Primary Care Perspectives on Access to Specialty Care in Rural Communities: A Mixed-Method Study

Context: Rural/urban health disparities are widening for leading causes of rural mortality, in part due to poor access to specialty services for heart disease, cancer, chronic respiratory disease, and stroke. Rural facilities report challenges and solutions to meet community needs for specialty care.

Objective: This study sought to analyze changes in the U.S. rural/urban supply of specialist physicians and understand how rural communities innovate to ensure access to care and support their primary care workforce

Study Design and Analysis: Mixed-method study of rural/urban changes in ratios per 100,000 residents of cardiologists, neurologists, oncologists, or pulmonologists providing patient care from 2012 to 2022 based on Rural-Urban Commuting Area Codes (P<0.01 for t-tests or Chi-square tests as appropriate). We interviewed 18 rural health system leaders across the U.S., using directed content analysis of interview data to identify themes.

Setting/Data Set: U.S./American Medical Association Physician Masterfile

Population Studied: Cardiologists, neurologists, oncologists, or pulmonologists; rural health systems leaders.

Intervention/Instrument: Descriptive analyses of secondary and interview data

Outcome Measures: Supply, distribution, and demographics for each type of specialist; (2) sociodemographics of counties with and without each specialist type; and (3) interview themes.

Results: The 2022 physician supply per 100,000 residents was lower in rural than urban areas for cardiologists (2.60 rural, 7.32 urban), neurologists (1.09 rural, 4.11 urban), oncologists (2.17 rural, 6.57 urban), and pulmonologists (0.87 rural, 1.37 urban). From 2012 to 2022, rural supply decreased for pulmonologists (-41.7%), neurologists (-16.5%), and cardiologists (-5.6%); oncologists increased (20.0%). Rural health system leaders described 5 methods to provide rural specialty access: community-based, visiting, referrals to larger towns, telehealth, and management by primary care with specialist support. Barriers included workforce shortages, travel times, geography, inclement weather, and insurance limitations.

Conclusions: Specialists are far less concentrated in rural than urban areas, creating access barriers. Telehealth services are underutilized; incentives for traveling specialists could increase access. Reducing or eliminating barriers to providing telehealth services across states may also help improve access to specialty care.