autonomy and reduction in market competition as reasons to resist this trend. This study seems to indicate that there may be something real and worrisome about the claims of the opponents. The authors assessed hospital-physician integration by categorizing hospitals into 4 groups, ie fully integrated organizations, closed physician-hospital organizations, open physician-hospital organizations and independent practice associations. During the study period (2001 to 2007) the fully integrated organizations demonstrated the greatest increase in hospital prices and hospital spending. In fact, of the 4 groups only the fully integrated organizations had an increase in hospital spending. The authors hypothesize that these findings may be due to decreased competition and to providers being implicitly or explicitly financially incentivized to supply more treatments. It is likely that hospital ownership of physician practices will improve communication and facilitate patient care. However, the question is, at what cost? David F. Penson, MD, MPH

Re: Attention to Surgeons and Surgical Care is Largely Missing from Early Medicare Accountable Care Organizations J. M. Dupree, K. Patel, S. J. Singer, M. West, R. Wang, M. J. Zinner and J. S. Weissman Scott Department of Urology, Baylor College of Medicine, Houston, Texas, Engelberg Center for Health Care Reform, Brookings Institution, Washington, D. C., Department of Health Policy and Management, Harvard School of Public Health, Departments of Medicine and Surgery, Harvard Medical School, Mongan Institute for Health Policy, Massachusetts General Hospital, and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, and Kinetix Group, New York, New York Health Aff (Millwood) 2014; 33: 972e979.

Abstract available at Editorial Comment: To date, it seems that accountable care organizations (ACOs) have tended to focus on primary care at the expense of specialists and specialty care. This study provides important qualitative data to support this observation. The authors conducted semistructured interviews with leaders of 4 representative ACOs from different regions of the country. Across the board there was little emphasis on surgical care. In fact, 1 ACO provided care for 10,000 to 20,000 patients and included no surgeons at all, and 1 provided care for 20,000 to 40,000 patients and had fewer than 5 surgeons in the organization. How can these ACOs provide comprehensive care for this many patients and not include access to high quality surgical care? It is unclear how ACOs will be effective in promoting value based health care if they supply only primary care and ignore specialty and/or surgical care. This approach is a recipe for failure, yet policy makers continue to cook the meal. David F. Penson, MD, MPH

Re: Procedures Take Less Time at Ambulatory Surgery Centers, Keeping Costs Down and Ability to Meet Demand Up E. L. Munnich and S. T. Parente Health Aff (Millwood) 2014; 33: 764e769.

Abstract available at Editorial Comment: Anyone who practices at an ambulatory surgery center (ASC) knows how efficient these organizations are. Room turnover time is shorter than in the hospital setting. Anesthesiology seems to do things faster. It just seems like the surgeon can get more done. This study documents this issue, and shows that even the surgical component of the case is quicker than if performed in the outpatient hospital setting. Of course, neither of the authors is a surgeon, so they failed to account for the fact that the types of procedures performed and patients treated at the ASC are often different than those in the hospital outpatient setting. However, their findings still have clinical face validity. Part of the reason why ASCs run so efficiently is that physicians and


Re: Attention to surgeons and surgical care is largely missing from early medicare accountable care organizations.

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