Insurance Coverage and Workforce Incentives to Improve Access to Surgical Care

项目总结摘要 在美国，改善获得外科护理的机会仍然是一个长期存在的挑战。虽然有些人 这个国家的地区集中了高强度的资源，超过三分之一的美国县没有 单身外科医生。即使在有足够供应商的地区，也有2900多万美国人缺乏 保险覆盖范围，防止获得选择性手术治疗。由于外科劳动力有限， 保险覆盖范围不足或两者兼而有之，机会有限的患者会推迟护理，直到病情需要 紧急干预。这些紧急手术，比他们的选择性手术成本更高 更多的并发症和再入院，估计占可预防的10亿美元以上 花销。作为回应，医疗保险和医疗补助服务中心(CMS)实施了多重访问 包括更广泛的保险覆盖范围(例如，医疗补助扩大)和劳动力激励(例如 卫生专业人员短缺地区(HPSA))。通过改善准入，这些政策旨在促进选举 手术护理，预防不良事件，减少剧情支出。因为这里概述的CMS政策 着眼于改善通路，我们将评估大范围通路敏感的手术条件。这些 当访问是最佳的时，优先使用可选或计划的操作来处理情况。然而， 当访问受到限制时，它们的自然发展会导致症状无法解决，最终需要 紧急外科手术。例子包括腹主动脉瘤，它可以破裂，腹侧 可能会勒死的疝气，以及可能导致危及生命的梗阻的结直肠癌。因此， 这些手术是选择性地进行的，而不是紧急地进行的，可以作为访问的指示器。每个CMS 政策的实施既有地理上的差异，也有时间上的差异，导致受益人面临一种 政策，两个政策或两个都不是。我们将利用这些相互重叠的自然实验来理解和分离 使用联邦医疗保险的行政索赔，每项政策单独的影响以及它们的综合影响 索赔和医疗费用利用项目。我们将利用我们在Natural方面的丰富经验 实验研究设计，以适当隔离每项政策对手术准入、质量和 成本。这项研究将为循证政策的制定带来重要的证据，因为许多州仍然 采用医疗补助扩大和国会辩论继续HPSA补贴的好处。

PROJECT SUMMARY ABSTRACT Improving access to surgical care remains a persistent challenge in the United States. While some areas of the country are crowded with high-intensity resources, more than a third of US counties do not have a single surgeon. Even in areas where there are enough providers, more than 29 million American lack insurance coverage preventing access to elective surgical care. As a result of a limited surgical workforce, inadequate insurance coverage or both, patients with limited access delay care until the condition requires emergent intervention. These emergency operations, that are more costly than their elective counterparts due to more complication and readmissions, are estimated to account for more than $1 billion in preventable spending. In response, the Centers for Medicare and Medicaid Services (CMS) implemented multiple access strategies including broader insurance coverage (e.g. Medicaid Expansion) and workforce incentives (e.g. Health Profession Shortage Areas (HPSA)). By improving access, the policies are meant to facilitate elective surgical care, prevent adverse events and reduce episode spending. Because the CMS policies outlined here focus on improving access, we will evaluate a broad range access sensitive surgical conditions. These conditions are preferentially treated with elective, or scheduled, operations when access is optimal. However, when access is limited, their natural progression leads to unresolving symptoms that ultimately require an emergency surgical procedure. Examples include abdominal aortic aneurysms which can rupture, ventral hernias which can strangulate, and colorectal cancers that can cause life-threatening obstructions. As such, these operations being performed electively versus emergently can serve as an indicator of access. Each CMS policy was implemented with both geographic and temporal variation resulting in beneficiaries exposed to one policy, both policies or neither. We will exploit these overlapping natural experiments to understand and isolate the effects of each policy alone as well as their combined effects using administrative claims from Medicare Claims and Healthcare Costs Utilization Project. We will leverage our extensive experience with natural experiment study design to appropriately isolate the effects of each policy on surgical access, quality and costs. This study will bring important evidence to evidence-based policy making as many states are still adopting Medicaid Expansion and congress debates the merits of continued HPSA subsidies.