Many Medicare Patients Travel 50-Plus Miles for Neurology Visits

— Telemedicine can improve access to care, researchers argue

by
Judy George, Deputy Managing Editor, MedPage Today
September 15, 2023

Nearly one in five Medicare beneficiaries who saw a neurologist traveled long distances for their office visit, 2018 cross-sectional data suggested.

Out of over 563,000 Medicare beneficiaries with a neurologist visit that year, 17% traveled 50 miles or more one way for care, reported Chun Chieh Lin, PhD, MBA, of Ohio State University in Columbus, and co-authors.

The median driving distance and time were 81 miles and 90 minutes for these patients, compared with 13 miles and 22 minutes for patients without long-distance travel, the researchers wrote in Neurology.

Long distances were most often traveled by patients who needed specialty care for nervous system cancer (39.6%), amyotrophic lateral sclerosis (ALS, 32.1%), multiple sclerosis (MS, 22.8%).

“Our study found a substantial travel burden exists for some people with neurologic conditions, including people living in areas with fewer neurologists and rural areas,” said co-author Brian Callaghan, MD, MS, of the University of Michigan in Ann Arbor, in a statement. “We also found that people who traveled long distances were less likely to return for a follow-up visit with a neurologist.”

Nearly a third of Medicare beneficiaries bypassed the nearest neurologist by 20 miles or more to see another neurologist and 7.3% crossed state lines for neurologic care. “It is possible some people bypass the nearest neurologist as a matter of preference for a particular physician or they may need to travel farther to reach neurologists with shorter wait times,” Callaghan observed.

The study was conducted in 2018, and a subsequent shift to telemedicine during the COVID-19 pandemic — with relaxed requirements and expanded coverage possible with public health emergency waivers — may have changed some of these patterns, the researchers noted.

“Many patients utilized telemedicine to access health care services for the first time and were satisfied with the convenience,” they added. “Benefits may also extend to neurologists, clinics, and hospitals by allowing physicians to care for patients in remote clinics without traveling between facilities, decreasing patient no-show rate, and alleviating demand for exam rooms.”

At the Cleveland Clinic, for example, MS patients who had telemedicine as part of their care during the pandemic had similar clinical outcomes as MS patients who received only in-person care. And in the Parkinson’s disease community, telemedicine has been promoted for more than 10 years, the limiting factor having been poor Medicare reimbursement prior the pandemic.

Lin and colleagues studied a 20% national sample of Medicare carrier files of patients with at least one outpatient neurologist visit in 2018. Files included fee-for-service claims for persons 65 and older, and people with end-stage renal disease, ALS, or disability, regardless of age.

Long-distance travel was defined as a driving distance 50 or more miles one way to the visit, assessed by Google Maps.

Overall, 14,439 neurologists provided 1.2 million office visits for Medicare-insured adults in 2018. The average density of neurologists was 25.3 per 100,000 Medicare beneficiaries. The most common subspecialties were general neurology (24.6%), endovascular, interventional, or vascular neurology or stroke (7.3%), epilepsy (7%), clinical neurophysiology (6.5%), and autonomic disorders or neuromuscular medicine (6.5%).

Mean age of Medicare-insured patients in the study was 70; 57% were women and 81% were white. Their most common conditions were dementia (12.3%), peripheral nervous system disorders (11.3%), epilepsy or convulsions (10.5%), chronic pain or gait abnormality (9.7%), and tremor or restless legs syndrome (9.5%).

Factors associated with long-distance travel included low neurologist density (OR 3.04 for first vs fifth quintile), rural setting (OR 4.89), and long-distance travel to primary care physician visit (OR 3.6).

Overall, long-distance travel was associated with decreased likelihood of having a follow-up neurology visit (OR 0.78).

The study assessed Medicare beneficiaries only and findings may not apply to other groups of patients, Lin and co-authors acknowledged. The researchers also did not include patients who were referred to a neurologist but didn’t see one.

“Our results suggest that policymakers should investigate feasible and affordable ways to improve necessary access to neurologic care, especially in areas with low availability of neurologists and in rural communities,” the study authors maintained.

“Future research should examine the differences in health outcomes between people who must travel long distances for care and those who do not,” they suggested.