PA’s in the wild, wild West for cardiac surgery’
The question: More regulation or less?
A source who requests anonymity told Hospital Peer Review he thinks there’s a dangerously low level of regulatory oversight in Pennsylvania. "Quality managers in some states complain of redundant regulation," he says, "and some would say that Pennsylvania has a more rational situation. But considering the changes going on in the fundamental structure of health care delivery — consolidations, expansions, and integrations — we don’t have nearly enough oversight."
Ensuring that quality of care is not jeopardized in the face of these financial difficulties and new arrangements is a severe challenge. Managed care is putting strains on hospitals and physicians to reduce utilization. This is not the time for less regulation, he says, but rather for more regulation or at least different regulation.
The source, a health care analyst, tells Hospital Peer Review that this summer, the state government decided that the Department of Health would no longer do routine hospital inspections. They would leave it up to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
Deregulation leads to proliferation
Pennsylvania’s certificate-of-need (CON) approval requirement was allowed to sunset a couple of years ago, and since then at least six hospitals in that state have begun offering bypass surgery. David B. Nash, MD, MBA, associate dean and director for health policy at Thomas Jefferson University in Philadelphia, has commented that Pennsylvania is in the "wild, wild West at this point for cardiac surgery."
Ted Ackroyd, director of QuadraMedi Corpor a tion, a Harrisburg, PA-area data analysis firm, says the result of allowing CON to sunset in Pennsylvania is an increase in the number of services offered. "Supply has increased," he says. "Has demand increased in an equivalent and proportional manner? Not likely." More providers are doing fewer services, he says, so they’re probably not getting appropriate experience or are being continually challenged.
Tom Piper, director of the CON program in Missouri’s Department of Health and past president of the American Health Planning Association in Falls Church, VA, says, "When Pennsylvania’s CON was permitted to sunset in late 1996, they were stunned. What do you do after CON? One statement was repeatedly made: If the CON did anything really well, it was to make sure that planning was a visible part of the acquisition process — for equipment and capital expenditures."
Under CON, planning questions were asked throughout the process. Officials had to make sure the plan in place was good. "Without CON," says Piper, "where do you find that planning resource?" They’re now working in Pennsylvania to convert what was previously the CON into quality and licensure standards.
Hospital Peer Review asked Stan Lane, director of the CON department for the state of Vermont in Montpelier, if he thought quality was suffering as thresholds for review are being raised.
Where do you draw the line?
"In a number of high-tech areas, we do have concerns about maintaining expertise as volumes decrease," says Lane. "If you do only 10 heart surgeries a year, there’s some question about whether your staff has enough experience to do a good job. That would hold true for other high-tech procedures as well." There’s discussion in a number of sections of Vermont’s Health Resource Management Plan about making sure providers have enough expertise and that the volumes are there. (See chart on Vermont’s hospital days and population, p. 202.)
"There’s reason to have regulation of some sort," says Lane, "especially oversight of organizations providing the more complicated services. A lot of states have moved away from CON laws and toward quality, licensing, and professional certification instead. Those are other routes toward regulatory oversight."
In Vermont, health care facilities are subject to CON review when they propose any new construction or the acquisition of diagnostic or therapeutic equipment costing more than $250,000. They also have to apply for any new health service that has an annual operating expense of more than $150,000.
Lane says, "We raised the thresholds for review for the CON in Vermont two years ago." For example, before 1996 the state would review any capital expenditure by any health care facility that exceeded $300,000. That threshold was raised to $1.5 million in hospitals and $750,000 in other facilities.
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