Travel time to get to an operating room (OR) has increased since 2010. In 2020, 44 percent of rural adults traveled for 60 minutes or longer to get to a place to receive surgery compared to approximately 37 percent in 2010.
Longer travel to receive surgery results in delayed treatment. Delayed treatment causes the development of more complicated cases, higher complication rates, and poorer outcomes for those who receive delayed treatment. Those who present to the hospital with acute abdominal pain, obstetric emergencies, and trauma-related injuries are sicker at presentation due to being treated after they have presented themselves to a health care provider.
The consequence: Distance turns routine care into emergencies
Additionally, longer travel distances suppress the demand for surgical care, an equity failure that selectively excludes low-income and rural patients from accessing procedures that wealthier, urban populations receive routinely. Patients often postpone important surgeries such as herniorrhaphies and cholecystectomies until they develop an emergency requiring immediate surgical intervention. They often do not attend follow-up visits with their physicians due to the distance. Many people suffer from chronic pain and decline in physical functioning because the “travel” time to obtain medical treatment is a severe burden.
The silent effect: Distance suppresses care
This lack of timely access to care does not only negatively impact individual patients; it exacerbates existing health disparities throughout entire communities and creates financial burdens when a patient develops an avoidable complication of an untreated condition. We use response time to assess emergency medical service (EMS) operations, and we measure hospital wait times and intensive care unit (ICU) bed availability. However, we do not measure the amount of time that elapses before a patient arrives at an OR, despite the fact that time-to-OR should function as a core performance metric with the same accountability standards we apply to EMS response times.
Therefore, it is time to create a national standard regarding access to surgical care. No patient should be required to travel more than 1 hour to access necessary surgical care. The most rapid method of achieving this standard is to implement mobile surgical units (MSUs) that provide fully equipped, mobile ORs capable of providing care to patients where they reside.
The standard: no more than 60 minutes to essential surgery
There is significant evidence supporting the use of MSUs, and it proves these platforms function as durable infrastructure, not emergency responses. For example, studies conducted in rural India found that the implementation of mobile surgical camps resulted in an increase of 20 to 30 percent in the number of surgical interventions performed. Pilot programs implemented in various underserved counties in the United States have demonstrated that MSUs are capable of delivering quality surgical care for minor surgical procedures, obstetrical procedures, and trauma stabilization while adhering to the same standards as traditional facilities. MSUs are not experimental charitable efforts; they are a viable form of established infrastructure that we choose not to fund at a larger scale. To treat travel time as an equity metric, we must take three actions.
Action 1: Publish county time-to-OR report cards
First, establish state “time-to-OR” targets with public county-by-county reporting. All states’ health departments currently track hospital capacity, physician supply, and immunization rates. Require each state to publish annual reports detailing the percentage of residents in each county that live within 1 hour of an OR. Allow counties to compare their performance with other counties and encourage competition to improve.
Action 2: Pay for travel-time reduction
Second, create a “mobile OR add-on” payment in Medicaid managed care contracts and Medicare demonstration projects. Reimburse providers for demonstrating a reduction in the average travel time to reach a surgical facility. If a managed care organization implements MSUs or contracts with an MSU vendor and demonstrates that patients in a particular area now travel 45 minutes to receive surgical care, rather than 90 minutes, award that organization financially for improving access to care.
Action 3: Require regional systems to deliver mobile capacity
Finally, require regional academic medical centers and hospital systems to enter into contractual agreements for mobile surgical capacity to be deployed into underserved counties as a condition of participation in their state’s Medicaid network or receipt of graduate medical education funding. If a tertiary care center in a state capital wishes to receive Medicaid payments for training surgeons or federal funding for graduate medical education, it should be held accountable for assuring that surgical care is available to the rural counties within its designated region.
The choice is simple: Accept surgical deserts, or build access that moves
We do not have to choose between constructing new hospitals and leaving rural communities behind; we can choose whether to consider a 3-hour journey to get to an operation an acceptable level of difficulty or if we are going to measure this as a quantifiable and identifiable policy shortcoming. We know how far our patients are having to travel for care. We know what happens to their health because of those distances. We also know that MSUs are effective. What we need now is the political will to take the information we have and use it to build and fund a system of MSU infrastructure and to hold ourselves accountable for its delivery.
We do not want to see Sarah Mitchell’s experience repeat itself 44 percent of the time in rural America. Let’s set a standard. Let’s measure the difference. Let’s fund the solution. If we ever decide to measure the delivery of surgical access (like we do with EMS response times) like we measure other performance metrics, we will no longer see mobile ORs as just a good idea and they will become part of the essential infrastructure of providing health care. The hidden cost for our rural patients is the time it takes to travel to receive medical care. Travel time represents a measurable, solvable policy failure. MSUs work. It is time to fund them and stop making patients pay for our governance gaps.
Pranav Ayyappan is an undergraduate student.
