- Dr. Michael Kitchell is an Ames-based neurologist.
A Dec. 25 Register editorial highlighted how rural America has been neglected by our politicians. Since 1992, the rural disparity that has been largely neglected in health care has worsened every year.
Rural Americans make up 20% of America’s population, but only 10% of doctors work there. Rural Americans are sicker and die earlier than city dwellers. The Centers for Medicare and Medicaid Services (CMS) physician payment policies, which have been in place for the past 30 years, have been largely responsible for this crisis, which has worsened since the COVID-19 pandemic.
Janice Probst of the University of South Carolina and others said in a study published in the December 2019 issue of the journal Health Affairs, “Rural populations experience negative health outcomes, including poorer health and age-related mortality.” They argued that “these disparities are partly due to reduced availability and accessibility of health care providers in rural communities.” Rural challenges are exacerbated by “structural urbanism”—the elements of current public health and health care systems that disadvantage rural communities.
The researchers also wrote that “current health care financing models … are inherently biased in favor of large populations.” They argued that such bias would “systematically shrink rural areas, slowly dry up the health care system in rural America, and threaten the health of rural US populations.” They suggested changing the payment system to stop this bias of “structural urbanism”.
St. Louis University’s Kenton Johnston and others studied why rural Americans have higher adverse outcomes, reporting in a December 2019 Health issue that rural residents have a 40% higher hospitalization rate and a 23% higher death rate compared to urban residents. Analyzing the reasons for the higher preventable rates of hospitalization and death, they found that the largest effect was due to “lack of specialist provision in the local area, which explained 55% of the variance in hospitalization rates and 40% of the variance. in death.” Johnston wrote that lack of access to specialists in rural areas “was a major factor in preventing deaths and hospitalizations among rural Medicare beneficiaries with chronic conditions.”
These authors proposed loan forgiveness programs and “differential payment rates” to increase the number of professionals in rural areas.
Medicare payment policy is the opposite: Medicare’s 30-year policy has chronically reduced payments to rural doctors and urban doctors.
In another Health Affairs report, Texas Tech University researcher Gordon Gong and other authors concluded that the increasingly high death rate in rural areas is due to three main factors: socioeconomic disadvantage, lack of health insurance, and rural physician shortages. regions. They said: “If their socio-economic conditions and access to medical care were similar, rural people would live longer than urban people.” They also recommended changes in federal policy to improve physician supply.
Medicare physician payment policies that discriminate against rural physicians date back to 1992, when CMS began regulating regional physician payments using a “geographic practice cost index,” or GPCI, methodology.
These GPCI Medicare payment-per-physician adjustments are indexed by region and have been used in 89 regions of the country to increase Medicare payments for urban physicians and decrease payments for rural physicians. These adjustments vary for each GPCI region and result in large differences in Medicare payment from one region to another. Iowa physicians now receive the lowest Medicare physician copayments compared to other regions. The results of GPCIs are indisputable. GPCIs result in rural physician Medicare payments up to 30% lower for evaluation and management codes, and up to 50% lower for diagnostic and imaging tests than urban physicians. These GPCI disparities cause many Medicare payments for rural services to be less than the cost of providing services.
This large difference in Medicare payment policies has led to significant challenges in recruiting and retaining physicians in rural areas. Although reduced payments are not the only reason why physicians choose not to practice in rural America, proposed remedies for the physician shortage have certainly included changing geographic payment disparities. This, the researchers noted, resulted in an increase in the number of hospitalizations and deaths. In large part because of the shortage of doctors in rural America.
It’s time to end this “structural urbanism” bias and Medicare’s chronic discrimination against rural doctors and residents. Medicare’s lopsided payment policies are largely responsible for high rates of rural morbidity and mortality. It’s time for our federal lawmakers to change Medicare payment policies and address health disparities for rural Americans.
Dr. Michael Kitchell is an Ames-based neurologist.