The secret to better rural healthcare: Pay doctors to travel from urban to rural areas
News from the Journal of Marketing
Researchers from University of Oxford, Arizona State University, and University of Iowa 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, forthcoming in the Journal of Marketing, 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 needs to 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.”
Full article and author contact information available at: https://doi.org/10.1177/00222429231207830
About the Journal of Marketing
The Journal of Marketing develops and disseminates knowledge about real-world marketing questions useful to scholars, educators, managers, policy makers, consumers, and other societal stakeholders around the world. Published by the American Marketing Association since its founding in 1936, JM has played a significant role in shaping the content and boundaries of the marketing discipline. Shrihari (Hari) Sridhar (Joe Foster ’56 Chair in Business Leadership, Professor of Marketing at Mays Business School, Texas A&M University) serves as the current Editor in Chief.
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About the American Marketing Association (AMA)
As the largest chapter-based marketing association in the world, the AMA is trusted by marketing and sales professionals to help them discover what is coming next in the industry. The AMA has a community of local chapters in more than 70 cities and 350 college campuses throughout North America. The AMA is home to award-winning content, PCM® professional certification, premiere academic journals, and industry-leading training events and conferences.
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JOURNAL
Journal of Marketing
ARTICLE TITLE
Bringing the Doctor to the Patients: Cardiology Outreach to Rural Areas
New research shows mobile methadone units are most impactful in rural areas
The research highlights the importance of expanding access to opioid treatments in remote locations
While mobile methadone units make a difference in expanding methadone use for patients with opioid addictions, they are likely to be most impactful in rural areas, according to new research.
The research was published today in Health Services Research and focused on the impact of adding new treatment services exclusively to rural Louisiana, where like in many other remote parts of the country, there are limited healthcare infrastructures and barriers to transportation. They compared this data to the impact of adding units statewide, where people have more access to traditional healthcare facilities.
The research team used predictive modeling approaches to estimate new methadone uptake following a hypothetical expansion of mobile methadone in the state. They looked specifically at cases where mobile methadone operators could choose their operation locations freely and in a separate instance where they were restricted to serving rural areas to identify potential geographic differences in their effectiveness.
“Several interconnected factors play a role in the prevalence of opioid use disorders in rural areas and this includes limited access to healthcare services, which is why we wanted to compare this data to help with decision-making when allocating resources to combat this public health crisis,” says first author Jason Gibbons, PhD, assistant professor and a health economist in the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus.
The research finds that adding ten units exclusively to rural Louisiana was associated with a 13 percentage point increase in Medication for Opioid Use Disorder (MOUD) treatment rates in rural zip codes.
Adding the same number of units across the state, not exclusively in rural areas, was predicted to increase MOUD treatment rates in Louisiana by up to nearly three percentage points.
“We find significant geographic variation in the impact of mobile methadone implementation, which means careful location planning will be required to maximize their benefit in other communities,” Gibbons says.
The researchers also predict that adding ten units to rural communities could provide nearly 20 percent of all beneficiaries residing in rural areas being treated with methadone to be around 24 miles closer to a methadone treatment provider. Their model also suggests that most patients will only be willing to travel up to 50 miles for methadone services, highlighting the potential for mobile units to close historical access gaps to methadone treatment.
To study the impact, the researchers looked at 43,341 Louisiana Medicaid patients with a diagnosis of opioid dependence identified in the Medicaid claims data between 2020 and 2021.
They then simulated the impact of mobile methadone units in Louisiana using two approaches: a “Poisson regression approach,” which involved predicting the number of opioid use disorder patients that might use methadone at mobile locations based on the underlying association between methadone use and proximity to a brick-and-mortar methadone clinic and a “policy approach,” which leveraged local treatment uptake rates following the expansion of methadone coverage to Louisiana Medicaid beneficiaries in 2020 to estimate methadone use following mobile unit implementation.
The analysis revealed mobile methadone would have a distinct impact in rural communities if these locations were prioritized and recommended operators collaborate with state and local policymakers regarding where to locate them to help maximize their impact.
About the University of Colorado Anschutz Medical Campus
The University of Colorado Anschutz Medical Campus is a world-class medical destination at the forefront of transformative science, medicine, education and patient care. The campus encompasses the University of Colorado health professional schools, more than 60 centers and institutes, and two nationally ranked independent hospitals - UCHealth University of Colorado Hospital and Children's Hospital Colorado - that treat more than two million adult and pediatric patients each year. Innovative, interconnected and highly collaborative, the University of Colorado Anschutz Medical Campus delivers life-changing treatments, patient care and professional training and conducts world-renowned research fueled by over $704 million in research grants. For more information, visit www.cuanschutz.edu.
About the Colorado School of Public Health
The Colorado School of Public Health is one of the only tri-institutional public health schools in the country. We leverage the power of three leading institutions—the University of Colorado (CU) Anschutz Medical Campus, Colorado State University (CSU), and the University of Northern Colorado (UNC) —to advance public health locally, nationally, and globally. Collectively, the School’s mission is to promote the physical, mental, social, and environmental health of people and communities. Through education, population-based research, and community service, the Colorado School of Public Health brings together institutions, agencies, and diverse populations. For more information, visit: https://coloradosph.cuanschutz.edu.
JOURNAL
Health Services Research
ARTICLE TITLE
Simulated impact of mobile opioid treatment program units on increasing access to methadone for opioid use disorder.
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