Heart valve surgery and myocardial infarction treatment: does competition improve care and decrease cost? The answer is “no.”

Hospitals publish outcome data in accessible databases, including the Hospital Compare database created by the Center for Medicare and Medicaid Services. The Hospital Compare database has information about the quality of care at over 4,000 hospitals, and permits consumers to compare quality of care at different hospitals.  Does access to hospital quality data lead to competition that subsequently results in improved performance?

Dr. David B. Glick, Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois, and colleagues obtained mortality rates, complication scores, and Center for Medicare and Medicaid Services Hospital Quality measures for heart valve surgery and acute myocardial infarction treatment based on 2007 and 2008 data from the United States Department of Health and Human Services Hospital Compare database. The results of their analysis are published in this month’s issue of Anesthesia & Analgesia in the article titled “The Relationship Between Competition and Quality in Procedural Cardiac Care.”

The authors found 653 hospitals that performed more than 10 heart valve operations per year and 1,898 hospitals that cared for more than 10 patients with acute myocardial infarction per year. They defined a locally competitive environment as being those hospitals within a 20-mile radius. For hospitals performing heart valve surgery there was no correlation between measures of competition and metrics of performance quality. This was also true when the inclusion threshold was increased to hospitals that performed more than 50 or 100 cases. There was a positive correlation between increased competition and increased Medicare costs, the opposite of how the market is supposed to function if increasing competition drives up efficiency and drives down cost.

Care for patients who acute suffer acute myocardial infarction is probably less dependent on consumer choice due to its emergent nature. Similar to the results for heart valve surgery, competition did not affect quality of care. Also similar to heart valve surgery, there was a positive correlation between increased competition and increased cost.

The authors’ analysis is based on data that’s more than five years old now. It would be interesting to see if the findings have changed. These findings are reminiscent of a recent article in JAMA Internal Medicine that showed that patients admitted with acute myocardial infarction when cardiologists were away at a meeting had lower mortality rates. The reason for the finding was that when the cardiologists were away, the patients were less likely to receive percutaneous coronary intervention. In that study as well as the current one, increased cost may be due to the use of costly interventions that do not improve outcome.

In his accompanying editorial “If More Competition Is the Answer, Why Hasn’t It Worked?” Dr. Liam O’Neill of the Department of Health Management and Policy, University of North Texas, Fort Worth, Texas, notes “many hospitals in urban markets have followed market leaders in purporting to offer luxury amenities and first-class accommodations. The other major difference with these specialty hospitals is that patients with health insurance are shielded from the true costs of their hospital stay. The result is an endless escalation in ‘nonprice competition,’ especially for the most lucrative service lines, such as cardiology and orthopedics…Even as health care costs continue their inexorable rise the science of marketing aims to stimulate demand for hospital resources while many regions already have excess capacity. If the overarching policy goal is to reign in health care spending via market-based competition, the Hospital Value-Based Purchasing Program may be one more example of ‘rewarding A, while hoping for B.”