Configuration and Delivery of Primary Care in Rural and Urban Settings

J Gen Intern Med. 2022 Sep;37(12):3045-3053. doi: 10.1007/s11606-022-07472-x. Epub 2022 Mar 9.


Background: There are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality.

Objective: Compare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries.

Design: Observational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%).

Participants: A total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices.

Main measures: We characterized practices' structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality.

Key results: Rural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices' care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care.

Conclusions: While most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban.

Keywords: access to care; inpatient utilization; outpatient utilization; practices; primary care; rural health.

Publication types

  • Observational Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Ambulatory Care
  • Delivery of Health Care
  • Humans
  • Medicare*
  • Primary Health Care
  • Rural Population*
  • United States