The Right Triangle

ThearticlebyGadzinskiandcolleagues1 raises importantquestions about howbest tomaintain access to surgical care inunderserved communities. As suggestedbyKissick,2 health care delivery is bound by an “iron triangle,”wherein alterations in accessexert influenceson the other apices of the triangle, namely, cost and quality. To maintain access to care inunderserved regions, the Medicare program elected to subsidize critical access hospitals (CAHs) through exemption from the Medicare Prospective Payment System, largely ensuring the financial health of rural health care access. However, “access enhancement”may have unintended consequences. Indeed, the study findings have important policy implications with respect to our ongoing attempts to optimize the dimensions of our iron triangle. Fundamentally, the health care delivery system must be structured in a fashion that maintains access to care for individuals living in underserved areas, particularly for primary and nonelective care. However, one cannot help but question whether encouraging access to specialty care at CAHs through cost-based reimbursement is the appropriate means to an end. Although one might tolerate slight variation in quality of care, considering the limitations posed to underresourced medical centers, efforts must be made to minimize quality variation across different practice settings. Similarly, one might expect costs to be higher in underserved areas, but the overages should be predictable, measurable, and contained, and the delivery system should be sustainable over time. Does the Medicare response to the CAH model satisfy these criteria? Perhaps not entirely— access is maintained, but variation in quality of care among CAHs is evident, and the cost overages are higher than policy makers find acceptable. How might we leverage the findings from Gadzinski and colleagues1 into actionable health care policy? Integrated delivery systemshavebeguntoorganizeandaggregate into large, regional “hub-and-spokes” models. Through affiliations between large referral centers and community-based facilities, patients in outlying areas have immediate access to the local hospital for routine nonelective surgical care, and the system provides logistical support for transferring complex nonelective or elective care to a larger referral center. Patient flow is frequently bidirectional so that routine elective surgery and other services may pass from the referral center back to the community hospitals, thereby satisfyingmutual financial interests. The transfer of processes of care, clinical care pathways, technology, and other systems intended to standardize the quality of care provided may also be bidirectional. The Affordable Care Act may accelerate the formation of theseregionalnetworksasaccountablecareorganizations,with newfound incentives to focus on individual hospitals’ core functionalities and optimize shared savings. Indeed, there is already evidence that commercial accountable care organization contracts can “bend the cost curve.”3,4 There remains no obvious mechanism to ensure the financial viability of indiRelated article page 671 Postoperative Care at Critical Access Hospitals Original Investigation Research