Many rural patients bypass local hospitals

The average person travels more than 22 miles for inpatient care rather than seek the same services at a community hospital, a study says.

By Carolyne Krupa — Posted Sept. 24, 2012

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Rural communities are particularly hard hit by growing physician shortages. Now a study by BlueCross BlueShield of Tennessee Health Institute shows that many rural residents in the state are bypassing their local hospital in favor of larger facilities farther away — even when the services they need are offered locally.

Researchers evaluated 47,300 inpatient hospital stays by BlueCross BlueShield of Tennessee members. They found that 69.9% of the stays were not at the facilities closest to where the individual members lived. In 43.4% of those cases, individuals traveled to a larger facility, even though the services they required were offered at their local hospital.

Patients typically traveled more than 22 miles for care rather than go to the hospital in their town.

Researchers were surprised by the findings.

“We hypothesized that geographic proximity to a health care facility would have a statistically significant influence on a patient’s ability to seek care,” said Steven Coulter, MD, lead study author and president of the institute. “That hypothesis proved to be false.”

The findings are applicable to other states with large rural populations, Dr. Coulter said.

Many rural communities struggle to find physicians. Although an estimated 60 million Americans, or 20% of the nation’s population, live in rural areas, only 7.7% of the nation’s physicians practice in those areas, according to the Health Resources and Services Administration.

“We know without doubt that work force is a real problem in rural communities,” said Brock Slabach, MPH, senior vice president for member services with the National Rural Health Assn.

Patients may choose to go to other facilities if they can’t get care locally in a timely manner, Slabach said.

“The physicians are put in a double bind here,” he said. “There are generally not enough physicians to service the rural community. Because of that lack of access, I think patients do tend to go to other places.”

Craig Becker, president of the Tennessee Hospital Assn., said patients may be traveling to larger hospitals on the advice of a local primary care physician.

“Most people go wherever their physician sends them,” he said.

Implications on access

The BCBS study didn’t address why Tennessee Blues members bypass local facilities. A key contributing factor probably is that people perceive that the quality of care is better at an urban facility, Dr. Coulter said.

Previous studies by the institute have found that physicians in the state’s urban areas are busy, in part, because they get a lot of patients from the surrounding region, Dr. Coulter said.

“This obviously has implications from a public policy standpoint,” he said. “If you have a capacity problem, how you solve that problem is going to be different if you have a population that is willing to travel.”

The study cited multiple limitations, including the fact that it included only individuals insured by BlueCross BlueShield of Tennessee. For most rural hospitals, individuals with group health insurance coverage make up a small portion of their overall patient load, Slabach said. On average, 60% to 70% of rural hospital patients are on Medicare. They mostly are elderly and less likely to have the means or ability to travel for care, he said.

Other factors that the study didn’t take into consideration were where people work or whether they have relatives in the urban areas that may motivate them to seek care there, Slabach said. Also, the survey looked at inpatient services when most care today is done on an outpatient basis.

“There may be a lot of mitigating factors,” he said.

For hospital administrators and physicians, learning that any patient is traveling for services that are offered locally should be motivation to examine their services and how they could be marketed better, Slabach said.

“Physicians need to help engage the community around the services that they offer,” Slabach said. “A lot of times it’s just making the community aware.”

Rural hospitals often are the largest employer in an area and serve as the nucleus of health care services in a community.

“If you don’t have the hospital, physicians tend not to want to locate there,” Slabach said. “These hospitals are the glue that holds these community health care systems together.”

Dr. Coulter said the study raises the question of whether some communities may be better served by different types of facilities. For example, that might mean having a chronic care facility or an emergency department with a helipad instead of a full-fledged hospital, he said.

“The obvious question is ‘How do we most effectively and efficiently apply our limited resources for the maximum benefit of the population?’ ” Dr. Coulter said.

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External links

“Issue Brief: Patterns of Care in Tennessee, Use of rural vs. non-rural facilities,” BlueCross BlueShield of Tennessee, September (link)

“Rural Health,” Dept. of Health and Human Services’ Health Resources and Services Administration, Sept. 17, 2009 (link)

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