Bickell Nina A, Nattinger Ann B, McGinley Emily L, Schymura Maria J, Laud Purushottam W, Pezzin Liliana E
Department of Population Health Science and Policy, Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
J Clin Oncol. 2025 Jan;43(1):57-64. doi: 10.1200/JCO.23.02638. Epub 2024 Sep 30.
Reimbursement strategies to regionalize care can be effective for improving patient outcomes but may adversely affect access to care. We sought to determine the effect on travel distance for surgical treatment of a 2009 New York State (NYS) policy restricting Medicaid reimbursement for breast cancer surgery at low-volume hospitals.
From a linked data set merging the NYS tumor registry with hospital discharge data, we identified women younger than 65 years with stage I-III first breast tumors from pre- and post-policy periods. We classified patients by urbanicity of their residence into four geographic areas (New York City, other large urban core, suburban/large town, and small town/rural). A multivariable difference-in-difference-in-differences model was used to estimate the policy effect on the distance traveled by Medicaid and non-Medicaid insured patients before and after the policy, by area of residence.
Among the 46,029 study sample, 13.5% were covered by Medicaid. Regardless of insurance, women treated more recently traveled longer distances to their surgical facility than those in the prepolicy period. Regardless of time period, Medicaid beneficiaries drove fewer miles to treatment than women with other insurance. Although all women traveled greater distances postpolicy, the increase was not significantly different by insurance status (Medicaid or not), except for those living in suburban areas in which Medicaid patients traveled further postpolicy (+7.7 miles compared with +3.4 miles for non-Medicaid; = .007).
After a policy regionalizing surgical care, only suburban Medicaid patients experienced a statistically significant (albeit small) increase in travel distance compared with non-Medicaid patients. In the state of NY, regionalization of breast cancer care yielded improved outcomes with minimal decrease in access.
将医疗服务区域化的报销策略可能对改善患者预后有效，但可能对医疗服务的可及性产生不利影响。我们试图确定2009年纽约州（NYS）一项政策对乳腺癌手术低容量医院医疗补助报销的限制对手术治疗出行距离的影响。
从将纽约州肿瘤登记处与医院出院数据合并的关联数据集中，我们识别出政策实施前后年龄小于65岁、患有I - III期原发性乳腺癌的女性。我们根据患者居住的城市化程度将其分为四个地理区域（纽约市、其他大型城市核心区、郊区/大城镇以及小镇/农村）。采用多变量三重差分模型来估计该政策对政策实施前后医疗补助参保患者和非医疗补助参保患者按居住区域划分的出行距离的影响。
在46,029名研究样本中，13.5%由医疗补助覆盖。无论保险情况如何，与政策实施前相比，近期接受治疗的女性前往手术机构的距离更远。无论时间段如何，医疗补助受益患者前往治疗的里程数比其他保险的女性更少。尽管所有女性在政策实施后出行距离都更远，但除了居住在郊区的女性外，出行距离的增加在保险状态（是否为医疗补助）方面并无显著差异，在郊区，医疗补助患者政策实施后出行距离更远（医疗补助患者增加7.7英里，非医疗补助患者增加3.4英里；P = 0.007）。
在一项将外科护理区域化的政策实施后，与非医疗补助患者相比，只有郊区的医疗补助患者出行距离出现了统计学上显著的（尽管很小）增加。在纽约州，乳腺癌护理区域化在改善预后的同时，医疗服务可及性的降低最小。
