Access to Care for Rural Medicare Beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.     

Geographic Access to Health Care for Rural Medicare Beneficiaries

CONTEXT: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. PURPOSE: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington. METHODS: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes. FINDINGS: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists. CONCLUSIONS: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.     

Lower Rehospitalization Rates Among Rural Medicare Beneficiaries With Diabetes

Purpose: We estimated the 30‐day readmission rate of Medicare beneficiaries with diabetes, across levels of rurality. Methods: We merged the 2005 Medicare Chronic Conditions 5% sample data with the 2007 Area Resource File. The study population was delimited to those with diabetes and at least 1 hospitalization in the year. Unadjusted readmission rates were estimated across levels of rurality. Multivariate logistic regression estimated the factors associated with readmissions. Findings: Overall, 14.4% had a readmission; this was higher among urban (14.9%) than rural (12.9%) residents. The adjusted odds indicated that remote rural residents were less likely to have a readmission (OR 0.74, 0.57‐0.95) than urban residents. Also, those with a 30‐day physician follow‐up visit were more likely to have a readmission (OR 2.25, 1.96‐2.58) than those without a visit. Conclusion: The factors that contribute to hospital readmissions are complex; our findings indicate that access to follow‐up care is highly associated with having a readmission. It is possible that residents of remote rural counties may not receive necessary readmissions due to lower availability of such follow‐up care. Policy makers should continue to monitor this apparent disparity to determine the impact of these lower rates on both patients and hospitals alike.     

Rural Medicare Beneficiaries'Use of Rural and Urban Hospitals

This report examines the use of rural and urban hospitals by rural Medicare beneficiaries. Many rural Medicare beneficiaries are treated in urban hospitals, primarily for specialized care that is not available locally. This study examines Medicare inpatient hospital discharge data for rural beneficiaries from fiscal year 1990 to fiscal year 1998. Utilization patterns by diagnosis-related group (DRG) are examined for fiscal year (FY) 1997. The percentage of rural beneficiaries treated in urban hospitals ranged from 30 percent to 36 percent during the study period. For the most frequently occurring DRGs among rural beneficiaries, which were those for routine conditions, treatment occurred predominantly in rural hospitals. The conditions most often responsible for rural beneficiaries' use of urban hospitals during this period reflected the need for coronary and other specialized surgical care. The stability of volume and case-mix throughout the study period underscores the viability of rural hospitals during a period of substantial change in the organization of health care provision.     

Bypassing the Local Rural Hospital for Outpatient Procedures

ABSTRACT:  Purpose: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. Methods: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. Findings: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. Conclusions: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations .     

Promoting Pneumococcal Immunizations Among Rural Medicare Beneficiaries Using Multiple Strategies

CONTEXT: Vaccine-preventable diseases among adults are major contributing causes of morbidity and mortality in the United States. However, adult immunizations continue to be underutilized in both urban and rural areas. PURPOSE: To evaluate the effectiveness of a community-wide education campaign and mailed reminders promoting pneumococcal immunizations to rural Medicare beneficiaries. METHODS: We implemented a community-wide education campaign, and mailed reminders were sent to Medicare beneficiaries in 1 media market in Montana to increase pneumococcal immunizations. In a second distinct media market, mailed reminders only were sent to beneficiaries. FINDINGS: The proportion of respondents aged 65 years and older aware of pneumococcal immunizations increased significantly from baseline to follow-up among respondents both in the education-plus-reminder (63% to 78%, P = 0.04) and the reminder-only (64% to 74%, P = 0.05) markets. Overall from 1998 to 1999, there was a 3.7-percentage-point increase in pneumococcal immunization claims for Medicare beneficiaries in the education-plus-reminder market and a 1.5-percentage-point increase in the reminder-only market. Medicare beneficiaries sent reminders in the education-plus-reminder market compared to those in the reminder-only market were more likely to have a claim for pneumococcal immunization in 1999 (odds ratio 1.18, 95% confidence interval 1.08 to 1.28). The results suggest that these quality improvement strategies (community education plus reminders and reminders alone) modestly increased pneumococcal immunization awareness and pneumococcal immunization among rural adults. Mailed reminder exposure was associated with an increased prevalence of pneumococcal immunizations between 1998 and 1999 and was augmented somewhat by the education campaign.     

Variations in Influenza and Pneumonia Immunizations for Medicare Beneficiaries Served by Rural Health Clinics

The availability of a rural health clinic (RHC) database over the period of 6 years (2008–2013) offers a unique opportunity to examine the trends and patterns of disparities in immunization for influenza and pneumonia among Medicare beneficiaries in the southeastern states. The purpose of this exploratory study was twofold. First, it examined the rural trends and patterns of immunization rates before (2008–2009) and after (2010–2013) the Affordable Care Act (ACA) enactment by state and year. Second, it investigated how contextual, organizational, and aggregate patient characteristics may influence the variations in immunization for influenza and pneumonia of Medicare beneficiaries served by RHCs. Four data sources from federal agencies were merged to perform a longitudinal analysis of the influences of contextual, organizational, and aggregate patient characteristics on the disparities in immunization rates of rural Medicare beneficiaries for influenza and pneumonia. We included both time-varying and time-constant predictors in a multivariate analysis using Generalized Estimating Equation. This study revealed the increased immunization rates for both influenza and pneumonia over a period of 6 years. The ACA had a positive effect on increased immunization rates for pneumonia, but not for influenza, in rural Medicare beneficiaries in the eight states. The RHCs that served more dually-eligible patients had higher immunization rates. For influenza immunization, provider-based RHCs had a higher rate than the independent RHCs. For pneumonia immunization, no organizational variables were relevant in the explanation of the variability. The results also showed that no single dominant factor influenced health care disparities. This investigation suggested further improvements in preventive care are needed to target poor and isolated rural beneficiaries. Furthermore, the integration of immunization data from multiple sources is critically needed for understanding health disparities.     

Outcomes for Whites and Blacks at Hospitals That Disproportionately Care for Black Medicare Beneficiaries

Objective

Hospital care for blacks is concentrated among a small number of hospitals and whether they have worse outcomes across common medical conditions is unknown.

Data Source

We used the 2007 100% Medicare file to calculate 30- and 90-day mortality rates for white and black patients admitted for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia.

Study Design

We ranked all hospitals in the country by their proportion of discharged black patients and identified the top 10 percent of these hospitals as black serving. We examined race-specific adjusted mortality rates and adjusted for differences in hospital characteristics.

Principal Findings

At 30 days, black-serving hospitals had, compared with nonblack-serving hospitals, similar mortality for AMI, lower mortality for CHF, and higher mortality for pneumonia. At 90 days, mortality was higher at black-serving hospitals for both AMI and pneumonia and comparable for CHF compared with nonblack-serving hospitals. White patients had worse outcomes at black-serving hospitals for two conditions at 30 days and all three conditions at 90 days. Blacks also had worse outcomes at black-serving hospitals.

Conclusions

Hospitals with a high proportion of black patients had worse outcomes than other hospitals for both their white and black elderly patients.     

The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America

CONTEXT: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. PURPOSE: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. METHODS: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination). FINDINGS: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum. CONCLUSIONS: Urban-rural quality of care differences may be a function not just of geography but also of the presence of a large nonwhite population.     

Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel Outside Local Markets

Purpose: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum.
Methods: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA.
Findings: Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity.
Conclusions: Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.     

Fecal Occult Blood Test Use by Kansas Medicare Beneficiaries

PURPOSE: The aim of this study was to examine utilization of and trends in fecal occult blood testing (FOBT) among beneficiaries since Medicare began FOBT coverage on January 1, 1998. METHODS: We identified Kansas Medicare beneficiaries ages 65-79. Using Medicare claims, we determined which beneficiaries received FOBT during 1998-1999. We examined demographic variables associated with FOBT and rate changes over time. We linked beneficiaries to primary care practices (PCPs) and examined FOBT variations among 483 PCPs. RESULTS: FOBT use remained unchanged during the study period. Of the 215,322 beneficiaries, 11% received at least one FOBT in 1998 and 11% in 1999; 18% had at least one test during the 2-year period, but only 4% had a test during both years. Caucasians and females had the highest FOBT rates. Although FOBT rates among PCPs ranged from 0 to 71%, only 19% of the practice rates exceeded 10%. CONCLUSIONS: Few beneficiaries obtain annual FOBT and little change in rates has occurred since Medicare reimbursement began. Although FOBT rates vary widely between PCPs, most either do not provide FOBT or do not bill Medicare for FOBT. The FOBT claims rate is much lower than reported in patient surveys and may indicate that Medicare should reexamine its reimbursement policy.     

Hospital Choice of Medicare Beneficiaries in a Rural Market: Why Not the Closest?

As part of a larger study of hospital choice, the travel patterns of more than 12,000 Medicare beneficiaries residing in three overlapping rural areas were examined. During 1986 these Medicare beneficiaries were admitted to one of 53 hospitals in an area that encompassed parts of Minnesota, North Dakota, and South Dakota. Information on ZIP code of residence, closest hospital, and hospital of admission were used to analyze hospital choices of the Medicare rural elderly residing in this area. To summarize their travel patterns, the admitting hospital was categorized based on whether it was urban or rural, its size and whether or not it was the closest facility. Findings indicated that 60 percent of these rural Medicare beneficiaries used hospital services at their closest rural hospital, regardless of its size. However, 79 percent of those whose closest hospital was larger than 75 beds used it, while only 54 percent of those whose closest rural hospital was fewer than 75 beds obtained services there. Overall, 30 percent of those residing in this rural market area went to an urban hospital. These patterns appeared to reflect an evaluation by the physician and/or individual of the relative attractiveness of the local hospital versus alternatives available, as well as the individual's characteristics. Travel patterns varied by the beneficiary's age as well as his or her relative complexity of illness, as measured by a Disease Staging methodology. Findings have implications for the provision and financing of hospital services in rural areas.     

Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia

ObjectivesHospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia.DesignRetrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016.Setting and ParticipantsWe identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment.MethodsWe calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage).ResultsOf the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population.Conclusions and ImplicationsOne-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.     

Hospital Choice of Rural Medicare Beneficiaries: Patient, Hospital Attributes, and the Patient–Physician Relationship

Objective. To examine how patient and hospital attributes and the patient–physician relationship influence hospital choice of rural Medicare beneficiaries.
Data Sources. Medicare Current Beneficiary Survey (MCBS), Health Care Financing Administration (HCFA) Provider of Services (POS) file, American Hospital Association (AHA) Annual Survey, and Medicare Hospital Service Area (HSA) files for 1994 and 1995.
Study Design. The study sample consisted of 1,702 hospitalizations of rural Medicare beneficiaries. McFadden's conditional logit model was used to analyze hospital choices of rural Medicare beneficiaries. The model included independent variables to control for patients' and hospitals' attributes and the distance to hospital alternatives.
Principal Findings. The empirical results show strong preferences of aged patients for closer hospitals and those of greater scale and service capacity. Patients with complex acute medical conditions and those with more resources were more likely to bypass their closest rural hospitals. Beneficiaries were more likely to bypass their closest rural hospital if they had no regular physician, had a shorter patient–physician tie, were dissatisfied with the availability of health care, and had a longer travel time to their physician's office.
Conclusions. The significant influences of patients' socioeconomic, health, and functional status, their satisfaction with and access to primary care, and their strong preferences for certain hospital attributes should inform federal program initiatives about the likely impacts of policy changes on hospital bypassing behavior.