Access, quality, and costs of care at physician owned hospitals in the United States: observational studyBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4466 (Published 02 September 2015) Cite this as: BMJ 2015;351:h4466
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Re: Access, quality, and costs of care at physician owned hospitals in the United States: observational study
I would like to thank Mr. Ramsey for his insightful comments. I very much agree that social factors, including socioeconomic status, environment, education, and several others, play a critical role in determining access to health care services generally, and to high quality health care in particular. However, I am unaware of research showing that physician owned hospitals (POHs) preferentially avoid opening in poorer communities, or communities with larger proportions of underrepresented minorities, and Mr. Ramsey does not cite evidence to support his claim that POHs are preferentially avoiding these communities. More than 84% of POHs in our study were located in urban areas, versus 70% of Non-POHS. Thus, POHs do not appear to be avoiding urban locales.1 To be sure, we did not examine the demographics or socioeconomic status of the communities in which POHs operate, and it is quite possible that they locate preferentially in urban communities which are wealthier and less ethnically diverse than those to which Dr Ramsey refers in his letter. However, additional research is necessary to evaluate this hypothesis.
Mr. Ramsey's point that we did not evaluate the socioeconomic status of minority patients who received care at POHs and non-physician owned hospitals (non-POHs) is an interesting and valid one. Patients who receive care at specialty hospitals have been found to be wealthier than patients who receive care at general hospitals.2,3 To my knowledge, no study has ever demonstrated that these findings extend to POHs and Non-POHs. Emergency rooms (ER) serve as a critical means by which poorer, less well insured, and uninsured patients gain access to a health care services. We found that 29.0% of Non-POH admissions came through an ER, compared to 23.2% of POH admissions. In analyses originally conducted for, but not published with, the manuscript, ER visits accounted for 27.5% and 8.8% of general POHs’ and specialty POHs’ inpatient admissions, respectively (p <0.0001). A 2008 study performed by the Office of the Inspector General (OIG) showed that only half of specialty POHs have an ER, and that the majority of these ERs have just one hospital bed.4 Thus, it is quite possible that less wealthy patients’ access to specialty POHs is limited by the lack of ER capacity at these facilities (in addition to other factors). However, the same cannot be said of general POHs, which appear to admit comparable proportions of patients as Non-POHs through their ERs.
Mr. Ramsey's assertion that we compared non-POHs to general POHs, and POHs to specialty POHs, but "failed to compare” non-POHs to specialty POHs is inaccurate. Indeed, our study compared all POHs to all non-POHs in hospital referral regions with a POH. We then ran additional analyses which compared general POHs and specialty POHs. However, we neither compared general POHs with non-POHs, nor consciously chose to avoid comparing specialty POHs with non-POHs. What is very clear from our analyses, however, is that general POHs and non-POHs look very similar to each other in terms of their quality of care, case-mix, proportions of Medicaid and minority patients, and costs of care. In addition, compared to patients at general POHs, specialty POH patients are healthier, less likely to be on Medicaid, less likely to be black or Hispanic, and more likely to be readmitted within 30 days of discharge. While "eyeball" comparisons of these outcomes at non-POHs and specialty POHs demonstrates similar differences to those seen in comparisons of general and specialty POHs, we did not run analyses to confirm their statistical significance. Finally, Mr. Ramsey does not explain why he finds the omission of this comparison to be "concerning.” Without such an explanation, I’m afraid that I’m unable to address this particular apprehension in more detail.
Daniel M. Blumenthal MD, MBA
Massachusetts General Hospital
Harvard Medical School
1. Blumenthal DM, Orav EJ, Jena AB, Dudzinski DM, Le ST, Jha AK. Access, quality, and costs of care at physician owned hospitals in the United States: observational study. BMJ 2015;351.
2. Cram P, Vaughan-Sarrazin MS, Wolf B, Katz JN, Rosenthal GE. A Comparison of Total Hip and Knee Replacement in Specialty and General Hospitals. The Journal of Bone & Joint Surgery 2007;89:1675-84.
3. Hwang CW, Anderson GF, Diener-West M, Powe NR. Comorbidity and Outcomes of Coronary Artery Bypass Graft Surgery at Cardiac Specialty Hospitals Versus General Hospitals. Medical Care 2007;45:720-8.
4. Physician-Owned Specialty Hospitals' Ability to Manage Medical Emergencies. In: General OotI, ed. Washington, DC: Department of Health and Human Services; 2008.
Competing interests: No competing interests
I would like to commend Dr. Blumenthal et al. on their research on the access, quality and costs disparities that exist between physician owned hospitals (PHOs) and non-PHOs. The authors have, however, overlooked a few very important aspect in carrying out their research. Namely, they have failed to address how the establishment of PHOs, especially specialty PHOs, in non-urban areas restricts access to those facilities for minority and poor populations.
While it may be argued that PHOs are not actually pushing away minority and poor patients, by failing to establish PHOs in urban areas which serves these population, PHOs are implicitly making a stance that the minority and poor population is not their desired population. The social determinants of health are those personal, social, economic, and environmental factors that play a major role in an individual’s health outcomes. Such factors are vitally important in determining health equity. The research conducted by Blumenthal et al. does not address how the absence of PHOs in minority or poor neighbors impacts the overall health of the community. Even in the information that states that the minority populations that are served by non-PHOs and PHOs are similar, the authors fail to explore the socioeconomic status of those minorities, which may have made a difference in their ability to access PHO services. Equally interesting and concerning is that while the authors compare non-PHOs to general PHOs, and PHOs to specialty PHOs, they fail to compare non-PHOs to specialty PHOs.
In summary, the authors’ research is to be commended, however, any research into access and quality disparities is incomplete without considering that role of social determinants of health.
Mario D. Ramsey, JD, MPH
Satcher Health Leadership Fellow,
Morehouse School of Medicine
Competing interests: No competing interests