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Access to Surgical Care: A Growing Concern for Rural Americans
The challenges of accessing quality surgical care in the United States are significant, particularly for nearly one-third of Americans who may find themselves living over an hour’s drive from a reputable hospital. For many, insurance limitations exacerbate the situation, often leading to unexpected out-of-pocket costs that can be overwhelming.
According to two recent studies conducted by a research team at the University of Michigan, the outlook is especially grim for individuals in rural communities. These findings raise serious concerns regarding the implications for patient health, financial burdens on families, and the overall safety of surgical procedures conducted far from proper medical facilities.
The studies have been released in the esteemed journals Annals of Surgery and JAMA. They not only highlight the current state of surgical access but also propose a framework intended for researchers and policymakers to enhance access to high-quality, affordable surgical care within a reasonable travel distance.
Key Findings on Access to Surgical Care
The Annals of Surgery study indicates that as of 2020, about 99 million Americans did not have access to timely and affordable surgical care, reflecting an increase from 98 million in 2015. The rise in this statistic is particularly evident among rural residents, though non-rural individuals have also reported diminished access.
In defining access, the researchers note that it includes living within a reasonable commute—established as an hour’s drive—to a hospital that provides surgical services and has received at least a three-star rating from Medicare’s quality assessment system. Additionally, affordability is measured by the ability of patients to manage out-of-pocket expenses after insurance payments.
The complementary JAMA research examines rural adults who underwent one of 16 different surgical procedures during 2010 and 2020. It reveals a troubling trend: by 2020, 44% of rural adults traveled 60 minutes or longer for surgery, an increase from 37% in 2010. Disturbingly, the median travel time for these patients reached 55 minutes, with individuals in rural areas experiencing longer journeys compared to their urban counterparts.
Factors Contributing to Limited Access
Dr. Cody Mullens, M.D., M.P.H., the lead author of both studies, identifies hospital closures in rural regions as a major contributor to the decline in surgical accessibility. Over the past 14 years, more than 150 rural hospitals have shut their doors. Additionally, trends in health policy, including the rise of high-deductible insurance plans, have left many underinsured, further complicating access to necessary surgical care.
Interestingly, while the number of individuals lacking insurance has decreased—thanks in part to the Affordable Care Act—the issue of underinsurance has grown significantly. This has resulted in more patients needing to travel increasingly far to access quality hospitals, particularly those rated three stars or higher.
To derive their findings, Mullens and his colleagues combined data from various sources, offering a comprehensive view of the factors affecting surgical access. This holistic approach also helps to illustrate how the intricate policy landscape impacts patients’ decisions regarding necessary surgery and the potential consequences of delays in care.
The Impact of Rural Hospital Closures
In previous work, Mullens and his team have shed light on the far-reaching effects of rural hospital closures. They also discussed a recent policy aimed at providing additional Medicare funding to keep certain hospitals afloat, allowing them to transition into Rural Emergency Hospitals, which do not provide inpatient services or surgeries requiring overnight stays.
This pattern has led to a centralization of complex surgical procedures at designated facilities, driven by the need to enhance safety and minimize complications. However, the JAMA study identifies eight low-risk surgeries that are often overlooked in these discussions, including gallbladder removals and hernia repairs, emphasizing that patients should not face such long travel times for these simpler procedures.
Dr. Mullens argues that it’s unacceptable for a significant number of patients to undertake lengthy journeys for low-risk surgeries that can be delivered safely at smaller, more localized facilities. Surgeons are encouraged to consider patient travel times when determining which cases to accept or when offering telehealth options for pre- and post-operative consultations.
To address the issue of underinsurance, the researchers recommend that surgical candidates evaluate insurance plans based on total out-of-pocket expenses rather than solely focusing on monthly premiums. This proactive approach could help ensure that individuals are better prepared financially when facing potential surgical interventions.
Future surgical candidates are urged to be mindful of selecting plans that minimize their deductibles and to consider funding health savings or flexible spending accounts as part of their preparation, alongside confirming which hospitals are classified as in-network for surgical care.
The studies received funding from the Agency for Healthcare Research and Quality and the National Institutes of Health, with support from the University of Michigan’s National Clinician Scholars Program.
Co-authors of the Annals of Surgery paper include Nina Clark, MD; Nicholas Kunnath, MS; Joseph Dieleman, PhD; and Justin Dimick, MD, MPH. The JAMA research letter was co-authored by Reagan A. Collins, BA; Nicholas Kunnath, MS; and Janice C. Probst, PhD.
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