A. Diaz1, E. Schneider1, J. Cloyd1, T. M. Pawlik1 1Ohio State University,Columbus, OH, USA
Introduction: The American College of Surgeons has predicted a physician shortage in the US with a particular deficiency in general surgeons. Any shortage in surgical workforce is likely to impact underserved areas. The Affordable Care Act (ACA) established a Center for Medicare/Medicaid Services (CMS) based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas (HPSAs). We sought to assess the impact of the ACA Surgery Incentive Payment (SIP) on surgical procedures performed in HPSAs.
Methods: Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015 were used to categorize hospitals according to HPSA location. A difference in difference analysis was used to measure the effect of the SIP on year-to-year differences for in- and out-patient surgical procedures by hospital type pre-(2006-2010) versus post-(2011-2015) SIP implementation.
Results: Among 409 hospitals, two hospitals performed surgery in a designated HPSA. Both HPSA hospitals were located in a rural area, were non-teaching, and had <500 beds. The number of total surgical procedures was similar at both non-HPSA (Pre: n=210, 6,048 vs. Post: n=212,1,550) and HPSA (Pre: n=8,734 vs. Post: n=8,776) hospitals. Over the time period examined, inpatient (IP) procedures decreased (non-HPSA, Pre: 933,388 vs. Post: 890,322; HPSA, Pre: 5,166 vs. Post: 4,301), while outpatient (OP) procedures increased (non-HPSA, Pre: 1,172,660 vs. Post: 1,231,228; HPSA, Pre: 3,568 vs. Post: 4,475)(all p< 0.05). Post-SIP implementation, surgical procedures performed at HPSA hospitals markedly increased compared with non-HPSA hospitals (IP non-HPSA: -625 vs. HPSA: 363; OP non-HPSA: -111 vs. HPSA: 482)(both p<0.05). Of note, while the number of ORs increased over time among non-HPSA hospitals (Pre: n=3,042 vs. Post: n=3,206, p<0.05) OR numbers remained stable at HPSA hospitals (Pre: n=16 vs. Post: n=17). To estimate population-level effects of the SIP, a difference-in-differences model was used to adjust for cluster-related changes, as well as preexisting differences among non-HPSA and HPSA hospitals. Using this approach, the impact of the SIP on surgical procedure volume among HPSA relative to non-HPSA hospitals was noted to be considerable (Figure 1).
Conclusion: CMS SIP implementation was associated with a significant increase in the number of surgical procedures performed at HPSA hospitals relative to non-HPSA hospitals, essentially reversing the trend from negative to positive. Further analyses are warranted to determine whether bonus payment policies actually help to fill a need in underserved areas or whether incentives simply shift procedures from non-HPSA to HPSA hospitals.
