Howell J R
Health Serv Res. 1984 Dec;19(5):587-613.
Prior evaluations of certificate of need (CON) have concluded that such regulation did little to reduce the level of hospital capital investment. These studies, however, failed to examine the underlying patterns of hospital investment behavior onto which CON was imposed and further neglected to determine the lag period that separates the introduction of regulation and the appearance of outcomes actually attributable to the presence of CON. This article addresses these two issues by using rate-setting data to examine the details of hospital capital investment across the whole voluntary hospital industry in one state--Massachusetts--both before and after the introduction of certificate of need. Massachusetts voluntary hospitals were found to devote most of their capital expenditures to the construction of major new inpatient facilities built in cycles of 14 years average duration throughout the post-World War II period. The date of completion of such a facility proved to be the major determinant of a hospital's capital expenditure pattern over time, and hospitals of similar teaching status and geographic location showed considerable synchrony in the construction of such facilities. At least in Massachusetts, the introduction of certificate-of-need regulation coincided with but was not responsible for the conclusion of a major construction peak among nonteaching hospitals and the beginning of such a peak among teaching hospitals, greatly complicating the evaluation of actual CON effects. Further, capital expenditures actually approved by CON did not appear until the third year of program operation, and even five years post-CON, the majority of hospital capital expenditures reflected projects approved in the first year of regulation, a period during which the program had neither the expert staff nor extensive review capacity that characterized CON function in later years. These findings hold implications for the evaluation of CON effectiveness and, indeed, for the future existence of certificate of need.
此前对需求证书（CON）的评估得出结论，此类监管在降低医院资本投资水平方面作用甚微。然而，这些研究未能考察实施需求证书监管时医院投资行为的潜在模式，并且进一步忽视了确定从监管引入到实际可归因于需求证书存在的结果出现之间的滞后期。本文通过使用费率设定数据来研究在引入需求证书前后，一个州（马萨诸塞州）整个志愿医院行业的医院资本投资细节，从而解决这两个问题。研究发现，马萨诸塞州的志愿医院在整个二战后时期，将大部分资本支出用于建设平均周期为14年的大型新住院设施。事实证明，此类设施的竣工日期是医院随时间推移资本支出模式的主要决定因素，并且具有相似教学地位和地理位置的医院在建设此类设施方面表现出相当大的同步性。至少在马萨诸塞州，需求证书监管的引入与非教学医院主要建设高峰期的结束以及教学医院此类高峰期的开始同时发生，但并非导致这些情况的原因，这使得对需求证书实际效果的评估变得极为复杂。此外，需求证书实际批准的资本支出直到项目运营的第三年才出现，甚至在需求证书实施五年后，大多数医院的资本支出仍反映的是监管第一年批准的项目，而在这一时期，该项目既没有后来需求证书发挥作用时所具备的专家人员，也没有广泛的审查能力。这些发现对需求证书有效性的评估以及需求证书未来的存续都具有启示意义。
