The Economics of a Bed Shortage: Certificate-of-Need Regulation and Hospital Bed Utilization during the COVID-19 Pandemic
Round 1
Reviewer 1 Report
REVIEW REPORT FOR THE STUDY “THE ECONOMICS OF A BED SHORTAGE: CERTIFICATE-OF-NEED REGULATION AND HOSPITAL BED UTILIZATION DURING THE COVID-19 PANDEMIC”
The paper "The Economics of a Bed Shortage: Certificate-of-Need Regulation and Hospital Bed Utilization During the COVID-19 Pandemic", performs a study examining the fact that as the number of coronavirus (COVID-19) hospitalisations and the need for ICU beds increased in the United States, 13 states moved quickly to temporarily and selectively suspend Certificate of Need (CON) requirements for the construction or expansion of new healthcare facilities to remove regulatory barriers to meeting this critical health need.
Certificate of Need laws are state regulatory mechanisms used to determine whether there is a need for the construction or expansion of health facilities and services in an area. Currently, 35 states have CON laws. Typically, a health facility applies for a licence from a state agency when it plans to build an additional health facility, offer a new range of services, or increase the number and type of beds offered. The State then reviews and decides whether to approve the proposed change.
One of the key requirements of the state CON law is that over-development and redundancy in health facilities leads to increased health costs. Therefore, CON requirements can be a useful tool to contain healthcare costs. However, states are also working to ensure that these cost containment tools do not create unintended obstacles to addressing the COVID 19 crisis.
The study presented here aims to examine the extent to which access to hospital beds and hospitalisation rates increased following the relaxation of CON law requirements during the COVID-19 pandemic..
Title and summary. The title and abstract express well the object of study, objectives and results of the article.
Structure of the article. The contents are well organized and they adhere to the IMRaD structure. It include a theoretical framework of the research problem.
Focusing the opportunity of the study, it must be said that it is a useful work since it covers fields such as medicine and healthcare.
Materials and methods.
Regarding the material and methods section, the methodology is tailored to the object of study and the objectives and is explained in an appropriate manner while it has been validly applied to guarantee the results.
Results.
The results are significant and they are presented in an adequate and understandable way not only through narration, but also with self-explained tables and figures that are also well elaborated in terms of presentation. The results justify and relate to the objectives and methods and the results are of sufficient interest.
Discussion.
I would suggest the inclusion of a bibliographic reference in the discussion section:
Sánchez-Úbeda EF, Sánchez-Martín P, Torrego-Ellacuría M, Rey-Mejías ÁD, Morales-Contreras MF, Puerta JL. Flexibility and Bed Margins of the Community of Madrid's Hospitals during the First Wave of the SARS-CoV-2 Pandemic. Int J Environ Res Public Health. 2021;18(7):3510. Published 2021 Mar 28. doi:10.3390/ijerph18073510
Bibliography.
The 47.5% of the bibliography cited in the study belongs to the previous five years. It would be desirable to complete bibliographical references 3 and 28.
Overall, it is an interesting study, and should be considered for publication in Journal of Risk and Financial Management once the minor revisions proposed have been resolved.
Comments for author File: 
Comments.pdf
Author Response
We thank the reviewer for the helpful review. As requested, we have added references to the suggested paper and to some earlier empirical assessments of CON.
Reviewer 2 Report
The topic discussed in this study is interesting and important.
The introduction provides a good motivation for the empirical analysis and the methods are adequate to evaluate the research questions considered.
My overall opinion about the study is positive.
I have however two main concerns:
(i) the interpretation of the evidence obtained could be richer, namely with a closer link with previous studies on related topics;
(ii) I would like to see some discussion about key implications for policy action.
Author Response
We thank the reviewer for the helpful comments. We have added a short section relating these findings to previous work conducted in the spring of 2020. We also added some comments elaborating on the policy implications. We are much obliged.
