Revisiting States’ Experience With Certificate of Need

Abstract

Many states enforce certificate of need regulations that require hospitals to obtain approval from a designated state agency before opening new facilities, adding capacity, or offering particular complex, costly services, such as hearttransplants. Yet at least 9 states took steps in 2019 to modify their certificate of need rules, often because those laws are viewed as ineffective in controlling overutilization or improving quality. 1,2 As Yuce and colleagues 3 observed in this issue of JAMA, most of the literature examining the association between certificate of need and measures of utilization and patient outcomes is more than a decade old, and advances in quality measurement and improvement warrant the updated analysis that these authors undertook.Yuce et al analyzed claims for 1 545 952 Medicare beneficiaries who received 1 of 10 types of surgeries from 2016 through 2018 to compare the experience of patients treated in states with vs without hospital certificate of need regulations, including 468 236 (30.3%) in 15 states vs 1 077 716 (69.7%) in 35 states and the District of Columbia. In this comparison, they found no significant differences between states without vs with the regulation in adjusted overall median hospital procedural volume (241 vs 272 procedures per hospital for 3 years; absolute difference, 31; 95% CI, −27.64 to 89.64, P = .30); median hospital market share (median, 28% vs 52%, absolute difference, 24%; 95% CI, −5% to 55%; P = .11); procedure rates per 10 000 Medicare eligible population per capita (median, 239.23 vs 205.41 operations per Medicare-eligible population for 3 years, absolute difference, 33.82; 95% CI, −84.08 to 16.43; P = .19); or the number of low-volume hospitals (defined as at or below the fifth percentile of procedure-specific volume). With respect to patient outcomes, there were no significant differences in the adjusted odds of 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19).The study by Yuce et al has several strengths, including the analysis of recent data, examination of a wide range of common low-and high-risk procedures, and the use of 3 different measures of patient outcomes. However, the study also has limitations to consider. The analysis was crosssectional and compared states with and without a certificate of need in 2016 through 2018 rather than examining the experience of states that had previously repealed the legislation. If states that chose to maintain the regulation differ systematically from those that discontinued it in terms of factors that may influence quality such as health care system organi-

Associations Between Certificate of Need Policies and Hospice Quality Outcomes

“…[10][11][12] The effectiveness of CON regulations on quality outcomes and cost-effectiveness in health care remains poorly understood, with studies showing mixed results. [13][14][15] Proponents of CON claim price inflation is avoided if there are unused beds, and that the laws promote increased access to care for underserved communities, and prevent an oversaturated market. 2,6 However, opponents of CON laws argue that the measures restrict competition while protecting certain providers and raising health care costs.…”