The Doctor Weighs In

Remember how shocked we were when we first heard about Dr. Moon and Dr. Realyvasquez. These are the heart doctors who performed unnecessary cardiac procedures, including coronary artery bypass surgeries, at a Tenet Hospital in Redding, California.

These guys may have been at the far end of the spectrum when it comes to driving inappropriate cardiac care, however, a study in the March 7, 2007 issue of JAMA adds to the growing body of evidence that suggests that cardiac procedure rates are strongly influenced by competitive market dynamics and not just patient need.

A group of well-respected health services researchers, led by Brahmajee Nallamothu at the University of Michigan Medical School took a careful look at the impact of introduction of specialty heart hospitals in geographic areas that represent distinct markets for tertiary (advanced) cardiac care. As opposed to general hospitals, specialty heart hospitals provide services for, and generate revenue from, a narrow spectrum of diseases.

Some health policy gurus have argued that such specialization could lead to greater efficiency and better quality of care. However, others worry that adding excess capacity could drive demand, particularly if the owners of the hospitals are doctors in that same specialty. It doesn’t take a brain surgeon to understand that filling beds, operating rooms, and catheterization labs with high revenue patients is better for the bottom line than leaving them unused.

Of course, it is possible that new specialty hospitals would just compete with existing facilities in general hospitals, taking volume from them, but keeping the overall rates of services the same. But that doesn’t appear to be what happens when one of these cardiac specialty hospitals opens in a community. Instead, the JAMA study documents that there is an incremental increase in the number of coronary revascularization procedures performed after a specialty heart hospital opens. Capacity increases and more people get these procedures.

Now this study doesn’t prove that all of this capacity was supply-driven. In fact, some of the increase may be due to meeting unfilled need. The researchers tried to understand if this was indeed what was happening by comparing what occurred when a general hospital increased its capacity compared to what happened when capacity is increased via the opening a new specialty heart hospital. What they found was a greater increase in certain cardiac procedures in communities with a new heart hospital compared to those communities with a new cardiac program at a general hospital.

Of note is the finding that there is no increase in the number of PCI (percutaneous coronary interventions) in the subset of heart patients who might benefit most from that procedure (those coming into the hospital because of a heart attack), but there was a dramatic increase in the number of PCIs being done for individuals not having heart attacks, a situation in which there may be more discretion in deciding whether to do the procedure or not.

For all of you who think, more is better when it comes to health care, I suggest you read about Drs. Moon and Realyvasquez. They had some of the highest rates of coronary procedures in the country, but some of their patients would have been better off with nothing at all.

Pat Salber