Introduction: The Corporate Practice of Medicine (CPM) doctrine is the common law view that physician employment should not be permitted because of the inherent conflict between the corporate obligation to generate profits and the physician’s professional obligations. Historical enforcement of the doctrine varies substantially by state. Spine surgeons have driven recent trends in ambulatory surgery, demonstrating that three procedures - lumbar decompression, ACDF and ADR - can be safely performed on properly selected patients in an outpatient setting with lower costs. Our hypothesis is that fewer lumbar and cervical procedures will be performed in the hospital outpatient (HOPD) or ambulatory surgery center (ASC) setting in states with weak CPM enforcement.

Methods: ACDF and decompression claims data between 2009 and 2015 were used for analysis. Data for ADR are not yet available. Hospital inpatient, HOPD and ASC data were the dependent variables in a multinomial logit model. Hospital inpatient data was used as the base for comparison. Tennessee, Ohio, Mississippi, Alabama and Louisiana were identified as states permitting relatively unfettered physician employment.

Results: As compared to hospital inpatient, there were fewer procedures done in a HOPD or ASC in states where the CPM is relatively weak. The risk ratios for ACDF in weak states for HOPD and ASC were a significant 0.359 and 0.409 respectively. The risk ratio for decompression in a hospital outpatient facility was 0.267 and it was 0.635 in an ASC.

Conclusions: States with a weak CPM doctrine have fewer ACDFs and fewer decompressions performed in HOPD and ASC facilities. Patients undergoing an ACDF in a state with a weak CPM doctrine are 64% less likely to have the procedure performed in an HOPD and 59% less likely to have the procedure in an ASC than a hospital inpatient facility.

Patient Care: This research identifies a policy that could influence the cost to deliver surgical care for common spine procedures.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of the Corporate Practice of Medicine doctrine, 2) Discuss, in small groups, the impact of policy on the surgeon employment and the migration of common surgical procedures to lower cost settings.

References: 1. Morreim, E. H. (1999). Playing Doctor: Corporate Medical Practice and Medical Malpractice. University of Michigan Journal of Law Reform , 32 (4), 939-1040. 2. McGirt, M. J., Godil, S. S., Asher, A. L., Parker, S. L., & Devin, C. J. (2015). Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. Neurosurgical focus, 39(6), E9 3. Pugely, A. J., Martin, C. T., Gao, Y., & Mendoza-Lattes, S. A. (2013). Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-NSQIP database. Spine, 38(3), 264-271.