Making Improvements to Geographic Spacing, Access to Neurologists and MS Care

Marisa McGinley, DO

For patients with multiple sclerosis (MS), access to neurologists and the best available disease-modifying treatments is critical towards long-term prognosis and quality of life. The shortage of neurologists has been an issue for several years, not just within MS care, and new research is taking a closer look at the geographic disparities within the US.

Published in Neurology, a study led by Marisa McGinley, DO, and others assessed neurologist practice locations from 2022 CMS Care Compare Physician Data and MS Center locations for 70,858 US census tracts. Of these, 388 had no neurologists within 60 miles and 17,837 had no MS centers within 60 miles. Results showed that geographic access to neurologists was lower for rural (spatial access ratio, –80.49%; 99% CI, –81.65 to –79.30) and micropolitan (–60.50%; 99% CI, –62.40 to –58.51) areas compared with metropolitan areas.

Tracts with 10% greater percentage of Hispanic individuals (−4.53%; 99% CI, −5.23 to −3.83), men (−6.76%; 99% CI, −8.96 to −4.5), uninsured (−7.99%; 99% CI, −9.72 to −6.21), individuals with hearing difficulty (−40.72%; 99% CI, −44.62 to −36.54), vision difficulty (−13.0%; 99% CI, −18.72 to −6.89), and ambulatory difficulty (−15.68%; 99% CI, −19.25 to −11.95) had lower access to neurologists. Furthermore, Census tracts with 10% greater Black individuals (3.50%; CI [2.93–10.71]), college degree holders (−7.49%; 99% CI, 6.67–8.32), individuals with computers (16.57%, 99% CI, 13.82–19.40), individuals without a vehicle (9.57%; 99% CI, 8.69–10.47), individuals with cognitive difficulty (25.63%; 99% CI, 19.77–31.78), and individuals with limited English (18.5%; 99% CI, 16.30–20.73), and 10-year older individuals (8.85%; 99% CI, 7.03–10.71) had higher spatial access to neurologists.

McGinley, a staff neurologist at Cleveland Clinic’s Mellen Center for MS Treatment and Research, recently sat down with NeurologyLive® to discuss the study results and how neurologists should interpret the data. She provided thoughts on some of the potential reasons behind these geographic disparities and the steps needed to make change. Furthermore, she touched upon the issues of neurologists clustering in certain cities after school, problems with the licensure of clinicians, and the ways to considerately engage with underserved communities.

From a neurologist perspective, what are some of the greatest takeaways from your research?

I think the greatest takeaway is that there's just not enough neurologists. Obviously, this study is US-centric, but this is not unique to the United States; it's a problem worldwide. There's not enough neurologists given the increasing number of individuals who need neurologists. In this paper, we focus on general neurology needs, but also multiple sclerosis care in particular. Most neurologists probably feel overwhelmed, and that feeling is justified because there's just not enough of them to give to patients.

The other problem is that as neurologists, we tend to cluster in certain areas, which tends to do with where we do our training. There's an inclination to stay where you trained or in larger healthcare systems, and there's been a movement away from smaller solo or private practice type situations into more academic or larger healthcare system settings. Because of that, we're getting centralized. There's already a dearth of us, but then we're also centralizing to areas that are quite populous, but at the same time away from many of our patients' homes. There's a known geographic barrier than to patients physically getting to our locations. As neurologists, we need to start thinking about how we can bring high-quality neurologic care to patients in their communities and how we can reimagine those types of healthcare delivery models.

Aside from clustering, are there any other reasons as to why we’re seeing these issues with access?

Part of it is there's a longstanding within the US, there's a lot of reasons why certain communities were built, and there are socio-economic type factors of where housing communities were developed for lots of underrepresented populations. In particular, things like redlining that occurred in the US really segregated a lot of communities, which is obviously a systemic problem. It's not something that has just occurred in the last few years, obviously, systems back decades and really centuries. Because of that, the patterns of where individuals live in the US are different. We see in this study that not only is there a geographic issue with our rural populations having good access, but even when looking beyond that, we see communities such as our Hispanic populations, irrespective of a metropolitan micropolitan, or rural status, had worse access than our non-Hispanic populations. Then there's a more complex thing when you look at our Black populations, whereas there is good access for our Black communities in a metropolitan area, but worse access compared to our white communities in micropolitan and rural areas. A lot of that has to do with the systemic laws and structures that went into place that shape how communities are built in the US. As a healthcare system and providers, we need to be mindful of that. We can't fix that on our own, but it means that we need to be more proactive thinking about those communities and how we reach them.

How can we mask some of the issues of access? At least until we see more major changes.

The research that we published was specifically on geographic access issues. What we were trying to highlight in this study is that's an important dimension that we need to be considering. But I think it's important to highlight that's not the only barrier when it comes to access. We can't take a very simplistic view of popping people down in communities that are providers, and that'll fix the access problem. Because, like we saw in this study, our urban Black communities have kind of good geographic access, but we know that community has trouble accessing and has difficulty with the healthcare system getting what they need. When we're designing interventions to help with these access barriers, we have to think about the unique needs of the communities that we're trying to help. There's not going to be a one size fits all answer to this.

To answer your question, what can we think about doing? Telemedicine obviously has blossomed. It's something that we were doing before the pandemic, but now there's just better infrastructure, also, patients have now experienced it more, many of them see the value. That takes out the geographic issue; patients don't have to drive 60-120 miles to get to their physician. Expanding that is important, making sure it doesn't go away as we come further away from the pandemic. It's very easy to have regression to the norm of, let's just do everything in person again. We need to systematically keep that integrated into our models. But the problem with that is also in rural communities, sometimes there's not great broadband access. That's something that the US is working on, and there are acts with Congress to try to improve broadband access to communities, especially those that don't have that. If we want to expand telehealth, we also have to be mindful that individuals have the technology and the internet able to make those connections. That's at a larger policy level. Telemedicine absolutely has a good role here. We have to think about not all patients want to get their care in that way too. We can't have that be a one size fits all answer to this problem. Ultimately, you likely do need some in-person care, depending on the condition and the timeline.

Other things that need to be done is we need to think about how to provide more care within people's communities. Sponsoring things like waivers, promoting physicians and other clinicians to work in underserved populations and communities. Those types of programs can be supported more so we can move people out of these kinds of metropolitan hubs. Also thinking about how we partner better with those physicians and clinicians that are already in those communities. How do we partner with whether it's a general neurologist or a primary care or someone in those communities to be able to provide care there, but getting input from the neurologists that they need? How do we build a better network that benefits patients, which may be across healthcare systems, which is not necessarily how we've operated in the past?

The last thing I would say is thinking about licensure of clinicians. Another big barrier when we think about these geographic issues is that right now, you pretty much can practice medicine only in stature licensed, which sounds reasonable, but when you think about a lot of these underserved areas, they're kind of on border areas, right between states. Even thinking of myself practicing in Cleveland, many times the patients that I could care for in Pennsylvania or West Virginia are actually closer than some patients that live within my state. Practically when you're trying to deliver healthcare, sometimes that can be difficult. There are things like an interstate licensure compact that's developing. I think there's a movement for trying to think about how to be flexible with that so that we can provide care to patients in areas that just don't have clinicians that are within their community. Those are a couple of things. Obviously, there are many more, and I'm sure a lot of people in the policy world have ideas, but those are some things that at least I know are being worked on.

Transcript edited by artificial intelligence.

REFERENCE
1. McGinley M, Harvey T, Lopez R, Ontaneda D, Buchalter RB. Geographic disparities in access to neurologists and multiple sclerosis care in the united states. Neurology. 2024;102(2). doi:10.1212/WNL.00000000000207916