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Health Aff (Millwood). 2019 Dec;38(12):1993-2002. doi: 10.1377/hlthaff.2019.00838.

Lack Of Access To Specialists Associated With Mortality And Preventable Hospitalizations Of Rural Medicare Beneficiaries.

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Kenton J. Johnston ( johnstonkj@slu. edu ) is an assistant professor of health management and policy at Saint Louis University, in Missouri.
Hefei Wen is an assistant professor in the Division of Health Policy and Insurance Research, Department of Population Medicine, at Harvard Medical School and the Harvard Pilgrim Health Care Institute, in Boston, Massachusetts. This research was conducted when she was an assistant professor in the Department of Health Management and Policy at the University of Kentucky College of Public Health, in Lexington.
Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in Saint Louis, Missouri.


People living in rural areas have worse health outcomes than their urban counterparts do. Understanding what factors account for this could inform policy interventions for reducing rural-urban disparities in health. We examined a nationally representative survey of Medicare beneficiaries with one or more complex chronic conditions, which represented 61 percent of rural and 57 percent of urban Medicare beneficiaries. We found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate, compared to urban residence. Having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate for people with chronic conditions, after we controlled for having one or more primary care provider visits. Access to specialists accounted for 55 percent and 40 percent of the rural-urban difference in preventable hospitalizations and mortality, respectively. Medicare should consider interventions for rural beneficiaries who lack access to specialist care to reduce rural-urban disparities in health outcomes.


Access to care; Activities of daily living; Education; Health policy; Health savings accounts; Medicare savings programs; Mortality rates; Patient engagement; Populations; Preventable hospitalization; Rural health care; medicare; mortality


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