Physician division of labor and patient selection for outpatient procedures

Abstract

Little is known about the ability of incentives to influence decisions by physicians regarding choices of settings for care delivery. In the context of outpatient procedural care, the emergence of freestanding ambulatory surgery centers (ASCs) as alternatives to hospital-based outpatient departments (HOPDs) creates a unique opportunity to study this question. We advance a model where physicians' division of labor between ASCs and HOPDs affects the medical complexity of patients treated in low-acuity settings (i.e. ASCs). Analyses of outpatient surgical procedure data show that physicians working exclusively in low-acuity settings (i.e. ASCs) treat patients of significantly higher medical complexity in these settings than do physicians who also practice in higher-acuity settings (i.e. HOPDs). This discrepancy shrinks with increasing procedural risk and with increasing distance between ASCs and acute care hospitals. AbstractLittle is known about the effect of incentives on physicians' choices of settings for medical procedures. We advance a model where physicians' division of labor between ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs) affects the medical complexity of patients treated in low-acuity settings (i.e. ASCs). Analyses of outpatient surgical procedure data show that physicians working exclusively in low-acuity settings (i.e. ASCs) treat patients of significantly higher medical complexity in these settings than do physicians who also practice in higher-acuity settings (i.e. HOPDs).This discrepancy shrinks with increasing procedural risk and with increasing distance between ASCs and acute care hospitals.

Physicians on board: An examination of physician financial interests in ASCs using longitudinal data

“…Specific CPT code indicators are not used because of potential upcoding or differences in coding by provider. 14 Using this sample of physicians is consistent with findings from David and Neuman (2011), whose results suggested that physicians who split patients between ASCs and hospital outpatient departments were observed to sort their more severe cases to hospitals and their less severe cases to ASCs. 15 While other contracts between facilities and physicians may exist, they are unobservable to the researcher.…”

“…7 There are several mechanisms through 5 Winter (2003) has shown that ASCs treat less complex and less costly cases than hospitals. However, David and Neuman (2011) find that physicians who largely refer patients to ASCs treat more medically complex cases than physicians who refer to both hospital outpatient departments and ASCs. 6 Throughout this paper, hospital outpatient departments are referred to as hospitals.…”

“…Further, physician costs are endogenous. equipped to handle more complex cases, instead of ASCs, which is evidenced by David and Neuman (2011) and Winter (2003).…”

Measuring Welfare from Ambulatory Surgery Centers: A Spatial Analysis of Demand for Healthcare Facilities

“…Also, higher population in a patient's zip code is correlated with a lower likelihood of traveling further. This result echos repeated findings in the healthcare literature (see for example Gaynor and Vogt [2003], David and Neuman [2011], Capps, Dranove and Lindrooth [2010], and Town and Vistnes [2001]) that distance matters to healthcare consumers. 15 As well as across insurance types, see analogous results for private patients with and without fixed effects in the appendix and tables A.VI, A.VII and A.VIII.…”

“…Also, higher population in a patient's zip code is correlated with a lower likelihood of traveling further. This result echos repeated findings in the healthcare literature (see for example Gaynor and Vogt [], David and Neuman [], Capps, Dranove and Lindrooth [], and Town and Vistnes []) that distance matters to healthcare consumers.…”