ReviewEffects of physician-owned specialized facilities in health care: A systematic review
Introduction
In response to pervasive deficits in the quality of care [1] and skyrocketing health-care expenditure [2], the pressure to provide better and more efficient care continues to shape the health-care policy debate. Besides altering payment frameworks and the associated incentives (i.e. pay-for-quality initiatives), policymakers and providers have turned their attention to the way care is delivered. Specifically, care that has historically been delivered in a hospital inpatient setting can increasingly be performed in a more convenient short-stay or even ambulatory setting. Consequently, in the last two decades, specialized facilities have emerged beside the traditional full-service general hospital as alternative settings of care delivery. These specialized facilities are typically defined as hospitals that treat patients with specific medical conditions or those in need of specific medical or surgical procedures—most notably orthopaedic, spine, cardiac, and surgical procedures [3], [4]. Virtually all of these specialized facilities are either wholly or partly owned by physicians [3], [5], [6], [7].
The literature on the effects of physician-owned specialized facilities has expanded rapidly over the past decade. A great deal of research has been published on the theme, but the literature lacks an integrated and systematic overview on the extent to which the potential improvements in quality and cost of care are being realized. In addition, the feasibility of the approach becomes less clear when the corresponding impact on full-service general hospitals is taken into account.
Internationally, physician-owned specialized facilities have become a subject of intense policy debate. More precisely, proponents argue that these specialized facilities are ‘focused factories’, taking advantage of the associated economies of scale and scope. This potentially lowers the cost of healthcare delivery and possibly enhances the quality of care by concentrating the expertise associated with increased specialization [8]. In addition, ownership by physicians has been argued to improve quality of care, by reinforcing the physician's professional role as the primary enforcer of quality of care [9].
On the other hand, critics contend that physician ownership associated with specialized facilities presents a potential conflict of interest. Since physicians with an ownership stake generate additional revenue besides their professional fees, stronger financial incentives are induced, which could affect physicians’ practice patterns. This may lower thresholds for treatment, thus increasing the utilization of procedures [10] and focusing on the most profitable cases (e.g., well-insured patients and low-acuity procedures) [5]. This potentially undermines the financial health of full-service general hospitals [11].
The aim of this review is to assess and summarize the current evidence and to provide a structured, comprehensive overview of the evidence on physician-owned specialized facilities. We draw on the six dimensions of quality of care described by the Institute of Medicine [12]. Specifically, we investigate to what extent physician-owned specialized facilities are (1) safe, (2) effective, (3) equitable, (4) efficient, (5) patient-centred, and (6) accessible. In addition, we study (7) the impact on the performance of full-service general hospitals. Appendix 1 (Supplement) provides an overview.
Despite the increasing popularity of these facilities, no systematic evaluation or integration of the current evidence base has yet been conducted. Our results here are intended to inform policymakers of the nature of the evidence base. The next section describes the search strategy employed, as well as the inclusion and exclusion criteria. The results are presented for each dimension separately. The results are then integrated in the discussion, and the implications of our findings for research and policy are covered.
Section snippets
Data sources
This study draws upon an analysis of the literature from a systematic review perspective. The Embase, Pubmed, Cinahl, PsychInfo, Web of Science, and Eric databases, along with the Cochrane Library, were searched for relevant studies. The searches were conducted in October 2012 (Week 40). Two reviewers independently searched for relevant studies using a standardized strategy. The concepts of specialized facilities and the different dimensions of quality of care (explained above) were combined
Literature search
Our literature search initially yielded 6108 unique candidate articles. Their potential relevance was examined based on their titles, and 112 were selected for full-text retrieval (Fig. 1). The bibliographical references to these studies were examined in order to collect additional studies that had not been included in the records identified in the database search. In this way, 20 additional studies were included. On the basis of an abstract review, 75 articles (67 of which originated from our
Discussion
This paper provides an overview of the empirical literature on physician-owned specialized facilities. Our aim was to synthesize the available, though fragmentary, evidence. We structured the results according to seven substantive domains. As is typical of health services research, the reported effects are nuanced. However, the published results show some important findings.
Limitations and challenges
Our systematic review shows that the results of previous empirical studies are mixed and inconclusive. This finding supports the argument that determining and comparing hospital performance is highly complex, and that adequate measures of costs and quality are frequently not available [59]. In addition, when considering quality and the cost of the care provided, it is important to note that specialized facilities focus predominantly on elective procedures and have been found to treat more
Implications for research and policy
Notwithstanding these limitations, our findings have several implications. First, some studies have demonstrated improved performance of physician-owned specialized facilities as compared with full-service general hospitals. However, on this point the evidence base is too thin and insufficient to recommend a widespread policy of encouragement. Second, it is not clear to what extent these specialized facilities have an impact on the performance of full-service general hospitals, especially since
Conclusion
In this study, we reviewed the available evidence on physician-owned specialized facilities (specialized hospitals and ambulatory surgery centres). We examined the quality and cost of care at these facilities and their impact on the performance of full-service general hospitals. Our results show that little evidence exists in favour of physician-owned specialized facilities and that their impact to date on the performance of full-service general hospitals remains limited. Therefore, the
Declaration of conflicts of interest
The authors report no conflicts of interest.
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Evaluation of costs and outcomes of physician-owned hospitals across common surgical procedures
2020, American Journal of SurgeryCitation Excerpt :Critics of POH contend that physician ownership of a hospital is a direct financial conflict of interest. Specifically, POH may potentially aggravate healthcare disparities through deliberate targeting of lower-risk, wealthier patients, while also increasing resource utilization that in turn escalates cost of care.3–8 Meanwhile, proponents of POH claim that these hospitals are more efficient and provide better care with improved patient outcomes, in part due to the physician owner’s ability to risk-share around quality and cost of treatment.9–14
Financial considerations in outpatient spine surgery
2018, Seminars in Spine SurgeryCitation Excerpt :These results suggest that physician owners may be motivated by financial interests to perform more procedures and may lower their threshold for recommending surgical interventions to achieve this goal. Another criticism of physician investment in outpatient surgery centers is the potential for disparate referral patterns; mainly, stakeholders may be inclined to preferentially refer better paying patients to their ASCs over a traditional hospital which may instead see an increase in Medicaid or underinsured patients.37 Gabel et al. analyzed referral habits of physician owners and determined that they referred 92.1% of private insurance patients and 90.8% of Medicare patients to physician-owned facilities but only referred 55.4% of Medicaid patients to those facilities.40
Maximizing Physician-Hospital Alignment: Lessons Learned From Effective Models of Joint Arthroplasty Care
2018, Journal of ArthroplastyCitation Excerpt :Although the Affordable Care Act placed new restrictions on the expansion of physician-owned hospitals (POHs), supporters argue that POHs provide higher quality, more efficient care [3,23]. Full-service hospitals argue that POHs “cherry pick” only the healthiest of patients in higher reimbursing specialties, increase the cost of care while decreasing patient access [24–26]. In our practice, however, we found that for primary THA and TKA, patients at our POHs had a shorter length of hospital stay with no increase in resource utilization when compared to a matched cohort of patients at our full-service acute care hospitals [27].
Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program
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