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In Reply: We agree with Dr Ho that the absence of information on patients enrolled in Medicare managed care plans in the database used in our study represents a potential methodological limitation. However, we do not believe that the potential impact is as marked as Ho suggests.

First, the difference in managed care penetration between states with continuous CON regulation and no CON regulation cited by Ho (26% vs 18%, respectively) is not enough to eliminate the dramatic difference in mean annual hospital volumes for CABG surgery in the 2 groups (191 vs 104, respectively). Even if rates of CABG surgery were the same among managed care and traditional fee-for-service enrollees, mean hospital volumes would still be roughly 70% higher in states with continuous CON. However, the true impact of the missing managed care data is likely to be less, given that managed care enrollees are younger and healthier than . . . [Full Text of this Article]

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