Comparing Physicians’ Perceptions of Access to Behavioral Health Resources in Rural and Urban Practices

ABSTRACT

Purpose

Rural communities face persistent shortages of behavioral health clinicians, requiring primary care physicians to assume expanded mental health care roles. Our study assessed physicians’ access to behavioral health resources, such as referral networks, licensed and non‐licensed mental health providers, and telehealth supports, and examined whether perceived sufficiency of access upon referral differs between rural and urban physicians.

Methods

We analyzed data from the 2022 National Sample Survey of Physicians, a nationally representative survey of active US physicians. Practice ZIP Codes were categorized as rural or urban using Rural Urban Commuting Area (RUCA) codes. Descriptive statistics were calculated, and weighted logistic regression assessed the association between rurality and physician perceived sufficiency for mental health providers upon referral. Models were adjusted for physician demographics, specialty, and practice characteristics.

Findings

Most respondents practiced in urban settings (93.1%). Fewer than half of physicians (38.1%) reported access to licensed mental health providers, and only 10% reported access to call‐in services or non‐licensed support providers. A quarter (24.4%) of respondents agreed that patients had sufficient access upon referral. Rural physicians more often reported referral relationships with accessible mental health providers (55.3% vs. 44.5%). In adjusted models, rurality was not associated with sufficient access to behavioral health services upon referral.

Conclusion

While rural behavioral health workforce shortages receive much attention, both rural and urban physicians reported limited access to mental health resources. These findings highlight gaps in behavioral health infrastructure across geographical settings and opportunities to strengthen referral networks, telehealth support, and integration of mental health services across practice settings.

1. Introduction

The shortage of behavioral health clinicians in rural areas is well documented [1, 2, 3]. In response to these workforce constraints, primary care physicians frequently take on expanded roles as front‐line mental health providers. These additional roles include conducting behavioral health assessments, providing basic behavioral health interventions, addressing stigma as a barrier to care, and triaging patients for specialized services [4, 5]. Compared to their urban counterparts, rural physicians face additional challenges, including limited access to specialty referral networks and a lower likelihood of co‐locating (i.e., sharing the same physical space) with behavioral health professionals [6, 7, 8, 9]. These structural barriers further impede opportunities for integrated and coordinated behavioral health services.

Assessing the availability of physician resources, such as behavioral health integration, established referral networks, electronic consultations, and non‐clinician support, is essential for identifying strategies and supports needed to reduce rural–urban behavioral health disparities. This study examines physicians’ access to mental health resources including referrals, with a focus on how service availability differs for patients in rural versus urban settings. We hypothesized that rural physicians would be less likely than urban physicians to report having sufficient access for patients upon referral to mental health. We further hypothesized that, compared with urban physicians, rural physicians would have a different array of behavioral health providers and services available to care for their patients and that care would be delivered using different models, if at all. The findings from this study could help identify gaps in existing infrastructure, such as formalized referral networks or lack of telehealth capabilities, which may impact effective care delivery in rural areas.

2. Methods

We used data from the 2022 National Sample Survey of Physicians (NSSP), conducted by the Association of American Medical Colleges (AAMC) [10]. It collected comprehensive information on physician demographics, medical training history, practice characteristics such as current practice location and telehealth usage, and time allocation for patient care, teaching, training, and administration on 5,917 physicians [10]. The NSSP 2022, which was conducted online from May 2022 to November 2022, used the following sampling strategy: (1) inclusion of all eligible respondents from NSSP 2019, some of whom also responded to NSSP 2022; and (2) replenishment of the cohort through stratified random sampling [10, 11, 12]. NSSP data were weighted using AAMC‐created weights based on the American Medical Association Physician Masterfile to reflect the known US practicing physician population by age, gender, international medical graduate status, and specialty group [10].

We limited the analytic sample to unique respondents who were active, reported their practice's ZIP Codes, and who did not select “Not applicable” in response to the question, “Which of the following resources are used in your practice when treating patients with mental/behavioral health conditions?” For this question, respondents were asked to identify applicable resources from the following options: (1) Access to licensed mental health providers who are part of their practice staff and available to see patients; (2) Access to electronic asynchronous consultations or call‐in services to licensed mental/behavioral health providers; (3) Provider‐to‐provider learning programs; (4) Non‐licensed mental health support providers such as peer support or community health workers; and (5) Access to referral relationships with mental health providers. Our analytical sample included 4,744 unweighted respondents.

We categorized respondents based on the ZIP Code of the respondents’ primary practice location as urban and rural using Rural–Urban Commuting Area (RUCA) 2010 codes [13] as follows: (1) urban: RUCA codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, 10.1; (2) rural: RUCA codes 4.0, 5.0, 6.0, 7.0, 7.2, 8.0, 8.2, 9.0, 10.0, 10.2, 10.3.

2.1. Analysis

We cleaned the data and calculated descriptive statistics using Stata 14.1 [14], with weights applied throughout. To assess the relationship between provider perception of access to mental health resources for referred patients and the rural/urban location of the provider, we conducted weighted logistic regression. Survey participants were presented with the following prompt and asked to indicate their level of agreement on a 5‐point Likert scale (strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree): “You indicated that you have referral relationship(s) with mental health providers who are accessible to your patients. Please indicate whether you agree or disagree with the following statement: ‘There is sufficient access for patients upon referral to mental health.’” Due to the limited number of rural respondents, we collapsed Likert responses into two categories: agree (agree, somewhat agree) and disagree/neutral (strongly disagree, somewhat disagree, neither agree nor disagree). This binary variable served as the outcome in the regression model. We conducted exploratory data analyses to assess associations between the outcome and potential covariates and to evaluate multicollinearity among candidate variables. We used this exploratory work and a theory‐driven approach to select variables for our final model, which we ran using SAS statistical software version 9.4 [15]. Our adjusted regression model included rurality (urban, rural), physician characteristics, including age group (≤39, 40–49, 50–59, ≥60 years), gender (male, female), relationship status (single/never married, widowed, divorced/separated), grew up in the United States (yes, no), grew up in a rural area (yes, no), US military service history (active/former vs. none), specialty group (medical, primary care, surgery, other), employment status (owner, employee, independent contractor/other), and the proportion of Medicaid patients on the provider's panel (0%–25%, >25%). Race was self‐reported and categorized as Asian, White, or Other. Small sample sizes limited the number of racial and gender categories that could be included in our regression analyses. The ‘Other’ racial group includes all respondents who did not identify as Asian and/or White. Due to the very small sample (n = 2) of rural respondents who reported a gender other than male or female, and who were queried and provided a response for the primary regression outcome variable, these respondents were excluded from the regression analysis but retained in all other tables.

Statistical significance was assessed at an alpha level of 0.05. Because the outcome was common, adjusted odds ratios were converted to approximate risk ratios to reduce potential overestimation of the relative risk associated with odds ratios [16].

3. Results

Table 1 shows the demographic and socioeconomic characteristics of physicians by rural–urban practice location. Most respondents practiced in urban locations (93.1%), while 6.9% worked in rural settings. The average age was 55.5 years among rural respondents and 53.6 years among their urban counterparts. Over half of respondents in both groups were men. A larger percentage of rural than urban respondents identified as White (74.4% vs. 64.7%, respectively). Conversely, more than one‐fourth of urban respondents were Asian (27.9%), compared to less than one‐fifth of rural respondents (18.0%). A similar percentage of urban and rural respondents identified as Hispanic (3.3%), American Indian/Alaska Native (0.5%), Black (2.8%), or another race (2.5%). More urban respondents reported they were Native Hawaiian/Pacific Islander (0.2%) than rural respondents (0.01%). The combined percentage of respondents from Other racial and ethnic groups was similar among rural (6.3%) and urban (6.9%) respondents. Detailed racial and ethnic breakdowns for this group are available in Table 1. Nearly twice as many urban respondents as rural respondents reported being single and never married (7.8% vs. 4.2%, respectively).

TABLE 1.

Characteristics of respondents in the 2022 National Sample Survey of Physicians.

	Weighted values a
	Urban	Rural	Total
Characteristic	715,540 (93.1%)	53,031 (6.9%)	768,571 (100.0%)	p‐value b
Age, average	53.6	55.5	53.7	0.06
Age categories, years				0.30
≤39	9.6%	6.8%	9.4%
40–49	32.4%	26.6%	32.0%
50–59	23.8%	26.6%	24.0%
≥60	34.3%	40.1%	34.7%
Gender c				0.09
Man	58.8%	67.1%	59.4%
Woman	40.9%	32.0%	40.3%
Other	0.3%	0.9%	0.3%
Race/ethnicityc,d
American Indian or Alaskan Native	0.5%	1.0%	0.5%	0.47
Asian	27.9%	18.0%	27.2%	0.02
Black or African American	2.8%	2.7%	2.8%	0.95
Hispanic, Latino/Latina/Latinx, Spanish origin	3.3%	2.5%	3.3%	0.55
Native Hawaiian or Other Pacific Islander	0.2%	0.01%	0.2%	<0.001
White	64.7%	74.4%	65.4%	0.03
Other	2.5%	2.8%	2.5%	0.82
Combined race/ethnicity d.e				0.06
White	64.3%	74.5%	65.0%
Asian	28.9%	19.2%	28.2%
Other race/ethnicity	6.9%	6.3%	6.9%
Marital status				0.03
Single, never married	7.8%	4.2%	7.6%
Married/committed relationship	83.7%	84.8%	83.7%
Widowed	1.6%	4.9%	1.8%
Divorced/separated	6.9%	6.1%	6.9%
Area where you grew up				<0.001
Rural	11.3%	40.8%	13.3%
Suburban	58.3%	42.5%	57.2%
Urban	30.2%	15.8%	29.3%
Military or Government Installation	0.2%	0.8%	0.2%
Grew up in the United States or Canada	82.8%	87.5%	83.1%	0.17
US citizen	97.6%	96.5%	97.5%	0.44
US military service, current or past	7.0%	8.3%	7.1%	0.56
US or Canadian medical graduate	79.9%	85.6%	80.3%	0.12
Years of practice (since residency/fellowship)		0.08
≤10 years	14.5%	17.2%	14.6%
11–20 years	31.6%	19.6%	30.8%
21–30 years	27.9%	31.4%	28.2%
31–40 years	20.1%	26.0%	20.5%
≥41 years	5.9%	5.8%	5.9%
Spent 50% or more of residency in… f
Urban location	68.6%	60.8%	68.0%	0.06
Suburban location	31.3%	26.0%	31.0%	0.21
Rural location	3.6%	13.7%	4.3%	<0.001
Current medical school faculty appointment	37.6%	26.1%	36.8%	0.01

Note: Missing responses among the unweighted sample: gender 2, race 177, relationship status 7, area where grew up 5, grew up in the United States or Canada 13, citizenship 44, military 9, years in practice 82, faculty appointment 25. Excluded respondents with missing geographic information (4 removed from unweighted sample), respondents who reported being retired at the time of the 2022 NSSP (14 removed from unweighted sample) and those who reported “Not applicable” regarding use of mental health and behavioral health resources when treating patients with mental/behavioral conditions in their practice (1096 removed from unweighted sample).

^a All weighted values based on the following unweighted numbers (urban, N = 4420; rural, N = 324; total, N = 4744).

^b p‐values for the average age comparison are calculated from independent‐samples t‐tests comparing group means across geographic categories. All other comparisons in table use p‐value for the Pearson's chi‐square test assessing the difference in distribution across geographic categories.

^c Participants requested to select all applicable options, thus total may not equal 100%.

^d Examples of self‐identified race categories provided by NSSP 2022 survey: American Indian or Alaskan Native (e.g., Navajo, Blackfeet, Aztec); Asian (e.g., Chinese, Filipino, Indian, Japanese, Korean, Pakistani); Black or African American (e.g., African American, Afro‐Caribbean); Native Hawaiian or Other Pacific Islander (e.g., Guamanian, Native Hawaiian); White (e.g., German, Irish, English, Italian).

^e Asian category includes respondents who self‐identified as Asian or Asian/White; Other race/ethnicity include all respondents identifying as American Indian, Alaskan Native, Native Hawaiian, Other Pacific Islander, Hispanic, Latino/Latina/Latinx, or of Spanish origin, Black or African American.

^f Totals may exceed 100% as some respondents self‐reported spending equal time (50%) in both rural and urban/suburban settings and were counted in each category.

More than three times as many rural respondents as urban respondents reported growing up in a rural area (40.8% vs. 11.3%, respectively), and almost four times as many reported spending more than 50% of their residency training in a rural location (13.7% vs. 3.6%, respectively). In contrast, urban physicians more frequently reported growing up in suburban or urban areas. Similar percentages of rural and urban respondents reported being US citizens (97.5%), having grown up in the United States or Canada (83.1%), attending a US or Canadian medical school (80.3%), and having served in the US military (7.1%). More urban than rural respondents reported holding a medical school faculty appointment (37.6% vs. 26.1%, respectively).

The practice characteristics of rural and urban respondents are reported in Table 2. Overall, about one‐third of respondents (35.7%) were primary care physicians and nearly one‐fifth of respondents reported practicing in a medical specialty (16.4%). Physicians in both groups reported working a similar number of weekly hours, and about two‐thirds (63.7%) reported taking call during a typical week. Comparable percentages of rural and urban respondents reported working more than half of the previous year (>26 weeks) (92.8%) and practicing alongside nurse practitioners (49.7%) or physician assistants (44.2%). About half of both rural and urban physicians (50.7%, overall) provided care at a single location, while one‐third (32.0%) practiced care at two locations. The remaining 17.3% provided care across three or more sites. The number of years physicians had worked at their current practice location and their employment status (i.e., owner, employee, contractor) were similarly distributed across the two groups.

TABLE 2.

Practice characteristics of respondents in the 2022 National Sample Survey of Physicians.

	Weighted values a
	Urban	Rural	Total
Characteristic	715,540 (93.1%)	53,031 (6.9%)	768,571 (100.0%)	p‐value b
Specialty c				0.26
Medical specialty	16.7%	13.7%	16.4%
Primary care	35.2%	42.6%	35.7%
Surgery	15.4%	17.2%	15.5%
Other	32.7%	26.5%	32.3%
Hours worked in an average week, mean (median) d	45.3 (45)	45.1 (44)	45.3 (45)	0.98
Hours worked in an average week d				0.16
1–20 h	8.2%	4.4%	8.0%
21–40 h	37.5%	43.3%	37.9%
≥41 h	54.2%	52.3%	54.1%
On call during typical week	63.4%	67.2%	63.7%	0.39
Weeks worked, past 12 months, mean (median) e	45.2 (48)	45.2 (48)	45.2 (48)	0.98
Weeks worked, past 12 months e				0.28
≤26 weeks	7.5%	4.6%	7.3%
>26 weeks	92.6%	95.4%	92.8%
Years in current practice location				0.81
<1 year	4.2%	2.8%	4.1%
1–10 years	40.2%	44.0%	40.4%
11–20	27.1%	25.5%	26.9%
21–30	19.2%	20.1%	19.3%
≥31	9.4%	7.7%	9.3%
≥ 50% of patient care time spent in rural locations f	7.1%	71.2%	11.5%	<0.001
Current employment status				0.92
Employee	65.6%	63.6%	65.5%
Owner	24.7%	25.1%	24.7%
Independent contractor	8.8%	10.1%	8.9%
Other, please specify	0.9%	1.3%	0.9%
Patient care delivered via telehealth, past month, %	0.15
0%	16.0%	23.5%	16.5%
1%–10%	44.7%	46.0%	44.8%
11%–20%	14.5%	14.1%	14.5%
>20%	24.7%	16.4%	24.2%
In last 12 months routinely worked with…
Physician assistants	44.0%	46.8%	44.2%	0.53
Nurse practitioners	49.7%	50.1%	49.7%	0.93
No. of places currently provide patient care				0.78
1 place	50.5%	53.6%	50.7%
2 places	31.9%	33.7%	32.0%
≥3 places	17.6%	12.7%	17.3%
Patient panel enrolled in Medicaid				0.04
0%–25%	79.2%	71.5%	78.7%
>25%	20.8%	28.6%	21.3%
Mean % of care time per location (weekly)	Mean (median)	Mean (median)	Mean (median)
Ambulatory or outpatient	66.3% (90.0%)	70.4% (90.0%)	66.6% (90.0%)	0.252
Urgent care	1.8% (0.0%)	3.3% (0.0%)	3.2% (0.0%)	0.067
Inpatient	19.3% (0.0%)	14.4% (1.0%)	19.0% (0.0%)	0.055
Emergency department	7.3% (0.0%)	10.4% (0.0%)	7.5% (0.0%)	0.246
Other location g	1.9% (0.0%)	0.3% (0.0%)	1.8% (0.0%)	0.000

Note: Excluded respondents with missing geographic information (4 removed from unweighted sample), respondents who reported being retired at the time of the 2022 NSSP (14 removed from unweighted sample) and those who reported “Not applicable” regarding use of mental health and behavioral health resources when treating patients with mental/behavioral conditions in their practice (1096 removed from unweighted sample). Missing responses among the unweighted sample: on call during typical week 6, employment status 3, telehealth provision 1034, work with physician assistants 28, work with nurse practitioners 53, number of places currently provide care 1654.

^a All weighted values based on the following unweighted numbers (urban, N = 4420; rural, N = 324; total, N = 4744).

^b p‐values for the average number of hours worked per week, weeks worked in past 12 months, and the percentage of care time per location are calculated from independent‐samples t‐tests comparing group means across geographic categories. All other comparisons in table use p‐value for the Pearson's chi‐square test assessing the difference in distribution across geographic categories.

^c Respondents asked to select the specialty in which they currently spend the most time.

^d Drops n = 15 cases that reported working zero hours in an average week.

^e Includes part‐time and full‐time work.

^f Respondents who self‐reported spending 50% of patient care time in rural areas and 50% in urban/suburban areas were categorized as ≥ 50% of patient care time in rural areas.

^g Write in responses included cardiac catheter lab, dialysis center, free clinic, remote work, patient home visits, jail services, and laboratory.

On average, rural physicians reported similar percentages of weekly care hours in ambulatory or outpatient settings to their urban counterparts (70.4% vs. 66.3%, respectively) and time spent in emergency department settings (10.4% vs. 7.3%, respectively). Urban physicians reported a greater share of time spent providing inpatient care than rural physicians (19.3% vs. 14.4%, respectively). A higher percentage of rural vs. urban physicians (28.6% vs. 20.8%, respectively) reported that more than one‐quarter of their patient panel was enrolled in Medicaid.

Physicians in both rural and urban settings reported on the behavioral health resources available to them (Table 3). Fewer than half of physicians (38.1% overall)—with similar percentages across rural and urban settings—reported having licensed mental health providers either integrated within their clinic or available virtually. A greater proportion of rural physicians (55.3%) than urban physicians (44.5%) reported having referral relationships with mental health providers accessible to their patients. When restricted to primary care physicians, the difference between rural and urban physicians who reported having a referral relationship with a mental health provider was even larger (rural 70.0%, urban 54.5%, p = 0.0113, not tabled). One in 10 respondents (9.9%), across both rural and urban settings, reported access to non‐licensed mental health support providers such as peer support specialists and community health workers. Similarly, 10.1% reported availability of a call‐in service connecting patients to licensed mental health and behavioral health providers. About a quarter (27.0%) of urban physicians and a fifth (20.4%) of rural physicians reported having no access to mental or behavioral health resources.

TABLE 3.

Availability of mental and behavioral health resources, by urban–rural classification.

	Weighted values a
	Urban	Rural	Total
	715,540 (93.1%)	53,031 (6.9%)	768,571 (100.0%)
Mental health (MH) and behavioral health (BH) resources				p‐value b
Licensed MH providers, co‐located within the clinic where you practice or available virtually	38.4%	34.1%	38.1%	0.32
Patients screened for MH/BH issues, then seen by team MH providers as needed c	21.9%	22.9%	21.9%	0.27
Patients with MH/BH needs referred to the team MH providers c	26.5%	27.6%	26.5%	0.17
Team MH providers help facilitate MH referrals to MH providers outside of the practice c	14.1%	10.4%	13.9%	0.43
Other resources co‐located within your practice clinic or available virtuallyc,d	0.4%	0.0%	0.4%	0.26
Electronic asynchronous consultations (i.e., eConsults) with licensed MH/BH providers	8.9%	10.0%	9.0%	0.69
Call‐in service to licensed MH/BH providers	10.0%	11.5%	10.1%	0.58
Provider‐to‐provider learning programs (e.g., Project ECHO, other clinical support training)	3.6%	6.0%	3.8%	0.19
Non‐licensed MH support providers (peer support, community health workers, etc.)	9.7%	11.7%	9.9%	0.46
Referral relationship(s) with MH providers who are accessible to your patients	44.5%	55.3%	45.3%	0.02
Other resources e	0.7%	1.4%	0.7%	0.39
None of the above	27.0%	20.4%	26.5%	0.12

Note: Excluded respondents with missing geographic information (4 removed from unweighted sample), respondents who reported being retired at the time of the 2022 NSSP (14 removed from unweighted sample) and those who reported “Not applicable” regarding use of mental health and behavioral health resources when treating patients with mental/behavioral conditions in their practice (1096 removed from unweighted sample).

^a All weighted values based on the following unweighted numbers (urban, N = 4420; rural, N = 324; total, N = 4744).

^b All comparisons use p‐values for the Pearson's chi‐square test assessing the difference in distribution across geographic categories.

^c Denominator includes the full sample. This question was only seen by the 1880 unweighted respondents who reported “yes” when asked if “Licensed mental health providers (e.g., psychologists, clinical social workers, mental health therapists, psychiatrists, etc.) who are part of your practice staff and available to see your patients are co‐located within the clinic where you practice or available virtually.” Respondents who reported not having MH providers were coded as “no” for services provided by licensed mental health providers.

^d Write in examples include: provides own mental health services; veterans support groups; community resources.

^e Most write‐in responses indicate that the respondent is a mental health provider.

Physicians who reported access to licensed mental health providers, either integrated within their clinic or available virtually, described the role these team members played on the broader care team. These roles were consistent across rural and urban physician practices. Approximately one‐fifth of physicians overall (21.9%) reported that mental health providers on their team screened patients for mental health and behavioral concerns and provided care as needed. About a quarter (26.5%) reported that these integrated providers treated patients referred by the physician, while 13.9% reported that team mental health providers help facilitate referrals to external mental health professionals. Finally, physicians who reported having a referral relationship were asked to express the level of their agreement with the statement: “There is sufficient access for patients upon referral to mental health specialists” (Table 4). Only about one‐quarter of both urban and rural responding physicians reported that they strongly agreed or somewhat agreed (24.4%). Similar percentages of urban and rural responding physicians expressed agreement (19.2% and 18.4%, respectively) and slightly more urban than rural expressed strong agreement (6.2% vs. 3.3%, p = 0.03).

TABLE 4.

Agreement on mental health referral access by urban–rural status.

	Weighted values a
	Urban	Rural	Total
	322,648 (93.1%)	23,913 (6.9%)	346,561 (100.0%)
Agreement with “There is sufficient access for patients upon referral to mental health specialists” b , c				p‐value d
Strongly agree/somewhat agree (ref)	24.6%	22.5%	24.4%	0.70
Neither agree nor disagree/somewhat disagree/strongly disagree	75.4%	77.5%	75.6%

Excluded respondents with missing geographic information (4 removed from unweighted sample), respondents who reported being retired at the time of the 2022 NSSP (14 removed from unweighted sample) and those who reported “Not applicable” regarding use of mental health and behavioral health resources when treating patients with mental/behavioral conditions in their practice (1096 removed from unweighted sample).

^a All weighted values based on the following unweighted numbers (urban, N = 4420; rural, N = 324; total, N = 4744).

^b Question seen only by the 2250 unweighted respondents who reported “yes” when asked if they have “Referral relationship(s) with mental health providers who are accessible to your patients.”

^c Excluded N = 4 unweighted cases that reported “not applicable.”

^d All comparisons use p‐values for the Pearson's chi‐square test assessing the difference in distribution across geographic categories.

In the adjusted regression analysis, we investigated the association of physician location, demographics, and practice characteristics and agreement with the statement “There is sufficient access for patients upon referral to mental health specialists” (Table 5). There was no significant association between physician rurality and agreement on access sufficiency. There were also no significant differences between physician age groups, racial groups, or relationship status. Female physicians were less likely to agree that there was sufficient access to mental health services upon referral than male physicians (aRR 0.64, 95% CI 0.45‐0.90), while physicians who grew up outside the United States were more likely to report sufficient access than those who grew up in the United States (aRR 1.51, 95% CI 1.20, 1.78). Physician specialty was not associated with perceived sufficiency of access to mental health services. We also found no significant differences based on whether the physician grew up in a rural location, their prior military service, or employment status. Additionally, agreement levels did not differ between physicians with a higher proportion of Medicaid patients and those with fewer.

TABLE 5.

Adjusted risk ratios between agreement with the statement “There is sufficient access for patients upon referral to mental health specialists” and physician location, demographics, and practice characteristics.

	aRR	95% CI
Geography a
Urban	REF
Rural	0.87	0.51, 1.40
Age, years
≤39	0.76	0.42, 1.33
40–49	0.83	0.56, 1.18
50–59	0.84	0.59, 1.16
≥60	REF
Specialty group b
Primary care	REF
Medical specialty	1.15	0.83, 1.52
Surgery	1.16	0.79, 1.61
Other	1.12	0.80, 1.51
Gender
Male	REF
Female	0.64	0.45, 0.90
Race/ethnicity c , d
White	REF
Asian	1.09	0.80, 1.43
Other	0.78	0.44, 1.31
Relationship status
Married/committed relationship	REF
Single/never married	1.39	0.91, 1.93
Widowed	0.89	0.33, 1.96
Divorced/separated	0.87	0.47, 1.49
US military service
No military service	REF
Current/past military service	1.05	0.84, 1.27
Employment status
Employee	REF
Owner	0.83	0.59, 1.12
Independent contractor/Other	0.80	0.49, 1.25
Medicaid
0%–25%	REF
>25%	0.69	0.46, 1.00
Grew up in the United States
Yes	REF
No	1.51	1.20, 1.78
Grew up in a rural area
No	REF
Yes	1.13	0.87, 1.42

Note: Missing responses among the unweighted sample: gender 2, race 177, relationship status 7, area where grew up 5, grew up in the United States or Canada 13, citizenship 44, military 9, years in practice 82, faculty appointment 25. Sample excludes respondents with missing geographic information (4 removed from unweighted sample), respondents who reported being retired at the time of the 2022 NSSP (14 removed from unweighted sample) and those who reported “Not applicable” regarding use of mental health and behavioral health resources when treating patients with mental/behavioral conditions in their practice (1096 removed from unweighted sample).

^a Urban practice location zip code classified with Rural–Urban Commuting Area (RUCA) codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1. Rural practice location zip code classified with RUCA codes 4.0, 5.0, 6.0, 7.0, 7.2, 8.0, 8.2, 9.0, 10.0, 10.2, and 10.3.

^b Respondents asked to select the specialty in which they currently spend the most time.

^c Examples of self‐identified race categories provided by NSSP 2022 survey: American Indian or Alaskan Native (e.g., Navajo, Blackfeet, Aztec); Asian (e.g., Chinese, Filipino, Indian, Japanese, Korean, Pakistani); Black or African American (e.g., African American, Afro‐Caribbean); Native Hawaiian or Other Pacific Islander (e.g., Guamanian, Native Hawaiian); White (e.g., German, Irish, English, Italian).

^d Asian category includes respondents who self‐identified as Asian or Asian/White; Other race/ethnicity include all respondents identifying as American Indian, Alaskan Native, Native Hawaiian, Other Pacific Islander, Hispanic, Latino/Latina/Latinx, or of Spanish origin, Black or African American.

4. Discussion

The demographic representation of rural physicians was as expected. They tended to be older, more likely to identify as White, had greater exposure to training in rural settings, were disproportionately represented in primary care, and cared for a higher proportion of patients covered by Medicaid. However, several findings from this study were unexpected. Aside from a higher percentage of rural physicians (55.3%) having referral relationships with accessible mental health providers than urban physicians (44.5%), rural and urban physicians reported similar availability of mental and behavioral health resources. This similarity was noteworthy given the significant urban–rural differences in the population‐adjusted supply of psychologists, social workers, counselors, and psychiatric nurse practitioners [17]. Although the overall distribution of physician specialties was not statistically different, a higher percentage of rural doctors (42.6%) identified as primary care physicians compared to their urban counterparts (35.2%). As such, rural physicians may have a greater need for mental health referral relationships and thus be more likely to establish them. When we restricted our analysis to include only primary care physicians, we found that 15% more rural than urban primary care physicians reported having a referral relationship, providing additional evidence that referral relationships may be more common in rural places out of necessity due to the limited availability of other mental/behavioral health clinicians. Only 10% of both rural and urban physicians reported having access to a call‐in service for mental health or behavioral health providers. Given the services provided by the Substance Abuse and Mental Health Services Administration's 988 crisis line and other call‐in support resources, we expected this percentage to be higher. Increasing physician awareness of these programs may enhance their use and, in turn, improve patient access to care.

Contrary to expectations, we found no difference between rural and urban physicians’ perceptions of sufficient access to behavioral health services. We anticipated that rurally located physicians would report lower levels of agreement with the statement regarding sufficient access to behavioral health service for their patients. One possible explanation for the absence of differences is the uniformly high level of disagreement with the statement across all physicians. The comparative lack of rural behavioral health providers is well documented [18], but urban communities are also experiencing a behavioral health provider supply deficit. The widespread shortage of behavioral health providers may help explain why only one in four responding physicians agreed that their patients had sufficient access to these services, and why no differences emerged between rural and urban physicians.

4.1. Limitations

These study findings are subject to some limitations. Although the overall sample size of the physicians surveyed was relatively large, less than 10% were rurally located. The relatively small number of rural respondents (n = 324) may have contributed to the lack of statistically significant differences observed. Additionally, the rurality of the physician's location is based on the ZIP Code of the main location. However, about half of responding physicians practice at two or more locations, sometimes across rural and urban areas, which may not fully reflect the nature of the work environment or other reported characteristics, including access to referral mental health and behavioral providers.

5. Conclusion

In this study, rural and urban physicians reported similarly limited access to behavioral health resources available to their patients. Despite well‐documented urban–rural disparities in behavioral health workforce supply, the findings suggest that access challenges persist across the urban–rural spectrum. Rural physicians were more likely to report established referral relationships, yet this did not translate into greater perceived access for their patients. The consistently low levels of agreement about sufficient access highlight both urban and rural shortages of behavioral health providers, and opportunities to strengthen referral networks, integrate behavioral health services within primary care, and improve crisis‐support infrastructure. Addressing these systemic gaps will be essential to improving timely, coordinated behavioral health care for patients in both rural and urban communities.

Funding

This publication was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $500,000 with zero percentage financed with non‐governmental sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the US Government. For more information, please visit HRSA.gov.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Research data are not shared.