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Luring cardiologists to rural parts of Iowa may mean subsidizing their salaries, a new study has found.

Tom Gruca, a marketing professor at the University of Iowa’s Tippie College of Business, looked at data from more than 40 years of public health in his state. His study, Bringing the Doctor to the Patients: Cardiology Outreach to Rural Areas, found that paying doctors to participate in traveling practice models could help alleviate the coming cardiologist shortage in his state.

Using subsidies and an existing Visiting Consultant Clinic (VCC) model would be a better and more cost-effective way to get cardiology care to rural patients, he said.

A VCC model is a formal arrangement between a rural hospital or clinic and a specialist physician, typically from an urban area nearby. In a VCC arrangement, the specialists travel to rural areas on a regular basis to see patients in their own communities. There, they can use the rural hospital to examine them and provide basic support and non-invasive procedures, and treat them in larger hospitals for more complex procedures.

“The policy that the American Heart Association and everybody else always talks about is let's get doctors to move to rural areas,” Gruca said in an interview with the Deesmealz. “That might work with the primary care physician because if there's a hospital there, there's probably enough equipment and staff for them to do what they're doing. This will not work for almost any specialist because they need the imaging equipment, the surgical equipment, the surgery nurses, and all that other stuff to do their jobs.”

The VCC model is used in every state, he said. Looking at the numbers the research found that the model would not only provide rural patients with access to care, but save money.

Putting a cardiologist in a rural community would mean the doctor would not have enough patients or patient visits to support their practice, Gruca said. And paying cardiologists on a per mile basis to drive to rural communities would be excessively expensive. In some cases, getting doctors to give up patient time to spend up to three hours of “windshield time” to get rural communities to participate in the VCC model was a challenge.

His research found that a state investment of about $430,000 per year would provide doctors with the necessary funding to cover “windshield time” and still provide current levels of cardiology coverage in the state.

Getting that cardiology care to rural communities is important on a number of levels, he said. First, rural residents are more likely to have cardiology issues. According to one study, between 2010 and 2015, the death rate for rural residents from coronary heart disease was significantly higher than it was for those in urban areas. And a 2017 study found that people in rural areas have a 30 percent higher risk of dying from a stroke due to their increased chronic disease, and reduced access to pre-hospital care.

Second, research shows that rural residents who have access to cardiology care are better off for it.

“What we can say is that the difference between having VCC outreach and not having VCC outreach means anywhere between 700,000 and a million rural residents having better access,” he said. “And studies show that Medicaid patients who see a specialist at least once a year are way more likely to stay out of the hospital and way more likely to live for another year.”

Even more important, he said, is that rural America is facing a pending shortage of cardiologists. Currently, the state has fewer than 200 cardiologists, Gruca said, almost all of them in urban areas. Nationally, the number of cardiologists is expected to decline by as much as 10% due to retirement and aging workloads. While fellowship programs graduate about 1,500 new cardiologists a year, he said, about 2,000 leave the practice annually.

“I thought, what’s going to happen when the number of cardiologists goes down?” he said. “When this shortage actually hits… If we lose 10% of our current cardiologists… there are a lot of cities (in Iowa) that will get no outreach at all.”

Similar programs have worked in Australia, he said. The same kind of subsidies could be successful in encouraging specialist physicians to work in rural areas as well.

Even though the program was expensive, he said, it will still save states money over the alternative.

“We looked at what it would take to hire people and put them into rural areas and the cost was many, many times (the annual subsidies) simply because they would have very little to do,” he said. “If we pay them some amount to do this outreach and we build a mathematical model to figure out how much would we have to pay them per mile or per minute… it's actually really many, many, many times the $400,000 for the subsidy that we calculated.”

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