Published 10/27/2020
Kaitlyn D’Onofrio

Cost-effectiveness Analysis of Anterior Cervical Diskectomy and Fusions at Physician-owned Versus Nonphysician-owned Hospitals

Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.

A new study assessed the impact of sanctions imposed by the Affordable Care Act (ACA) on the creation and expansion of physician-owned hospitals (POHs). The researchers compared safety and cost-effectiveness of elective one- to three-level anterior cervical diskectomy and fusions (ACDFs) performed at physician-owned versus nonphysician-owned hospitals. They concluded that not only do ACDFs performed at POHs yield significant cost savings, they also result in fewer 90-day medical complications and readmissions. The findings of the study were presented as part of the Annual Meeting Virtual Experience.

“While POHs have been around for quite a while, they have been shrouded in quite a bit of controversy. Due to concerns surrounding practices of cherry-picking, a financial incentive toward driving up costs and/or questionable delivery of high-quality care, the ACA placed a restriction on the formation of new POHs and prevented the expansion of current facilities in the study,” Azeem Tariq Malik, MBBS, a spine research fellow in the Department of Orthopaedics at the Ohio State University Wexner Medical Center, told AAOS Now.

“As the healthcare system now begins to move toward implementing value in delivery of care, there has been a renewed interest to evaluate this so-called restriction so as to ensure that access to care is maintained for an ever-rising [older] population. Unfortunately, current evidence regarding differences in quality and cost of care between physician- and nonphysician-owned hospitals is largely limited to nonorthopaedic and/or general surgical literature.”

The researchers collected national Medicare claims data spanning 2005 to 2014 on patients undergoing elective one- to three-level ACDFs. Comparisons were made based on whether patients were treated at physician- or nonphysician-owned hospitals; differences between 90-day complications, readmissions, and costs were assessed.

Despite different patient populations, POHs came out on top

Elective ACDFs were performed at 45 POHs and 1,843 nonphysician-owned hospitals. Most patients (n = 249,999, 97.3 percent) were treated at a nonphysician-owned hospital, whereas 6,962 (2.7 percent) went to a POH. Dr. Malik noted that although the patient population was slightly younger at POHs, the overall comorbidity burden was comparable between the groups.

When adjusting for various confounding patient and hospital (socioeconomic status area, urban versus rural location, and annual case volume) factors, patients who underwent elective ACDFs at POHs (versus to nonphysician-owned hospitals) had lower risks for cardiac complications, septic complications, deep vein thrombosis, renal complications, and readmissions. There were no significant differences regarding wound complications, pulmonary complications, urinary tract infections, pain complications, dysphagia, or revision surgery between the two hospital types.

Patients who were treated at POHs, compared to nonphysician-owned hospitals, incurred significantly lower risk-adjusted inpatient (–$1,517) and 90-day (–$1,927) costs.

The results did not come as a surprise to the researchers and generally echoed previous research findings. The outcomes “make sense,” according to Dr. Malik: “When physicians are given control over the administration of their clinical practice and day-to-day management, they are in a better position to implement changes that are best targeted to improve the quality of care.”

Contrary to popular perception, “POHs do not do worse in terms of value of care, with lower rates of complications and costs across the 90-day episode of care,” said Dr. Malik. “The finding supports the current discussion on the reintroduction of physician-owned facilities back into the healthcare market.”

The results point to two key future research topics, Dr. Malik shared: (1) Why is care better at POHs? (2) How will expanding POHs affect competition in the market?

A limitation of the study is that it relied on the Medicare claims database, preventing the researchers from performing more in-depth analyses on functional and patient-reported outcomes.

The authors concluded: “The findings call for the need to reevaluate/reconsider the ACA’s restriction on the expansion of these POHs.”

Dr. Malik’s coauthors of “Anterior Cervical Discectomy and Fusions at Physician-Owned Hospitals—Is it Time to Reconsider the Sanctions of the Affordable Care Act?” are Frank M. Phillips, MD; Sheldon M. Retchin, MD; Wendy Xu, PhD; and Safdar N. Khan, MD.

Kaitlyn D’Onofrio is the associate editor for AAOS Now. She can be reached at kdonofrio@aaos.org.