Department of Urology, Medical School, University of Michigan, Ann Arbor2Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor3Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor.
Robert Wood Johnson Foundation Scholar in Health Policy Research, University of Michigan, Ann Arbor.
JAMA Surg. 2014 Aug;149(8):829-36. doi: 10.1001/jamasurg.2014.857.
Enhanced access to preventive and primary care services is a primary focus of the Affordable Care Act, but the potential effect of this law on surgical care is not well defined.
To estimate the differential effect of insurance expansion on utilization of discretionary vs nondiscretionary inpatient surgery with Massachusetts health care reform as a natural experimental condition.
DESIGN, SETTING, AND PARTICIPANTS: We used the state inpatient databases from Massachusetts and 2 control states (New Jersey and New York) to identify nonelderly adult patients (aged 19-64 years) who underwent discretionary vs nondiscretionary surgical procedures from January 1, 2003, through December 31, 2010. We defined discretionary surgery as elective, preference-sensitive procedures (eg, joint replacement and back surgery) and nondiscretionary surgery as imperative and potentially life-saving procedures (eg, cancer surgery and hip fracture repair).
All surgical procedures in the study and control populations.
Using July 1, 2007, as the transition point between the prereform and postreform periods, we performed a difference-in-differences analysis to estimate the effect of insurance expansion on rates of discretionary and nondiscretionary surgical procedures in the entire study population and for subgroups defined by race, income, and insurance status. We then extrapolated our results from Massachusetts to the entire US population.
We identified a total of 836 311 surgical procedures during the study period. Insurance expansion was associated with a 9.3% increase in the use of discretionary surgery in Massachusetts (P = .02). Conversely, the rate of nondiscretionary surgery decreased by 4.5% (P = .009). We found similar effects for discretionary surgery in all subgroups, with the greatest increase observed for nonwhite participants (19.9% [P < .001]). Based on the findings in Massachusetts, we estimated that full implementation of national insurance expansion would yield an additional 465 934 discretionary surgical procedures by 2017.
Insurance expansion in Massachusetts was associated with increased rates of discretionary surgery and a concurrent decrease in rates of nondiscretionary surgery. If similar changes are seen nationally under the Affordable Care Act, the value of insurance expansion for surgical care may depend on the relative balance between increased expenditures and potential health benefits of greater access to elective inpatient procedures.
可负担医疗法案的主要重点是增强获得预防和初级保健服务的机会，但该法律对手术护理的潜在影响尚不清楚。
以马萨诸塞州医疗改革为自然实验条件，估计保险范围扩大对选择性与非选择性住院手术利用的差异影响。
设计、设置和参与者：我们使用马萨诸塞州和 2 个对照州（新泽西州和纽约州）的州住院数据库，从 2003 年 1 月 1 日至 2010 年 12 月 31 日期间，确定非老年成年患者（19-64 岁）进行选择性与非选择性手术。我们将选择性手术定义为选择性、偏好敏感的手术（例如关节置换和背部手术），而非选择性手术定义为强制性和潜在救命的手术（例如癌症手术和髋部骨折修复）。
研究和对照人群中的所有手术。
我们以 2007 年 7 月 1 日为改革前和改革后时期的过渡点，进行差异差异分析，以估计保险范围扩大对整个研究人群中选择性和非选择性手术的影响，以及按种族、收入和保险状况定义的亚组。然后，我们将我们在马萨诸塞州的结果推断到整个美国人口。
我们在研究期间共确定了 836311 例手术。马萨诸塞州的保险范围扩大与选择性手术使用率增加了 9.3%（P=0.02）相关。相反，非选择性手术的比率下降了 4.5%（P=0.009）。我们在所有亚组中都发现了类似的选择性手术效果，其中非白人参与者的增幅最大（19.9%[P<0.001]）。根据马萨诸塞州的发现，我们估计到 2017 年，全国性保险范围扩大将产生额外的 465934 例选择性手术。
马萨诸塞州的保险范围扩大与选择性手术率的增加有关，同时非选择性手术率的下降。如果在平价医疗法案下全国范围内出现类似变化，那么保险范围扩大对手术护理的价值可能取决于增加的支出和增加获得选择性住院手术的潜在健康益处之间的相对平衡。
