| Issue: |
The continued trend toward
managed health care has caused both legislators and state
health departments to reassess regulation of the health
care industry as a whole. Given the nationwide trend toward
market-oriented approaches to ensure the quality and appropriateness
of care, states are showing a growing interest in revising
or eliminating one of the icons of state regulation, the
certificate-of-need (CON) law. |
| Background: |
CON laws emerged in the 1970s and require
providers to receive state approval for major capital
expenditures, purchase of high-technology equipment, and
expansion of services. These laws were enacted to prevent
over utilization of services and keep health care costs
in check. Proponents of CON believe that strict regulation
is necessary to hold down health care costs and maintain
quality. Opponents argue that the market produces more
effective controls. |
| Why Is It Important to Cardiologists? |
CON remains the primary method of regulating
cardiac surgical and some cardiovascular interventional
programs. State health agencies are continually seeking
to ensure quality of health care by reviewing, revising,
and implementing alternative strategies designed to keep
up with the rapid pace of technology in the health care
arena. Primary targets for such regulation and oversight
are coronary artery bypass surgery programs. An emergent
trend is the regulation and oversight of cardiac catheterization
and diagnostic imaging. |
| ACC Position: |
While the ACC has not endorsed a
position on CON, an ACC working group on CON and related
issues has proposed six “working principles”
upon which to base CON discussions:
1. Current and proposed open-heart surgery programs,
cardiac catheterization and Diagnostic Imaging programs
should be evaluated according to the incidence of heart
disease of the population in the geographic region that
the programs serve or will serve. Staffing and technology
levels, as well as the total number of services rendered
(coronary artery bypass graft surgery, valve replacement,
and interventions, diagnostic imaging), need to be estimated.
The incidence of acute interventions and the need for
treatment of acute myocardial infarction must be considered.
2. The issue of transportation regionally must be considered.
The infrastructure that will allow quick emergency transport
of patients suffering acute myocardial infarction to
reach a state-of-the-art facility needs to be considered.
The time involved in emergency transfer during an acute
event to a properly equipped facility needs to be taken
into account, as should the time required for transfer
between an acute care hospital and a tertiary-care facility.
3. The availability of adequately trained allied health
personnel (nursing, laboratory, radiology, and anesthesia)
in regions’ institutions should be carefully evaluated.
Recommendations that define the meaning of adequately
trained personnel should be developed with advice and
input from the appropriate allied health professional
societies. Guidelines for personnel continuing medical
education and training need to be developed.
4. CON program modifications or repeal efforts need
to consider the impact on the availability of physician
training programs, fellows, and residents and the training
of allied health personnel as well as access by inner
city and/or underserved populations to hospitals and
institutions that currently deliver care to the inner-city
and underserved populations.
5. The quality of outcomes and mortality data must
be considered. Often, CON programs place little emphasis
on the measurement of quality parameters, such as morbidity
and quality-of-life issues.
6. Appropriate national specialty organizations and
their state affiliates should be consulted in the development
and/or modification of specific CON requirements concerning
personnel, technology and support facilities, and quality-of-care
measurement tools. |
| State Action: |
State: Currently, 14 states have repealed
CON laws. A number of states continue to examine the extent
to which CON programs should play a role in regulating
their health care systems. Such revisions are largely
being considered in the areas of long-term health care,
nursing facility beds, and the expansion of surgical programs,
including open-heart surgery. Although there are reports
that state budgets are improving, many states are looking
for ways to decrease costs, several states have introduced
amendments to either strengthen or relax their CON laws
to satisfy health care needs.
In 2004, 14 states--Alaska, Connecticut, Florida, Hawaii,
Illinois, Kentucky, Maine, Minnesota, Mississippi, Oklahoma,
Rhode Island, Tennessee, Virginia and Washington--enacted
legislation to address the applicability of their certificate
of need (CON) programs. An emerging trend, particularly
in Connecticut, Florida and Tennessee concerned the
certificate of need process and specialty hospitals.
In addition, a number of state legislatures enacted
laws to create exemptions to the CON process.
The Federal Trade Commission and the Department of
Justice released “Improving Health Care: A Dose
of Competition,” in 2004. The report addresses
CON’s ability to control health care costs at
the state level. The two agencies found that “Where
CON programs are intended to control health care costs,
there is considerable evidence that they can actually
drive up prices by fostering anticompetitive barriers
to entry.” ACC is currently evaluating the report. |
| ACC Contacts: |
Adam Nelson, CAE, senior specialist,
State Legislative Affairs, 301-897-2612 |
