Medicare’s physician payment policies hurting rural Americans

  • 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.

Rural doctors get paid less from Medicare than their urban counterparts.  Pictured is Carroll's St. Anthony Regional Hospital.

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”.

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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.”


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