Travel Burden for Healthcare among Rural Populations, with Marvellous Akinlotan and Alva Ferdinand

Organizations and resources mentioned in this episode:

• Federal Office of Rural Health Policy
• Rural Hospital Closures, North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research
• Texas Transportation Institute

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. And in this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

This is the final episode of our three-part series about transportation in rural America.

Joining us today as Dr. Alva Ferdinand. She's the director of the Southwest Rural Health Research Center, that center, funded by the Federal Office of Rural Health Policy, focuses on policy relevant research on meeting the needs of rural populations, minority populations, and health disparities, including border health.

Also joining us from the SRHRC is Dr. Marvellous Akinlotan, where she is a research assistant professor. Now you are both involved in researching and writing a policy brief entitled Rural-Urban Variations in Travel Burdens for Care. So, Dr. Akinlotan, if I could ask you first, you spearheaded this project, why was this something that you wanted to dig into and learn more about?

Dr. Marvellous Akinlotan: Thank you, Andrew. The last documentation of the national estimates for the travel distance and time for medical care using the national household travel survey was done in the year 2001. And so, it was important to look into the data to provide current national estimates of the travel distance and time to medical or dental care, and to determine what has changed over time where the changes have occurred and what groups have been mostly affected.

Dr. Alva Ferdinand: Yeah. I think that in just looking at the literature, there were lots of studies sort of focusing on one particular disease, for example, cancer or looking at different types of cancers and travel burden, for example, to radiation therapy or to other kinds of therapies for cancer related conditions. But just generally speaking, there wasn't a nationally representative study that had been done for a really long time. So I think that we were just curious to see, in the grand scheme of things, what does travel burden look like for rural residents and how does that compare to urban residents. And I think one of the nice things about what we do in the center and academics across the country is to sort of look at what we already know how old that data might be and just work on providing contemporary findings to sort of see how far we've come or not come. And I think that was one of the reasons that this was a really exciting project for us.

Andrew Nelson: Yeah. I can see how that could be kind of a secondary element of rural healthcare that kind of gets overlooked providing the services are one thing, but people need to be able to get to the doctor as well. Dr. Akinlotan, your research on travel burden built on information, as you said from the mid 2000s about travel behaviors of rural and urban residents for those seeking healthcare. What have you found has changed since that time?

Dr. Marvellous Akinlotan: Yes. So for this study, we looked at three years, that's from the national household travel survey. We looked at year 2001, year 2009, and year 2017. And those were the three most recent versions of that dataset. We looked at the travel time and distance among urban residents and among rural residents. And for urban residents, we found that the travel distance did not change significantly between 2001 and 2017, but for rural residents, the travel distance changed quite significantly. And so, in 2001, rural residents were traveling about 15 miles to get care. But in 2017, that number had risen up to 18 miles. And that change was statistically significant. When we looked that at a time, we did find that the travel time increased for both urban and rural residents. So even though for those residing in urban area, they didn't necessarily need to travel further, they still traveled longer. They still spent more time in their travels. And the same finding was made for rural residents as well. When we also compared and looked at the rural urban differences in the travel trends and found that compared to their urban counterpart, rural residents traveled seven miles farther for care in 2001, but that number increased to 10 miles in 2017. Also for travel time, rural residents traveled five more minutes to get care in 2001, but 10 more minutes in 2017. And so we found that the rural-urban disparities widened over the study period.

Another measure we looked at was the travel burden, and that was defined as the percentage of trips that lasted either 30 miles or 30 minutes. And we found that in rural areas, one in three trips for medical or dental care lasted 30 minutes or more in 2001, but in 2017, almost one in two trips for medical or dental care lasted more than 30 minutes. And so the travel burden increased substantially in rural areas as well.

Dr. Alva Ferdinand: I think, and thinking about rural residents not as a monolith, but sort of understanding that there are different types of rural residents. There are racial and ethnic minorities. There are folks that are covered with different types of insurance plans, et cetera. One of the interesting things for me is just sort of seeing how for certain populations subpopulations, the story hasn't gotten better for them either despite what we've seen as an evolving transportation system in the US with respect to rideshare, et cetera. We're still seeing that minority populations. I think Blacks and Hispanics, in particular, are continuing to face a very significant travel burdens.

Another thing that sort of popped out for me in reading the travel burden literature comprehensively, it was sort of the burden that folks that are on public insurance, such as Medicaid and Medicare also face in trying to seek care. Even though the findings that Dr. Akinlotan shared just now are really, really interest for rural and hold true for the population at large, it's important to understand that when you see one rural community, you've seen one rural community and that there are various subpopulations within rural that continue to face of substantial travel burdens.

Andrew Nelson: And Dr. Akinlotan, you mentioned that this disparity had increased in the last 15 or 20 years. What causes were you able to identify for that disparity?

Dr. Marvellous Akinlotan: So just looking at the datasets that we used, the causes weren't apparent, but we could look at our findings and also take a contextual look at what has been going on in rural areas to make sense of that finding. Well, first one of the causes we see would be the closure of rural hospitals. Data from the UNC Sheps Center on rural hospital closures lets us know that they were about 126 complete and partial rural hospital closures between 2005 and 2017. And so, for residents who lived close to, or in communities where they were hospital closures, you can imagine that they would've had to travel even further to get care following the closure, whether it was full or partial.

In addition to that, there have been fewer primary and specialty services available in rural areas over time. And that has also meant that rural residents would need to travel even further. And the third cause or probable cause would be fewer options for public transportation. As opportunities for public transportation continue to dwindle over time, those who had to rely on public transportation to get medical or dental care would have to seek for other options, which may have translated into spending more time.

Andrew Nelson: Can you tell us a little bit about the rural experience of travel when people living in rural areas are seeking after-hours care?

Dr. Marvellous Akinlotan: First aspect of the study we conducted that was the policy brief. We looked at characteristics of the trips made at night, and we found that rural trips that were made between midnight and 7:00 AM were 22 miles farther and 24 minutes longer than urban nights trips. And so, just looking at that tells us that there's higher burden for rural residents who needed care in the middle of the night.

There was no way to tell whether those trips were emergent or not, but one came infer that traveling at 2:00 AM for care would be something that was at least pretty urgent, would be for a condition that was pretty urgent. And that also lets us know that emergency and urgent care centers were more likely to be located farther away in rural areas, and there might also be consequences associated with that. We weren't able to capture that from our data. But for an individual who needed to get access to urgent care or emergency care, having to travel 22 miles further or even 24 minutes longer, one can only tell what consequences or what complications may have resulted from having to wait or travel much longer just to get care in the middle of the night.

Dr. Alva Ferdinand: I think that certainly we were limited in what the data that we used could tell us, but I think in thinking about the literature in general, what we know is that when access is difficult for individuals, sometimes what ends up happening is that they forgo care. So a condition that may not have escalated to the point of needing emergency care at 2:00 AM, for example, may have been mitigated if access was somewhat better, a little bit easier to reach a primary care physician, for example, or perhaps even a specialty physician as the case might be. And so, I think when we're thinking about those hours, not too many people would elect to go to find a physician at 2:00 AM as opposed to 3:00 PM or 11:00 AM for an outpatient visit. So what that sort of tells us is that there might be some forgone care and delayed care happening as well, such that when they do eventually need to seek care, the disease condition is much higher or more detrimental than perhaps it could have been if access to outpatient care was more readily available.

Andrew Nelson: You can definitely have kind of a domino effect, I suppose, with relatively trivial things becoming very serious just because of that impediment to access. Rural areas often don't have as many public transit options. How does that reliance on personal automobiles affect access to care?

Dr. Marvellous Akinlotan: We knew from the literature that nearly 4% of rural households, which is almost 2 million rural residents do not have access to a car. And in addition to that, rural areas are also much less likely to have access to public transportation. And so, in the light of this, they may be forced to rely on friends and family for transportation. And without reliable options for transportation, the special populations such as older adults, those with disabilities special needs will be personally vulnerable to isolation. In addition to the foregone care, missed appointments, delayed care, they may also be vulnerable to isolation, which can also increase the risk of mobility and mortality.

Dr. Alva Ferdinand: I think that in thinking about how transportation is evolving in general, we've been talking quite a lot about autonomous vehicles and the impact that they might have in reducing some disparities and inequities that we see throughout the country. And this might be something that we think about and delve into the research as autonomous vehicles become a thing as it were. I think that rideshare, certainly rideshare and other types of transportation have really evolved and come to be pretty commonplace in metropolitan areas of the United States. But I think there's certainly still a lag in these kinds of innovations for rural populations. And so, I think it's going to be important for us to kind of see how the transportation infrastructure evolves and how that impacts rural residents throughout the United States.

Andrew Nelson: Can you tell us a little bit about the financial impact of large distances that people need to traverse to get access to rural healthcare? For example, how gas prices might impact whether or not rural residents can get the care that they need?

Dr. Marvellous Akinlotan: Our data showed that more than half of rural residents agreed or strongly agreed that the price of gasoline affects their travel compared to just 45% of urban residents stating that the price of gasoline was a barrier to their travel. And one can also infer that with the higher travel burden, just imagine one in two trips for medical or dental care taking up to 30 minutes or more than 30 miles, spending more than 30 miles to get to care, with that burden would also come the increased costs of gasoline. But from the literature, we know that compared to urban households, rural residents are less likely to reduce their travel when gasoline prices rise, because they have less transit options and they have fewer and they have less access to rideshare services. And so, they have fewer opportunities to adapt their travel patterns. So one can see that the financial impact is there and the price of gasoline is a problem, but they are still less likely to reduce their travel just because of that because they have fewer options to travel.

Andrew Nelson: Beyond that, have you found that there are any particular groups of rural residents that are especially impacted by transportation challenges?

Dr. Marvellous Akinlotan: There are two major groups that came to mind. The first group will be groups that have conditions that limit mobility. Those are more likely to be older adults, those with disabilities and special needs children, for example. And for older adults, definitely elevated burden of transportation will reduce the likelihood that they need to leave the communities where they leave to get into long term care. And improving transportation among that population would also reduce isolation and improve mental health. But apart from the special groups that we already mentioned, and Dr. Ferdinand mentioned this much earlier in the podcast, we also looked at the travel burden by race and ethnicity and found that over time, the travel time and distance increased disproportionately for Blacks and Hispanics.

For example, the travel distance for rural Hispanics increased by 11 miles and 19 minutes in 2017 compared to 2001. And that was the highest increase of any of the other groups. There were also substantial increases for Blacks as well. The distance for Whites didn't increase as much. And so, this suggests that the increased travel burden that we are seeing among rural populations over time, the brunt of that is being born by the minority populations, particularly the rural Hispanics. So these groups are definitely more impacted by transportation challenges. And that's important to note.

Dr. Alva Ferdinand: What we know from the literature, as I mentioned previously, is that folks that are covered through public insurance, Medicaid really stands out, because certainly the Medicare program is sort of the based on age and citizenship and that kind of thing. But if you're covered on Medicaid, it means that you're in the lower income categories. And what we learned from our work is that if you make less than $25,000 a year, that you were also more likely to have substantial travel burden associated with finding appropriate care for a health condition. So if we think about the jobs that are tied to that bracket of salary, there's probably less flexibility. You're probably not necessarily able to work from home. So if we're thinking about the pandemic, for example, you might actually have higher exposure to infectious disease such as COVID-19, and really not much of a choice in terms of getting childcare or arranging for expectation like with an Uber or renting a car for a day, for example. Those options are very limited, if you happen to be in that income category.

Andrew Nelson: What are some potential solutions to address these rural travel burdens?

Dr. Marvellous Akinlotan: Well, the first is telehealth. Increasing access to telehealth for the entire rural population, but particularly for the minority population and adapting it in such a way that it can be used by them is critical. Providing travel discounts so that individuals who need to travel and have cost as a barrier are able to overcome that is another potential solution. Ridesharing services, and they are currently programs in different pockets of the country that want to use ridesharing platforms, such as Uber or Lyft to improve travels specifically for medical care.

Another important solution is bringing increasing access to primary care. In the literature, there was a study done some time ago that... I think this was a qualitative study and it was like the rural resident saying, “Okay, we get it if we need to travel further for specialty care. But for primary care, which is what we need on a fairly consistent basis, it's important that is close by.” And I know, Dr. Ferdinand still in our lines here, but she would often say, “Rural residents sometimes... They just want to see someone in white coat.” Someone who, whether a nurse practitioner, someone who has some qualification and can address their health conditions. If that's available at a primary level, that is a good solution. That's an important solution. And then, they know that for specialty care, the potential for further travel is still is welcome.

Andrew Nelson: Dr. Ferdinand, you've already mentioned one possible solution to the rural healthcare burden that I thought was very interesting, and that was autonomous vehicles. Could you expand on that a little bit?

Dr. Alva Ferdinand: Yeah, certainly. So I know at Texas A&M University, we have Texas Transportation Institute, which does a lot of testing on top autonomous vehicles. I think we have of a few buses on campus that are running and folks are being invited to try those out. So I think that having a personal vehicle has been shown in our work to be a barrier to accessing healthcare. But I think that to the extent that there are, for example, fleets of autonomous vehicles that can be dispatched to rural and remote areas, that might be something that policy makers try to invest in, in the future. I think we're currently seeing lots of investments on the telehealth side of things, which is pretty interesting because I think that while telehealth is welcomed by lots of urban and maybe even millennial individuals, I think that we need to do a little bit more digging on how accepted telehealth services are to rural residents. I think we are making lots of investments in that infrastructure, but I think that there's a level of comfort that has to go hand in hand with that modality for care.

And I think that's something that we need to explore a little bit more. I'm just thinking about my parents. For example, older patients, older generations might actually want to see a human being in person, and so telehealth for them may not be something that they immediately think of as an alternative to getting in a car and driving to access care. So I think telehealth certainly is one potential solution. I think autonomous vehicles, as they begin to roll out, like I said, I think that we can think about it more broadly than just an individual buying an autonomous vehicle because they don't want to have to spend the cognitive load on driving. I think that we can even now begin to creatively think about how we can leverage autonomous vehicles in a way that really benefits rural residents in the US.

Andrew Nelson: That's really interesting. We often think of autonomous vehicles as being kind of luxury things for wealthy people, but it's interesting to consider the benefits that kind of technology could have for people on the other end of the economic spectrum. We're wrapping things up here. I'll ask you first, Dr. Akinlotan, do you have anything lined up for your research center in terms of further considering the issue of rural travel burdens?

Dr. Marvellous Akinlotan: Going forward in the light of the current expansion of telehealth, we would like to see how, for example, how different racial groups are responding to the increased uptake of telehealth. Particularly as we found in our study, rural Hispanics and rural Black residents, and of course, rural Whites as well. Just wanted to see whether there's a racial variation in the uptake of telehealth. And then, one aspect we couldn't delve into, as I said earlier was whether the travel burden differed by the type of care that was sought. So primary care we wanted to know... We will want to know in the future, what is the average time and travel... What is the average travel distance and time to get primary care compared to specialty care. Because in this data set, everything was lumped together.

And then, for those with different types of insurance coverage, what are the variations, those who have Medicaid. I mean, we can already... We can suspect those who are covered by Medicaid, I'm more like it's a travel further, but we would like to have more hard evidence of that. And then, look at those who are covered by private insurance, what is the travel distance? Rural residents are more likely to be older, so we want to know the travel distance among those who are covered by Medicare and how that also impacts their care. So just looking at these three measures by other metrics such as insurance status and the type of care sought will be important for future research.

Dr. Alva Ferdinand: Again, just thinking about the literature in general, there's lots of studies on travel burden associated with cancer and different types of cancer, colorectal, uterine, et cetera, I am particularly curious about the travel burden associated with other kinds of conditions, some of the ones that kind of float to the top in the US. So diabetes comes to mind, heart disease, COPD, for example. I just wonder for folks that have those particular conditions, what the travel burden looks like. And I think, to Marvellous's point earlier, I think certainly access to primary care is going to help with some of that. And so, what we know is that in the primary care setting, you can kind of get some information and counseling on lifestyle changes that might help with those particular conditions.

And so, if we are continuing to see that the burden of travel associated with getting treatment for those kinds of conditions also remains high, I think that tells us that we have an opportunity to really try to work on this so that when we're thinking about healthy people, for example, the initiative set out by health and human services to meet certain benchmarks for reductions in certain diseases. I think that it's more than what new drugs can we come up with. It's more than how many more providers can we put in certain places. It's also about looking at the transportation burden as it currently is and really trying to think creatively about how to reduce that burden so that the gaps that we see in meeting healthy people benchmarks aren't as wide as they currently are. And so, I'm sort of excited to look into that. I know that's something, the leading causes of death is something that the center tries to look at very closely.

And I think that providing some recommendations, I'm thinking about transportation as an important piece of that is also going to be something that we'll look at in the future. I think it might also be interesting to look at potentially avoidable hospitalizations for things like ambulatory care sensitive conditions. So again, those conditions that could be managed pretty well in an outpatient setting, I think that as we're trying to work on these issues of travel burden and trying to reduce them, I think that we should also be looking to see how those efforts play into reducing unnecessary care in emergency departments, for example, which we know is substantially more expensive to obtain than care that you would otherwise have gotten in an outpatient setting. So I think for me, if I'm thinking futuristically, I would want to see how efforts in our travel burden reductions translate into outcomes in the emergency department setting, as an example.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to Dr. Alva Ferdinand and Dr. Marvelous Akinlotan from the Southwest Rural Health Research Center. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health. Join us next time for a discussion about palliative care here on Exploring Rural Health.