Insurance Coverage and Workforce Incentives to Improve Access to Surgical Care

项目摘要 在美国，改善获得外科护理的机会仍然是一个持续的挑战。虽然一些 美国的许多地区都挤满了高强度的资源，超过三分之一的美国县没有 一个外科医生即使在有足够供应商的地区，也有超过2900万美国人缺乏 保险覆盖面，无法获得选择性外科护理。由于外科手术人员有限， 保险覆盖范围不足或两者兼而有之，患者获得有限的护理延迟，直到病情需要 紧急干预。这些紧急行动，这是更昂贵的比他们的选择同行， 更多的并发症和再入院，估计占10亿美元以上的可预防的 支出.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（如医疗补助扩展）和劳动力激励措施（如 卫生专业人员短缺地区（HPSA）。通过改善入学机会，这些政策旨在促进选修课的普及。 手术护理、预防不良事件并减少治疗费用。因为这里概述的CMS政策 重点是改善入路，我们将评估大范围入路敏感的手术条件。这些 当进入最佳时，优先用选择性或预定的手术来治疗病症。然而，在这方面， 当接触受到限制时，它们的自然发展导致无法解决的症状，最终需要治疗。 紧急外科手术例子包括腹主动脉瘤，它可以破裂，腹 疝气会造成绞窄，结肠直肠癌会造成危及生命的梗阻。因此，在本发明中， 这些操作是选择性地还是紧急地执行的，可以作为访问的指标。每个CMS 政策的实施存在地域和时间差异，导致受益人面临一个 政策，两个政策或都没有。我们将利用这些重叠的自然实验来了解和分离 每项政策单独的影响以及使用Medicare行政索赔的综合影响 索赔和医疗费用利用项目。我们将利用我们丰富的经验， 实验研究设计，以适当隔离每项政策对手术入路、质量和 成本这项研究将为基于证据的政策制定带来重要证据，因为许多州仍然 通过医疗补助扩展和国会辩论的优点，继续HPSA补贴。

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.