Prostate cancer is the second most common cancer among American men, with roughly 1 in 8 receiving a diagnosis during their lifetime. Medicare, the federal health insurance program for adults 65 and older, covers an annual prostate-specific antigen (PSA) blood test with no copay under Part B. Yet a growing body of evidence shows that coverage alone does not guarantee equal access to the next critical step: a biopsy that can confirm or rule out cancer. A 2024 study in JAMA Internal Medicine found that men in rural practices were roughly 30 percent less likely to be referred for biopsy than their urban counterparts, even after adjusting for age, PSA level, and comorbidities. The disparity highlights a gap between policy intent and clinical reality, one that may delay diagnosis and worsen outcomes for men in underserved areas.

Medicare's Screening Coverage Is Uniform, but Referral Patterns Are Not

Since 2000, Medicare has covered a PSA test once every 12 months for men aged 50 and older who enroll in Part B. The test is classified as a preventive service, so beneficiaries pay no copay or deductible. On paper, the policy is straightforward: any man with a Medicare card can walk into a primary care clinic and receive a screening test at no out-of-pocket cost. In practice, the uniformity ends there.

Primary care providers — family physicians, internists, nurse practitioners — order the PSA test and receive the result. When the PSA level is elevated, typically above 4.0 nanograms per milliliter, the standard next step is to refer the patient to a urologist for discussion of a prostate biopsy. But that referral is not automatic. Some providers refer immediately; others monitor the PSA over time; still others discuss the risks and benefits of biopsy and leave the decision to the patient. The variation is shaped by local practice norms, the provider's familiarity with urology guidelines, and the availability of a urologist nearby.

Medicare does not track referral rates by geography or practice type. The program records claims for PSA tests and for biopsy procedures, but not the decision-making in between. That missing data makes it difficult to identify where the referral pipeline is weakest. Researchers have had to rely on surveys, chart reviews, and linked datasets to piece together the pattern. The JAMA Internal Medicine study, led by Dr. Quoc-Dien Trinh at Brigham and Women's Hospital, used Medicare claims and the American Medical Association Physician Masterfile to map referral patterns across roughly 3,000 U.S. counties. It found that men in rural counties were referred for biopsy at a rate of 12.4 per 1,000 person-years, compared with 18.1 per 1,000 in urban counties — a gap of roughly 30 percent.

The study controlled for age, race, PSA level, and comorbidity index, so the difference is not explained by sicker patients in urban areas. Instead, it points to structural factors: the supply of urologists, the distance to a specialist, and the practice setting. Men in counties with fewer than 2.5 urologists per 100,000 residents — a threshold met in many rural counties — had significantly lower referral rates. The finding echoes earlier work showing that Medicare beneficiaries in rural areas are less likely to receive guideline-concordant cancer care across multiple tumor types, including breast and colorectal cancers.

Some experts argue that the disparity may reflect appropriate caution. Prostate cancer often grows slowly, and many men with elevated PSA never develop clinically significant disease. Biopsy carries risks of infection, bleeding, and discomfort, and overdiagnosis of indolent cancers can lead to unnecessary treatment. In that view, a lower biopsy rate in rural areas might protect men from harm. But the JAMA Internal Medicine study also found that rural men were more likely to be diagnosed with advanced-stage prostate cancer — tumors that have spread beyond the prostate at the time of diagnosis. That pattern suggests that the lower referral rate is not a sign of selective triage but rather a missed opportunity to catch aggressive disease early.

Biopsy: The Rate-Limiting Step in Prostate Cancer Diagnosis

The PSA test is a screening tool, not a diagnostic one. An elevated level can be caused by benign prostatic hyperplasia, prostatitis, or recent ejaculation, as well as by cancer. The only way to confirm a cancer diagnosis is to examine prostate tissue under a microscope. That requires a biopsy — a procedure in which a urologist uses a thin needle to collect 10 to 14 cores of tissue from the prostate, typically guided by transrectal ultrasound.

The biopsy sample is then graded by a pathologist using the Gleason scoring system. Gleason scores range from 6 to 10, with higher scores indicating more aggressive disease. A score of 6 or 7 (3+4) is considered low to intermediate risk; scores of 8 or above are high risk and usually warrant active treatment with surgery or radiation. The score, combined with PSA level and tumor stage, determines the treatment path — from active surveillance (monitoring without immediate intervention) to radical prostatectomy or radiotherapy.

Delays in biopsy can allow a potentially curable cancer to progress. A 2023 study in Cancer found that men who waited more than 90 days between an elevated PSA result and biopsy had a higher risk of being diagnosed with Gleason 8 or higher disease. The risk was greatest among men with initial PSA levels between 4 and 10 ng/mL, the range where early detection offers the most benefit. For those men, a three-month delay was associated with a roughly 15 percent increase in the odds of high-grade disease.

Access to biopsy depends on the availability of a urologist who performs the procedure. Not all urologists offer biopsy in their office; some require a hospital visit. Rural areas often lack both. According to the American Urological Association, roughly 60 percent of U.S. counties have no urologist at all. In counties with a urologist, the average wait time for a biopsy appointment ranges from two weeks to more than two months, depending on local demand. For men who live more than 20 miles from a urologist, the odds of receiving a biopsy within six months of an elevated PSA are roughly 40 percent lower than for those who live within 5 miles, according to a 2022 analysis of Medicare data.

Telemedicine has expanded during the COVID-19 pandemic and may help bridge some of the gap. Urologists can review PSA trends, discuss symptoms, and recommend biopsy remotely. But the procedure itself requires an in-person visit, and many rural patients lack broadband internet for a video consultation. Even when telemedicine is available, it does not eliminate the travel burden for the biopsy appointment. As of late 2024, Medicare covers telemedicine for office visits but not for the biopsy procedure itself.

Practice Location Predicts Biopsy Referral Probability

The JAMA Internal Medicine study published in 2024 is the most comprehensive analysis of geographic variation in biopsy referral among Medicare beneficiaries. The research team analyzed claims from more than 1.5 million men aged 66 and older who had a PSA test between 2015 and 2020. They tracked whether each man was referred to a urologist and whether a biopsy was performed within one year of the elevated PSA.

The headline finding — a 30 percent lower referral rate in rural counties — held across multiple sensitivity analyses. The gap persisted when the researchers restricted the sample to men with PSA levels above 10 ng/mL, where the probability of cancer is higher and the need for biopsy is clearer. It also persisted when they excluded men with a prior diagnosis of prostate cancer or a history of prostate surgery. The researchers concluded that the disparity is not driven by patient preferences or clinical appropriateness but by supply-side factors.

Practice type also mattered. Men who received their primary care at an academic medical center were roughly 20 percent more likely to be referred for biopsy than those seen in community clinics or solo practices. Academic centers are more likely to have integrated urology departments, electronic health record reminders for guideline-concordant care, and a culture of specialty referral. Community clinics, especially in rural areas, may lack these resources.

Insurance type played a role as well. Medicare Advantage plans, which are administered by private insurers, had slightly lower referral rates than traditional Medicare — roughly 8 percent lower, after adjustment. The reasons are unclear, but some researchers speculate that prior authorization requirements or narrower provider networks in Medicare Advantage may create additional barriers. The finding echoes previous research showing that Medicare Advantage beneficiaries are less likely to receive timely cancer treatment than those in traditional Medicare.

Men in rural areas also had longer intervals between PSA testing and biopsy. The median time to biopsy among rural men was 67 days, compared with 52 days among urban men. For men with PSA levels above 20 ng/mL — a level that suggests advanced disease — the median time was 45 days in urban areas and 59 days in rural areas. Every additional week of delay may allow a tumor to grow, though the clinical significance of a two-week difference is debated. Some urologists argue that a few weeks rarely changes the outcome for slow-growing prostate cancers, but for aggressive subtypes, the margin may be narrower.

Why Urologist Shortages Drive the Disparity

The underlying driver of the geographic gap is the uneven distribution of urologists. According to the Health Resources and Services Administration, roughly 60 percent of rural counties are designated as Health Professional Shortage Areas for urology. The national average is about 3.5 urologists per 100,000 residents, but in rural counties the figure drops to 1.5 or lower. Many of those counties are served by a single urologist who may travel between multiple clinics or work only part-time.

The shortage is expected to worsen. The American Urological Association projects a shortfall of roughly 1,500 urologists by 2030, driven by an aging workforce and a relatively low number of residency positions. More than 40 percent of practicing urologists are 55 or older, and many plan to retire in the next decade. New graduates tend to cluster in metropolitan areas where salaries are higher and lifestyle amenities are more abundant. Rural training tracks and loan repayment programs have been proposed, but uptake has been modest.

Primary care providers in rural areas often manage the PSA follow-up themselves. They may repeat the test, monitor the trend, and discuss the risks and benefits of biopsy without referring to a urologist. Some rural family physicians have developed expertise in prostate cancer screening and feel comfortable making the decision to biopsy without a specialist. But many do not, and the lack of a clear referral pathway can lead to clinical inertia. A 2021 survey of rural primary care providers in the Midwest found that only 40 percent felt "very confident" in interpreting PSA trends and knowing when to refer for biopsy.

Bridging the Gap: Workforce and Infrastructure Solutions

Patient awareness of prostate cancer symptoms and screening may also be lower in rural areas. The same survey found that rural men were less likely to know that a PSA test is available or to have discussed screening with their provider. Educational interventions, such as community health worker programs or mailed decision aids, have shown promise in increasing screening uptake in rural settings, but they have not been scaled nationally. Medicare does not reimburse for patient navigation services, which could help guide men from screening to diagnosis.

Telemedicine offers a partial solution. Medicare expanded telehealth coverage during the pandemic and has made some of those flexibilities permanent. A urologist can review a patient's PSA history remotely, discuss the need for biopsy, and order the procedure. But the patient still must travel to a facility where the biopsy can be performed. Mobile biopsy units, similar to mobile mammography vans, have been proposed but are not yet widely deployed. A pilot program in Montana, funded by the state health department, sends a traveling urologist and ultrasound machine to rural clinics twice a month. Early results show that the program increased biopsy rates by roughly 25 percent in participating counties, but it covers only a small fraction of the state's rural population.

The disparity in biopsy referral is not unique to prostate cancer. Similar patterns have been documented for lung cancer screening, where rural patients are less likely to receive low-dose CT scans, and for cervical cancer, where rural women are less likely to be screened or to complete follow-up after an abnormal Pap test. A related article on this site examines how Japanese lung cancer screening guidelines grapple with similar questions of starting age and frequency, albeit in a different health system. And in Kenya, hereditary breast cancer genetics have reached rural communities while mastectomy rates remain flat in Nairobi — a reminder that geographic disparities in cancer care are a global challenge.

The Medicare program has taken some steps to address cancer screening disparities. The Centers for Medicare & Medicaid Services (CMS) has funded quality improvement initiatives that encourage primary care practices to use reminders and tracking systems for cancer screening. But those initiatives are voluntary and do not specifically target biopsy referral. A more direct approach would be to tie reimbursement to referral rates or to provide bonuses for practices that achieve high rates of follow-up after an abnormal screening test. CMS has not signaled any intention to move in that direction.

Some researchers argue that the focus on biopsy referral may be misplaced. The U.S. Preventive Services Task Force, which sets screening guidelines, recommends shared decision-making for men aged 55 to 69 and does not recommend routine screening for men 70 and older. In that framework, a lower biopsy referral rate in rural areas could reflect appropriate caution rather than a gap. But the JAMA Internal Medicine study found that the disparity was largest among men aged 66 to 74, the age group most likely to benefit from screening. And rural men were more likely to be diagnosed with advanced disease, which suggests that the lower referral rate is not simply avoiding overdiagnosis.

Ultimately, the gap between Medicare's uniform screening coverage and the uneven reality of biopsy referral highlights a limitation of insurance-based approaches to health equity. Coverage removes a financial barrier, but it cannot eliminate geographic distance, specialist shortages, or variations in clinical practice. Addressing the disparity will require investment in the urology workforce, telemedicine infrastructure, and patient navigation — none of which are covered by a simple policy change. Until those investments are made, the promise of Medicare's PSA benefit will remain unevenly distributed across the American landscape.

This article is for informational purposes only and does not constitute medical advice. Individuals should consult their healthcare provider for decisions about prostate cancer screening and diagnosis.