The business of health care: financial ownership increases surgeries

Several decades of health care research has found wide geographic variation in your likelihood of receiving certain elective procedures that aren't tied to your health or even your personal preferences, but to the number of doctors providing those procedures. These patterns have been charted, literally, in the Dartmouth Atlas of Healthcare. And now a new study, from researchers not affiliated with the creators of the Dartmouth Atlas (who are my employers) report another potential non-health related link to the increase in unnecessary surgeries: Doctors' ownership of surgical centers.

Specialty surgical centers are private operations separate from hospitals, and in 83% of them the doctors providing care in them also have a financial investment stake in the businesses. They are becoming an increasingly familiar piece of the hodge-podge health care system in the US, with 50% more opening up over the past decade. Researchers from the University of Michigan looked at all patients in the state of Florida who had one of five common procedures: Carpal tunnel release, cataract surgery, colonoscopy, knee arthroscopy, and ear-tube placement. After finding out who the doctors were, researchers compared rates of surgery in two time periods: An earlier time period when none of the docs had a financial stake in their place of practice, and a second time period when a large percentage did have a stake. Over time all the docs performed more procedures, but those with a financial stake in their place of practice operated on twice as many patients as those with no such financial stake. And it wasn't just that they were high-volume before buying into their own practices, their increased procedure rates were only apparent after they gained financial stake in their centers.

While the researchers aren't crying malpractice, they believe that owner-operators may be lowering the bar for when they recommend surgery. Assuming that their decision to operate isn't based on recommended practice guidelines, and is not a function of informed patient choice (both of which are good bets), this amounts to many thousands of potentially unnecessary surgeries associated with risks, discomfort, and many health care dollars that might otherwise have paid for care that actually helps maintain health or cure disease.  Other research, much of it from Dartmouth Atlas researchers, suggests that up to 30% of elective health care procedures such as non-emergency angioplasty, are unnecessary. As such they can only cause harm.

Does this amount to innocent differences in medical opinion, or conflict of interest? Would you be leery of a doctor who performs twice as many surgeries than the average, or merely view him/her as confident and experienced in their procedure?

Photo credit: The author