Access to transportation is a critically important aspect of
healthcare usage. It is a growing problem, particularly for patients living in
rural areas compared to patients living in urban or suburban communities. Patients
may have access to a vehicle or public transportation; however, they are less
likely to go if they live too far. Depending on where you live, you might have
to travel farther to see a doctor.
How Far Do Patients Travel To See A Doctor?
A 2018 Pew
Research Center poll has suggested that nearly a quarter of rural-dwelling
Americans say that access to quality doctors and hospitals is a significant
problem in their community, compared with 18% of city livers and 9% of
suburbanites. After collecting their participants' concerns, the study looked
at how far each of the three groups must travel in distance and time to see a
doctor on average. They found that rural Americans live 10.5 miles (17 minutes)
from the nearest hospital on average, compared with 5.6 miles (12 minutes) for
suburbanites and 4.4 miles (10 minutes) for those in urban areas.
A 2005 study
surveyed more than 1,000 adults in 12 rural Appalachian North Carolina counties
and suggested that distance to regular medical care was strongly negatively
correlated with the number of regular checkups. On the other hand, the same
study found that distance was not a significant factor in determining the amount
of chronic care and patient care. One possible reason is that these patients
may not deem regular hospital visits essential unless diagnosed with an illness
or condition. We must note that infrequent regular checkups make it challenging
for the healthcare system to catch the disease or condition early when
checkups. This causes the treatment to become more complex, affecting
patient outcomes. This causes the treatment to become expensive
for the patient, the hospital, and the insurance carrier.
Hospital Closures Affect Travel Distance To A Doctor
A significant concern for rural areas has been the growing
closure of hospitals, especially since one in five Americans (65.6 million)
lives in a rural area. Since 2010, at least 130
hospitals have closed, making access to a primary care doctor even more
challenging. "We follow the convention of the Office of Inspector General
that a closed hospital is 'a facility that stopped providing general,
short-term, acute inpatient care,'" reads a statement on the Cecil
G. Sheps Center for Health Services Research's website. "We did not
consider a hospital closed if it merged with, or was sold to another hospital,
but the physical plant continued to provide inpatient acute care, converted to
critical access status, or both closed and reopened during the same calendar
year and at the same physical location."
How Does Travel Distance And Time Impact Patient Outcome?
In 2017, CNN
analyzed a study
published in the journal Injury, showing that about 30 million Americans
lacked access to trauma care. Their definition of access was 60 minutes driving
to a center. According to the CDC, most of those at risk of being far from a
trauma center were in rural areas, where the rate of accidental deaths is more
than 50% higher than in urban areas. The CDC
noted that distance to an emergency room was a key factor.
Also, having these "hospital deserts" means that
in rural areas are more likely to die from cancer, heart disease, stroke,
and chronic lower respiratory disease than patients living in urban areas. Rural
residents are also more
likely than urban residents to experience a severe mental illness.
Doctor Shortages In Rural Communities
Because of the growth of hospital closures in the United
States, patients living in rural areas must contend with clinician shortages. According
to National Rural Health Association statistics, the
patient-to-primary care physician ratio in rural areas is 39.8 doctors per
100,000 people, compared to 53.3 doctors per 100,000 in urban areas. The
patient-to-primary care physician ratio may worsen over the years due to
retirement. A study
published in The New England Journal of Medicine suggests that there
will be a quarter fewer rural doctors by 2030. Also, between 2002 and 2017, the
number of medical school students in rural areas declined by 28%, according to
a 2019 study.
"We have seen increasing rural-urban disparities in
life expectancy and mortality emerge in the past few years. CDC's focus on
these critical rural health issues comes at an important time," said Health
Resources and Services Administration (HRSA) Acting Administrator Jim
Why Are Rural Doctors Important?
Rural doctors are essential to the community because they provide the following:
- Screening of patients for high blood pressure, which is a risk factor for heart disease and stroke. (Stroke mortality is higher in rural than urban areas of the United States, which seems to be because of higher stroke incidence rather than stroke case fatality.)
- Comprehensive cancer control programs that focus on cancer prevention, screening, early detection, and support. (Death rates are higher in rural areas (180 deaths per 100,000 persons) compared with urban areas (158 deaths per 100,000 persons).)
- The promotion of physical activity to battle the obesity epidemic in the country. (The obesity rate is significantly higher among adults living in rural counties (34.2 percent) than among those living in metropolitan counties (28.7 percent).)
- The promotion of smoking cessation. Smoking is strongly correlated with preventable chronic illnesses like lung cancer and COPD. (Incidence rates were higher in rural areas for several diseases, including those related to tobacco use, such as lung cancer, and those that can be prevented by cancer screening, such as colorectal and cervical cancers.)
- The promotion of motor vehicle safety like seatbelts. (Nineteen percent of people in the United States live in rural areas; however, almost half of the crash deaths occur there.)
- The promotion of safer prescribing of opioids for chronic pain. (Rates were higher in rural than in urban counties for drug overdose deaths involving natural and semisynthetic opioids (4.9 and 4.3) and psychostimulants with abuse potential (4.0 and 3.1).)
Why Are There Physician Shortages In Rural Areas?
Rural opportunities have fewer working opportunities for doctors'
spouses. Also, rural doctors worry that they may not be paid as much in rural
communities versus urban areas. A study
published in the Journal of General Internal Medicine found that more doctors,
physician assistants, and chiropractors can be found in more affluent areas with
high life expectancy compared to nurse practitioners who were more likely to
practice in lower-income areas with low life expectancy. The researchers identified
more than 270,000 primary care doctors, 63,000 nurse practitioners, 47,000
physician assistants, and 43,0000 chiropractors for the study.
Doctor Recruitment From Rural Areas
Academy of Family Physicians (AAFP) conducted a detailed report discussing
ways to recruit doctors in rural communities. They found two strong predictors
that show a doctor will choose rural practice: Specialty and background. Family
doctors were likelier than those with less general training to go into rural
practice. Also, medical student candidates from rural communities are more
likely to practice in rural areas than those with urban backgrounds.
Increase rural rotations and other rural curricular elements
in medical schools to keep those from rural areas interested.
Like the University
of Kansas School of Medicine some medical
schools have identified and encouraged prospective undergraduate students under
the Scholars in Rural Health program, which guarantees admission to those
students if they complete college.
The Association of American Medical Colleges (AAMC) wrote an
article discussing ways to improve doctors' next generation.
Mobilization Of Doctors To Rural Areas
The Oregon Health & Science University (OHSU) School of
Medicine and the University of California, Davis School of Medicine have joined
forces to create COMPADRE — California Oregon Medical Partnership
to Address Disparities in Rural Education and Health — to place more
doctors in rural and underserved communities.
Improvement Of Transportation Barriers To Rural Health Clinics
Patients with limited access to transportation may have a
more difficult time having someone drive them to the doctor due to the
committed time and effort it takes on the bus or person driving the patient.
Uber, Lyft, or hospital-subsidized transportation can decrease the reliance on
public transport or family. Read more about ridesharing
apps and their impact on healthcare access here.
Telemedicine Growth In Rural Areas
Telemedicine has been a growing way for doctors to reach
patients far in physical distance and have broadband internet access. According
to AmWell's Telehealth Index: 2019 Consumer Survey, 67
percent of patients older than 54 are willing to try virtual care for
chronic care visits.
Rural areas have limited access to high-speed
broadband internet, with only 69% of the rural regions and 65% of tribal
areas having access to high-speed broadband internet that met the minimum
benchmark set by the Federal Communications Commission (FCC). This makes it
challenging for patients to participate in telehealth consultations, transmit
health information to doctors, and monitor their health at home.
In 2019, 71%
of rural residents reported owning a smartphone, compared to 83% of
suburban and urban residents. There might be an increased limitation with age
since only 53% of people over 64 have smartphones. That demographic may
struggle to drive far distances in rural areas and require frequent visits.
There is hope, though. In 2018, the FCC and the U.S.
Department of Agriculture (USDA) distributed loans and grants to push for
high-speed broadband internet in rural communities. That year, Congress
allocated $600 million to the USDA for a new broadband pilot program focusing
on cities with 20,000 or fewer populations. Meanwhile, the FCC has distributed nearly
$2 billion over ten years as part of its Connect America Fund Phase II.
Telehealth may be one of the several ways to bridge the gap
between doctors not living in rural communities and patients. Also, telehealth
could help patients see their primary care doctors more often.
How Has COVID-19 Affected Rural Health Care?
The need for increased investment in rural health care has been
noticed since the rise of the COVID-19 pandemic. According to the United Nations, 90% of
COVID-19 cases were concentrated in urban areas. For this reason, people with
the economic means with jobs relying on the internet have picked up and moved
from large, densely-populated
cities like New York, Los Angeles, San Francisco, Houston, Chicago, Dallas,
and Miami to move to smaller, more sparsely populated suburbs or rural areas
County, New York. Since people are stuck at home not to transmit the
disease, they are leaving the big city, where social distancing is more
accessible, and they can get the best bang for their buck in real estate.
People of higher socioeconomic status are more likely already
to have delivery subscriptions like Amazon
Prime and Walmart+. These services have increased to reduce the need to
visit brick-and-mortar stores. When comparing July 2019 to July 2020, Amazon
has doubled its profit to $5.2 billion. Because of the shift of online use
from people of higher socioeconomic status, telemedicine has become a staple
for healthcare professionals to maintain social distancing with their new
patients once they move out to rural areas.
in the Journal of the American Medical Informatics Association
has found that caring for patients through telehealth has increased during the
COVID-19 pandemic, limiting exposure to the virus to healthcare workers. Also,
using telehealth in COVID-19-designated inpatient hospital rooms improves
communication between clinicians, support services, and patient family members.
Limited high-speed internet remains a hurdle in rural areas; however, there is
hope that an increase in investment will continue as families move farther into
rural places. Thus, this increased investment can improve other chronic
diseases like obesity and diabetes, drastically affecting rural areas.
Rural communities have a unique problem in helping citizens
access health care. Health centers struggle to recruit doctors to live in those
areas. Hospitals continued to close over the years because of the significant
expenses and declining profits in rural hospitals. Public transportation
remains a struggle since it is a cost sink due to the lack of population.
The rise of modern technology like ridesharing
companies and telemedicine and the forced demand for rural real estate due to
COVID-19 have helped rural health centers become more creative in serving their
patients. Hopefully, we will see a more significant investment in rural
infrastructure like broadband to improve health outcomes and increase healthcare
access despite doctors not living in the area.