Primary care is not sufficient for residents in rural communities with complex chronic conditions, according to new research that revealed a lack of access to specialists has driven up mortality rates and preventable hospitalizations.
Medicare beneficiaries who lived in rural areas had a 40% higher preventable hospitalization rate and a 23% higher mortality rate compared with their urban peers, according to a new study published in Health Affairs. But attending one or more specialist visits during the previous year dropped mortality rates for people with complex chronic conditions by 16.6% and preventable hospitalization rates by 15.9%, the researchers' analysis of nearly 12,000 Medicare beneficiaries from 2006 to 2013 found.
The conventional wisdom from the CMS is that expanding access to primary-care providers is a big part of the solution to the disparities in rural health outcomes, said Kenton Johnston, lead author of the study and an assistant professor of health management and policy at St. Louis University.
But researchers did not find disparities in access to primary care between rural and urban residents, nor did they find that primary care access was a driver of existing outcome disparities.
"Based on the results of our study, that conventional wisdom seems misguided," he said.
While rural residents tend to be older, poorer and more likely to suffer from chronic diseases, the fact that rural residents with chronic conditions are less likely to receive specialized care from a clinician with disease-relevant expertise is the most influential contributor to their health. It explained 55% of the difference in preventable hospitalization rates and 40% of the difference in mortality, according to the study.
The supply of specialists was 31% lower in rural areas. This led to a range of preventable hospitalization rates per 100 beneficiaries from 14.9 in rural areas to 10.6 in metro areas. Annual mortality rates per 100 beneficiaries ranged from 8.6 in rural areas to 7 in metro areas. Access to cardiologists seemed to have the largest impact on those metrics, researchers found.
"CMS and other health policymakers are misguided if they think that expanding access to primary-care providers alone will eliminate disparities in health outcomes for chronically ill rural Americans," Johnston said. "The specialized skills and expertise brought by specialists for treating particular chronic conditions are necessary."
Specialty care outside of the tertiary setting is just as important if not more critical than rural primary-care access, said Dr. Jeffrey Balser, president and CEO of Vanderbilt University Medical Center and dean of the Vanderbilt University School of Medicine.
"Specialty services in rural areas is where the cost is," he said.
Although the impact on cost is limited, a recent study from University of Michigan academics published in an American Heart Association journal found that accountable care organizations with cardiologist participation were associated with greater cost savings than in ACOs without cardiologists.
Telemedicine can fill rural specialist shortages in areas like stroke neurology, diabetes and infectious disease consultation. But reimbursement remains an issue, Balser said.
The CMS aims to bridge primary-care gaps by paying for virtual check-ins by telephone, remote evaluations of imaging and remote wellness visits. The agency also expanded the scope of practice of lower-level nonphysician providers to offer primary care and increased the wage index of rural hospitals to allow them to recruit more clinicians.
"I expected that access to specialty care would be a problem in rural areas," Johnston said. "However, I was surprised that access to primary care does not appear to be a problem."
Part of the problem is that many physicians do not want to live in rural areas. Telemedicine has helped, as have urban health systems that partnered with rural providers to send specialists weekly or monthly, Johnston said. Expanding primary-care access via rural health clinics and federally qualified health centers has also helped, he said.
Meanwhile, a lack of specialist access remains an often-overlooked issue, Johnston said.
"It seems to be overlooked by policymakers. However, if you were to ask actual rural chronically ill patients, they would identify regular access to specialists as a major issue," he said. "It would not be uncommon for people from rural areas to drive several hours into a city somewhere in order to have a medical appointment with a cardiologist."
Stakeholders and policymakers need to better understand what's driving outcome variability to address the problem, researchers said.
Beneficiaries with higher risk scores, disabilities, heart failure and who had a harder time completing basic tasks like bathing and cooking were associated with higher preventable hospitalization and mortality rates, according to the study. Those with lower incomes, less education and who were unmarried also had poorer health.
A lack of understanding may explain why not much has changed in rural healthcare—access to regular specialty physician care was a problem in rural areas 50 years ago and is still a problem today, Johnston said.
"It is not a problem that is likely to be solved anytime soon," he said.
The study excluded about a quarter of the Medicare population enrolled in managed care. Researchers tried to limit any unobserved differences between urban and rural residents by comparing individuals with the same complex conditions and controlling for social risk and functional status, but the estimates may not imply causal relationships given those inherent differences, they noted.
There seemed to be greater "coding intensity" in urban areas since specialists were more frequently visited, which may have artificially caused outcomes to appear better for beneficiaries who visited specialists. Though the authors tried to mitigate the impact of coding bias by using self-reported measures of both disease and functional status.
