Transportation, Distance, and Health Care Utilization for Older Adults in Rural and Small Urban Areas

Transportation, Distance, and Health Care Utilization for Older Adults in Rural and Small Urban Areas Jeremy Mattson Small Urban & Rural Transit Center Upper Great Plains Transportation Institute North Dakota State University, Fargo December 2010

Acknowledgements This research was sponsored by the Federal Transit Administration, United States Department of Transportation, and conducted by the Small Urban & Rural Transit Center within the Upper Great Plains Transportation Institute at North Dakota State University. The guidance of Jill Hough, Director of the Small Urban & Rural Transit Center, and Jarrett Stoltzfus, FTA Project Manager for the project, is also acknowledged. North Dakota State University does not discriminate on the basis of age, color, disability, gender identity, marital status, national origin, public assistance status, sex, sexual orientation, status as a U.S. veteran, race or religion. Direct inquiries to the Vice President for Equity, Diversity and Global Outreach, 205 Old Main, (701)231-7708.

ABSTRACT Transportation is a vital issue for access to health care, especially in rural areas where travel distances are great and access to alternative modes such as transit is less prevalent. This study estimates the impacts of transportation and geography on utilization of health care services for older adults in rural and small urban areas. Using data collected from a survey, a model was developed based on the Health Behavior Model that considered transportation and distance as factors that could enable or impede health care utilization. A random sample of individuals aged 60 or older living in the rural Upper Great Plains states of North Dakota, South Dakota, Montana, and Wyoming was surveyed by mail. With a response rate of 20%, responses were received from 543 individuals. An ordered probit model was used to estimate trip frequency, and a binary probit model was used to estimate the likelihood that an individual would miss or delay a health care trip. Distance and transportation variables were not found to significantly influence the total number of routine or chronic care trips made overall, while emergency care visits were impacted by transportation options. However, additional results showed that those who cannot drive make more trips if someone else in the household can drive; distance and access to transportation impact the likelihood that someone will miss or delay a trip; and difficulty reported in making trips is significantly affected by distance and transportation options. The greatest problems for people using public transportation for health care trips is inconvenient schedules, the need to match transit and medical schedules, and infrequent service.

EXECUTIVE SUMMARY There is significant evidence that health care utilization is lower in rural areas compared to urban areas. While there are a number of possible explanations for these differences, such as differences in the number of physicians available or individual characteristics, the longer travel distances and fewer transportation options available in rural areas could be a significant factor. Distances to regional health care centers in rural areas can often be great. The problem becomes compounded when a growing portion of residents in rural areas are older adults who need access to health care services but may have limited transportation options. There are an increasing number of senior citizens living in rural areas who prefer to age in place but may be forced into moving to improve their access to health care. If providing transportation to health care for those who lack it increases the utilization of these services, there could be cost benefits in terms of reduced need for emergency care and preventable hospitalizations. The objective of this study is to assess the impacts of transportation and travel distance on utilization of health care services for older adults in rural and small urban areas. Other objectives are to find how many missed trips there are due to lack of transportation and estimate the characteristics of those people who miss trips, to determine how much older adults rely on public transportation for medical trips, to discover the concerns older adults have with using public transportation for medical trips, and to estimate the demand for using public transportation for medical trips among those who do not currently have access to transit. A survey was developed and distributed to a random sample of individuals aged 60 or older living in the rural Upper Great Plains states of North Dakota, South Dakota, Montana, and Wyoming. Using data collected from the survey, a model was developed based on the Health Behavior Model (HBM) that considered transportation and geography as factors that could enable or impede health care utilization. The HBM, which has been effectively applied by health economists, states that an individual s use of health services is a function of his/her predisposition to use services, factors enabling or impeding use, and need for care. A total of 543 responses was received, yielding a response rate of 20.0%. The age of respondents ranged from 60 to 95, with the median age being 70. The median distance that respondents said they travel to health care services is 5 miles for routine health checkups, 9 miles for chronic health care visits, and 5 miles for emergency care. There is considerable variation in the reported distances, as some respondents living in towns with health care facilities are within a few blocks of service, while others reported the need to travel 100 or more miles. Eighty-nine percent said they drive themselves for health care trips, 55% said they will at least sometimes get a ride from a family member or friend, 5% use a public van or bus, 4% walk or ride bicycle, 3% get a ride from a volunteer driver, 2% ride in a human service agency car or van, and 1% take a taxi. The types of transportation used differ somewhat based on gender, age, whether the person has a disability, and geographic characteristics. The findings indicate that need for care is the most significant variable determining the number of health care trips taken. Distance and transportation variables did not significantly influence the number of routine or chronic care trips made overall, indicating that people who needed to make health care trips were able to access the necessary transportation, regardless of distance or ability to drive. The results were different for emergency care, however, where the number of transportation options used positively influenced the number of trips, with the effect being greater for those who do not drive.

Additional results, however, found that distance and transportation factors do have an influence on routine and chronic care. First, those who cannot drive make more trips if someone else in the household can drive. Second, distance and access to transportation impact the likelihood that someone will miss or delay a trip. Third, difficulty reported in making trips is significantly affected by distance and availability of transportation options. For those who do not drive, the odds of making additional routine or chronic care trips increase by a factor of about 2.3 to 2.4 when there is someone else in the household who can drive. Older adults who are widowed or living alone, therefore, are less likely to obtain their needed health care. These results have important implications regarding the need for providing additional transportation services for older adults. Findings also show that people who drive are substantially less likely to miss or delay a medical trip, and those with someone else in the household who can drive are also less likely to miss or delay trips, while the likelihood of missing or delaying routine trips increases with distance. These results suggest that even though the total number of trips taken may not be affected by distance or transportation factors, individuals are more likely to miss a scheduled trip if they cannot drive, do not have someone else in the household who can drive, or the distance is too great. Individuals that miss a scheduled trip then have to make up that missed appointment at a later time. Results indicate that they do eventually make those trips, but if they are delaying the trips to a later time, they may not get the care at the time they most need it. Moreover, the level of care required may be more serious and more costly. Individuals who must travel longer distances are also significantly more likely to say that getting transportation to health care is difficult. The burden of getting transportation to health care is found to increase with distance and is also greater for those who ride with a family member or friend or a volunteer driver. Those who rely on friends, family, or volunteer drivers for a ride may benefit from access to public transportation. To suit their needs, the type of transit service provided needs to be convenient and frequent enough, and the transit and medical schedules need be coordinated, as these were the greatest concerns noted by the survey respondents. Respondents also cited a need for door-to-door service. Greater coordination between transit providers and health care providers would benefit those relying on transit. Expansion of transit service and greater awareness of available service in rural areas could also be beneficial for those who cannot or prefer not to drive. As the survey showed, more than half of respondents said they either do not have demand-response service available to them or they are not aware of such service, more than twothirds said the same about fixed-route service, and nearly three-quarters indicated either a lack of intercity service or no awareness of such a service. Future research on the impacts of public transportation on health care utilization and transportation difficulties will need to gather data from a larger number of transit users. The number of transit users who responded to this survey was too small to make too many conclusions regarding transit. In response to an open-ended question about concerns with transportation to health care, respondents commonly mentioned that they currently do not have problems with transportation, but many noted that it could be an issue in the future and that they would be very grateful to have public transportation services available to them if and when that time comes.

TABLE OF CONTENTS 1. INTRODUCTION... 1 2. DIFFERENCES BETWEEN RURAL AND URBAN HEALTH CARE UTILIZATION... 3 2.1 Fewer Physicians in Rural Areas... 3 2.2 Differences in Characteristics of Urban and Rural Individuals... 3 2.3 Impact of Distance on Health Care Utilization... 4 3. TRANSPORTATION AND HEALTH CARE BACKGROUND... 5 4. MODELING HEALTH CARE UTILIZATION... 7 5. SURVEY DEVELOPMENT... 9 6. CHARACTERISTICS OF RESPONDENTS... 11 6.1 Demographics... 11 6.2 Enabling Factors... 13 6.2.1 Geography... 13 6.2.2 Transportation... 14 6.2.3 Other Enabling Factors... 18 6.3 Need for Care... 18 6.4 Health Care Trips Made and Missed... 19 7. EMPIRICAL ANALYSIS... 21 7.1 Trip Frequency... 21 7.2 Missed or Delayed Trips... 24 7.3 Difficulty Getting Transportation... 25 8. USE OF PUBLIC TRANSPORTATION FOR HEALTH CARE... 27 8.1 Current Use and Demand for Public Transportation... 27 8.2 Problems with Using Public Transportation... 27 8.3 Other Comments... 30 9. KEY FINDINGS AND CONCLUSIONS... 31 REFERENCES... 35 APPENDIX A. SURVEY... 39 APPENDIX B. OTHER COMMENTS... 47

LIST OF FIGURES Figure 6.1 Transportation Used to Access Health Care for those Who Do Not Drive (n=55)... 17 Figure 6.2 Difficulty Reported for Getting Transportation to Medical Appointments... 18 Figure 8.1 Problems with Using Public Transportation for In-Town Medical Trips... 28 Figure 8.2 Problems with Public Transportation for Out-of-Town Medical Trips... 29 LIST OF TABLES Table 6.1 Comparison of Survey Respondents and Target Population Characteristics... 11 Table 6.2 Marital Status by Age and Gender... 13 Table 6.3 Distances Traveled to Health Care Services... 14 Table 6.4 Access to Automobile... 15 Table 6.5 Reported Access to Public Transportation... 16 Table 6.6 Transportation Used to Access Health Care... 17 Table 6.7 Number of Health Care Trips Taken and Missed or Delayed... 19 Table 7.1 Estimated Results from Ordered Probit Model of Health Care Trip Frequency... 22 Table 7.2 Estimated Results from Ordered Probit Model of Health Care Trip Frequency for Individuals who Do Not Drive... 23 Table 7.3 Estimated Results for Binary Probit Model of Missed or Delayed Health Care Trips... 25 Table 7.4 Factors Impacting the Difficulty for Getting Transportation for Out-of-Town... 26 Table 8.1 Current Use and Demand for Public Transportation... 27 Table B.1 Survey Respondents' Comments... 47

1. INTRODUCTION Access to transportation is a critically important aspect of health care utilization. This is especially true in rural areas where individuals often have to travel long distances to access health care services. Previous research has shown that increased distance between residents and health care providers decreases utilization of health care services. The problem becomes compounded when a growing portion of residents in rural areas such as the Upper Great Plains are older adults who need access to health care services but may have limited transportation options. There are an increasing number of senior citizens living in rural areas who would prefer to age in place but may be forced into moving to improve their access to health care. Public transportation could play an important role in providing rural residents access to health care while allowing them to stay where they prefer to live. The objective of this study is to assess the impacts of transportation and geography on utilization of health care services for older adults in rural and small urban areas. To that end, a survey was developed and distributed to people aged 60 or older living in the rural Upper Great Plains states of North Dakota, South Dakota, Montana, and Wyoming. Using data collected from the survey, a model was developed based on the Health Behavior Model that considered transportation and distance as factors that could enable or impede health care utilization. The impacts of the ability to drive, having someone else in the household who can drive, and having access to transit on health care use were estimated. Other objectives are to find how many missed trips there are due to lack of transportation and estimate the characteristics of those people who miss trips, to determine how much older adults rely on public transportation for medical trips, to discover the concerns older adults have with using public transportation for medical trips, and to estimate the demand for using public transportation for medical trips among those who do not currently have access to transit. The paper is organized as follows. Section two discusses the differences in health care utilization between rural and urban areas and reviews the literature on the topic. Previous studies examining the effect of distance on health care utilization are examined. The third section reviews previous research relating transportation to health care. In section four, the Health Behavior Model, which will be used to estimate the impacts of transportation and geography on health care use, will be introduced. A discussion of survey development is provided in section five, and the characteristics of the respondents are detailed in the sixth section. The data from the survey are analyzed in section seven. The analysis includes an ordered probit model of health care trip frequency, a binary probit model estimating the likelihood that the respondent has missed or delayed a health care trip over the past year, and an ordered probit model estimating the difficulty in getting transportation to health care as reported by the respondents. Current use and demand for public transportation, the problems identified with using public transportation for health care, and other comments made by survey respondents are discussed in section eight. The final section provides a discussion of key findings and conclusions. 1

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2. DIFFERENCES BETWEEN RURAL AND URBAN HEALTH CARE UTILIZATION There is significant evidence that health care utilization is lower in rural areas compared to urban areas (Horner et al. 1994, Blazer et al. 1995, Casey et al. 2001, Arcury et al. 2005, Iezzoni et al. 2006, Winters et al. 2006). According to Jones et al. (2009), rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than those living in urban areas, and they have lower access to health care in terms of affordability, proximity, and quality. These differences could be due to a number of reasons, such as differences in the number of physicians available, possible differences in individual characteristics between rural and urban residents, and the longer travel distances and fewer transportation options available for people in rural areas. 2.1 Fewer Physicians in Rural Areas One possible explanation for lower health care utilization in rural areas is that there are fewer doctors and specialists per capita. As Jones et al. (2009) explain, many rural counties do not have sufficient patient volume to support full-service hospitals, so the rural health care model focuses on providing primary care and emergency care locally, while referring patients to regional health care centers for specialized care. Fordyce et al. (2007) found that not only are there fewer specialists per capita in rural areas, but that there are also fewer generalists per capita. Their study found, overall, that rural areas contained 19% of the population in the United States but only 11% of physicians. More specifically, they found the number of generalists per 100,000 people declined from 72 in urban areas to 55 in rural areas and 36 in the most isolated rural areas. These isolated, or frontier, areas are defined as those having a population density of six people or fewer per square mile. The decrease in specialists in rural regions is more severe. The number of medical, surgical, pediatric, or other specialists per 100,000 people dropped from 138 in urban areas to 58 in rural areas and 17 in the most isolated rural areas. Physicians practicing family medicine are the only ones that do not decrease in number per capita as population declines. Lishner et al. (1996) found that the lack of health care services in rural areas is especially concerning for people with disabilities. 2.2 Differences in Characteristics of Urban and Rural Individuals Differences between urban and rural areas in terms of income, insurance coverage, education, culture, and attitudes could explain some of the differences in health care utilization. A study of the use of preventive services found that those with low income, less education, lack of health insurance, and lack of knowledge about the potential benefits were less likely to utilize the service (Casey et al. 2001). No significant difference in health insurance coverage between metro and non-metro areas was found in a study by Jones et al. (2009), but they did find average incomes are higher in metro areas, so non-metro residents pay, on average, a higher percentage of their income on health care. Furthermore, Jones et al. (2009) found that non-metro households are more likely than metro households to report that health care costs limit their medical care. The culture of a region could also impact the probability that one would seek health care services. Casey et al. (2001) noted that previous research has shown that traditional rural values such as self-reliance, individualism, a preference for informal support networks, and reluctance to seek medical care may hinder use of preventive care services. Arcury et al. (2005) studied the Appalachian Region and included in their model cultural health beliefs and practices of the area such as detrimental health behaviors, use of folk medicine, effects of conservative religion on medical care use, and alienation from national society. 3

2.3 Impact of Distance on Health Care Utilization Distance to health care facilities and access to transportation could significantly impact health care utilization. The distances to regional health care centers can often be great, especially in the most rural areas. The distance decay effect states that the interaction between two locales decreases as the distance between them increases. This effect is often found to occur in consumer travel behavior, as increasingly smaller proportions of the population will travel to certain locations as the distance to those locations increases. A number of studies have measured the impact of distance on health care utilization and have found the same effect to occur. Nemet and Bailey (2000) studied the relationship between distance and utilization of health care by a group of elderly residents in rural Vermont, focusing on a county on the Canadian border where 82% of the residents live in rural areas. They found that people who had to travel more than 10 miles to their physician tended to go to their physicians less frequently than those who had to travel shorter distances. Goodman et al. (1997) also studied northern New England, including Maine, New Hampshire, and Vermont, and found that those who lived farther from the hospital were substantially less likely to be hospitalized for medical illness. Distance to regular care services was found to have a significant negative relationship with the number of regular care check-up visits in a study of rural North Carolina (Arcury et al. 2005). This study, though, did not find distance to impact the number of chronic care or acute care visits. Winters et al. (2006) conducted a study on the self-management of chronic illness by women living in isolated, rural areas of five western states. The study found that distance had a significant impact. They found that travel distance to health services and the related costs affected their healthcare decisions, and the time spent traveling affected them physically and was a cause of stress. Other studies have examined more specific health care issues. For example, Gregory et al. (2000) found that use of cardiac revascularization services in New Jersey decreased as distance to the service increased. Similarly, Harris et al. (2008) found that proximity to a hospital predicted higher hospitalization rates for cardiovascular disease (more specifically, myocardial infarction and heart failure) in Maine. Since it is unlikely that those living in communities distant from hospitals are healthier, the results suggest they are less likely to seek hospitalization. Littenberg et al. (2006) found that insulin use declines as patients live farther from their source of care, and a study in France found that detection rates of hepatitis C decreased as the distance to the general practitioner increased (Monnet et al. 2006). Although many of these studies examine specific geographic regions and different health care issues, the effect seems to be largely universal. For example, a study in Honduras found that walking time to the clinic negatively impacted primary health care utilization (Baker and Liu 2006). Underutilization of preventive health care services in rural areas is also a concern. Casey et al. (2001) found that after controlling for demographic factors, rural residents are less likely than urban residents to obtain certain preventive health services. 4

3. TRANSPORTATION AND HEALTH CARE BACKGROUND Access to transportation is critically important for utilization of health care services. While long travel distance makes trips to medical care burdensome, lack of transportation makes those trips impossible. In rural areas where travel distances are longer and access to alternative modes such as transit is less prevalent, transportation becomes a vital issue for access to health care. While many studies have analyzed the relationship between distance and health care use, fewer have examined the relationship between transportation and health care. Arcury et al. (2005) conducted one such study in rural North Carolina. They found that those who had a driver s license had roughly twice as many health care visits as those who did not, and those who had family or a friend who could provide transportation had about 1.6 times more visits than those who did not. A very small percentage of residents surveyed had used public transportation to access health care, but transit was very important to those who did use it. The small number of respondents who used public transportation had four more chronic care visits per year than those who did not. If providing transportation to health services for those who lack it increases the utilization of these services, there could be cost benefits in terms of reduced need for emergency care and preventable hospitalizations. It has been estimated that 3.6 million Americans do not obtain medical care in a given year because of lack of transportation, and that may be a conservative estimate (Wallace et al. 2005, 2006). Missing a trip for routine care or preventive services can often result in a medical trip that is more costly than the trip that was missed. While providing non-emergency medical transportation (NEMT) for those who lack it may be expensive, it has the potential to provide cost savings. A study by Wallace et al. (2006), in fact, did find the provision of NEMT to those who lack access to transportation to have net societal benefits. For the seven chronic conditions and five preventive conditions analyzed in their study, Wallace et al. (2006) found that the net health care benefits of increased access to NEMT for those transportation-disadvantaged individuals who lack it exceeded the additional costs of transportation for all of these conditions. The benefits included actual decreases in health care costs for some conditions and improved quality of life. For some of the conditions they found a net cost savings, and for the others, the improvements in quality of life or life expectancy were found to be sufficient to justify the added expense. NEMT is not expensive when compared with emergency transportation. Flaherty et al. (2003) cite costs of $400-$525 per ambulance trip and $10-$20 per NEMT trip. They argued that a significant number of ambulance rides for Medicare patients are not for true emergencies, especially in rural areas, and that if just half of the these ambulance trips could be prevented, the savings to Medicare would be substantial. Flaherty et al. (2003) considered whether a NEMT program could be included within the Medicare program as it is in Medicaid. Medicaid s assurance of transportation to medically necessary health care is one of the features that sets it apart from traditional health insurance. Medicaid NEMT expenditures totaled slightly more than $3 billion in FY 2006, which was almost 20% of the entire federal transit budget but only a small portion of the Medicaid budget (Rosenbaum 2009). 5

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4. MODELING HEALTH CARE UTILIZATION Following Arcury et al. (2005), the model used in this analysis integrates concepts from the Health Behavior Model (HBM). This model, which has been effectively applied by health economists, was initially developed in the late 1960s to help understand why families use health services, to define and measure equitable access to health care, and to help develop policies to promote equitable access (Andersen 1995). The HBM states that an individual s use of health services is a function of his/her predisposition to use services, factors enabling or impeding use, and need for care. Predisposing factors include demographic characteristics such as age and gender; social structure, which has traditionally been measured using education, occupation, and ethnicity and can also include social networks and interaction and culture; and health beliefs, which are the attitudes, values, and knowledge that might influence use of health care services (Andersen 1995). Enabling factors include availability of health personnel and facilities, income, health insurance, regular source of care, travel and waiting times, and social relationships (Andersen 1995). Arcury et al. (2005) included transportation as an enabling factor. They added measures of geographic access and spatial behavior to the HBM, including distance, transportation availability, and activity space. Although studies show that increased distance to a provider reduces utilization, Nemet and Bailey (2000) found that an individual s activity space may be more important. Activity space consists of the places or areas than an individual travels to, or interacts with, on a frequent basis. Research has shown that people who have providers located outside their activity space are less likely to utilize health care services (Nemet and Bailey 2000). Sherman et al. (2005) analyzed methods for representing a person s activity space in healthcare accessibility studies, including the use of geospatial technologies. 7

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5. SURVEY DEVELOPMENT A survey was developed to collect information on use of health care services and the predisposing factors, enabling factors, and need for care. Specifically, the survey asked how many trips the respondent made for routine health checkups, chronic health care visits, and emergency care visits over the last year, following Arcury et al. (2005). Respondents were also asked how many trips they missed or had to delay due to a lack of transportation. The survey collected information on the following predisposing factors: age, gender, education, marital status, and propensity to seek care. Propensity to seek care was determined, following Nemet and Bailey (2000) and Haynes (1991), by asking how often the respondent would wait to see a doctor, assuming cost and ability to get to a health care facility were not a concern, for each of the following: chest pains, fever, stomach pains, pain from a fall, can t stop coughing, and blood in bowel movement. An average propensity to seek care score was calculated based on the response to this question. The survey collected information on the following geographic and transportation factors: distance from health care facilities (classified by those for routine health checkups, chronic health care visits, and emergency care), activity space, ability to drive, having someone else in the household who can drive, number of vehicles in the household, access to public transportation, and use of various transportation options. Activity space was determined by simply asking which cities or towns the respondent visits at least once per month. Zip code data were also collected, which allows the respondents to be classified based on the size of their community. The survey also asked how difficult it is for respondents to get transportation to their medical provider, what percentage of their medical trips are out of town, and what problems they have with using public transportation for medical trips. Other enabling factors included in the survey were income, insurance, and whether the respondent has a regular medical doctor or physician. Need for service was determined by asking if they have any chronic conditions or illnesses, what they consider their overall level of health to be, if they have any disabilities, and how severe they consider their disability to be. Finally, the survey included an open-ended question that gave respondents the opportunity to provide any comments or concerns they have regarding transportation to health care. The complete survey is provided in Appendix A. The survey was distributed by mail to a random sample of 2,850 people aged 60 or older living in North Dakota, South Dakota, Montana, and Wyoming. These four Upper Great Plains states were chosen due to similarities in geography. Each state is very rural with a few small urban centers. There are no large urban areas in these states. The largest metropolitan statistical areas (MSAs) in the region, according to 2009 Census estimates, are Sioux Falls, SD, with a population of 238,000 and Fargo, ND, with a population of 200,000. There are a total of 11 MSAs in the four-state region and 26 micropolitan areas. The survey was targeted at people aged 60 or older because they are most likely to be impacted. The survey was conducted in May and June of 2010. The random sample of names and addresses was obtained from AccuData Integrated Marketing. The survey was also provided online. The survey cover letter mailed to each respondent included a web address for the online survey if the respondent preferred that method. (The online survey was not advertised in any other way). One hundred thirty-five surveys were not received due to incorrect addresses or, in a few cases, the intended respondent being deceased. That left 2,715 surveys that, presumably, were received. Three weeks after the survey was mailed, a reminder card was sent out to survey participants. This card included the web address to the online survey, provided a phone number if the respondent needed a new copy, and gave a date for when the survey would close. 9