With all the focus on better primary care, it might be easy to ignore the importance of specialists. Health resources in general tend to be scarce in rural areas, and that tendency is exacerbated for specialty care. A study in Health Affairs finds that the lack of easy access to specialists in rural areas is associated with poor outcomes. (HA Article) The researchers first detail the well-known disadvantages rural residents face in finding health care. They then focus on comparing fee-for-service Medicare beneficiaries with complex chronic conditions from urban and rural areas over the period 2006 to 2013. The primary outcomes were preventable hospitalizations and mortality. As usual a bunch of adjustments based on patient characteristics were made. Local supply of physicians and other health care resources was evaluated as was actual rates of visits with primary care and specialist doctors. About 10% of patients lived in rural areas and another 18% in small cities/large towns. There was a higher burden of heart disease in rural areas and social risk factors were more prevalent, otherwise the comparison populations were similar. The supply of specialists was 31% lower in rural areas and fewer beneficiaries had any specialist visits. Preventable hospitalization and mortality rates were highest in rural areas and lowest in urban areas, with small cities/large towns in between. An increase of one standard deviation in specialist supply was associated with an 8.3% lower mortality rate and having one or more visits with a specialist in addition to a primary care visit was associated with a 16% reduction in preventable hospitalizations and a 17% reduction in mortality rate. These effects were even greater for beneficiaries with heart disease. The authors believe access to care factors explain 89% of the difference in preventable hospitalizations and 32% of the difference in mortality between urban and rural populations, with access to specialty care being the single greatest factor.
One obvious solution to this problem is to encourage greater use of telemedicine, which often can provide equal quality care to in-person visits. Another solution might be to subsidize travel costs to allow physicians from more urban areas to make regular visits and establish regular office hours in nearby rural areas. Relying on physician substitutes like nurse practitioners and physician assistants is less likely to be helpful in regard to specialty care. This issue of Health Affairs focussed on problems in rural health care, and details the significant health burdens and lack of access to care that population endures. Rural parts of the United States are literally derided as flyover country by residents of large cities, and the view includes policymakers in Washington. No population has its health care, and other, needs so regularly ignored. Additional funding might help medical schools train doctors with the specific intent of practicing in rural areas. I am sure others can come up with better solutions than I have, but this is clearly a problem that needs more attention.