Is this population sicker than its urban/suburban/exurban counterparts? Does it need these surgeries at greater rates than its urban/suburban/exurban counterparts? Is there a true medical need for 30% more knee replacement surgeries, or do Medicare reimbursements enter into the "to cut, or not to cut" decision-making process?
The study looked only at Medicare recipients, which usually covers persons age 65 and older, so it's logically sound to presume that this population is sicker. This group might also tend to delay getting care because of limited access to providers and/or other reasons (cost, for example).
Treatment delays, of course, may exacerbate certain conditions, speeding a patient's course toward surgery. So perhaps, the finding was not as surprising as on first glance.
Concerns about poor access to rural healthcare services, and the costs associated with private payers are very real. In remarks published in the Kansas City Star last week, Department of Health and Human Services Secretary Kathleen Sebelius spoke in defense of the Affordable Care Act: