A May 2017 Wall Street Journal analysis highlights the plight of rural America: People there who are sick are getting sicker because health systems are struggling to deliver care in rural areas. The challenges are multifactorial, but a key driver is the availability of providers. Only 10 percent of physicians serve rural populations, and the number of specialists per capita is a third of the number that practice in urban areas. The Centers for Medicare and Medicaid Services (CMS) considers the per capita physician shortage to be an important health care access problem. In an effort to improve access to care, CMS has created preferential payment schedules including reimbursement for telemedicine services for patients located in geographic health professional shortage areas (HPSAs).
But while geography is an important aspect of access to health care, it fails to accurately capture the relationship between supply (providers) and demand (patients) within an area. We are concerned that while rural America has access problems because there are not enough doctors, urban America has access problems because there are not enough appointments. We propose that appointment timeliness be used to frame the discussion around access to health care, as this approach better captures the relationship between the supply of health providers and the demand for their services—independent of geography.
Urban And Rural Areas Face Similar Access Challenges
Access challenges exist in both urban and rural settings. In a 10-state study of primary care practices using 11,347 simulated patient calls, urban Medicaid patients were offered an appointment 60 percent of the time, while rural patients were offered appointments 80 percent of the time. This observation aligns with patient perception about availability of care. A stratified sample of rural and urban patients in Minnesota was asked about availability of care. Fifty-one percent of uninsured urban patients and 69 percent of uninsured rural patients reported that they had a regular source of care. Among uninsured or individually insured respondents, 32 percent of urban and 21 percent of rural patients said they had delayed care when they thought they needed it sooner.
Access to specialist appointments appears to be similar. Among 203 orthopedic practices in North Carolina, rural practices were more likely than urban practices to offer a patient with Medicaid an appointment (65 percent versus 57 percent, respectively). A survey of 250 dermatology practices in Ohio revealed that no correlation existed between rural areas and the ability of patients with urgent symptoms to schedule urgent appointments. Similarly, nationally representative Medicare Payment Advisory Commission phone surveys from 2007 to 2012 reveal that the proportion of rural and urban Medicare beneficiaries who experienced unwanted delays in getting an appointment was roughly equal most of the time.
Current Medicare payment policies target geography, and therefore do not focus on the real problem, which is access. The ability to use health care resources virtually (that is, via telemedicine) would allow for improved access to care in the same way that virtual connectivity has decreased access barriers in other industries, such as banking and commerce. To successfully transform health care through telemedicine, expectations and incentives must be aligned across payers, health systems, providers, and patients.
Changing Telemedicine Reimbursement Policies Can Improve Access
A focus on access instead of geography is important to advance care for patients in both rural and urban areas. In large health care systems, strategic business decisions are made centrally. Most large health systems are located in urban areas, so it’s not practical for most of them to invest heavily in providing care to rural patients unless they can leverage the same systems to also care for their local urban populations who suffer from the same access challenges.
Good examples exist that demonstrate how aligning payment and treatment expectations can improve care for patients who lack access to care. Among them is the adoption of telemedicine in the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) program. ANGELS’s interactive video network has allowed specialists to consult with women anywhere in Arkansas with high-risk pregnancies covered by Medicaid. This has made specialty physicians from the University of Arkansas for Medical Sciences accessible to patients in high-density cities such as Little Rock as well as towns in rural areas. Supporting telehealth programs, regardless of geography, through better incentives has increased access for high-risk obstetrics patients in the state as a result.
What’s Next
The best way to care for patients in rural environments is to build programs that synchronize rural and urban care. Health systems, patients, and providers are all poised to interact with the health care system differently; aligning payment structures to focus on the availability of timely care instead of historic geographic constructs is essential. Current Medicare HPSA metrics indicate that people in rural areas have less access to care in comparison to people in urban areas, but health care delivery, like every other industry, need not be as geographically constrained as it once was. The use of appointment timeliness as a marker for access would allow private-sector health care to maximize their efforts to innovate to improve access. Health systems are ready to further innovate to place the patient squarely at the center, no matter where they live. A minor pivot in our conceptualization of access would allow them to do so.
Authors’ Note
Dr. Carr spends a portion of his time as the director of the Emergency Care Coordination Center at the US Department of Health and Human Services. The views expressed here do not represent those of the federal government.
