Health Affairs: Fewer CABGs performed, more programs openedwhy?

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Despite the decreasing demand for CABG, 301 new cardiac surgery programs were opened at U.S. hospitals between 1993 and 2004, according to a study published online June 23 in Health Affairs. While travel time to the nearest cardiac surgery programs remained static, the researchers said that the duplication of services increased.

“The number of bypass surgeries performed in the U.S. increased during the mid-1990s, peaked in 1997 and decreased thereafter. Despite this, the number of new cardiac surgery programs continued to increase between 1993 and 2004. Has this expansion served patients and the healthcare system well?” asked Frances Leslie Lucas, PhD, associate director of the Center for Outcomes Research and Evaluation at the Maine Medical Center in Portland, Maine, and colleagues.

To better understand where new cardiac programs opened and the impact they had on access and efficiency, Lucas and colleagues used Medicare data from the Medicare Provider Analysis and Review files to identify all hospital performing CABG from 1992 to 2004.

While Lucas et al suggested the incentive for developing a new surgery program would be to improve access to care; it also may be due to the fact that cardiac services are important revenue drivers. In fiscal year 2004, cardiac surgery was tapped as the third most profitable surgical service, after neurosurgery and transplant surgery.

The authors noted that cardiac services contribute to 25 to 40 percent of hospitals' net revenues.

As far as the development of new CABG programs, a dilemma for policy makers is portraying how these services will improve care access and without increasing demand and duplicate services. Due to the fact that the demand for CABG surgery has decreased, Lucas et al offered that this may result in unnecessary duplicative services.

Of the 301 new programs that opened between January 1993 and September 2004, 276 were opened in general hospitals and 25 opened in specialty hospitals. The researchers reported that the majority of these new programs were opened in the East and Midwest regions of the U.S., and a very high concentration in the mid-Atlantic region.

Previously, those looking to open a new program had to demonstrate the need for and capacity of providing high-cost new medical services through the certificate-of-need process; however, many states repealed these laws after the federal mandate for their provision was repealed.

Results showed that of the 276 general programs developed, 53 percent opened in states with certificate-of-need regulations and all specialty hospitals opened in states without this need.

Lucas et al found that 42 percent of the new cardiac surgery programs (37 percent of general programs and 100 percent of specialty programs) were opened in competitive market environments. In addition, 6.5 percent of general programs and 28 percent of specialty programs opened in the same ZIP Code where another CABG program already existed—31.9 percent of general programs and 80 percent of specialty programs opened within five miles of an existing program.

Between 1993 and 2004, the median travel time for Medicare beneficiaries declined from 17 minutes to 14 minutes. In 1993, 36 percent of beneficiaries lived more than 30 minutes away from the nearest cardiac surgery program and in 2004, this number fell to 28 percent. The researchers reported that travel times were longer for residents in rural areas compared with those living in urban areas.

“The close proximity of these new programs to existing programs resulted in a negligible decrease in travel time for the 72 percent of Medicare beneficiaries who live in urban areas,” the authors wrote. “Thus, these programs have done little to improve geographic access overall. Instead, their creation has led to a fight for shares of a shrinking market.

“Our results show the negative impact when the creation of new healthcare services is not carefully planned,” the authors wrote. “New specialty programs opened in an especially inefficient pattern. In fact, all of these programs opened within 20 miles of existing programs."

Some hospitals probably added cardiac surgery programs so that they could perform primary PCI, they suggested. "Increasing access to primary coronary interventions might be a positive effect of new cardiac surgery programs,” the authors wrote.

Lucas et al concluded that certificate-of-need processes may be one way to avoid spending money and duplicating services. “If the nation is serious about restraining the rate of growth of health spending, such programs may need to be reinvigorated or reinstituted in states that have dismantled them.”