DIN is building for lasting change. We believe that solving surgical access challenges requires more than short-term fixes—it demands systems-level understanding and long-term vision. That’s why we’re compiling and sharing white papers grounded in expert perspectives and publicly available data.

These papers explore the structural barriers facing hospitals, clinics, and surgeons today and outline potential pathways forward. We’ll continue to publish new insights as the healthcare landscape evolves.

You can explore our current white papers below:

  1. Expanding Access to Specialty Microsurgery in Underserved Areas

  2. Flexible Practice Models for Microsurgical Specialists

  3. Bridging the Urban-Rural Divide in Hospital-Based Microsurgery

DIN White Paper #1

Expanding Access to Specialty Microsurgery in Underserved Areas

A Regional Strategy to Address Workforce Gaps and Underused Operating Rooms in Rural and Underserved Communities

Authored and reviewed by the DIN team, April 2025

Introduction

Access to specialized “microsurgery” – delicate surgical care in fields like ophthalmology (eye surgery), otolaryngology/ENT (ear, nose, and throat), dermatology (skin surgery), and urology (urinary tract and reproductive surgery) – has become a national challenge. Demand for these specialists is rising as the population grows and ages, but the supply of surgeons is not keeping up (Urology Times, 2021). By 2034, the United States may face a shortfall of up to 30,200 surgeons across specialties (Urology Times, 2021). This imbalance is felt most acutely in rural and underserved regions, where patients often struggle to find any local specialist. In many areas, people cannot access an ophthalmologist, dermatologist, ENT, or urologist within a reasonable driving distance (often defined as a two-hour radius). The result is a growing care gap that leaves millions without timely surgical care.

Demand Exceeds Supply: A Widening Gap

Several national statistics highlight how the need for specialty surgeons exceeds the current supply, especially outside urban centers:

  • Ophthalmology: About 61% of U.S. counties have no ophthalmologist at all (AAO, 2022). Nearly 17% of patients needing eye surgery live in rural areas, yet only ~5.6% of ophthalmic surgeons practice in rural communities (Ophthalmology Advisor, 2023).

  • Dermatology: Roughly 69% of U.S. counties lack a dermatologist (Reuters, 2019). Although the number of skin doctors per capita has increased over the years, these gains have mostly benefited cities, not rural towns (Reuters, 2019).

  • ENT (Otolaryngology): An estimated 66–72% of counties have no ENT surgeon available (PMC, 2023). Many states have vast areas without any local ear, nose, and throat specialists, forcing patients to travel long distances for care.

  • Urology: Only 38% of U.S. counties have a practicing urologist, meaning 62% have none (Urology Times, 2021). Nearly half of urologists are over age 55, and few younger doctors are entering rural practice (Urology Times, 2021).

This mismatch between public need and provider availability is most stark in rural America. About 20% of Americans live in rural areas, but only ~10% of physicians practice there (PMC, 2023). For specialists, the gap is even greater: there are only 30 specialists per 100,000 people in rural areas versus 263 per 100,000 in urban areas (NRHA, 2024).

Impact on Rural Patients and Communities

When patients lack access to specialty surgeons within a two-hour drive, the consequences can be serious. A recent study found that the percentage of rural Americans traveling more than an hour for surgical care jumped from about 37% in 2010 to 44% in 2020 (Renal & Urology News, 2020). In one analysis, rural Nebraskans had to travel 5.5 times farther than urban residents to see an ENT specialist (PMC, 2023).

Without local specialists, patients may forgo or postpone care. A shortage of dermatologists leads to later-stage melanoma diagnoses (Reuters, 2019). Dr. Hao Feng noted, “if patients can’t get in to see a dermatologist about a melanoma, it will continue to grow and potentially spread and become fatal” (Reuters, 2019). Similarly, shortages in ENT or ophthalmology mean delays in identifying head and neck cancers or treatable eye disease. General practitioners often step in, but they may lack the training for complex cases (Reuters, 2019).

Beyond health outcomes, these gaps strain communities. Families lose workdays traveling for care. Elderly or immobile patients may simply skip it. Rural hospitals lose revenue to distant centers, eroding the viability of the local health system.

Traditional Care Models Are Leaving Rural Hospitals Behind

Under traditional models, specialty surgeons practice in high-volume urban hospitals. Critical Access Hospitals (CAHs) and rural systems cannot often support full-time microsurgeons. One-third of CAHs offer no surgical services at all (Flex Monitoring Team, 2023). Even those that do typically rely on occasional visiting specialists.

In urology, only 7% of urologists under age 45 practice outside metro areas (Urology Times, 2021). In ophthalmology, younger and female surgeons are less likely to work rurally than their more senior peers (Ophthalmology Advisor, 2023). The pipeline to replenish rural specialists is drying up. Hospitals are left with underused ORs and patients with unmet needs.

Willing Providers, but a Lack of Coordination

Many microsurgeons are open to outreach. Iowa’s Visiting Consultant Network shows how structured coordination can close gaps. Over half of Iowa’s urologists travel to rural clinics. With outreach included, 84% of Iowans live within 30 minutes of a urologist, up from 57% relying on permanent practices alone (Urology, 2018). Monthly, 55 urologists log over 20,000 miles to hold 200 clinic days across the state (Urology, 2018).

However, these models remain rare. Barriers like credentialing, scheduling, and malpractice limits make outreach difficult. Surgeons and hospitals lack infrastructure to match capacity with community need. As a result, resources exist—but remain untapped.

Rethinking Resource Deployment: A Community-Centered Approach

  1. Coordination and Networks: Build rotating specialty care networks. For example, dermatologists could rotate weekly across regional clinics. ENT and ophthalmology teams could serve critical access hospitals on predictable schedules.

  2. Support for Local Hospitals: Provide grants and fast-track credentialing to empower rural hospitals to host rotating surgeons. Local access boosts outcomes and reinforces financial stability.

  3. Extend Specialists' Reach: Encourage flexible practice models and use telehealth for pre/post-op visits. Offer travel stipends, housing, or licensing flexibility to support regional rotations.

  4. Community Partnerships: Maintain trust by integrating visiting surgeons with local care teams. Ensure local providers remain the continuity anchors before and after specialty visits.

Conclusion
This access challenge is solvable—but only if we rethink how surgical care is delivered. While national shortages persist, many microsurgeons are open to broader practice models. Meanwhile, hospital-based ORs in rural areas sit underused. With better coordination, infrastructure, and policy support, we can bridge the gaps between available providers and the patients who need them. By investing in rotating care networks, supporting local systems, and enabling more flexible practice options, we can bring specialty surgical care closer to home for millions.

Works Cited

DIN White Paper #2

Flexible Practice Models for Microsurgical Specialists

A Call to Expand Regional Access and Provider Mobility Through Technology and Policy Reform

Authored and reviewed by the DIN team, April 2025

Introduction


Millions of patients in underserved areas struggle to access microsurgical specialists – ophthalmologists, dermatologists, ENTs, urologists, etc. – due to a misalignment between where specialists practice and where patients live. Recent findings show that only 5.6% of ophthalmic surgeons practice in rural communities despite 17.4% of patients living there, forcing rural residents to travel long distances or go without care (Ophthalmology Advisor, 2023). Similar disparities exist in fields like dermatology and urology.

Meanwhile, many specialists feel trapped in rigid, traditional practice setups that limit their flexibility and reach. This white paper explores how structural challenges in today’s healthcare system constrain both providers and patients, and why new flexible practice models are needed to expand specialist microsurgery services into broader and underserved communities.

Structural Challenges Limiting Specialty Care Access

Several entrenched factors make it difficult for microsurgical specialists to serve patients outside major population centers:

  • Rigid Practice Models: Most specialists work in fixed locations (private offices or hospitals), bound by strict schedules and employment terms. These traditional models leave little room for providers to offer services in multiple communities or adapt their practice to areas of need. Rural patients often face “inflexible scheduling and long in-clinic wait times”, compounding their access issues (Commonwealth Fund, 2023). With care centralized in cities, patients in remote areas must travel hours for routine visits, relying on family for transport and incurring high costs. Such rigidity in care delivery means those unable to travel simply go without specialist care.

  • Private Equity Consolidation: Over 25% of urologists in some states are now employed by private equity (PE)-backed groups, and ophthalmology and dermatology show similar trends (Khullar et al., 2023). While consolidation can bring efficiency, it often prioritizes profitability over access. PE-backed practices tend to concentrate in dense, high-revenue markets, closing satellite clinics and limiting physician autonomy (GAO, 2022). This shift reshapes workforce distribution and reduces availability of care in rural or lower-income areas.

  • Declining Reimbursement: Medicare physician payments are 33% lower today (adjusted for inflation) than in 2001 (AMA, 2023). With successive annual cuts, many independent specialists struggle to sustain rural practice. Consolidated systems often centralize care in urban hubs to maintain margins, leaving underserved communities behind.

  • Restrictive Non-Compete Clauses: Many physicians are contractually barred from practicing in nearby regions after leaving a group. These clauses limit flexibility and discourage moonlighting or relocation to underserved areas. Some states have moved to void non-competes in rural health settings, recognizing their harm to access (FTC, 2024).

  • Lack of Infrastructure for Mobility: Few systems exist to support regional or mobile practice. Licensing, credentialing, equipment access, and referral logistics create steep barriers. Itinerant models have existed in ad-hoc formats, but no widespread infrastructure currently enables consistent, scalable specialist rotations (Burkhalter et al., 2019).

Consequences for Providers and Patients

Providers face limited flexibility, mounting administrative demands, and burnout. Many younger specialists feel forced into rigid jobs that underutilize their skills or constrain their values. Dr. Elizabeth Jones notes, “teledermatology can reduce burnout by offering flexibility” (Health Affairs, 2023).

Patients, especially in rural areas, suffer most. Elderly or chronically ill individuals often must drive over an hour for short appointments—or go without care altogether. Long travel times and delays worsen outcomes and exacerbate inequity (Health Affairs, 2023).

Opportunity: Tech-Enabled Regional Models

  1. Telehealth Integration: Secure image sharing, virtual triage, and remote consultations allow for expanded reach. Tele-ophthalmology and teledermatology have shown success in diabetic screening and dermatologic triage, improving access and reducing unnecessary travel (Eagle, 2023; Health Affairs, 2023).

  2. Regional Collaboration: Multi-site, hub-and-spoke models can allow ENT, dermatology, and urology specialists to rotate across rural hospitals with centralized coordination. Legal reform to ease licensure and non-competes would bolster these networks (FTC, 2024).

  3. Improved Efficiency and Access: These models reduce fragmentation and geographic mismatch. Providers practice at the top of their license. Systems operate more efficiently, matching provider time with true demand. Patient outcomes and satisfaction improve.

Conclusion
Building flexible practice models for microsurgical specialists is both necessary and feasible. Technology, regulatory reform, and regional coordination can expand access while preserving professional satisfaction. Policymakers and healthcare systems should invest in scalable infrastructure to enable specialists to deliver care across wider geographies—no longer confined to traditional models that leave too many patients behind.

Works Cited

  • AMA. (2023). Medicare pay cuts: How they endanger physician practices. https://www.ama-assn.org/delivering-care/payment-delivery-models/medicare-pay-cuts-how-they-endanger-physician-practices

  • Burkhalter, H., Pathman, D.E., & Ricketts, T.C. (2019). Itinerant surgical and medical specialist care in Kansas: Report of a survey of rural hospital administrators. PubMed. https://pubmed.ncbi.nlm.nih.gov/31116137/

  • Commonwealth Fund. (2023). Rural health care challenges go beyond a lack of doctors. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/rural-health-care-challenges-go-beyond-lack-doctors

  • Eagle. (2023). Tele-Ophthalmology is Transforming Eye Care. https://www.eaglemds.com/tele-ophthalmology

  • FTC. (2024). Non-Compete Clause Rulemaking and Rural Access to Care. https://www.ftc.gov/legal-library/browse/federal-register-notices/non-compete-clause-rulemaking

  • GAO. (2022). Private Equity and Physician Practice Consolidation. https://www.gao.gov/products/gao-23-105876

  • Health Affairs. (2023). Teledermatology Benefits Underserved Populations, Reduces Physician Burnout. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00125

  • Khullar, D., Bond, A.M., & Casalino, L.P. (2023). Private equity in ophthalmology and optometry: A time series analysis from 2012 to 2021. JAMA Health Forum, 4(3), e230030. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802302

  • Ophthalmology Advisor. (2023). Rural Areas Face Growing Shortages of Ophthalmic Specialists. https://www.ophthalmologyadvisor.com/home/topics/general-ophthalmology/rural-us-may-face-rising-ophthalmic-subspecialists-shortages/

DIN White Paper #3

Bridging the Urban-Rural Divide in Hospital-Based Microsurgery

An Analysis of Operating Room Utilization in Ophthalmology, ENT, Dermatology, and Urology (2019–2024)

Authored and reviewed by the DIN team, April 2025

Introduction


The divide between rural and urban access to specialty surgical care in the U.S. has grown sharper in the past five years. This paper explores the utilization of hospital-based operating rooms (ORs) for outpatient microsurgical procedures in ophthalmology, ENT, dermatology, and urology—anchored in Medicare data and supported by all-payer datasets—to better understand where surgical resources are underused and why. By examining trends across five U.S. regions (Northeast, Southeast, Midwest, Southwest, and West), we highlight key gaps and propose strategies to improve surgical access in rural areas.

Background & Context


Outpatient microsurgery has become the norm for many procedures thanks to advances in technology and anesthesia. Cataract surgery, sinus procedures, Mohs surgery, and cystoscopies are routinely performed outside inpatient settings. In 2019, more than 11.9 million ambulatory surgeries were performed in hospital-based outpatient settings, with cataract surgery alone representing over 3 million cases (AHRQ, 2021).

While urban areas benefit from both hospital outpatient departments and ambulatory surgery centers (ASCs), rural communities rely almost entirely on hospital-based ORs. However, from 2010 to 2020, the number of rural hospitals offering surgical services declined by over 14% (UNC Sheps Center, 2023). Over 140 rural hospitals have closed since 2010, with more than 50% of rural counties now lacking even a single full-time surgeon (GAO, 2020).

Key Findings

1. National Trends in Microsurgical Volume

Hospital-based outpatient surgery volumes dipped sharply in 2020 due to COVID-19, with a 45% decline reported nationally between March and May 2020 (FAIR Health, 2021). Volumes have only partially rebounded. Cataract surgery remains the most common outpatient microsurgery, with nearly 8% of all ambulatory procedures falling into this category (AHRQ, 2021). Yet many rural residents must travel over 30 miles for access (Lee et al., 2017).

2. Regional Disparities

  • Southeast: Highest demand, lowest rural OR access. The Southeast accounts for 44% of all rural hospital closures between 2010 and 2023 (UNC Sheps Center, 2023). States like Alabama, Georgia, and Mississippi show the largest gaps between surgical need and OR access.

  • Southwest: Texas alone has experienced over 25 rural hospital closures. Rural OR access is limited in West Texas and tribal regions of New Mexico and Arizona.

  • Midwest: Kansas and Nebraska face extreme specialist shortages. Half of rural counties in the Great Plains region have no local surgeon (GAO, 2020).

  • West: Montana, Wyoming, and Nevada are home to some of the longest travel distances for cataract and ENT surgeries, often exceeding 50 miles (Lee et al., 2017).

  • Northeast: Although rural areas are smaller and denser, states like Maine and Vermont still face low OR utilization due to difficulty recruiting surgical specialists.

3. Urban-Rural Gap in OR Utilization

While rural residents have higher per-capita surgical rates due to age-related need, the procedures often occur in distant urban centers. In 2019, rural Medicare beneficiaries underwent 51 ambulatory surgeries per 1,000 people, versus 30–37 per 1,000 for urban counterparts (AHRQ, 2021). Yet many rural ORs remain underused or inactive due to staffing and equipment limitations.

4. Specialty-Level Disparities

  • Ophthalmology: Only 5.6% of ophthalmologists practice in rural areas, despite 17.4% of the population living there (AAO, 2022). Cataract surgery rates vary fivefold across states, with rural communities in the Southeast and West most underserved.

  • ENT: ENT services are concentrated in urban ASCs; rural ENT surgery rates are lowest in the Appalachian and Deep South regions (Otolaryngology Clinics of NA, 2020).

  • Dermatology: Urban areas have 40x more dermatologists per capita than rural counties, delaying access to Mohs surgery and other cancer-related procedures (JAMA Dermatol, 2019).

  • Urology: Rural patients with prostate cancer are 40% less likely to receive surgical treatment compared to urban peers (Renal & Urology News, 2020).

Implications

  • Underutilization of rural hospital ORs represents a missed opportunity to meet existing demand with existing infrastructure.

  • Delayed or forgone care results in worse outcomes, especially for progressive conditions like cataracts or cancers.

  • Financial instability of rural hospitals is worsened by underused ORs, as outpatient procedures are a key revenue driver.

Strategies for Improvement

  1. Rotating Specialist Networks
    DIN’s model coordinates rotating surgeons to rural hospitals based on OR availability and community need—reviving underused surgical infrastructure without the burden of full-time staffing.

  2. Telehealth as an Enabler
    Remote consultations and pre-op/post-op care coordination allow for better triaging and planning, reducing patient burden while optimizing OR scheduling.

  3. Data-Driven Expansion
    Policymakers and health systems should use CMS and all-payer data to identify surgical deserts and invest in flexible care delivery models that activate existing rural OR capacity.

Conclusion
Rural communities across the U.S. face an urgent mismatch: significant need for outpatient microsurgery and declining access to local hospital-based ORs. This underutilization isn't due to lack of demand—it's the result of a fractured system unable to connect surgical capacity with patients. By deploying rotating specialist models and reinforcing rural surgical networks, we can close these gaps and bring high-value care back to where it’s needed most.

Works Cited

  • Agency for Healthcare Research and Quality (AHRQ). (2021). Overview of Major Ambulatory Surgeries in 2019. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb286-Ambulatory-Surgery-Overview-2019.pdf

  • UNC Sheps Center. (2023). Rural Hospital Closures. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/

  • Government Accountability Office (GAO). (2020). Rural Hospital Closures. https://www.gao.gov/assets/gao-21-93.pdf

  • FAIR Health. (2021). COVID-19 and Outpatient Trends. https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/COVID-19%20Outpatient%20Trends%20-%20A%20FAIR%20Health%20White%20Paper.pdf

  • Lee, P.P., Hoskins, H.D., & Parke, D.W. (2017). Disparities in delivery of ophthalmic care: An exploration of public Medicare data. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487266/

  • American Academy of Ophthalmology (AAO). (2022). Ophthalmology Workforce Projections. https://www.aao.org/newsroom/news-releases/detail/ophthalmologist-shortage-report

  • Otolaryngologic Clinics of North America. (2020). ENT Workforce Data. https://www.oto.theclinics.com/

  • JAMA Dermatology. (2019). Urban vs Rural Dermatologist Access. https://jamanetwork.com/journals/jamadermatology/fullarticle/2737188

  • Renal & Urology News. (2020). Geographic Disparities in Prostate Cancer Care. https://www.renalandurologynews.com/view/increase-in-percentage-of-rural-patients-traveling-more-than-an-hour-for-surgical-care