Health disparities are quantifiable differences in disease burden, morbidity, and mortality experienced by any socially disadvantaged group due to differences in access and quality of health care. Socioeconomic status, proximity to health care services, race, age, and gender contribute to health care disparities. This article will focus on health disparities affecting rural populations and examine factors that confer worse outcomes.
Approximately 60 million Americans live in rural or highly rural areas. Rates of tobacco use, hypertension, obesity, and suicide are higher in rural than urban populations and likely contribute to higher mortality rates among rural patients. While approximately one-third of America’s hospitals are considered rural, health disparities, including reduced access to primary and tertiary care facilities, physician shortages, resource redistribution, and socioeconomic deprivation, likely contribute to these increased morbidity and mortality rates. The COVID-19 pandemic and general economic forces have compounded the problem in recent years.
Before the COVID-19 pandemic, rural patients traveled 59% further than urban residents to access care. The widespread closure of rural health care facilities over the past decade has compounded this issue. Health care system consolidation brought about by the Affordable Care Act (ACA) and the interests of private equity firms have been accelerating since 2010. One risk of these changes is worsening access disparities.
Historically, increases in mergers and affiliations of health systems have disproportionately affected rural patients. Mergers may delay elective and emergent care by increasing patient commutes to the nearest hospital. From 2005-2015, the number of patients who had to commute at least one hour to the nearest hospital increased by 80% following mergers and consolidations. Consolidations and mergers may also impact insurance access and affordability at the patient level. In addition to these immediate burdens upon patients, consolidation of care, superimposed upon existing resource limitations, may result in the regionalization of specialized care. The nearest provider may no longer be in the patient’s insurance network, and the nearest facility may no longer have the services or equipment to treat some complex conditions. Interhospital transfers, associated with a 2.7-fold increase in mortality, will increase. While transferred patients account for approximately 10% of hospital admissions, they constitute almost 30% of mortality. Additionally, transferred patients frequently receive redundant testing. In one study of transferred patients, 70%-99.5% of studies performed following transfer were deemed inappropriate and excessive.
Although hospital administrators often describe mergers as a cost-saving stratagem, horizontal and vertical mergers (i.e., within and across systems) increase health care costs for insurance companies and patients. While administrators may argue that they can increase negotiation power with insurance companies, improve purchasing power for equipment, and decrease administrative needs when they restructure their organizations, administrative costs often increase when facilities grow.
Health care corporations also herald mergers as benefitting smaller facilities, arguing that consolidation increases their ability to enhance service lines and expand a facility’s footprint into more markets. Operating under the umbrella of a larger system may allow smaller facilities to retain patients within their larger system and may also provide opportunities for expanding local services and sharing of their medical staffs. Cash-poor hospitals may seek a merger with a larger system that can provide resources for capital improvements or technological innovation. This approach fails when necessary services become offered only periodically or when service lines are condensed.
In addition to its institutional and patient impacts, the regionalization of rural health care, compounded by the COVID-19 pandemic, also directly impacts clinician availability and willingness to practice in rural areas. Approximately 10% of physicians practice in rural areas. Rural clinicians face expanded patient loads, heavy call burdens, long commutes, and ever-broadening catchment areas.
Health professional shortage areas (HPSAs) are regions with a shortage of primary care, dental, or mental health care providers. Access to other specialists is typically also reduced. While efforts have been made to increase rural access to specialists through multiple federal and state programs, including the CARES Act of 2020, these efforts have not provided adequate support to meet regional recruitment needs.
Medical training typically does not emphasize rural primary care. Few medical schools have developed specialized programs to attract future clinicians interested in serving rural areas. Programs incorporating international medical graduates into the rural workforce alleviate some of this shortage, but deficits remain. Some organizations, such as the Department of Veterans Affairs, have hired advanced practice providers to fill gaps in primary care; however, gaps persist, particularly in access to surgical and obstetrical care. Systematic reviews suggest that, while financial incentives such as loan forgiveness may play some role in increasing physician willingness to practice in rural areas, recruitment of student doctors from these rural areas and training in a rural environment are more effective strategies for recruitment and retention of clinicians in rural areas.
The core principles of bioethics are beneficence, nonmaleficence, respect for autonomy, and justice Beneficence implores physicians to act in the patient’s best interest, which can mean advocating on their behalf. Physicians have an ethical duty to make reasonable efforts to help patients access care.
It is unfortunate that despite these challenges faced in providing much-needed care in rural areas, there has been decreasing state and local government oversight while the mergers mentioned above prevail. This has limited the ability of patients and clinicians to voice their concerns and minimize the impact on the affected communities.
In the past, consolidating hospitals and those offering new services were required to apply for a certificate of need (CON) under state oversight. However, reforms in 2008 made state oversight over hospital mergers optional. At this time, of the 37 state programs, only four programs are in place to review hospital closures and provide oversight. Also, only eight programs can assess and evaluate stock transfers and financial oversight. Those CON programs that exist are outdated and lack elements of consumer and patient representation.
“What role can a single anesthesiologist or small group of anesthesiologists or physicians do to affect this pattern of consolidation and its impact on access to care? The answer lies in getting more involved with advocacy efforts and being active in all aspects of care, including structural and organizational decisions.”
What role can a single anesthesiologist or small group of anesthesiologists or physicians do to affect this pattern of consolidation and its impact on access to care? The answer lies in getting more involved with advocacy efforts and being active in all aspects of care, including structural and organizational decisions. Active discussion of these issues may allow earlier participation and effective representation by our profession in discussions around service provision and planned changes.
Anesthesiologists should be aware of these challenges and understand both the impact on rural communities and our ethical duty to care for the individuals within these communities. You are encouraged to be an active member of your hospital’s physician group and medical staff meetings and/or governance so that your voice will be heard. You should also strive to be active members of your state and local professional societies to have your voices heard at the state, local, and federal levels. You should aim to communicate openly with local representatives and government officials so they recognize the importance of these issues to our field and become aware of the importance we place on solving them. You should encourage all of your colleagues to be active members of ASA to amplify your voices.
Lastly, there are times when we may be the only voice for our patients and the community. It can be difficult to argue for or against an acquisition, consolidation, or merger when our life and lifestyles may be affected. However, we must balance these pressures and assess the situation unbiasedly and support what is right for our patients and community.