Project Grant F32AG104373

ACCESS, UTILIZATION, AND OUTCOMES OF SURGERY UNDER MEDICARE ADVANTAGE - PROJECT SUMMARY/ABSTRACT MEDICARE ADVANTAGE (MA) NOW INSURES MORE THAN HALF OF ALL MEDICARE BENEFICIARIES, YET ITS IMPLICATIONS FOR SURGICAL CARE DELIVERY REMAIN POORLY UNDERSTOOD. COMPARED TO TRADITIONAL MEDICARE (TM), MA PLANS IMPOSE ADDITIONAL CONSTRAINTS ON SITE-OF-CARE DECISIONS THROUGH NARROWER PROVIDER NETWORKS, PRIOR AUTHORIZATION REQUIREMENTS, AND COVERAGE DENIALS. THESE PLAN DESIGN FEATURES MAY SHAPE ACCESS TO HIGH-QUALITY SURGICAL CARE AND INFLUENCE POSTOPERATIVE OUTCOMES. SURGERY IN OLDER ADULTS IS ESPECIALLY HIGH STAKES GIVEN THEIR COMORBIDITY BURDEN, LIMITED PHYSIOLOGICAL RESERVE, AND FRAILTY, MAKING DECISIONS ABOUT WHERE AND HOW SURGERY IS DELIVERED PARTICULARLY CONSEQUENTIAL. THE PROPOSED RESEARCH WILL INVESTIGATE HOW MA PLAN DESIGN AFFECTS SURGICAL CARE ACCESS, UTILIZATION, AND OUTCOMES FOR OLDER ADULTS THROUGH THREE AIMS: (1) ASSESS WHETHER MA BENEFICIARIES ARE LESS LIKELY THAN TM BENEFICIARIES TO UNDERGO HIGH-RISK OPERATIONS AT HIGH-VOLUME HOSPITALS AND WHETHER THIS AFFECTS OUTCOMES; (2) COMPARE MA AND TM BENEFICIARIES IN TERMS OF ACCESS TO AMBULATORY SURGICAL CENTERS, TRENDS IN OUTPATIENT UTILIZATION, AND ASSOCIATED OUTCOMES FOR ESTABLISHED OUTPATIENT-ELIGIBLE OPERATIONS; AND (3) EVALUATE DIFFERENCES IN HOW MA AND TM BENEFICIARIES RESPOND TO THE PHASED REMOVAL OF OPERATIONS FROM MEDICARE'S INPATIENT ONLY (IPO) LIST. USING NATIONWIDE TM CLAIMS AND MA ENCOUNTER DATA, AIMS 1 AND 2 WILL APPLY CAUSAL INFERENCE METHODS, INCLUDING ENTROPY BALANCING AND FIXED-EFFECTS, TO REGRESSION MODELING; AIM 3 WILL USE QUASI-EXPERIMENTAL APPROACHES, INCLUDING INTERRUPTED TIME SERIES AND DIFFERENCE-IN-DIFFERENCES ANALYSES, TO EVALUATE THE IMPACT OF IPO LIST CHANGES. THE CENTRAL HYPOTHESIS IS THAT MA BENEFICIARIES MAY BE STEERED TOWARD LOWER-COST SURGICAL SETTINGS BY PLAN-LEVEL INCENTIVES, WITH POTENTIAL CONSEQUENCES FOR SAFETY AND OUTCOMES. THIS WORK CLOSELY ALIGNS WITH THE MISSION OF THE NATIONAL INSTITUTE ON AGING BY ADDRESSING POLICY-RELEVANT QUESTIONS ABOUT HOW INSURANCE DESIGN AFFECTS SAFETY AND DELIVERY OF SURGICAL CARE FOR OLDER ADULTS. THE RESEARCH WILL BE CONDUCTED AT THE HEALTHCARE QUALITY AND OUTCOMES LAB AT HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH (HSPH) AND THE CENTER FOR SURGERY AND PUBLIC HEALTH AT BRIGHAM AND WOMEN'S HOSPITAL. DR. JULIA SONG WILL BE JOINTLY MENTORED BY DRS. THOMAS TSAI, MD, MPH, JOSE FIGUEROA, MD, MPH AND MELISSA GARRIDO, PHD, A MULTIDISCIPLINARY TEAM OF CLINICAL INVESTIGATORS AND HEALTH ECONOMISTS WITH COMPLEMENTARY QUANTITATIVE RESEARCH EXPERTISE IN MEDICARE POLICY, AGING, AND SURGICAL OUTCOMES. THE TRAINING PLAN INCLUDES COURSEWORK IN LONGITUDINAL AND CAUSAL INFERENCE METHODS AS DR. SONG PURSUES A MASTER OF PUBLIC HEALTH IN HSPH'S QUANTITATIVE METHODS PROGRAM, MENTORED RESEARCH USING LARGE-SCALE MEDICARE DATA, AND STRUCTURED CAREER DEVELOPMENT. TOGETHER, THIS RESEARCH AND TRAINING WILL PREPARE DR. SONG FOR A CAREER AS AN INDEPENDENT SURGEON-SCIENTIST FOCUSED ON IMPROVING SURGICAL CARE DELIVERY FOR OLDER ADULTS THROUGH DATA-DRIVEN HEALTH POLICY RESEARCH.