United Health Group points to rural care shortcomings, fixes

United Health Group has weighed in on the simmering debate over how good rural health care is and what to do about it.

Almost a quarter of the nation's rural residents consider the health care in their communities to be only fair or poor, according to a poll commissioned by the big health care insurer. That's twice the rate for urban residents in the 2,000-respondent national telephone survey.

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Earlier this month the Journal of the American Medical Association ruffled rural feathers by publishing a Harvard study indicating rural hospitals aren't as good as urban hospitals in handling heart attacks, congestive heart failure and pneumonia cases. In fact, that was cited in the United Health report.

But the researchers went further. They examined the nation's 300 "hospital referral areas," geographic regions that tend to use the same set of hospitals. Within each, they compared rural and urban doctors by looking at how often they adhered to accepted ways of handling various patient conditions. In all, they looked at 33 million opportunities for doctors to provide care that could be measured by evidence-based standards. Half of those involved hypertension, diabetes or high cholesterol.

They found that rural physicians usually performed worse.

Out of the 300 referral areas, 256 generated enough data to be comparable. Of those, 75 percent showed better performance for urban and suburban doctors. Twenty percent showed no difference and in 5 percent, rural doctors did better.

In a typical area, rural doctors were 3 percent less likely than urban and suburban doctors to provide "high-quality" care, the report says. Rural doctors did best on this comparison in the Upper Midwest and in the Northeast.

The authors highlighted a couple specifics:

--Rural service ranked lower on cervical and breast cancer screenings.

--For cholesterol and blood pressure, there wasn't a lot of difference.

The authors cite a few difficulties in interpreting the research, including noting that some rural providers could be above the national average but look bad because they're in a region with very good urban hospitals.

And Lew Sandy, senior vice president for clinical advancement for UnitedHealth Group, said it's not clear why the differences might exist. It's possible patients are sicker in rural areas, although the methodology tries to account for that. He also said there have been suggestions that the disparity could be the result of older physicians in rural areas that haven't kept up.

"But we don't really know the actual reason," he said.

The report goes on to estimate that national health care reform will result in a greater increase in insured patients in rural areas than in urban areas. This additional demand, it suggests, will add to the much-documented difficulties resulting from a shortage of rural physicians.

Again, this problem will be worse out west and down south than in the Midwest, the report says.

So what to do about all this? The report lists what it considers a promising list of possibilities. If you've looked at our Ground Level package on rural health care, you've seen much of this before:

Incentives to get more physicians into rural areas; more teamwork among doctors, nurse practitioners and others; more collaboration between rural and urban providers; greater use of health information technology and telemedicine.

The last point leads United Health to join those calling for greater availability of high-speed Internet access and specifically for physicians to do more to incorporate it into their practices.

Terry Hill, executive director of the National Rural Health Center in Duluth, said the study, taken in combination with the Harvard study, might help build momentum for initiatives to improve rural health care.

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