Impacts of a Rural Hospital Global Budget Alternative Payment Model on Patterns of Cancer Surgery

BACKGROUND: Rural patients often experience barriers accessing high-quality surgical care. The Pennsylvania Rural Health Model (PARHM) aimed to improve rural health through all-payer hospital global budgets and transformation plans, which may influence hospitals' incentives and capacity to provide various surgical services, including cancer surgery. OBJECTIVES: Examine the association between PARHM and patterns of cancer surgery overall, by timing of entry into PARHM, and by cancer type. RESEARCH DESIGN: Stacked difference-in-differences (DID) models including hospital service area (HSA)-level propensity score weights, comparing patients living in HSAs with hospitals participating in PARHM to those in HSAs with eligible nonparticipating hospitals. SUBJECTS: Patients in eligible HSAs who had surgery between 2016 and 2023 for one of 11 cancers with evidence of surgical volume-outcome relationships. MEASURES: Surgery at a high-volume, Commission on Cancer (CoC) accredited, or National Cancer Institute (NCI)-designated hospital, and travel distance to the surgical hospital. RESULTS: The sample included 22,728 cancer surgeries for patients across 60 HSAs. Pooled estimates indicate no statistically significant differential changes in outcomes. In HSAs served by the 2019 cohort of PARHM hospitals (smaller and more remote facilities), PARHM was associated with a differential increase in surgery at CoC hospitals (DID estimate: 8.7 percentage points, 95% CI: 1.5- 16.0). We observed differential increases in surgery at CoC hospitals for colon and rectal cancers, and decreases in surgery at CoC and high-volume hospitals for liver cancer and at NCI centers for bladder cancer. CONCLUSION: PARHM had limited overall effects on surgical cancer care, with some variation across hospitals and cancer types.