by Katherine Restrepo
Director of Health Care Policy, John Locke Foundation
Proponents of Certificate of Need (CON) argue that it helps
preserve health care infrastructure, especially in rural areas. They contend,
for example, that repealing the law could lead to a greater concentration of
ambulatory surgery centers (ASCs) in more urbanized areas, which would lead to rural
patients traveling there for treatment and put community hospitals at risk.
But to the extent that market forces can operate under CON,
patients are already migrating to access ambulatory surgical care outside of
their counties of residence. While CON is supposed to effectively allocate
health care resources across different geographic areas within North Carolina,
the graph below illustrates a different story:
The data on outpatient surgery patient migration
patterns presented above was collected from 2014 hospital and ASC license
renewal applications. These applications must be submitted annually to the
Division of Health Service Regulation, an arm of the state’s Department of
Health and Human Services. With this data, the Division documents a statewide
inventory of the varying types of health care entities, assets, equipment, and
services offered. As previously mentioned, this inventory is used to calculate
what health care resources are "needed" and is published in the annual state
medical facilities plan. It should be noted that the number of outpatient
surgery cases is self-reported.
The six highlighted counties are mostly rural and do not
have any existing freestanding ASCs.
Anson County, with a population
of around 26,000, may not have sufficient volume to support a free standing
ASC, but it does have a high outpatient
migration rate of 95 percent. A majority of these patients are forgoing
care at Anson County Hospital and are instead seeking outpatient surgery
treatment at the Carolinas Medical Center’s hospital outpatient department. Others
are traveling to free standing ASCs such as the Eye Surgery Center of the
Carolinas in Moore County.
Meanwhile, Onslow County’s population size of 194,000 holds
promise for a viable ambulatory surgery center that can certainly help offset
its 61 percent patient migration rate to six different counties. Patients are
traveling from 40 miles to either the Surgery Center of Morehead City or
Carteret General Hospital in New Hanover County up to 140 miles to the
University of North Carolina Medical Center in Orange County.
Without CON, if the market itself determines
a demand for more freestanding outpatient surgery centers, they can be
built, which will enhance patient access,
and also enable patients to enjoy lower health care costs. Let’s not forget
what’s best for the patient.
Rural health care infrastructure is fragile, but evidence
suggests that CON does not stabilize medical access in these areas. Other
factors have led to the decline of rural health care, such as demographic
pressures placed on these programs in regions that have a higher percentage of elderly
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