Access to specialty care associated with care quality for rural Medicare patients

Access to specialty care could reduce preventable hospitalizations and mortality among rural Medicare patients, according to a new study. (Getty/OgnjenO)

Patients in rural areas experience higher preventable hospitalization and mortality rates than those in urban areas and new study suggests a lack of access to specialists could be the main culprit.

Published in the latest edition of Health Affairs, researchers found higher rates of preventable hospitalization and mortality among rural Medicare patients suffering from chronic illness. They also found that access to specialists is associated with lower hospitalization and mortality rates for these patients.

Taken together, these findings suggest access to specialty care is a logical area for policymakers to target in their ongoing attempts to reduce disparities in care experienced between rural and urban patients.


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Study author Kenton J. Johnston, Ph.D., M.P.H., an assistant professor of health management and policy at Saint Louis University, says these findings make sense given the expanded skill sets specialists have when it comes to treating patients with complex chronic diseases, such as the ones in the study.

“A cardiologist has years of training and expertise in treating patients with heart failure that a primary care provider does not. Primary care providers are generalists, which is not a bad thing, but by definition, a generalist is not going to have the same level of expertise in treating a particular disease that a specialist has been trained to treat,” he told FierceHealthcare via email.

As with many observational studies, the mechanism that creates the disparity in care remains somewhat unclear, despite the seemingly straightforward explanations available. For example, the study used patient survey data to measure patients’ functional status to get a more complete picture of patient health than previous studies, which Johnston says have mainly relied solely on medical claims data. As a result, they found that patients who saw specialists were simultaneously comparatively healthier based on their functional status, while also less healthy based on their claims diagnosis.

“It is also important to know that worse functional status and greater social risk are associated with poorer health outcomes,” Johnston points out. “If we didn’t control for these factors in our study, it would appear that specialists produced better outcomes among these patients than they actually did. However, we controlled for these variables and still found a beneficial association of health outcomes with specialty care.”

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Based on these findings, the authors suggest that policymakers should shift their focus from incentives that increase primary care access in rural areas to target greater access to specialty care instead. For example, the study suggests expansion of telemedicine or better workplace incentives for key areas such as cardiology have the potential to benefit these vulnerable patient populations.

Johnston also recommends further study to nail down the mechanism behind the better care outcomes for the patients in the study. “The gold standard is a randomized controlled trial, but obviously we can’t ethically randomize heart failure patients to cardiology versus no cardiology care,” he says. “In the absence of a gold standard, more observational studies are needed using a variety of methods in a variety of datasets to replicate our findings.”