of specialty hospitals claim they improve quality and lower cost; critics contend they concentrate on providing profitable procedures and attracting relatively healthy patients, leaving (predominantly nonprofit) general hospitals with a less-remunerative, sicker patient population. We find support for both sides of this debate. Markets experiencing entry by a cardiac specialty hospital have lower spending for cardiac care without significantly worse clinical outcomes. In markets with a specialty hospital, however, specialty hospitals tend to attract healthier patients and provide higher levels of intensive procedures than general hospitals.

The debate over the welfare implications of specialty hospitals – for-profit, physician-owned institutions that serve patients with a particular illness, such as cardiac disease – involves several issues of long-standing interest to economists. Opponents of specialty hospitals argue that theyare a vehicle to disguise kickbacks to physicians for referrals, and that they thereby contribute to the “medical arms race” of competition through the provision of medically unnecessary services.1 Opponents also argue that specialty hospitals “cherry pick” profitable services and healthy patients from general hospitals. Specialty hospitals, for example, are less likely than general hospitals to have emergency departments (US GAO, 2003b). In contrast, proponents argue that specialty hospitals are “focused factories” that not only offer their own patients more efficient specialized care but also lead neighboring general hospitals to become more responsive and up-to-date in their practices. These opposing views have been manifest in two distinct policy perspectives. If competition from specialty hospitals has social benefits, then state regulators and public insurers such as Medicare and Medicaid should allow, and perhaps even facilitate, their entry. If competition from specialty hospitals has social costs, however, then policy makers should set regulations and financial incentives to account for the negative external effects that specialty hospitals create. As a result of this debate, the federal government imposed an 18-month moratorium in December 2003 on Medicare reimbursement for care at new specialty hospitals to allow for greater analysis of their impact. Despite both practical and academic interest in this question, we are not aware of any existing research that has simultaneously estimated the effects of specialty hospital entry on health care costs and patient health outcomes; without information on both costs and outcomes, conclusions about welfare are necessarily speculative. In this paper, we assess empirically the two main hypotheses about specialty hospitals.We focus on the treatment of elderly Medicare beneficiaries with cardiac disease at single-specialty cardiac hospitals. Most of these hospitals are jointly owned by for-profit chains and the local cardiologists and cardiac surgeons who practice at the facilities. First, we estimate how the Medicare expenditures, treatments, and outcomes for patients in geographic areas that experienced specialty hospital entry between 1996 and 1999 changed over this period. If specialty hospital entry leads to lower expenditures and better outcomes, we would conclude that it increases welfare. If it leads to higher expenditures and worse outcomes, we would conclude that it decreases welfare. If it leads to lower expenditures and worse outcomes (or higher expenditures and better outcomes), we would calculate the implied cost per life saved of specialty hospital entry to determine its welfare effects. Our approach provides an unbiased assessment of the effects of specialty hospitals even if specialty hospitals select healthier patients for treatment, because it estimates the effect of specialty hospital entry by the difference in all patients’ expenditures and outcomes – not just those for patients at specialty hospitals – between entry and control geographic areas. It identifies the direct plus any spillover effects of specialty hospitals. The consistency of these estimates depends on the assumption that trends in the unobservable characteristics of patients and markets in entry versus control areas are uncorrelated with the unobserved determinants of costs and outcomes. We investigate the validity of this assumption in detail below.

What are the effects of specialty hospitals on the costs and quality of care of Medicare beneficiaries? Advocates of these hospitals contend that their focused mission improves quality and lowers costs. Critics contend that these (predominantly for-profit) hospitals concentrate on providing profitable procedures and attracting relatively healthy patients—leaving (predominantly nonprofit) general hospitals with a less-remunerative, sicker patient population. We find evidence in support of both of these hypotheses. Between 1996 and 1999, patients in HRRs with specialty-hospital entry experienced lower growth in expenditures than patients in control HRRs. This finding is robust to different specifications of the control group, and for AMI as well as other cardiac illnesses. The expenditure savings from entry is not driven by any particular HRR, by differential trends in Medicare reimbursement rates, or by changes in procedure or diagnosis mix. There is only weak evidence of differences in trends in health outcomes in entry versus control HRRs.Over a longer period, estimates of the efficiency benefits of specialty hospital entry are more dependent on assumptions about whatwould have happened in entry HRRs in the absence of entry. Under the assumption that entry HRRs would have remained at the same level of expenditures and outcomes as in 1993, entry reduces efficiency: entry does not affect cost, but leads to an increase in mortality. Under the assumption that entry HRRs would have retained their 1993–1996 trend in expenditures and outcomes in the absence of entry, entry improves efficiency: entry leads to both a reduction in expenditures and a decrease in mortality. Balancing this, there is evidence that specialty hospitals choose to enter markets with healthier patients, to provide additional intensive treatments of questionable cost-effectiveness, and to treat healthier patients within markets—behaviors that, under reasonable assumptions, may reduce social welfare. Specialty hospitals enter markets that have slightly lower pre-entry levels of mortality. In HRRs with a specialty hospital, those who attend specialty hospitals are much more likely to receive a profitable intensive cardiac procedure in the year after their onset of illness than those who do not, even controlling for demographic characteristics, diagnosis, and Medicare claims history. In addition, specialty hospitals have patient populations that are younger, more likely to be non-black and male, and healthier than their counterparts at general hospitals—characteristics that may be positively correlated with profitability. However, because we do not observe all of the determinants of costs, treatments, and health outcomes, we cannot definitively apportion the observed cross-sectional effect of specialty hospital admission into socially-constructive versus socially-harmful effects. These seemingly-conflicting findings are consistent with other research by one of us presenting a similarly mixed view of for-profit hospitals. For-profits increase market-wide efficiency by improving the performance of competing nonprofits (Kessler and McClellan, 2002) even though they themselves provide additional treatment that has only marginal medical benefit (Becker et al., 2005). Our study reaches a similar conclusion. Because the share of specialty hospitals in markets with a specialty hospital is only 6%, market-wide increases in efficiency from specialty hospital entry must come from entry-induced increases in efficiency at general hospitals, even though specialty hospitals engage in behavior that has the potential to reduce social welfare. Identifying the mechanism through which specialty hospitals improve general hospital performance is an important topic for future research. Future research might also focus on ways to alter the incentives provided by the Medicare reimbursement system to maximize the efficiency benefits from specialty hospitals while minimizing their costs. In addition, further analysis could investigate whether the entry of specialty hospitals impacts the provision of less-remunerative, non-cardiac services by general hospitals. Understanding the impact of specialty hospitals on other aspects of hospitals’ decision-making will allow for a broader assessment of the implications of specialty hospitals for social welfare.