Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Division of Cardiac Surgery, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont.
J Surg Res. 2024 Oct;302:403-410. doi: 10.1016/j.jss.2024.07.073. Epub 2024 Aug 16.
We evaluated equity in access to esophagectomy after Maryland's 2014 "Global Budget Revenue" (GBR) implementation, which equalizes reimbursement rates irrespective of patient insurance and employs an annual hospital revenue ceiling to incentivize reductions in unnecessary resource utilization. We hypothesized that more traditionally underserved patients would undergo surgical treatment for esophageal cancers after GBR.
Using Maryland's Health Services Cost Review Commission database, we retrospectively analyzed patient demographics, insurance statuses, inflation-adjusted hospital charges, postoperative outcomes, and discharge dispositions for esophagectomies for neoplasms between 2012 and 2018.
Four hundred eighty six patients were included: 22.0% (107) pre-GBR and 78.0% (379) post-GBR. The proportion of African-American patients increased post-GBR (5.6% versus 12.9%, P = 0.035) and subsequently exhibited year-over-year increases. While not statistically significant, the proportion of Medicaid patients increased from 4.7% to 10.0% (P = 0.085). The post-GBR era also saw patients from 10 new counties, six of which were in Maryland's bottom half of counties ranked by median household income, receive operative esophageal cancer treatment without losing representation from pre-GBR counties. Patient age and sex were comparable between the two groups, and there were no significant differences in mortality or 30-day readmissions. Inflation-adjusted hospital charges and length of hospital stay did not appreciably change post-GBR, including after adjusting for age, comorbidities, and surgical approach.
GBR increased access to esophagectomy for African-Americans, those insured by Medicaid, and those from lower socioeconomic status counties. Contrary to prior studies of outpatient and emergency room settings, we found the GBR program's goal of reduction of resource utilization and cost were not apparent in this complex surgical population.
我们评估了马里兰州 2014 年“全球预算收入”（GBR）实施后，食管癌手术机会的公平性。GBR 使报销率均等化，不论患者的保险类型如何，并采用医院年收入上限来激励减少不必要的资源利用。我们假设在 GBR 之后，更多传统上服务不足的患者将接受食管癌的手术治疗。
我们使用马里兰州卫生服务成本审查委员会数据库，回顾性分析了 2012 年至 2018 年间，接受肿瘤切除术的患者的人口统计学特征、保险状况、经通胀调整后的医院收费、术后结果和出院去向。
共纳入 486 例患者：22.0%（107 例）为 GBR 前，78.0%（379 例）为 GBR 后。非裔美国人患者的比例在 GBR 后增加（5.6%对 12.9%，P=0.035），并且呈逐年上升趋势。虽然没有统计学意义，但 Medicaid 患者的比例从 4.7%增加到 10.0%（P=0.085）。在 GBR 后时代，来自 10 个新县的患者也接受了食管癌手术治疗，其中 6 个县位于马里兰州按家庭中位数收入排名的下半部分，而没有失去 GBR 前县的代表性。两组患者的年龄和性别相似，死亡率或 30 天再入院率没有显著差异。GBR 后，经通胀调整后的医院收费和住院时间没有明显变化，包括在调整了年龄、合并症和手术方式后。
GBR 增加了非裔美国人、医疗补助保险和来自社会经济地位较低的县的患者接受食管癌手术的机会。与之前关于门诊和急诊室环境的研究相反，我们发现 GBR 计划减少资源利用和成本的目标在这个复杂的手术人群中并不明显。
