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Invited Commentary
July 2014

The Right Triangle

Author Affiliations
  • 1Center for Surgical Quality and Outcomes Research, Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee
JAMA Surg. 2014;149(7):677-678. doi:10.1001/jamasurg.2013.5707

The article by Gadzinski and colleagues1 raises important questions about how best to maintain access to surgical care in underserved communities. As suggested by Kissick,2 health care delivery is bound by an “iron triangle,” wherein alterations in access exert influences on the other apices of the triangle, namely, cost and quality. To maintain access to care in underserved 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.

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