Health Affairs, 24, no. 4 (2005): 1128-1139 doi: 10.1377/hlthaff.24.4.1128 © 2005 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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DataWatch

Access And Quality: Does Rural America Lag Behind?

Abstract

 
Numerous state and federal programs and policies aim to improve rural health care. This study compares access to and quality of medical care in urban and rural areas from the perspective of physicians and patients, using a broad set of indicators taken from the 2000–2001 Community Tracking Study (CTS) Physician and Household Surveys. Across most dimensions examined, access and quality in rural areas—even rural counties not adjacent to metropolitan areas—were either equivalent or superior to that provided in urban areas. However, rural residents have greater difficulty obtaining mental health services and generally face greater financial barriers to care.

As such, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 included funds for rural hospitals and home health agencies and increased Medicare payments to all rural physicians, with additional payments going to those practicing in underserved areas. This is on top of existing federal programs encouraging physicians to practice in underserved areas and subsidies for other rural services. On the other hand, President Bush’s proposed fiscal year 2006 budget either greatly cuts or eliminates a number of rural health programs.² Given this recent policy activity, this is an opportune time to examine differences in rural and urban patients’ access to and quality of care.

We compare health care in urban and rural areas from both physician and patient perspectives. Our assessments do not encompass hospital quality, although we include perceptions of both hospital- and non-hospital-based physicians. In addition to urban-rural comparisons, we also compare how areas that are more or less rural compare with urban areas as well as with each other. With some important exceptions, the general picture that emerges is that across many dimensions, quality and access in rural areas are at least on par with urban areas.

Study Data And Methods

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 
Data are primarily from the 2000–2001 Community Tracking Study (CTS) Physician and Household Surveys, conducted by the Center for Studying Health System Change. Samples were representative of the population of physicians and civilian, noninstitutionalized individuals in the forty-eight contiguous states (12,406 and 59,725, respectively) in 2000–01. Samples were clustered in sixty local health care markets, comprising fifty-one metropolitan statistical areas (MSAs) and nine nonmetropolitan portions of economic areas defined by the Bureau of Economic Analysis (BEA), supplemented by a nonclustered sample, comprising roughly 10 percent of all interviews to enhance the statistical power of national estimates.

Detailed information on demographics, insurance coverage, health care use, and attitudes was gathered about all adult family members and one randomly selected child in the Household Survey. The Physician Survey obtained detailed information on demographics, practices, and attitudes for nonfederal patient care physicians providing at least twenty hours of direct patient care per week. Both surveys used telephone interviews, supplemented in the Household Survey with in-person interviews of households without telephones. We classified physicians and patients by the location of their practice or home, respectively. Urban areas are defined as those contained in MSAs; rural areas fall outside of MSAs. We further divided rural areas into those adjacent or nonadjacent to an MSA (Exhibit 1).³ We compared the mean characteristics of urban physicians and patients with those of their rural peers. Statistical significance tests accounted for the CTS surveys’ complex sampling structure. For selected measures, we calculated regression-adjusted means to hold constant a set of predictors. Comparisons discussed in the text, unless otherwise stated, are statistically significant at the 5 percent level.

The supply of physicians, particularly specialists, was much lower in rural areas. There were 5.3 PCPs and 5.4 specialists per 10,000 population in rural areas, compared with 7.8 and 13.4, respectively, in urban areas. Referral patterns between rural and urban areas likely explain some of the difference in specialist supply, since many rural areas were unlikely to be able to support subspecialist practices. Consistent with this, physician supply was greater in nonadjacent rural counties than adjacent ones, although still much lower than urban areas. Conversely, the supply of hospital beds (from American Hospital Association data) was greater in rural areas than in urban areas (36 versus 29 per 10,000 population).⁵

Rural residents were older and were more likely to be uninsured or covered by public insurance, to have lower incomes, and to be in poorer health on average.⁶ Generally, residents of counties nonadjacent to metropolitan areas tended to be more disadvantaged than those in adjacent counties, with lower incomes and rates of insurance coverage.

Urban-Rural Access Differences

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 
Access to care defies simple measurement; it encompasses both patients’ care-seeking decisions and system responses once the patient has initiated contact. We framed our comparisons around three sets of potential barriers, which all plausibly point to lower access to care in rural areas. The first set relates to "convenience of use." Because of lower population density and fewer providers in rural areas, patients may wait longer to get appointments, travel longer to see providers, and wait longer in doctors’ offices. Less convenient access essentially makes care more costly to use. The second set is "provider supply" factors. Having fewer providers in rural areas may make it more difficult to obtain services because physicians are less likely to accept new patients and can charge higher fees, or because physicians themselves will have difficulties getting the services their patients need. The third set of factors, "patient resource constraints," is related to patients’ demand for services. Because rural patients tend to be poorer and are less likely to have insurance coverage, they are more likely to face financial barriers that discourage seeking care and hinder their providers’ ability to obtain services for them.⁷ Hence, the demand for care will be lower in rural areas.

General access measures. Exhibit 2 presents access indicators. First, we present three general access measures from the CTS Household Survey: any unmet medical need, whether getting needed care was put off, and whether patients had a usual source of care. There were no significant differences in the percentage reporting unmet needs between rural and urban areas, and rural patients were only slightly more likely to report delayed care (p .10). Rural patients were more likely to report having a usual source of care—long identified as an important component of access to care and crucial for ensuring continuity of care (Exhibit 2).

Results were mixed. The average number of days needed to get an appointment with a PCP did not differ significantly between urban and rural patients, but rural patients reported longer waits to get specialist appointments. As expected, the time reported traveling to the physician was longer in rural areas, although differences were not great.⁸ Travel times to specialists were longer, with a twenty-minute urban-rural differential (Exhibit 2). There were no significant urban-rural differences in wait times in PCP or specialists’ offices (data not shown).

Household Survey respondents reporting unmet or delayed care needs were asked to list reasons. We identified several related to convenience factors (Exhibit 2). Of these, only the first had significant urban-rural differences, with urban residents more likely to indicate that they couldn’t get an appointment soon enough. This suggests that although rural patients might have had longer waits, they were less likely to consider this a reason for experiencing delayed or unmet care needs.

Provider supply. If the lower supply of physicians in rural areas affects access to care, this might be reflected in fewer rural physicians accepting new patients. Although there was little urban-rural difference in the percentage of physicians accepting new private patients, rural physicians were more likely to accept new Medicare, Medicaid, and uninsured patients. They also provided more charity care, although differences are not statistically significant (Exhibit 2).

Although highly important, getting in to see a physician does not guarantee access to care. Physicians have to be able to obtain the needed services. We next show the percentage of physicians indicating that they had difficulty obtaining various services for their patients.⁹ Surprisingly, rural physicians were less likely than their urban counterparts to report problems obtaining needed services (Exhibit 2). Despite the low specialist supply in rural areas, there was little difference across urban and rural areas in the ability to obtain referrals to high-quality specialists. Rural physicians were less likely to indicate problems obtaining hospital admissions, ancillary services, and diagnostic imaging. However, they were much more likely to report problems obtaining inpatient mental health services.¹⁰

The Physician Survey asked physicians who indicated difficulties obtaining these services how important the lack of qualified providers (or facilities), health plan networks or administrative procedures, or patients with no or inadequate insurance coverage were in explaining these difficulties. Results suggest that urban and rural physicians differed in the reasons contributing to problems obtaining needed services (data not shown). Among those indicating problems obtaining services, the lack of qualified providers was more often cited as an important factor by rural than urban physicians in the case of specialist referrals (85 percent versus 40 percent), mental health outpatient services (88 percent versus 66 percent), and hospital admission (37 percent versus 29 percent), although the last comparison was significant only at the 10 percent level.

We next assess whether patients perceived an inadequate supply of physicians. Patients were asked whether they were satisfied with their choice of PCPs and specialists. Little difference was found in responses between urban and rural respondents. These comparisons might be confounded by greater health maintenance organization (HMO) penetration in urban areas. When we compared satisfaction with physician choice separately for those insured by HMO and non-HMO plans, we found that rural patients covered by non-HMOs were less likely than their urban counterparts to be dissatisfied with the choice of specialists.

Patient resource constraints. As indicated, rural residents were poorer and less likely to have insurance coverage than urban residents, which suggests that they will face greater resource constraints in accessing care.¹¹ Indeed, the percentage of people reporting out-of-pocket health care spending in excess of 5 percent of income was much greater in rural than urban areas (Exhibit 2).

When Household Survey respondents who indicated they had unmet or delayed care needs were asked to list reasons, the most prevalent reason given by both urban and rural residents was concern about the cost. Rural residents were much more likely than urban residents to give this response, which suggests that patients’ financial differences figure prominently in urban-rural access-to-care differences (Exhibit 2). On the other hand, rural physicians indicating serious problems obtaining specialist referrals, hospital admissions, or outpatient mental health services were no more likely than urban physicians to mention patients’ inadequate insurance coverage as an important factor (data not shown).

Urban-rural differences in utilization. Although often used to indicate access to care, use of health care provides an imperfect measure. This is because we do not know what the "right" level of use is and because overuse of services is common (and potentially harmful). We examined selected annual health care usage measures for urban and rural patients. Because there were significant population differences across urban and rural areas that were likely to affect the demand for health care, we present regression-adjusted means that control for demand-side factors: age, sex, income, health status, family composition, and type of insurance coverage. Adjusted means provide a better indicator of usage differences attributable to disparities in the provider supply, including the effect on convenience of use. However, additional unmeasured patient-demand factors, such as cultural differences, could also account for the remaining urban-rural differences.

Rural residents had more adjusted annual hospital admissions (excluding for births) than urban residents, although the total length-of-stay did not differ significantly (Exhibit 2). Controlling for demand factors reduced estimated rural hospital use, which suggests that rural residents are more likely than their urban peers to have conditions or injuries requiring hospitalization.

Findings were mixed regarding outpatient utilization. Use of hospital emergency departments for conditions not requiring an overnight stay serves as an indicator of access to outpatient care, but little difference between urban and rural residents was found.¹² On the other hand, rural residents were found to have fewer outpatient visits (Exhibit 2). Similar patterns were evident when only physician visits are examined (data not shown). Rural residents made greater use of nonphysician providers than urban residents. Finally, consistent with physician difficulties obtaining mental health care, rural residents were less likely than urban residents were to report a mental health visit (Exhibit 2).

Quality Of Care

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 
For this study, we lacked specific clinical measures of health care quality and relied mostly on physicians’ and patients’ perceptions. One objective measure, although limited, is physician board certification.¹³ Rural specialists were less likely than urban specialists to be board certified, although no differences were found among PCPs, who figure more prominently in the care of rural residents than urban residents (Exhibit 3). However, our subjective quality measures consistently pointed to a conclusion of better-quality care in rural areas.

Generally, rural PCPs treated a broader range of conditions and were more likely than urban PCPs to staff emergency departments. One concern is whether the scope of care rural PCPs are expected to provide without referral is broader than it should be. Rural PCPs do not perceive this to be the case. PCPs were asked whether the complexity or severity of patients’ conditions for which they provided care without referral to specialists was greater than it should be, about right, or less than it should be. Although 28 percent of urban PCPs indicated it was greater than it should be, only 22 percent of rural PCPs did so.¹⁵

Greater perceived quality among rural physicians was confirmed by patients’ reports. Patients with a doctor’s appointment in the past year were asked how much they trusted their doctor to meet their medical care needs and were asked to rate the thoroughness of the exam during their last physician visit and how well their physician explained things. In each case, rural patients gave more positive responses about their physicians, although differences were small and only significant at the 10 percent level. However, rural patients were slightly more likely than their urban peers to indicate that their physician might be performing unnecessary tests and procedures (Exhibit 3).¹⁶

Adjacent Versus Nonadjacent Rural Areas

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 
Only a few access indicators differed significantly between adjacent and non-adjacent rural counties (Exhibit 2). Among these, no consistent pattern emerges indicating that access is better or worse in nonadjacent counties than in adjacent ones. Problems of patient resource constraints were greater in nonadjacent counties, reflecting residents’ lower incomes and rates of insurance coverage. Moreover, accessing specialist care appeared to be less convenient in nonadjacent counties. On the other hand, nonadjacent rural residents were less likely than those in adjacent rural counties to have emergency department visits that did not result in overnight stays, and their physicians were less likely to indicate problems obtaining adequate hospital lengths-of-stay for their patients.

Conclusions And Policy Implications

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 
Limitations. This study is unique in bringing together both physicians’ and patients’ perspectives and in employing a broad set of access and quality indicators; however, it does have limitations. First, by reporting means across large geographic divisions, we provided a broad picture but could not address the considerable variation likely within both urban and rural areas. Second, some of the access measures and nearly all of the quality measures were subjective in nature. Urban-rural differences in these measures could be affected by differing cultural values, experiences, expectations, and standards among respondents.

Physician/patient perspectives. In general, physicians and patients provided concordant perspectives on access to and quality of care in urban and rural areas. While perceived quality was consistently found to be superior in rural areas, a more complex picture emerged with respect to access.

Because rural residents were poorer and less likely to be insured than their urban peers, they faced greater access problems related to cost. This suggests that policymakers should employ policies aimed at increasing low-income patients’ purchasing power by expanding safety-net, income assistance, or public health insurance programs. Even broad-based reforms not specifically targeted to rural areas would alleviate some of the disparities we observed. These "demand-side" access problems could be somewhat mitigated by rural physicians’ greater willingness to serve these patients. Although rural physicians worked longer hours than urban physicians, they appeared to be more willing to accept patients for whom they were likely to obtain little or no compensation: Medicaid recipients and the uninsured.¹⁷ This could be in recognition that few, if any, local alternatives exist; however, rural physicians’ greater willingness to treat disadvantaged patients could also reflect greater "social capital" in rural areas—that is, the "norms and networks that enable collective action."¹⁸

Although rural areas have far fewer physicians than urban areas, our results suggest that in 2000–01, overall rural supply was adequate to provide access to care on par with that in urban areas. Lower rural supply does not necessarily imply inadequate supply, as geographic differences may reflect oversupply in urban areas or differences in patients’ demand for care.¹⁹ Moreover, for some specialized services, it is reasonable to expect that rural patients will use urban providers.

If the supply of rural providers were inadequate, we would expect that patients would have to wait for appointments and that physicians would be unable to obtain needed services for their patients. We observed neither of these situations. Longer travel distances to providers also could be an implication, although this would also be expected because of lower population densities in rural areas. Generally, we saw little evidence suggesting that an inadequate supply of providers prevented rural patients from obtaining needed care. Some evidence does point to localized areas of shortage, however. One area where provider shortages did appear to be pervasive is mental health. Rural physicians reported greater difficulties getting these services for their patients and were more likely to cite supply problems as the reason. Moreover, rural patients reported fewer mental health visits than their urban counterparts.

Rural health care policy is in a state of flux. With respect to demand-side programs, Bush administration support for additional community health centers will alleviate patient resource constraints in many rural areas, while proposed Medicaid cuts, which are much larger in magnitude, would likely have the opposite effect for at least some segments of the rural and urban low-income populations.

On the supply side, MMA contained some $17 billion over ten years in rural health care subsidies, the price of obtaining key Senate support for the Medicare drug benefit. (Our results predate MMA implementation.) The MMA subsidies mostly benefit small rural hospitals, although the Medicare Bonus Payment Program, for physicians practicing in designated shortage areas, was enhanced; the Medicare fee formula was altered to increase payments to physicians practicing in low-cost, mostly rural areas; and payments to some other providers were raised. However, the MMA provisions are now being used to justify deep cuts or elimination of a number of other rural health programs in the administration’s FY 2006 budget.

Although our results do not allow us to make assessments about the appropriate level of support for rural health care, they do suggest that cuts in low-income entitlement programs, such as Medicaid, will have a disproportionate effect on rural populations, where enrollments relative to the size of the population are higher. Our results also suggest that subsidies directed to rural health care providers would be best targeted to those geographic areas with demonstrated shortages. This suggests, for instance, that enhancements to the geographically targeted Medicare Bonus Payment Program and some of the smaller programs slated for cuts or elimination may have greater effects on access to care in rural areas than the MMA’s broad-based physician payment formula changes and critical-access hospital provisions. Finally, broad-based programs might be appropriate when they are focused on a specific type of service, such as mental health care, for which widespread and serious problems have been shown to exist in rural areas.

Editor's Notes

 
James Reschovsky (jreschovsky{at}hschange.org) is a senior health researcher at the Center for Studying Health System Change in Washington, D.C. Andrea Staiti is a health research analyst there.

Support for this research came from the Robert Wood Johnson Foundation through its funding of the Center for Studying Health System Change. The authors thank Cynthia Saiontz-Martinez, Ellen Singer, and Valeriy Bakaushin of Social and Scientific Systems for their programming assistance as well as Len Nichols, Paul Ginsburg, Keith Mueller, and the anonymous reviewers for their comments on earlier drafts.

NOTES

Top Study Data And Methods Urban-Rural Access Differences Quality Of Care Adjacent Versus Nonadjacent... Conclusions And Policy... NOTES

 

1. For instance, see E.S. Salsberg and G.J. Forte, "Trends in the Physician Workforce, 1980–2000," Health Affairs 21, no. 5 (2002): 165–173[Abstract/Free Full Text]; and I. Moscovice and R. Rosenblatt, "Quality-of-Care Challenges for Rural Health," Journal of Rural Health 16, no. 2 (2000): 168–176.[Web of Science][Medline]
2. U.S. Department of Health and Human Services, Office of Budget, "FY 2006 Budget in Brief," 10 March 2005, www.hhs.gov/budget/06budget/ (20 April 2005); and National Rural Health Association, "NHRA’s Recommendations for the FY 2006 Budget," www.nrharural.org/dc/FY06recomendations.pdf (22 February 2005).
3. We also classified rural counties as those with and without at least 20,000 people living in towns and small cities. Results were often similar across these two classification schemes. We report results based on urban-area adjacency, because this is thought to be most relevant to issues of quality and access.
4. For instance, see M.E. Miller and S. Zuckerman, "Comparing Urban and Rural Physicians," Health Affairs 10, no. 4 (1991): 243–253[CrossRef][Medline]; M.P. Doescher, K.E. Ellsbury, and L.G. Hart, "The Distribution of Rural Female Generalist Physicians in the United States," Journal of Rural Health 16, no. 2 (2000): 111–118[Web of Science][Medline]; I. Moscovice, M. Casey, and S. Krein, "Expanding Rural Managed Care: Enrollment Patterns and Prospects," Health Affairs 17, no. 1 (1998): 192–199[Abstract]; and M.M. Casey, "Rural Managed Care," in Rural Health in the United States, ed. T.C. Ricketts III (New York: Oxford University Press, 1999), 113–118.
5. Physician supply data for 2001 are from the Area Resource File, Health Resources and Services Administration. Data on hospital bed supply are from the American Hospital Association 2001 Annual Survey of Hospitals. Greater rural hospital bed supply may reflect greater use of swing beds for long-term care.
6. Consistent evidence was found by E.C. Ziller et al., Health Insurance Coverage in Rural America (Washington: Kaiser Commission on Medicaid and the Uninsured, 2003).
7. C.L. Schur and S.J. Franco, "Access to Health Care," in Rural Health in the United States, 25–37.
8. Similar results were found by Schur and Franco; ibid.
9. Defined as the percentage of physicians responding that they "sometimes," "rarely," or "never" were able to obtain needed services for their patients (versus "always" and "almost always").
10. Difficulties obtaining needed services may reflect physicians’ managed care involvement, so we generated regression-adjusted means controlling for this. These controls affected results very little and are not reported.
11. Medicare Payment Advisory Commission, Report to the Congress: Medicare in Rural America (Washington: MedPAC, 2001).
12. Similar results are obtained when total number of ER visits was examined. There was also little difference in prevalence of surgical procedures.
13. Board certification has been found associated with better clinical quality; see, for example, L.K. Sharp et al., "Specialty Board Certification and Clinical Outcomes: The Missing Link," Academic Medicine 77, no. 6 (2002): 534–542. However, specialty mix and age patterns may confound urban/rural comparisons.[Web of Science][Medline]
14. As indicated by the percentage of practice revenue from managed care and from capitated contracts, revenue that is capitated, number of managed care contracts, and percentage of patients for whom the physician serves as gatekeeper.
15. PCPs’ assessment were confirmed by reports from specialists, who responded to a question whether the complexity or severity of patients at the time of referral by PCPs was greater or less than it should be, or about right. While 26 percent of rural specialists indicated that conditions were more complex or severe than they should be at the time of referral, one-third of urban specialists indicated this.
16. Previous research using Medical Expenditure Panel Survey (MEPS) data also indicated that quality-of-care satisfaction levels do not differ significantly between metropolitan and nonmetropolitan areas. Schur and Franco, "Access to Health Care."
17. Tabulations from the CTS Physician Survey indicate that rural physicians on average work about 4 percent (two hours) more each week than urban physicians. Differences are greatest among PCPs. Rural PCPs work about 10 percent or (5 hours) more a week than urban PCPs. Rural physicians are also likely than their urban counterparts to spend more time on call.
18. World Bank PovertyNet, "Social Capital for Development," www1.worldbank.org/prem/poverty/scapital/index.htm (20 April 2005).See also R. Putman, Bowling Alone: The Collapse and Revival of American Community (New York: Simon and Schuster, 2000).
19. R.A. Rosenblatt and L.G. Hart, "Physicians and Rural America," in Rural Health in the United States, 38–51.

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