In Modern Healthcare this week there is a good article on telemedicine and psychiatric services. However one line irks me a lot!
Half of the counties in the U.S. do not have a psychiatrist or an addiction medicine specialist, new data from George Washington University shows.
County is an incredibly bad unit of analysis. There is a county, Kalawao Hawaii, with less than 100 residents. There is one county, Los Angeles, with over 10,000,000 residents. But when we analyze things by county, we implicitly say that Kalawao and Los Angeles counties are equally weighted and equally important.
That is absurd in general. It is effectively the same as looking at the land area map of the United by Presidential vote so we equally weigh areas that have more cows than people and mid-town Manhattan.
The relevant question is can people readily access appropriate care within reasonable time and distance parameters?
Yeah, there are a lot of fuzziness in “appropriate”, “readily”, “readily access”, “reasonable”, “Time and distance parameters” but if we’re worried about psychiatric services not being readily accessible, I would be far more freaked out if there is no one in Los Angeles County able to take a patient than if there is no one in Kalawao County.
scav
Have fun getting into the Modifiable Areal Unit Problem as well. There are a lot of turtles all the way down as well as horizontally. Geographers have lots of fun beating their heads and building entire careers against these rocks.
OzarkHillbilly
My local hospital has one psychiatrist who comes from Granite City IL once a week. I saw him for depression and he wrote me a couple scrips. Holy fuck, talk about a bad trip… I didn’t know if it was one or the other or the combination of the 2 but I wasn’t going to take them any more. I figured we’d try something else after my next appointment.
I always make my appointments for as early as possible, I figured I was 3rd on the list that AM. Unfortunately, he was running a 1/2 hr to 45 mins late (not surprising to anyone who has driven 270 during rush hour). By the time he finally got there, the waiting room was overflowing with at least 50 patients. An hour later I was still waiting for my name to be called.
I walked over to the nurse and said I couldn’t wait any longer. She took my folder out of one pile and put it into another, crossed her arms and looked up at me not saying a word. That did it.
I didn’t say it, but I sure as hell thought it. I turned around and walked out the clinic door. I was willing to deal with him being overloaded with patients and being late from time to time, but I wasn’t going to deal with a….. a “nurse” who didn’t care enough to ask if I wanted to reschedule a new appointment. Nope, it was take it or leave it.
So I left it. I’ve been dealing with chronic depression for over 60 years, I can manage another decade or 2.
FastEdD
I taught Math and statistics to high schoolers. I added all the yearly incomes of my students and myself and divided by the number of people. Not much income per person! Now Bill Gates walks in the room and I did the calculations again. We are all multi-millionaires! Woo hoo!
sdstarr
I think journalists usually use analysis by county to indicate that some people in rural areas are far from services. The thing is that people in rural counties already know this. They choose to live far from others for a variety of reasons, but they understand the problems that come with rural living.
Aimai
I’m currently giving teletherapy via secure platform but my lisence only permits me to work with residents of my state. So people in states with low populations definitionally are also in states with low numbers of providers and can’t access excess space on the caseloads of providers in other states who might be able to work with them—regardless of payment issues which are also a factor.
Roger Moore
I’m also a bit less worried about people who live in the middle of nowhere having trouble getting to services as easily as people in cities. Ease of access to services is one of the tradeoffs people make when they decide where to live. It’s unreasonable to choose to live somewhere that has poor access and then demand the rest of the world jump through hoops to provide that access.
That’s not to say we shouldn’t be working on improving availability of services. If we can, it would be great to make it easier for people in remote areas to get the services they need. Telemedicine, mobile clinics providing preventive care on some kind of schedule, and the like are great. That’s doubly true for people who had less choice in their location, e.g. Indian reservations. But we shouldn’t devote too many resources on a tiny fraction of the population who mostly made a conscious decision to live where those things aren’t easily available.
Kelly
Salem, the capital of Oregon straddles 2 counties. Most of the city and services are in Marion county so mostly rural Polk county looks worse than it is. Also near the border with Linn county so about a quarter of Linn is kinda part of the Salem region. Many of these cases of big cities on a border scattered around out there.
Anonymous At Work
I’m guessing there are ways to normalize counties by aggregating adjacent counties but the level of aggregation (i.e. 2x the median county, median county, 10k, X% of state population, or even X% of state’s largest county) are a source of Academic Warfare on this topic?
Aimai
@Roger Moore: that is such a weird way of looking at it. What about people on reservations—should they not have access to services because the population is low on huge tracts of land? Some places don’t support high density.
Elizabelle
@Aimai: Spurring the transition to tele therapy/some telehealth was a beneficial outcome of the pandemic. Along with work from home.
A social worker friend tells me that many of the families she works with really prefer the telehealth — takes out the travel requirement; parents miss less work, and some of the adolescents are more comfortable interfacing with her through a screen. Also, the agency now offers appointments outside of the usual 9 to 5 hours.
Have to look for the silver linings. Took a pandemic to get some providers to take advantage of modern communication infrastructure.
lee
“The relevant question is can people readily access appropriate care within reasonable time and distance parameters?”
Or another way to put this is “Do they have to travel outside their county to see the appropriate care?”
JPL
Wellstar is considering closing Atlanta Medical Center. The hospital services those without insurance. This is what happens when the government decides not to expand Medicaid. It’s not just rural hospitals that will close.
scav
@lee: That doesn’t escape the problem at all. Having to get out of San Bernardino (CA) is very different than getting out any Iowa county. You could travel further within San B for in-county service than for different-county service in Iowa.
randy khan
There’s one other factor here – sparsely-populated counties often are the ones where the people are furthest from services of any kind. So while it’s true that you shouldn’t weigh LA and Kalawao the same, in practice Kalawao almost certainly does not have proximate access to any social services, let alone a hospital. So when you say a county doesn’t have a psychiatrist, even if it’s only 100 people, you’re most likely saying that there aren’t such services within reasonable travel distance.
David Anderson
@Aimai: Not neccassarily; low density regions of central Pennsylvania have two very large urban anchors….
JML
My university has just gone to fee-for-service for mental health (only one in the system!) and I was just approached about crowdfunding to pay for the students who are under-insured. *face palm* It’s not great, but the former VP decided that a good way to start balancing budgets was to generate revenue on mental health.
BCHS Class of 1980
Don’t forget that size matters too. i bet WV has a lot of small rural counties that don’t have those professionals but have relatively easy access to Charley West or Morganhole. Out West there are huge rural counties with populations greater than a former leper colony that are many hundreds of miles from help. I’m sure there are other places like northern Maine or that chunk of eastern Kentucky that lies between the interstates. My point is simply that rural America needs access to help too, even if they really suck right now.
WeimarGerman
Counties do suck as unit of aggregation for many things but there are other options like the wonderful work of people at Dartmouth Atlas.
The Dartmouth Atlas of Health Care has used commuting patterns from Census data to construct Hospital Service Areas (HSA) and Hospital Referral Regions (HRRs) by mapping zip codes to these regions. As expected 1 HSA is a set of zip codes where most people would use that hospital first. An HRR is more complicated as its a tertiary care center, think of a specialized burn unit, trauma or other major hospital that would receive these complex patients from other hospitals. There are about 300 HRRs in the US. Both HSAs and HRRs can cross state boundaries too.
This does not address the root issues of rural care, and non-existent specialist supply. In this case, one could ask about relevant drive time metrics per HRR, and # specialists per 10,000 people per HRR to have a more coherent view of the scale of the issue.