The secret to better rural health care: Pay doctors to travel from urban to rural areas

Researchers from University of Oxford, Arizona State University, and University of Iowa have published a new Journal of Marketing study that examines how paying doctors to visit rural areas is a cost-effective way to provide reasonable access and effective care to most rural communities.

The study is titled "Bringing the Doctor to the Patients: Cardiology Outreach to Rural Areas" and is authored by J. Jason Bell, Sanghak Lee, and Thomas S. Gruca.

Rural health care is in crisis.

Between 2010 and 2015, the death rate from coronary heart disease was significantly higher in rural areas (118.2 per million) than in urban areas (106.2 per million). The shortage of cardiologists is an especially serious issue facing over 60 million rural Americans who suffer from higher levels of heart disease, hypertension, and stroke. Reflecting concern over rising death rates for heart disease and stroke in rural areas, the American Heart Association (AHA) and American Stroke Association (ASA) issued a Call to Action in 2020 to address the rising inequities in cardiovascular health of rural Americans.

Since most rural communities are too small to support a full-time cardiologist, outreach clinics help increase access to cardiologists for under-served rural patients. Bringing cardiologists to the local community reduces the need for patients to travel inconvenient distances and can lead to more timely diagnoses and treatment, resulting in better patient outcomes. However, it is important for hospitals, policymakers, and insurance providers to understand outreach decisions and how they may be impacted by the coming cardiologist shortage.

This new study estimates the financial costs of mitigating cardiologist shortages by studying outreach patterns over 30 years in the state of Iowa. While rural areas are underserved by cardiologists, urban areas seem to be in a state of oversupply. As per 2019 data for Iowa, the number of cardiologists per 100,000 people is 10.6 in urban counties compared to 1.5 in rural counties and 6.5 nationwide. The level of competition for patients in urban locations provides further motivation for engaging in rural outreach.

Iowa has fewer than 200 cardiologists, almost all of whom live in urban areas—and their number is expected to drop by 10% in the coming years. To make up for the lack of rural presence in Iowa, many practices have developed a strong network of visiting consultant clinics where physicians in many specialties, including cardiology, make periodic visits from urban to rural areas. The networks provide reasonable access and effective care to most rural communities.

An Australian model

While the outreach clinic model has been the most successful in plugging holes in rural cardiology access, it still has weaknesses. Physicians who participate in the program are unable to see patients while they are driving to the outreach clinic. This "windshield time" can last as long as two to three hours in Iowa and includes not just lost opportunities to see patients, but also mileage and other vehicle expenses. The opportunity costs are significant enough that only about half of Iowa's cardiologists participate in an outreach clinic.

In Australia, which has an even greater rural health care crisis than the U.S., the government's Rural Health Outreach Fund subsidizes qualifying specialists to motivate them to practice in rural areas. As Bell explains, "our study finds that if a payment program were adopted in Iowa to subsidize physicians for their windshield time, the payments would cost about $405,000 a year to maintain the current level of cardiology care in rural areas, even after the anticipated decline in numbers."

The study also explores other options.

• The suggestion to recruit foreign doctors to practice in rural areas has met with some success for primary care physicians, where the bulk of the funding is targeted. For such a program to be more cost effective than the public subsidy, it would have to attract five cardiologists who would work for $81,000 or less a year, a highly unlikely outcome. That would provide far less coverage than the network of outreach clinics for the same cost.

• Increased use of telehealth has also been proposed, but patients have been reluctant to use it for complicated health concerns. Furthermore, there are issues regarding reimbursement for cardiac telehealth consultations and lack of reliable, high-speed internet access in many rural areas.

The study looks only at cardiology, but the findings suggest that similar public subsidies would be an effective way to at least maintain health care coverage in rural areas in other specialties.

"While we have generally been reluctant to suggest the government pay providers to practice in certain locations, we have few other feasible options to provide equitable access to necessary health care to some 60 million rural Americans," says Lee.

Future research mst move beyond the usual focus on merely improving provider outcomes to advancing our understanding of the implications for patients. Gruca states that "our novel way of viewing the problem of patient access shows how it is influenced by the competitive marketing decisions individual providers make. We expect that focusing on provider behavior and patient outcomes will enable marketing scholars to provide valuable insights into other important and complicated problems in health care."