Medical Device Daily

Across the country, states are embroiled in a debate over specialty hospitals, physician-owned hospitals that focus on a single disease process such as heart care or orthopedics. The debate has intensified ever since a federal government moratorium on opening new specialty hospitals expired last year.

The moratorium was part of the Medicare Prescription Drug Improvement and Modernization Act of 2003, which expired in 2005, but Congress extended it to August 2006 as part of 2005’s Deficit Reduction Act.

The issue heated up even more after the Jan. 23 death of a patient at West Texas Hospital (Abilene). Steve Spivey, a 44-year-old truck driver from Gorman, Texas, went into respiratory arrest after elective spinal surgery, and West Texas, lacking an emergency department, called 911. Spivey subsequently died at a hospital in the same town, Abilene Regional Medical Center.

The incident provoked a fresh round of outrage on Capitol Hill, in part because West Texas has garnered substantial reimbursement from the Centers for Medicare & Medicaid Services, despite the moratorium (Medical Device Daily, Feb. 14, 2007).

Now, a new study reveals more about the effect that new “heart” hospitals might have on heart care, and healthcare, usage in their local area, and suggesting a corollary to the “build it and they will come” rule.

Specifically, the study analyzes Medicare beneficiaries age 65 or older and indicates that the opening of a new specialty cardiac hospital is associated with a rise in heart procedures to open clogged arteries such as bypass surgery and angioplasties. The rise was twice as great as the rise that occurred in regions where an existing general hospital chose the alternative adding heart services, or where no new heart care facilities opened.

The data differ from previous findings, which suggested an uncertain relationship between heart hospitals and heart care use, according to its authors.

While the study wasn’t designed to look at whether each heart procedure was medically warranted, the authors note that the launch of a specialty hospital appears, in particular, to drive up the use of angioplasty in patients without heart attacks — a group where the procedure’s long-term clinical benefit may be less clear.

The findings, published in the March 7 issue of the Journal of the American Medical Association, come from a team from the University of Michigan (U-M) Cardiovascular Center, the VA Ann Arbor Healthcare System and the Michigan Surgical Collaborative for Outcomes Research and Evaluation (all Ann Arbor), and their colleagues from Harvard University (Cambridge, Massachusetts) and Yale University (New Haven, Connecticut). The Agency for Healthcare Research and Quality (Rockville, Maryland) paid for the study.

“This is the first study to show that specialty cardiac hospitals increased the use of these procedures in the hospital markets where they opened, compared with regions where existing hospitals added heart care services or regions where there was no change in heart care services,” said lead author Brahmajee Nallamothu, MD, an assistant professor of cardiovascular medicine at the U-M Medical School and interventional cardiologist at the U-M Cardiovascular Center. The authors emphasize that the specialty heart hospitals in the study are different from heart centers that operate as part of larger hospitals.

In many states in the U.S., especially in the South and West, specialty heart hospitals owned and operated by physicians cropped up throughout the late 1990s and the early part of this decade.

But in 2003, the moratorium halted the opening of new ones, due to concerns over the potential for doctors who co-own specialty hospitals to be influenced by financial rather than medical reasons when referring patients for hospital care. Concern has also arisen about specialty hospitals’ potential to “skim” the most lucrative patients from a region, leaving other hospitals with sicker and uninsured patients.

Meanwhile, advocates for specialty hospitals say they increase quality and efficiency of care by focusing clinical expertise for these disease processes.

In August 2006 the CMS presented a strategic plan to address the long-term development of specialty hospitals. The plan recommended adjustments to Medicare payments to limit financial incentives as well as rule changes to require physicians to disclose their financial interests to patients and to the government. Failure to comply with such requirements would cost a hospital as much as $10,000 a day (MDD, Aug. 17, 2006).

New specialty hospitals continue to be planned around the country, however, spurring considerable debate.

The new study used Medicare data from 1995 to 2003, and focused on heart hospitals that offered bypass surgery or percutaneous coronary intervention (PCI), which includes angioplasty, stenting and related procedures. The researchers looked at patterns of use within 306 hospital referral regions (HRRs), representing unique hospital markets for specialized care. After identifying 13 HRRs where one or more specialty cardiac hospital opened during the study period, the team calculated population-based rates for each year across the U.S.

In every region, the use of PCI rose steadily over the time period, and the use of bypass surgery was level in the 1990s and declined in the early 2000s reflecting a well-known national trend toward minimally invasive techniques instead of surgery to reopen clogged heart arteries. In that same time period, many general hospitals began to offer PCI for the first time.

But the use for these procedures rose even faster in the HRRs where a specialty cardiac hospital opened.

Four years after the specialty cardiac hospitals opened, the population-adjusted rates of heart procedures in their surrounding HRRs had grown by more than twice as much as the rates in HRRs where no specialty hospital had opened. There was no major difference in those rates when the researchers compared HRRs where a new heart program had begun at a general hospital, and HRRs where no new heart services launched.

When the researchers separated the bypass surgery numbers from the angioplasty and other PCI numbers, they found the same effect. And when they considered post-heart attack emergency PCI rates with PCI rates for patients who had not had a heart attack, the difference was much greater. In regions where specialty heart hospitals opened, the rate of these non-emergent PCI procedures rose 42% in four years, compared with a 23% rise in areas where a general hospital offered new heart services, and a 24.8% rise in areas where no new services began.

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