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Jonathan D. Ketcham and Michael F. Furukawa Hospital-Physician Gainsharing In Cardiology Health Affairs, May/June 2008; 27(3): 803-812. [Abstract] [Full Text] [PDF] [Appendix Exhibits] [Reprints & Permissions]

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In Support Of Physician-Ownership

Larry Ozeran   ( 11 June 2008 )

Conclusions About Gainsharing Based On Flawed Assumptions

Ziyad M. Hijazi, Bonnie H. Weiner   ( 1 July 2008 )

In Support Of Physician-Ownership 11 June 2008
Larry Ozeran, Surgeon Send comment to journal: Re: In Support Of Physician-Ownership doc{at}DrOzeran.com Larry Ozeran	Each study similar to this, which demonstrates the value of physician involvement in the activities of hospitals, explains why physicians' ownership of hospitals is beneficial. The complaint by hospitals not owned by physicians that there is a self-referral issue is spurious. If you own an auto body shop and your friend wrecks her car, you want her to come to you to ensure that she gets the best service possible. Physicians want their patients treated in a facility in which they have maximum control over quality, and when they own the facility, they also have an incentive to minimize costs. This incentive is comparable to gainsharing and enables physician-owned hospitals to specialize in and become expert at treating a narrow range of patients. This is no different than specialization of physicians, which has led to more effective therapies in many fields like cardiac surgery, oncology, and critical care medicine. Those who support true reform of our health care system should include support for physician hospital ownership as part of their plan because it promotes better care at lower cost. [Disclosure: Dr. Ozeran has ownership interest in a surgical hospital now under construction.]
Conclusions About Gainsharing Based On Flawed Assumptions 1 July 2008
Ziyad M. Hijazi, President The Society for Cardiovascular Angiography and Interventions, Bonnie H. Weiner Send comment to journal: Re: Conclusions About Gainsharing Based On Flawed Assumptions zhijazi{at}rush.edu Ziyad M. Hijazi, et al.	As President and Immediate Past President of the Society for Cardiovascular Angiography and Interventions (SCAI), we have several key concerns about the assessments made and conclusions offered in “Hospital-Physician Gainsharing in Cardiology” by Jonathan Ketcham and Michael Furukawa. The authors conclude that gainsharing, in which physicians are provided financial incentives for reducing hospital spending, helped promote a shift from higher-cost drug-eluting stents (DES) to lower-cost bare metal stents (BMS) and that there was also a greater use of antithrombotic therapy. In addition, the authors conclude that this shift resulted in significant savings to the hospitals -- and suggest that this shift be adopted by physicians and hospitals nationwide. We believe that the authors’ conclusions are flawed on numerous points. Many of the changes they attribute to the gainsharing program were more likely due to changing clinical practice during this time period, as a result of significant new research. Additionally, the conclusions are flawed by the narrow scope of the study; the secondary effects of greater restenosis with BMS were not considered. We question the conclusion that the shift from DES to BMS was due solely to the impact of gainsharing. Without a control or comparison group, which the investigators appear not to have used, it is not possible to assess this accurately. We believe that this shift could just as easily have been due to clinical judgment that prevailed at the time that the study was conducted, thereby reflecting new scientific data, uniformly changing practice patterns, and consideration for best patient care. More importantly, the authors did not account for the probability that the shift from DES to BMS led to significantly more repeat procedures among BMS patients than would have occurred among DES patients. This is a significant omission, given that there is ample and incontrovertible clinical evidence that, compared with BMS, DES dramatically reduce restenosis and the need for repeat procedures. Although the initial BMS procedure costs less than the DES procedure, the costs incurred over the next 12 months may not be reduced if far more BMS patients have to undergo additional procedures later if restenosis develops. This information is not presented in the article. Moreover, without taking into consideration patient readmissions to the hospital for repeat procedures, how can the authors suggest that a shift from DES to BMS is in the patients’ best interest or represents an opportunity for cost savings? Recent data suggest the opposite -- that DES, not BMS, result in overall cost savings.[1] Next, for the purposes of the study, antithrombotic therapy is not well defined. Indeed, the authors’ findings regarding antithrombotic therapy may actually suggest that the loading dose of antiplatelet agents should be increased. Finally, we would stress that the focus of this study may have been misguided, considering the short-term cost savings that might be realized with BMS rather than the potential for significant longer-term savings that DES provide. Even more important is the individual patient’s experience and long-term outcomes. The medical literature strongly supports DES as the better option for patients whose lesions can appropriately be treated with DES as long as those patients are willing and able to comply with prescribed antiplatelet therapies for at least one year. SCAI has not taken a position for or against gainsharing, nor will the Society do so until it is well-demonstrated that gainsharing is or is not in the best interest of patients. However, we do believe that negotiating price reduction as part of the gainsharing process is a promising concept that, if used appropriately, might allow physicians to work with hospitals to reduce costs while measuring and maintaining quality as well as improving patient outcomes. The Office of Inspector General (OIG), U.S. Department of Health and Human Services, has developed helpful guidelines for gainsharing arrangements that are aimed at keeping the focus on individual patients while making conscientious efforts to reduce costs. For example, the OIG recommends that gainsharing initiatives be monitored closely for any inappropriate or dramatic increases in procedural volume, that patient outcomes be measured and tracked, and that no party involved in the gainsharing relationship be overcompensated. We hope that in its continued involvement in this issue, the OIG will expand its guidelines to include long-term implications of gainsharing -- specifically, the implications of more than one hospitalization on overall outcomes. In all matters related to the care of patients, SCAI supports well-constructed research that will lead to improved patient care and outcomes. This includes the study of gainsharing and its impact on the delivery of quality care. While we commend Ketcham and Furukawa for their attempt to further explore the impact that gainsharing might have on the delivery of cost-effective care for interventional cardiology patients, we encourage them and other researchers to be cautious in the conclusions they draw from rather narrow assessments. Reference 1. Bakhai A, Stone GW, Mahoney E, et al. Cost effectiveness of paclitaxel-eluting stents for patients undergoing percutaneous coronary revascularization results from the TAXUS-IV Trial. J Am Coll Cardiol 2006;48(2):253-61.