Editor’s note: This commentery is by Gerry Silverstein, who lives in South Burlington and has interests in individual, community and global health. It was first published in the Rutland Herald.
[H]ealth care professionals who care for patients are expected to practice evidence-based medicine. This means that the care of patients should be determined by what health care workers publishing in the peer-reviewed medical literature over many decades have documented works. Conversely what has been shown to cause harm or provide no benefit should be avoided.
In an April commentary, Jeff Tieman, president and CEO of the Vermont Association of Hospitals and Health Systems, argued that an independent ambulatory surgical center proposed for Colchester is not needed and, indeed, might be harmful, as it “would be completely unregulated by the state.” He detailed that Vermont’s highly regulated hospitals take seriously the business of delivering the best care at the lowest possible cost. Does the peer-reviewed medical literature support this position?
In an article entitled “Making Healthcare Markets Work-Competition Policy for Health Care” published in the April 4 issue of the Journal of the American Medical Association (JAMA), a prestigious peer-reviewed medical practice journal, the authors state, “Many studies have examined trends toward increasing consolidation of physician practices and hospitals in the US health care system and the negative effects of decreased competition on the quality of patient care and health care costs …. Despite general consensus among economists and health policy experts that competition enhances patient choice, improves quality, and reduces cost, few actionable policy recommendations have been offered beyond greater antitrust enforcement by the Federal Trade Commission.”
When Al Gobeille was chair of the Green Mountain Care Board (GMCB), he detailed that accountable care organizations (ACOs) like the one proposed for the UVM Medical Center “work best with large systems that have been working on integration for a long time. They work least with small hospitals and independent physicians where they’re used to doing their own thing.”
Multiple articles in the peer-reviewed medical literature detail that high quality health outcomes occur at lower cost with independent practice groups compared to monopoly health care systems or hospitals.
In contrast, prominent physician and health care researchers at Dartmouth Medical Center in an August 2016 publication in JAMA refer to research that has shown that “ACOs led by primary care groups achieved greater savings than those integrated with hospitals.” In the same issue, investigators at the Duke Clinical Research Institute detail that “Monopoly hospitals, those that dominate a local market with no other competing hospital, have higher prices than hospitals in more competitive markets, and hospital consolidation is responsible for sharp price increases across markets within states.”
They offer an example in California where cost of care per patient was 56 percent more in physician practices owned by a multi-hospital system as compared to when the practice was physician owned.
In an August 2016 Wall Street Journal article, Bob Kocher, the only physician on the National Economic Council chosen to advise the president (Obama) on health care policy stated: “Over the past five years, published research … has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.”
Multiple articles in the peer-reviewed medical literature detail that high quality health outcomes occur at lower cost with independent practice groups compared to monopoly health care systems or hospitals. Just as health care providers who do not practice evidence-based medicine can harm not only their patients, but also society at large (such as by the spread of antibiotic resistance when an antibiotic should not be used or the wrong one chosen), so too can limiting health care delivery to a single monopolistic system lead to negative and possibly unsustainable cost outcomes.
The GMCB, the agency that will make the decision as to whether to issue a license for the ambulatory surgical center, should reflect on the accumulated knowledge of health care experts detailed in the peer-reviewed medical literature that emphasizes that competition is essential for the provision of quality care at a cost that is sustainable over the long term.
