Patients in rural areas less likely to receive specialty care

Two studies published simultaneously in Neurology examined patient-level and regional practice trends and found rising out-of-pocket costs and supply-demand mismatches, with implications for patients and policymakers.

In the first study, Chloe Hill, MD, MS, of University of Michigan in Ann Arbor, and co-authors examined patient out-of-pocket costs for neurologist visits and diagnostic tests ordered by neurologists for over 3.7 million people between 2001 and 2016. Data was from a single large commercial database insuring Medicaid patients. They found increasing costs, particularly for those with high deductible health plans, and significant cost variation by patient and by test.

In 2001, none of the patients studied were enrolled in high deductible plans; by 2016, 11% were. Examples comparing 2001 and 2016 average inflation-adjusted patient costs included office visit, which rose from $18 to $52; EEG, which climbed from $39 to $112; and MRI, which jumped from $84 to $242.

In 2001, patients paid an average of 7% of MRI cost versus 15% by 2016. While the median MRI cost was $103, some paid $875.

“An increasing number of patients pay out-of-pocket for neurologic diagnostic services,” wrote Hill and colleagues. “These costs are rising and vary greatly across patients and tests. The cost-sharing burden is particularly high for the growing population with high deductible health plans. In this setting, neurologic evaluation might result in financial hardship for patients.”

“The majority of patients had out-of-pocket costs for evaluation/management (E/M) neurology visits and this was consistent over time,” they added. “However, the out-of-pocket cost associated with an E/M visit remained relatively low (mean $52.3 in 2016). For diagnostic testing, both the proportion of patients paying out-of pocket costs and the out-of-pocket cost trended upward over time.”

The second study examined regional trends in neurology care. Chun Chien Lin, PhD, MBA, also of University of Michigan, and co-authors studied 1 year of data for 20% of patients enrolled in Medicare to identify 2.1 million with one visit or more for a neurologic condition. They compared the number of visits to neurologists versus other providers for a neurologic condition within hospital referral regions. The team also examined the distribution of neurologists.

Rural areas, with the fewest neurologists, averaged 10 neurologists per 100,000 people, compared with 43 per 100,000 in the most densely populated regions. In rural areas, 21% of patients with a neurologic condition were seen by a neurologist versus 27% in areas with the most neurologists; the difference was mostly accounted for by increased specialist care of dementia, pain conditions, and stroke.

The prevalence of patients diagnosed with neurologic conditions varied little across regions, but visit patterns differed. Comparing the percentage of rural and urban visits for common neurologic conditions that were seen by neurologists, they found:

  • Dementia: 38% in rural areas saw a neurologist, versus 47% in urban areas.
  • Stroke: 21% rural versus 31% urban.
  • Parkinson’s disease or multiple sclerosis: 80% saw a neurologist regardless of region.

“The supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not,” wrote Lin and co-authors. “As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson’s disease and multiple sclerosis). These data provide insight for policymakers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.”

In an accompanying editorial, Lyell Jones, Jr., MD, of Mayo Clinic in Rochester, Minnesota, and Heidi Schwarz, MD, of University of Rochester in New York, wrote that the studies “inform the conceptual spectrum of elasticity in healthcare,” seeing elasticity not only in economic terms — the tendency for higher prices to reduce demand — but as a metaphor for the evolving contexts that govern medical behaviors and assumptions.

“The increasing exposure of patients to their costs of care reflects a system-wide effort to curtail utilization,” the editorialists observed. “Shifting costs to patients is one of several approaches to risk transfer, wherein the goal is to encourage patients to shop for the lowest cost service to meet their needs. For this model to succeed, patients must have an accurate sense of the costs for which they are beholden, a competitive market within which to seek alternatives, valid quality benchmarks to facilitate comparison, and a reasonably navigable delivery and payment system. Satisfaction of any, much less all, of these requirements is unfortunately rare.”

Is this cost-shifting strategy effective? “U.S. healthcare costs continue to rise despite this and similar risk-transfer strategies,” they noted.

Pivoting to Lin and colleagues’ work on broader, regional patterns of neurologic practice, Jones and Schwarz noted that the extent to which neurologic patients are cared for by neurologists still offers a test of elasticity: “When access to neurologists is improved, patients appear to consume more of their services despite increasing associated costs of care.”

Physicians experience also varied with location, with “striking differences in face-to-face services delivered between areas of low and high neurologist supply,” they added. “Neurologists in low-density areas provided twice as many E/M services as their colleagues in high density settings.”

“In the context of well documented constraints on access to neurology services, these observations speak to an overextended neurologist labor pool, with attendant implications for provider sustainability and risk of burnout,” Jones and Schwarz noted.

“Collectively, these are important signals to policymakers as they design cost reduction programs, which should be carefully examined for their effectiveness, impact on access to care, and risk of financial harm to patients,” they wrote. “The explosion of telemedicine services and the increasing integration of advanced practice providers into coordinated care teams may allow us to extend delivery of high quality neurologic care into under-resourced settings.”

  1. Two studies published simultaneously found rising out-of-pocket costs and supply-demand mismatches in neurologic practice, with implications for patients and policymakers.

  2. Collectively, these are important signals to policymakers as they design cost-reduction programs which should be carefully examined for effectiveness, access to care, and risk of financial harm to patients, the editorialists noted.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Both studies were funded by the American Academy of Neurology.

Hill reported no disclosures relevant to the manuscript. Lin reported no disclosures.

The editorialists reported no disclosures.

Cat ID: 130

Topic ID: 82,130,556,730,130,192,925