North Carolina Rural Health Research and Policy Analysis Center: Rural Health Research Products & Journal Articles

2024

Rural-Urban Medicaid and CHIP Enrollee Comparisons Using the 2019 T-MSIS Analytic File
Policy Brief
Date: 12/2024
In 2019, nearly 25 percent of rural residents under age 65 had Medicaid or CHIP health insurance coverage. Researchers used data from the 2019 T-MSIS Analytic Files to compare urban and rural residents enrolled in either fee for-service or managed care Medicaid. This brief provides descriptive data on enrollment and demographics.
Utilization of Inpatient and Emergency Services by Rural and Urban Medicaid Enrollees
Policy Brief
Date: 12/2024
In 2019, nearly 25 percent of rural residents under age 65 had Medicaid or CHIP health insurance coverage. Researchers used data from the 2019 T-MSIS Analytic Files to describe health care utilization among rural Medicaid beneficiaries at the national level and to compare these results to utilization among urban Medicaid beneficiaries.
The First Year of Rural Emergency Hospitals: REHs Serve Relatively Disadvantaged Counties
Policy Brief
Date: 10/2024
This brief looks at community characteristics (socio-economic, race and ethnicity, and health status and access characteristics) of communities with a hospital that converted to a Rural Emergency Hospital (REH) in 2023—the first year of the new rural hospital payment designation.
News Media Coverage of Rural Hospital Closures and the Causes
Policy Brief
Date: 10/2024
This study augments previous research with findings from a structured framework of attributed causes of rural hospital closures through the analysis of news media reports.
An Updated Model of Rural Hospital Financial Distress
Journal Article
Date: 10/2024
In fall 2024, the North Carolina Rural Health Research Program completed a study modeling financial distress among rural hospitals, "An Updated Model of Rural Hospital Financial Distress." The model updates a 2016 version, by adding recent changes in the operating environment.
The Low-Volume Hospital Adjustment Before and During COVID-19
Policy Brief
Date: 07/2024
This brief uses current low-volume hospital adjustment qualifying criteria to compare low-volume hospitals to other rural hospitals and explores the effect of removing the adjustment before COVID-19 and during COVID.
2018-23 Profitability of Rural Hospitals by Ownership and System Affiliation
Policy Brief
Date: 06/2024
This study compares the 2018-23 profitability of rural hospitals based on ownership and system affiliation status. The purpose of this brief is to describe the profitability of rural hospitals over a five-year period consisting of two years before and three years after COVID-19.
2018-23 Profitability of Rural Hospitals by With and Without Rural Health Clinics and Long-Term Care
Policy Brief
Date: 06/2024
This study compares the 2018-23 profitability of rural hospitals for hospitals that provide and do not provide long-term care, and that operate and do not operate rural health clinics.
2018‐23 Profitability of Rural and Urban Hospitals by Medicare Payment Designation
Policy Brief
Date: 06/2024
This study compares profitability of three types of hospitals in both urban and rural locations: Critical Access Hospitals, Prospective Payment System-only (PPS) hospitals by number of acute beds, and PPS hospitals with special payment designations hospitals over a five-year period.
Differences in Measurement of Operating Margin: An Update
Policy Brief
Date: 05/2024
This study uses recent Medicare Cost Report data to compare rural and urban hospitals using the three definitions for operating margin. Researchers assess the distribution and extent of extreme values of operating margin.
Using the Updated Financial Distress Index to Describe Relative Risk of Hospital Financial Distress
Policy Brief
Date: 04/2024
Using a recent revision of the Financial Distress Index (FDI) model, this study aimed to describe the relative risk of experiencing financial distress for rural hospitals and selected urban hospitals.
COVID-19 Affected Rural and Urban Hospital Uncompensated Care
Fact Sheet
Date: 03/2024
The purpose of this infographic is to illustrate the impact COVID-19 had on uncompensated care and operating margin among rural and urban hospitals.
A Comparison of 2017-19 Uncompensated Care of Rural and Urban Hospitals by Net Patient Revenue, System Affiliation, and Ownership
Policy Brief
Date: 01/2024
The purpose of this study is to better understand patterns of uncompensated care. It extends a 2018 study of geographic variation in uncompensated care between rural and urban hospitals. Specifically, researchers investigate the association of uncompensated care with net patient revenue, system affiliation, and ownership.

2023

Rural Emergency Hospital Map and Data
Date: 10/2023
This interactive map tracks hospitals that have converted to Rural Emergency Hospitals since January 2023.
Suitability of Low-Volume Rural Emergency Departments to New Rural Emergency Hospital Designation
Journal Article
Date: 09/2023
The Rural Emergency Hospital is a new Medicare payment model that requires hospitals to focus on emergency, observation, and outpatient services in lieu of inpatient care. This study's exploratory objective was to examine care delivery from eligible hospitals to assess their fit with the new payment model.
Rural Population Health in the United States: A Chartbook
Chartbook
Date: 02/2023
This chartbook uses a range of indicators to describe population health in rural America and document health disparities between rural and urban areas. This report includes 33 measures of population health, organized into five domains: Access to Care, Health Outcomes and Risks, Mortality, Social Determinants of Health, and Socioeconomics.

2022

Characteristics of Rural Hospitals Eligible for Conversion to Rural Emergency Hospitals and Three Rural Hospitals Considering Conversion
Policy Brief
Date: 12/2022
This brief presents 2021 data for Rural Emergency Hospital (REH)-eligible hospitals, compares financial and operational measures of three rural hospitals that have expressed interest in REH conversion to all REH-eligible hospitals, and discusses what factors may ultimately determine the number of rural hospitals that convert to REH.
Factors Predicting Swing Bed Versus Skilled Nursing Facility Use
Policy Brief
Date: 10/2022
This study examines differences between patients discharged to swing beds versus skilled nursing facilities, stratifying by admitting hospital type (i.e., rural Critical Access Hospital versus rural Prospective Payment System hospital).
Key Considerations for a Rural Hospital Assessing Conversion to Rural Emergency Hospital
Policy Brief
Date: 10/2022
Based on findings from a literature review and consultation with practitioners, a conceptual framework and checklist were developed to organize and guide conversations about key considerations for conversion to a Rural Emergency Hospital.
Small Rural Hospitals with Low-Volume Emergency Departments That May Convert to a Rural Emergency Hospital (REH)
Policy Brief
Date: 10/2022
This study profiles rural hospitals eligible to convert to Rural Emergency Hospitals. The objective is to characterize rural hospitals with very low emergency department volume to inform the clinical and operational decisions that will be required to implement this new provider model.
Changes in the Provision of Health Care Services by Rural Critical Access Hospitals and Prospective Payment System Hospitals in 2009 Compared to 2017
Policy Brief
Date: 08/2022
The purpose of this brief is to explore changes in the availability and provision of different health care services among rural CAHs and PPS hospitals in 2009 compared to 2017.
Predictors of Hospital Bypass for Rural Residents Seeking Common Elective Surgery
Journal Article
Date: 08/2022
This article used Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates and predictors for patients bypassing rural hospitals for common procedures.
Types of Rural and Urban Hospitals and Counties Where They Are Located
Policy Brief
Date: 07/2022
The purpose of this brief is to provide a snapshot of the types of rural and urban hospitals and the counties where they are located.
Association Between Rural Hospital Service Changes and Community Demographics
Policy Brief
Date: 05/2022
Research has shown that among rural communities, those with a larger percentage of Black or Hispanic residents were more likely to experience a local hospital closure. This brief explores possible associations between the proportion of a rural community belonging to a AHRQ-identified priority population and local hospital service changes.
Trends in Revenue Sources Among Rural Hospitals
Policy Brief
Date: 05/2022
Possible issues with existing rural hospital financing models suggest that outpatient-centric payment methods may be more effective in providing financial relief to rural hospitals. Given this, we explored the financial importance of outpatient care to rural hospitals by estimating changes in outpatient care as a source of revenue.
Predictors of Hospital Choice Among Rural Patients Seeking Elective Surgery: A Scoping Review
Policy Brief
Date: 04/2022
The purpose of this scoping review was to identify literature describing determinants of hospital choice among rural patients seeking elective surgery.
The Economic Effects of Rural Hospital Closures
Journal Article
Date: 03/2022
This study updates previous research (Holmes, et al. 2006) on the economic effects of rural hospital closures by measuring the economic changes over time among U.S. rural counties that had a hospital closure from 2001-2018.
Rural Hospital Profitability During the Global COVID-19 Pandemic Requires Careful Interpretation
Policy Brief
Date: 03/2022
Many small rural hospitals struggle with profitability compared to their urban counterparts. The findings brief describes the pre-pandemic (2011-19) trend of rural hospital profitability and explains why possible increases in reported profitability during the pandemic (2020-21) may mask the long-term financial challenges of rural hospitals.
Since 1990, Rural Hospital Closures Have Increasingly Occurred in Counties That Are More Urbanized, Diverse, and Economically Unequal
Policy Brief
Date: 03/2022
The brief describes the socio‐economic, demographic, and health system characteristics for rural counties with and without hospital closures between 1990 and 2020. We analyzed potential differences among counties that experienced rural hospital closures from 2010‐2020 compared to counties with rural hospital closures from 1990‐2009.
Rural Hospitals That Closed Between 2017‐20: Profitability and Liquidity in the Year Before Closure
Policy Brief
Date: 01/2022
This brief examines the preclosure profitability and liquidity performance of rural hospitals that closed between 2017‐20 and compare it to the median performance of rural hospitals that remained open during the same year.

2021

2021 CMS Hospital Quality Star Ratings of Rural Hospitals
Policy Brief
Date: 10/2021
The purpose of this study is to 1) compare the 2021 CMS Hospital Quality Star Rating results for rural and urban hospitals, 2) to compare the 2021 and 2016 CMS Hospital Quality Star Rating results for rural hospitals, and 3) to identify implications for the usefulness of the CMS Hospital Quality Star Ratings for rural hospitals.
Medicare Covers a Lower Percentage of Outpatient Costs in Hospitals Located in Rural Areas
Policy Brief
Date: 09/2021
The purpose of this brief is to describe differences in Medicare Outpatient Prospective Payment System (OPPS) payments between rural and urban hospitals by Medicare payment classification and by number of acute beds.
Cardiovascular & Cancer Rates for the Rural Delta Region: Rural Delta Region Map Tool
Date: 08/2021
The Rural Delta Region Map Tool is an interactive tool that shows 13 health measures for people in Delta Region counties/parishes. It can be used to compare rates of cancer and cardiovascular disease by county, by rural-urban status, to peer counties, to the national average, and to national quartiles.
How Many Hospitals Might Convert to a Rural Emergency Hospital?
Date: 07/2021
In this study, three measures were used to predict the number of rural hospitals with 50 beds or less that are likely to consider conversion to a Rural Emergency Hospital: 1) three years negative total margin; 2) average daily census (acute + swing) less than three; and 3) net patient revenue less than $20 million.
Changes in Provision of Selected Services by Rural and Urban Hospitals Between 2009 and 2017
Policy Brief
Date: 04/2021
The purpose of this study is to gain a better understanding of recent trends in hospital service provision and whether there were disparities between rural and urban hospitals. This brief describes and compares the changes in service provision for rural and urban hospitals between 2009 and 2017.
The Effect of Medicare Payment Standardization Methods on the Perceived Cost of Post-Acute Swing Bed Care in Critical Access Hospitals
Policy Brief
Date: 03/2021
The purpose of this study is to describe the effects of current Medicare payment standardization methods on the perceived cost of Critical Access Hospital swing bed care as it relates to the Medicare Spending per Beneficiary measure.
Alternatives to Hospital Closure: Findings From a National Survey of CAH Executives
Date: 02/2021
Despite the many challenges of operating a Critical Access Hospital (CAH), little research examines the perspectives of CAH executives on potential community healthcare options if the CAH closed. This brief provides policymakers with a better understanding of what CAH executives think about the viability of various alternatives to closure.
Health System Challenges for Critical Access Hospitals: Findings From a National Survey of CAH Executives
Policy Brief
Date: 02/2021
Despite the numerous challenges of operating a Critical Access Hospital (CAH), there is little research examining the perspectives of CAH executives on potential community healthcare options if the CAH closed. This brief presents a subset of results from a national survey of CAH executive perspectives on pressing challenges.

2020

Association of CMS‐HCC Risk Scores With Health Care Utilization Among Rural and Urban Medicare Beneficiaries
Policy Brief
Date: 12/2020
The study examines the relationship between Centers for Medicare & Medicaid Services Hierarchical Condition Categories risk scores and future healthcare utilization among rural and urban Medicare beneficiaries.
CMS Hierarchical Condition Category 2014 Risk Scores Are Lower for Rural Medicare Beneficiaries Than for Urban Beneficiaries
Policy Brief
Date: 12/2020
The study investigates potential differences in rural and urban Centers for Medicare & Medicaid Services Hierarchical Condition Category risk scores by rurality, census region, and beneficiary race or ethnicity.
Decline in Inpatient Volume at Rural Hospitals
Journal Article
Date: 12/2020
This study examined inpatient volume in rural hospitals between 2011 and 2017. Patient population and the organizational and geographic characteristics of hospitals that were significant predictors of inpatient volume included census region, Medicare payment type, ownership type, total margin, and percent of the population in poverty.
Rural Hospitalizations for COVID-19: Snapshot on December 10, 2020
Date: 12/2020
U.S. Department of Health and Human Services data were analyzed to compare rural and urban hospitals on two metrics: 1) the percentage of hospitalized patients with COVID-19, and 2) the percentage of hospital beds occupied by patients that have COVID-19.
Rural Hospitals Have Higher Percentages of Patients With COVID-19
Date: 12/2020
U.S. Department of Health and Human Services data were analyzed to compare the percentage of hospitalized patients with COVID-19 in rural versus urban hospitals.
Urban Hospitals With a High Percentage of Inpatient Days for Rural Patients
Policy Brief
Date: 09/2020
The purpose of this brief is to describe characteristics of urban hospitals with a high percentage of inpatient days for rural patients and to compare how they differ from urban hospitals with lower percentages of rural inpatient days.
Changes in Care-Seeking After Rural Hospitals Merge
Policy Brief
Date: 07/2020
Rural hospital mergers have increased significantly since 2010. Enhanced financial performance and improved quality are often cited as benefits, but hospital mergers can also lead to changes in the services provided by acquired hospitals. This brief estimates the use of inpatient services delivered by acquired rural hospitals following a merger.
Estimated Reduction in CAH Proﬁtability From Loss of Cost‐Based Reimbursement for Swing Beds
Policy Brief
Date: 05/2020
The purpose of this study was to estimate the impact of potential loss of cost-based reimbursement for swing beds on Critical Access Hospital (CAH) profitability and to examine the characteristics of CAHs that would be most affected by such a change in reimbursement.
Most Rural Hospitals Have Little Cash Going Into COVID
Date: 05/2020
This infographic uses Medicare Cost Report data to illustrate the type of rural hospitals most likely to struggle financially during the pandemic as measured by lower median days cash on hand.
2016-18 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
Policy Brief
Date: 04/2020
This study compares the 2016-18 profitability of urban Prospective Payment System (PPS) hospitals to that of rural hospitals. Rural hospitals are further divided by size of rural PPS hospitals and by the rural Medicare payment classifications.
Geographic Variation in the 2018 Profitability of Urban and Rural Hospitals
Policy Brief
Date: 04/2020
This study describes the geographic variability in 2018 profitability of Critical Access Hospitals, other rural hospitals, and urban Prospective Payment System hospitals by census region, census division, and state.
Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents
Policy Brief
Date: 04/2020
Hospital bypass, the tendency of local rural residents to not seek care at their closest hospital, is thought to be a contributing factor for rural hospital closure. The purpose of this brief is to update the knowledge base of determinants of bypass behavior by analyzing state inpatient data from 2014-2016.
Rural Hospitals With Long-Term Unprofitability
Policy Brief
Date: 04/2020
The purpose of this study is to examine the characteristics of rural hospitals that had negative total margins in 2016, 2017, and 2018. We examined net patient revenue, Medicare payment classification, region, and state for 311 rural hospitals.
Understanding the Broader Context of Rural Hospitals and Profitability
Date: 04/2020
The intent of this infographic is to quantify rural hospital profitability in the broader context of all hospitals. This infographic compares the number of rural and urban hospitals and rural and urban operating revenue and operating income.
Occupancy Rates in Rural and Urban Hospitals: Value and Limitations in Use as a Measure of Surge Capacity
Policy Brief
Date: 03/2020
The purpose of this brief is to provide healthcare leaders and policymakers with information about historic occupancy rates (the percent of available beds that are occupied) as an input for state and system-level planning to manage population health during a pandemic.

2019

Risk Factors and Potentially Preventable Deaths in Rural Communities
Policy Brief
Date: 10/2019
In this study, we use variation in three risk factors – smoking, obesity, and excessive alcohol use – to identify their relative contribution to common causes of mortality.
Cost-Sharing as a Barrier to Accessing Care at FQHCs and RHCs for Rural Medicare Beneficiaries
Date: 06/2019
The purpose of this study is to investigate cost barriers to accessing care at Federally Qualified Health Centers and Rural Health Clinics for the rural Medicare population.
Facility-Based Ambulatory Care Provided to Rural Medicare Beneficiaries in 2014
Chartbook
Date: 03/2019
This chartbook uses available Medicare claims data to describe facility-based (i.e., excludes private practitioners) ambulatory care provided to rural Medicare beneficiaries and includes claims, costs, and common diagnoses.

2018

Rural Hospital Mergers From 2005 Through 2016
Policy Brief
Date: 08/2018
This brief describes the number and geographic distribution of rural hospital mergers from 2005-2016.
Average Beneficiary CMS Hierarchical Condition Category (HCC) Risk Scores for Rural and Urban Providers
Policy Brief
Date: 07/2018
This brief investigates potential differences in urban and rural Centers for Medicare & Medicaid Services (CMS) hierarchical condition category (HCC) risk scores at the provider's patient panel level.
Geographic Variation in Uncompensated Care Between Rural and Urban Hospitals
Policy Brief
Date: 06/2018
The purpose of this brief is to compare uncompensated care in rural and urban hospitals and to describe how it varies across regions of the country.
Market Characteristics Associated With Rural Hospitals' Provision of Post-Acute Care
Policy Brief
Date: 04/2018
This brief uses data from Medicare cost reports, the Provider of Services File, and the U.S. Department of Agriculture to provide a window into current hospital-based post-acute care offerings by summarizing both hospital- and market-level factors that are associated with rural hospitals that provided post-acute care between 2012 and 2015.
Rural and Urban Provider Market Share of Inpatient Post-Acute Care Services Provided to Rural Medicare Beneficiaries
Policy Brief
Date: 04/2018
The purpose of this brief is to characterize rural providers' market share of inpatient post-acute care services provided to rural Medicare beneficiaries.
Geographic Variation in the 2016 Profitability of Urban and Rural Hospitals
Policy Brief
Date: 03/2018
This study describes the geographic variation in 2016 profitability of critical access hospitals (CAHs), other rural hospitals (Medicare Dependent Hospitals, Sole Community Hospitals, and rural Prospective Payment System (PPS) hospitals denoted as "ORH"), and urban PPS hospitals by census region, census division, and state.
Access to Care: Populations in Counties With No FQHC, RHC, or Acute Care Hospital
Policy Brief
Date: 01/2018
To help provide a quick understanding of how many people may have more limited access to primary care and where they live, this brief focuses on three main primary care providers in rural areas (Federally Qualified Health Centers, Rural Health Centers, and acute care hospitals).
Range Matters: Rural Averages Can Conceal Important Information
Policy Brief
Date: 01/2018
This short brief uses three examples to demonstrate how focusing on averages without also considering the data range can conceal important information: 1) average rural hospital profitability, 2) distance from closed rural hospitals to the next closest hospital, and 3) HIV prevalence by county.

2017

Characteristics of Communities Served by Hospitals at High Risk of Financial Distress
Report
Date: 12/2017
This brief compares the characteristics of communities served by rural hospitals at high risk of financial distress to those served by rural hospitals that are not at high risk of financial distress.
Differences in Community Characteristics of Sole Community Hospitals
Policy Brief
Date: 11/2017
The purpose of this brief is to present a snapshot of Sole Community Hospitals (SCHs) and the communities served by them in 2015 (cross-sectional analysis), and identify some trends in selected SCH and community characteristics between 2006 and 2015 (longitudinal analysis).
Regional Differences in Rural and Urban Mortality Trends
Policy Brief
Date: 08/2017
This brief explores the differences in mortality rates over time by (1) urban and rural location, (2) census division, and (3) urban and rural location within each census division.
The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals
Policy Brief
Date: 07/2017
This brief describes Medicare post-acute and hospice care provided by hospitals in rural areas by characterizing the variation in the number of rural hospitals that provide PAC and hospice care, the average amount of Medicare revenue rural hospitals receive for these services, and the financial importance of PAC and hospice care to rural hospitals.
A Positive Association Between Hospice Profit Margin and the Rate at Which Patients Are Discharged Before Death
Journal Article
Date: 07/2017
The links between the increasing live discharge rate from hospice and the quality of care is examined.
Predicting Financial Distress and Closure in Rural Hospitals
Journal Article
Date: 06/2017
Examines the financial distress of rural hospitals to better predict closures within two years.
Rural Health Snapshot (2017)
Date: 05/2017
The Rural Health Snapshot (2017) updates the 2010 Rural Health Snapshot. The document is a data sheet that compares a selection of health and healthcare access indicators for populations in rural and urban areas.

2016

How Would Rural Hospitals Be Affected by Loss of the Affordable Care Act's Medicare Low-Volume Hospital Adjustment?
Journal Article
Date: 11/2016
Using data from the Hospital Market Service Area File, the Hospital Cost Report Information System, and Nielsen-Claritas Pop-Facts, this study examined the effect the low-volume hospital payment adjustment has on a hospital's finances. It also looked at the effects of losing the payment adjustment.
The Financial Importance of the Sole Community Hospital Payment Designation
Policy Brief
Date: 11/2016
Assesses the financial importance of the Sole Community Hospital (SCH) program by: the proportion of SCHs that was reimbursed at the hospital specific rate between 2006 and 2015; the profitability of providing services to Medicare patients in SCHs between 2006 and 2015, and; the financial consequences if the SCH program had not existed in 2015.
To What Extent Do Community Characteristics Explain Differences in Closure Among Financially Distressed Rural Hospitals?
Journal Article
Date: 11/2016
This study examined the differences between rural hospitals at high risk of financial distress that stayed open and those that closed.
The Impact of the Low Volume Hospital (LVH) Program on the Viability of Small, Rural Hospitals
Policy Brief
Date: 10/2016
This brief compares rural Low Volume Hospital (LVH) to non-LVH characteristics and estimates the financial impact of eliminating the LVH program and reverting to the original (2005) LVH classification and payment adjustment.
Trends in Risk of Financial Distress Among Rural Hospitals
Policy Brief
Date: 10/2016
From January 2005 to July 2016, 118 rural hospitals have closed permanently, and the rate of rural hospital closures is increasing. Hospital closures impact millions of rural residents. Identifying hospitals at high risk of closure and assessing the trends over time may inform strategies to prevent or mitigate the effects of closures.
Characteristics of Medicaid Beneficiaries Who Use Rural Health Clinics
Policy Brief
Date: 05/2016
The RHC role varies by state. While we don't have an understanding of what this looks like for each state, we can see that RHCs are an important provider for Medicaid beneficiaries. One of the most important differences is by age groups. All states tend to cater RHC services toward children, with a minimum of 39% of the RHC population < 18.
Identifying Rural Health Clinics in Medicaid Data
Policy Brief
Date: 05/2016
Identifying Rural Health Clinics (RHCs) in Medicaid claims across states is challenging, but this brief recommends methods for identifying the majority of these claims in four states.
Does ACA Insurance Coverage Expansion Improve the Financial Performance of Rural Hospitals?
Policy Brief
Date: 04/2016
Views on how the implementation of the Affordable Care Act's (ACA) expanded insurance coverage is affecting the financial performance of rural hospitals. The study found that while respondents believe the expanded insurance coverage was the right thing to do for patients, they worried coverage may not be adequate to ensure access to care.
2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
Policy Brief
Date: 03/2016
The profitability of urban hospitals to that of rural hospitals are compared for fiscal years 2012-2014 based on size and rural Medicare payment classifications.
Geographic Variation in the Profitability of Urban and Rural Hospitals
Policy Brief
Date: 03/2016
Historic and recent evidence suggest that unprofitability can reduce hospital services and quality, or worse, lead to closure. This study describes the current geographic variability of hospital profitability by comparing the 2014 profitability of CAHs, other rural hospitals, and urban hospitals by census region, census division, and state.
Geographic Variation in Risk of Financial Distress Among Rural Hospitals
Policy Brief
Date: 01/2016
From 2005 to 2015, 112 rural hospital closures have been identified. The closures impact millions of rural residents. This brief describes the geographic variation in the proportion of rural hospitals forecasted to be at high risk of distress in 2015.
Prediction of Financial Distress Among Rural Hospitals
Policy Brief
Date: 01/2016
From 2005 to 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services. To understand factors affecting rural hospital financial distress and to develop an early warning system to identify hospitals at risk, the North Carolina Rural Health Research Program developed the Financial Distress Index.

2015

Estimated Costs of Rural Freestanding Emergency Departments
Policy Brief
Date: 11/2015
A rural freestanding emergency department (RFED) is one potential model for providing emergency services in areas where hospitals have closed. The North Carolina Rural Health Research Program's Findings Brief, Estimated Costs of Rural Freestanding Emergency Departments explains the RFED concept and estimates RFED costs in three scenarios.
Rural Hospital Mergers and Acquisitions: Which Hospitals Are Being Acquired and How Are They Performing Afterward?
Journal Article
Date: 11/2015
Examines characteristics of rural hospitals that have merged or were acquired during 2005 and 2012. Also compares the change is rural hospital finances, staffing, or services after the merger or acquisition.
Uncompensated Care Burden May Mean Financial Vulnerability for Rural Hospitals in States That Did Not Expand Medicaid
Journal Article
Date: 10/2015
Explores the differences of rural hospitals in states with Medicaid expansion and those with nonexpansion, in terms of the amount of uncompensated care they provided and their profitability and market characteristics in 2013.
Rural Medicare Beneficiaries Have Fewer Follow-Up Visits and Greater Emergency Department Use Post-Discharge
Journal Article
Date: 09/2015
Compares rates of post hospital discharge care among Medicare beneficiaries in rural and urban settings. Discusses the effect on policies for follow-up care and readmission penalties.
The Rising Rate of Rural Hospital Closures
Journal Article
Date: 07/2015
Discusses the increase in rural hospital closure rates, including the causes of closures and its impact on rural communities.
A Comparison of Closed Rural Hospitals and Perceived Impact
Policy Brief
Date: 04/2015
This policy brief compares selected characteristics of abandoned rural hospitals and their markets to those of converted rural hospitals.
Minimum Distance Requirements Could Harm High-Performing CAHs and Rural Communities
Journal Article
Date: 04/2015
Compares the effect of location on critical access hospitals' size, quality of care, and financial strength. Discusses implications of minimum distance requirements on critical access hospitals.
The 21st Century Rural Hospital: A Chart Book
Chartbook
Date: 03/2015
This chartbook presents a broad profile of rural hospitals and includes information on location, who they serve, services they provide, how they ensure outpatient services for their communities, other community benefits they provide, and financial performance. Each page includes charts comparing rural hospitals to each other and to urban hospitals.
Do Current Medicare Rural Hospital Payment Systems Align With Cost Determinants?
Policy Brief
Date: 02/2015
To inform policy discussions on how complex current payment models may affect rural hospitals, the North Carolina Rural Health Research Program studied differences in financial condition among rural hospitals and important determinants of differences in rural hospital costs.
Rural Provider Perceptions of the ACA: Case Studies in Four States
Policy Brief
Date: 02/2015
This brief summarizes the perceptions from rural providers in four states regarding the early effects of the Affordable Care Act, including changes to patient populations, financial health, and capacity for rural hospitals and rural federally qualified health centers.
Financially Fragile Hospitals: Mergers and Closures
Journal Article
Date: 01/2015
Evaluates the causes of financial stress in rural hospitals, and describes the impact rural hospitals have on their communities. Also discusses the ways in which rural hospitals and communities have responded to this financial stress.
The Effect of Surgery on the Profitability of Rural Hospitals
Journal Article
Date: 2015
Presents research on the effect of providing surgery in rural hospitals. Examines the availability of surgery's effect on trauma outcomes and economies in rural communities.

2014

Best Practices for Health Insurance Marketplace Outreach and Enrollment in Rural Areas
Fact Sheet
Date: 12/2014
Research suggests enrollment rates for those in rural areas was less than urban areas during the first Health Insurance Marketplace enrollment period. Interviews of navigators, health centers, and others in rural counties with high enrollment rates were conducted to uncover best practices for marketing, outreach/education, in-reach, and enrollment.
Rural-Urban Differences in Continuity of Care Among Medicare Beneficiaries
Policy Brief
Date: 12/2014
In response to the ACA and other reforms in the healthcare market, new care models are being tested and implemented. To addresses concerns that healthcare in rural areas may be more fractured and thus a difficult place for the models to succeed, we measured continuity of care using detailed data on a sample of Medicare beneficiaries from 2000-2009.
Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
Policy Brief
Date: 10/2014
This brief combines the data on plan selection in the federally facilitated marketplaces with estimates of those likely to qualify for the marketplace to calculate the percentage of potential eligible individuals who chose a health insurance plan (the uptake rate). It contains a heat map showing the variation in uptake rates across the country.
Rural Hospital Mergers and Acquisitions: Who Is Being Acquired and What Happens Afterward?
Policy Brief
Date: 08/2014
A brief from the North Carolina Rural Health Research and Policy Analysis Center examines the implications of mergers and acquisitions for small rural hospitals. The brief addresses the characteristics of rural hospitals that merged and the changes in hospital financial performance, staffing, or services following a merger.
How Does Medicaid Expansion Affect Insurance Coverage of Rural Populations?
Policy Brief
Date: 07/2014
This brief examines how states' decisions on Medicaid expansion are impacting rural areas in the United States. Population estimates, current state expansion status, and state-level insurance estimates were used to answer two main questions—how is expansion affecting rural populations and how would it differ if every state were to expand Medicaid.
Safety Net Clinics Serving the Elderly in Rural Areas: Rural Health Clinic Patients Compared to Federally Qualified Health Center Patients
Policy Brief
Date: 05/2014
This brief, the third and final in a series on rural health centers (RHC), uses data from 2009 Medicare outpatient provider claims to look at clinic locations, number of beneficiaries served, and number of/cost per claim for each type of rural safety net clinic, as well as beneficiaries' ages, health problems, and distance traveled for care.
Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where?
Policy Brief
Date: 02/2014
This brief examines health conditions of patients discharged from rural prospective payment system (PPS) hospitals and critical access hospitals (CAHs) to swing beds and skilled nursing facilities (SNFs).

2013

Geographic Variation in the Profitability of Critical Access Hospitals
Policy Brief
Date: 09/2013
This study describes geographic variation in the profitability of Critical Access Hospitals (CAHs) in 2012 to understand some of the regional differences in the potential effects of implementing policy proposals impacting CAHs.
Profitability of Rural Hospitals
Policy Brief
Date: 08/2013
This study compares the profitability between 2010 and 2012 of urban and rural hospitals paid under the Medicare Prospective Payment System (U-PPS and R-PPS, respectively) to rural hospitals with special Medicare payment provisions.
Provision of Uncompensated Care by Rural Hospitals: A Preliminary Look at Medicare Cost Report Worksheet S-10
Policy Brief
Date: 08/2013
This brief is a preliminary assessment of uncompensated care data quality included in Medicare Cost Report Worksheet S-10 for critical access hospitals and other rural hospitals to identify data quality issue implications for research and policy decisions. Worksheet S-10 data were collected from the Healthcare Cost Reporting Information System.
Profile of Rural Health Clinics: Clinic & Medicare Patient Characteristics
Date: 03/2013
This brief presents a summary of the geographic distribution and clinic-level characteristics of rural health clinics, as well as an overview of the Medicare beneficiaries they served.

2012

Profile of Rural Health Clinics: Medicare Payments & Common Diagnoses: Review of 2009 Medicare Outpatient Claims Data
Date: 12/2012
Using data extracted from 2009 Medicare outpatient provider claims, this brief presents a summary profile of Medicare billing and reimbursement activity for independent and provider-based RHCs.
Flux in Loan Repayment Programs for Healthcare Professionals With States' Budget Cuts and National Health Service Corps Budget Increases
Date: 05/2012
This brief discusses how states' loan repayment programs are weathering economic conditions and competition with the expanding federal National Health Service Corps Loan Repayment Program. It also presents survey results from directors of 96 of the 98 identified state programs addressing changes in workforce size/composition and budget changes.
Why Use Swing Beds? Conversations With Hospital Administrators and Staff (Findings Brief)
Date: 04/2012
In this study, we interview hospital administrators and staff about the use of swing beds. Topics include the role of swing beds in patient care, swing bed volume and financial considerations, swing beds in the context of all community post-acute skilled care, and swing beds as a benefit for community residents.
Communities Served by Rural Medicare Dependent Hospitals
Date: 03/2012
This findings brief explores the potential consequences of termination of the Medicare Dependent Hospitals (MDHs) program by comparing MDHs to rural prospective payment system hospitals in terms of utilization and the characteristics of the communities they serve.

2011

Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals
Date: 12/2011
This analysis estimates the average net cost to Medicare of a SNF swing day by simulating the elimination of all Medicare SNF swing bed days in CAHs in 2009.
Trends in Skilled Nursing Facility and Swing Bed Use in Rural Areas Following the Medicare Modernization Act of 2003 (Findings Brief)
Date: 08/2011
This findings brief looks at whether the availability of post-acute skilled care stabilized and how and where is it being provided today now that the reimbursement policy changes begun in the late 1990s have been fully implemented.
Trends in the Provision of Surgery by Rural Hospitals
Date: 07/2011
This findings brief describes trends in the provision of surgery by rural hospitals.
Recent Changes in Health Insurance Coverage in Rural and Urban Areas
Date: 05/2011
This findings brief compares changes in health insurance coverage for non-elderly Americans in rural areas to changes in urban areas during the recent economic recession.

2010

Rural Hospital Support for Emergency Medical Services (Final Report)
Date: 11/2010
This report shares information on rural hospitals related to these questions: what proportion support/operate emergency medical services (EMS) units; has this changed; what are the characteristics of the hospitals that support/operate EMS; what investments were made in EMS; and what describes the communities where the hospitals are located?
Rural Hospital Support for Emergency Medical Services (Findings Brief)
Date: 11/2010
This study looked at rural hospitals to answer these questions: what proportion support/operate emergency medical services (EMS) units; has this changed; what are the characteristics of the hospitals that support/operate EMS; what financial investments were made in EMS; and what describes the communities where the hospitals are located?
Profitability of Rural Hospitals Paid Under Prospective Payment Compared to Rural Hospitals With Special Medicare Payment Provisions (Findings Brief)
Date: 09/2010
This study compares the profitability of urban/rural hospitals paid under PPS (U-PPS and R-PPS, respectively) to rural hospitals with special Medicare payment provisions between 2007 and 2009.
Rural Volunteer EMS: Reports From the Field (Findings Brief)
Date: 09/2010
This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondents were encouraged to speculate on the future viability of their local service, describe the challenges they face, and what they need to ensure continuance.
A Comparison of Rural Hospitals With Special Medicare Payment Provisions to Urban and Rural Hospitals Paid Under Prospective Payment (Final Report)
Date: 08/2010
This final report compares the financial performance and condition of rural hospitals with special Medicare payment provisions to urban and rural hospitals paid under prospective payment (UPPS and R-PPS hospitals, respectively). Nine ratios from the three most common categories of ratios used in financial statement analysis (profitability, liquidity, and capital structure) as well as four other ratios that are commonly used to evaluate rural hospital financial performance are assessed.
Rural Volunteer EMS: Reports From the Field (Final Report)
Date: 08/2010
This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondents were encouraged to speculate on the future viability of their local service, describe the challenges they face, and what they need to ensure continuance.
Pediatric Care in Rural Hospital Emergency Departments (Final Report)
Date: 05/2010
This report analyzes data from the Emergency Pediatric Services and Equipment Supplement to the National Hospital Ambulatory Medicare Care Survey to compare rural and urban hospitals' responses on various dimensions of pediatric emergency department care.
Pediatric Care in Rural Hospital Emergency Departments (Findings Brief)
Date: 05/2010
This brief analyzes data from the Emergency Pediatric Services and Equipment Supplement to the National Hospital Ambulatory Medical Care Survey. Rural/urban hospitals' responses on pediatric emergency department (ED) care were compared. Rural ED directors also were surveyed to further explore rural pediatric ED care in more detail.
A Financial Comparison of Rural Hospitals With Special Medicare Payment Provisions to Hospitals Paid Under Prospective Payment (Findings Brief)
Date: 04/2010
This brief compares the profitability of hospitals in the four classifications of rural hospitals that can qualify for special payment provisions under Medicare (critical access, Medicare-dependent, and sole community hospitals and rural referral centers) to urban and rural hospitals paid under prospective payment during a recent three-year period.
States' Use of Cost-Based Reimbursement for Medicaid Services at Critical Access Hospitals
Date: 04/2010
This brief documents which states utilize a cost-based reimbursement methodology for Medicaid.
The Effect of Medicare Part D Plan Switching and Formulary Changes on Sole Community Pharmacies and the Patients They Serve
Date: 03/2010
This brief presents findings from a 2008 survey of 401 pharmacist-owners of sole community independent pharmacies.

2009

A Case Study of Rural Health Care in the Economic Downturn
Date: 07/2009
This report describes the economic and healthcare environment in Ashe County, a rural community in the mountains of western North Carolina. The experience in Ashe County exemplifies the healthcare challenges faced in many rural areas across the country.
Characteristics of Rural & Urban Children Who Qualify for Medicaid or CHIP but Are Not Enrolled
Policy Brief
Date: 07/2009
About three-quarters of children who qualify for Medicaid or CHIP are enrolled, with slightly higher rates in rural areas than in urban areas. This leaves one in four qualified children without insurance coverage.
Medicaid & CHIP Participation Among Rural & Urban Children
Policy Brief
Date: 07/2009
This policy brief describes the characteristics of rural and urban children who qualify for Medicaid or CHIP but are uninsured.
Workforce Issues Among Sole Community Pharmacies
Date: 07/2009
This brief explores the shared experiences of sole community pharmacist-owners regarding the challenges facing the pharmacy workforce in their communities and their concerns about their pharmacies' futures.
The Key Role of Sole Community Pharmacists in Their Local Healthcare Delivery Systems
Date: 03/2009
This brief presents findings from a survey of 401 community pharmacists who are the only retail providers in their communities. It documents their extended relationships with other healthcare providers and the additional healthcare services these pharmacists provide to their patients.
Sole Community Pharmacies and Part D Participation: Implications for Rural Residents (Findings Brief)
Date: 02/2009
This findings brief describes the contracting rates of sole rural community pharmacies in 16 states to assess the extent to which each pharmacy contracts with the most commonly used prescription drug plans available in their state.
Medicare Beneficiaries' Access to Pharmacy Services in Small Rural Towns: Implications of Contracting Patterns of Sole Community Pharmacies With Part D Plans
Date: 01/2009
This report describes the contracting patterns of sole rural community pharmacies to assess the extent to which each pharmacy contracts with the most commonly used PDPs available in their state.
A Rural-Urban Comparison of Allied Health Average Hourly Wages
Date: 01/2009
This report uses data from the Bureau of Labor Statistics to describe the extent to which rural-urban differentials exist in wages for 11 allied health professions, focusing on professions that are both likely to be found in rural communities and have adequate data to support hourly wage estimates.

2008

What Does the Allied Health Clinical Doctorate Mean for Rural Areas (Findings Brief)
Date: 12/2008
This findings brief examines how the transition to the doctor of physical therapy degree has affected the supply and quality of rural physical therapy care.
The Trend Toward the Clinical Doctorate in Allied Health: Implications for Rural Communities (Final Report)
Date: 08/2008
This final report examines how the transition to the doctor of physical therapy degree has affected the supply and quality of rural physical therapy care.
Challenges for Rural Emergency Medical Services: Medical Oversight
Date: 05/2008
This findings brief examines the challenges faced by local rural emergency medical services (EMS) agencies in obtaining medical directors and ensuring medical oversight for EMS personnel and also describes how the challenges faced in rural areas differ from those in urban ones.
Issues in Staffing Emergency Medical Services: A National Survey of Local Rural and Urban EMS Directors
Date: 05/2008
This report explores rural-urban differences in medical oversight and the recruitment and retention of emergency medical technicians and paramedics as reported by a survey of 1,425 local emergency medical services directors.
Rural-Urban Differences in Characteristics of Local EMS Agencies
Date: 05/2008
This findings brief describes the general characteristics of local rural emergency medical services agencies and important ways they differ from agencies in urban areas.

2007

One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Findings Brief)
Date: 10/2007
This brief describes the experiences of 51 rural independently-owned pharmacies that are the sole providers of pharmacy services in their communities one year after implementation of the Medicare Part D prescription drug benefit.
State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program
Date: 10/2007
This report explores activities funded by the Medicare Rural Hospital Flexibility Program (Flex Program) to strengthen the rural healthcare infrastructure and discusses which activities were considered most successful by state Flex coordinators.
One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Final Report)
Date: 09/2007
This report describes the experiences of 51 rural, independently owned pharmacies that are the sole providers of pharmacy services in their communities one year after implementation of the Medicare Part D prescription drug benefit.
Rural Hospitals' Experience With the 340B Drug Pricing Program
Policy Brief
Date: 09/2007
This policy brief describes the results of surveys of rural hospitals participating in the 340B drug-pricing program and of rural eligible but non-participating hospitals. It includes information on factors affecting participation in the program and the benefits and challenges of participation.
State Profiles of Medicaid and SCHIP in Rural and Urban Areas
Date: 08/2007
This final report is one component of a larger project that includes the development of web-based State Profiles of Medicaid and SCHIP in Rural and Urban Areas. The report provides national data comparing Medicaid enrollment and expenditures in rural and urban counties.
340B Drug Pricing Program: Results of a Survey of Participating Hospitals
Date: 05/2007
This report presents survey results of pharmacy directors at rural hospitals buying discounted outpatient drugs through the 340B program. The purpose was to understand the perspectives of pharmacy directors on the 340B program, the program's financial impact, and which program features presented barriers to its broader implementation.
Allied Health Job Vacancy Tracking Report
Date: 04/2007
This report quantifies workforce demand for selected allied health professions in North Carolina, tracks job vacancy advertisements in print and online sources, summarizes vacancy advertisements by profession, region, and employer type, and describes the types of sign-on bonuses offered by employers.
State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program (Policy Brief)
Policy Brief
Date: 04/2007
To understand the priorities/accomplishments of state Flex Grant Programs, the Flex Monitoring Team asked Flex coordinators to identify and discuss their states' three most successful initiatives in the last two years. Interviews were conducted with Flex coordinators and State Office of Rural Health staff in 45 states.
Becoming an Emergency Medical Technician: Urban-Rural Differences in Motivation and Job Satisfaction
Date: 03/2007
This study uses cross-sectional data from the 2003 national Longitudinal Emergency Medical Technician Attributes and Demographic Study Project to explore urban-rural differences in why emergency medical technicians enter the field, what is important in their jobs, and whether they are satisfied with their profession.
The Community Impact of Critical Access Hospitals
Date: 02/2007
This policy brief discusses the findings of a project to understand the community involvement and impact of critical access hospitals and the Medicare Rural Hospital Flexibility Program (Flex Program).
340B Drug Pricing Program: Results of a Survey of Eligible but Non-Participating Rural Hospitals
Date: 01/2007
This paper summarizes the results of a 2006 survey of pharmacy directors at rural hospitals that are eligible but currently not participating in the 340B Drug Pricing Program, which enables certain types of safety-net organizations to obtain discounted outpatient medications.
Exploring the Community Impact of Critical Access Hospitals
Date: 01/2007
This paper reports on a series of site visits to six diverse rural communities and critical access hospitals to assess the experiences and impact of these hospitals in responding to their community's health infrastructure needs.
The Experience of Rural Independent Pharmacies With Medicare Part D: Reports From the Field
Journal Article
Date: 2007
Describes first-hand reports from rural pharmacist-owners about their experiences with Medicare Part D plans in the first 7 months of 2006 in order to gain a more thorough understanding of the challenges faced by rural independent pharmacies as a result of program implementation.
Intensive Care in Critical Access Hospitals
Journal Article
Date: 2007
Describes the facilities, equipment, and staffing used by Critical Access Hospitals (CAHs) for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community.
Rural/Urban Differences in Barriers to and Burden of Care for Children With Special Health Care Needs
Journal Article
Date: 2007
Examines the barriers and difficulties experienced by rural families of children with special healthcare needs in caring for their children. Covers rural-urban differences in types of providers used, reasons for unmet healthcare needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care.
Urban-Rural Flows of Physicians
Journal Article
Date: 2007
Reports findings from a study to determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs.
Variations in Financial Performance Among Peer Groups of Critical Access Hospitals
Journal Article
Date: 2007
Reports findings from a study that investigated whether indicators of financial performance and condition systematically vary among peer groups of Critical Access Hospitals (CAHs).

2006

The Experience of Sole Community Rural Independent Pharmacies With Medicare Part D: Reports From the Field
Date: 11/2006
This case study describes firsthand reports from 12 rural independent pharmacists in seven states about their experiences with Medicare Part D plans in the first seven months of 2006.
Impact of Conversion to Critical Access Hospital Status on Hospital Financial Performance and Condition
Policy Brief
Date: 11/2006
This policy brief analyzes financial ratios associated with critical access hospitals' profitability, liquidity, and capital structure.
A Primer on the Occupational Mix Adjustment to the Medicare Hospital Wage Index
Date: 09/2006
This paper focuses on the occupational mix adjustment (OMA) to the labor-related share in the hospital inpatient prospective payment system. The primer explains what the OMA is, why it is needed, and how it has been calculated. In addition, reasons why the effect of the OMA has been less than some rural advocates anticipated are discussed.
The Effect of Rural Hospital Closures on Community Economic Health
Journal Article
Date: 04/2006
This article describes the effect of hospital closures on the local economies based on a study of county-level economic data for 1990-2000 in rural counties experiencing hospital closures.
Emergency Medical Services (EMS) Activities Funded by the Medicare Rural Hospital Flexibility Program
Date: 02/2006
This paper describes the emergency medical services-related activities that the 45 states receiving funding from the Medicare Rural Hospital Flexibility (Flex) Program proposed to conduct in fiscal year 2004-05.
Trends Over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
Date: 02/2006
This findings brief examines trends in the delivery of skilled nursing facility services in both hospital-based units and swing beds during a period of dramatic change in Medicare payments for post-acute care, focusing on critical access hospitals.
Premium Assistance Programs for Low Income Families: How Well Does It Work in Rural Areas?
Date: 01/2006
This paper reports the results of a study on the viability in rural areas of premium assistance programs use Medicaid or State Children's Health Insurance funding to subsidize the premium costs of employer-sponsored insurance or private non-group policies for eligible individuals.
The Effect of Rural Residence On Dental Unmet Need for Children With Special Health Care Needs
Journal Article
Date: 2006
Unmet need for dental care is the most prevalent unmet healthcare need among children with special healthcare needs (CSHCN). The combination of rural residence and special healthcare needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs.
Emergency Medical Services and the Federal Government's Evolving Role: What Rural and Frontier Emergency Medical Services Advocates Should Know
Journal Article
Date: 2006
Examines the debate around recent recommendations for an expanded federal role in supporting Emergency Medical Services (EMS). If federal expansion were to occur, the author recommends that responsibility for EMS be placed in the Department of Health and Human Services.

2005

Contracting With Medicare Advantage Plans: A Brief for Critical Access Hospital Administrators
Policy Brief
Date: 12/2005
This policy brief summarizes the experience of critical access hospital (CAH) administrators with contracts offered by Medicare Advantage (MA) plans. Telephone surveys were conducted with CAH administrators across the country to learn about their experiences with MA plans.
Rural and Urban Parents Report on Access to Health Care for Their Children With Medicaid Managed Care
Date: 12/2005
This study considers rural beneficiaries' perspectives to broaden understanding of whether Medicaid-managed care programs provide acceptable access to healthcare services for children.
Trends in Skilled Nursing and Swing-Bed Use in Rural Areas, 1996-2003
Date: 12/2005
This paper examines trends in the delivery of skilled nursing facility (SNF) services in rural areas during a time of dramatic change in Medicare payments for acute and post-acute care. It focuses on the role of rural hospitals in providing SNF services as they respond to the new reimbursement environment.
The Impact of Medicaid Cuts on Rural Communities
Date: 08/2005
This study assesses the perception of state Medicaid staff and individuals from State Offices of Rural Health (SORH) and Rural Health Associations (RHA) regarding the impact on rural areas of state Medicaid policy changes that occurred between 2002 and 2004.
Financial Indicators for Critical Access Hospitals
Date: 05/2005
The purpose of this study was to develop and disseminate comparative financial indicators specifically for critical access hospitals using Medicare Cost Report data.
Cesarean Section Rates in Rural Hospitals
Date: 03/2005
This findings brief examines childbirth delivery patterns in rural hospitals and compares the C-section rate in rural hospitals to that in urban hospitals using the Nationwide Inpatient Sample.
Community Involvement of Critical Access Hospitals: Results of the 2004 National CAH Survey
Date: 03/2005
This report provides a start for understanding critical access hospital (CAH) community involvement. Data were collected and analyzed from a survey of CAH administrators conducted in 2004. Respondents were asked about community involvement activities, such as community needs assessments and hospital activities supporting special populations.
Intensive Care in Critical Access Hospitals (Working Paper)
Date: 03/2005
This paper describes what officials at critical access hospitals mean when they report that they provide intensive care and the importance of these services to the hospital and the community it serves.
The Effects of Rural Residence and Other Social Vulnerabilities on Subjective Measures of Unmet Need
Journal Article
Date: 2005
Are self-reports of unmet need a biased measure of access to healthcare? We examined the relationship between rural residence and perceived need for physician services and the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs.
How Might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial Viability of Rural Pharmacies? An Analysis of Preimplementation Prescription Volume and Payment Sources in Rural and Urban Areas
Journal Article
Date: 2005
Presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs. urban areas. Together, these data provide a baseline for evaluating how implementation of the Medicare Prescription Drug, Improvement, and Modernization Act may affect the financial viability of rural independent pharmacies.

2004

Reducing Mortality From Motor Vehicle Crashes for Children 0 through 14 Years of Age: Success in New York and North Dakota
Date: 12/2004
This report reviews effective interventions to reduce motor vehicle crash mortality among children. It explores what is happening in New York and North Dakota that contributes to their success in being among the best performing states in regard to this measure of child health.
Cesarean Section Patterns in Rural Hospitals
Date: 11/2004
This paper examines childbirth delivery patterns in rural hospitals and compares the cesarean section rate in rural hospitals to that in urban hospitals.
Definition of Rural in the Context of the MMA Access Standards for Prescription Drug Plans
Date: 09/2004
This study assesses how the definition of rural affects the potential impact of the access standards in the Proposed Rule to implement Title I of the MMA and finds that the congressional objective to achieve convenient access to pharmacies (other than mail order) would be more fully realized if the Proposed Rule definition of rural is changed.
Core Based Statistical Areas and the Medicare Wage Index
Date: 02/2004
This document discusses the potential impact of the 2003 Office of Management and Budget statistical area standards on the hospital wage index and Medicare payments to rural providers. Additionally, three other options for defining labor markets using the 2003 classifications are presented.
Rural-Urban Issues in the Wage Index Adjustment for Prospective Payment in Skilled Nursing Facilities (Brief Report)
Date: 01/2004
Hourly wage data from Medicare-participating nursing homes were used to examine urban/rural patterns in average hourly nursing home wages and wage variation within the statewide rural labor markets defined by CMS. The data were also used to examine the adequacy of the hospital wage index as an adjuster for skilled nursing facility rates.
Comparative Performance Data for Critical Access Hospitals
Journal Article
Date: 2004
Discusses the potential use of comparative performance data for critical access hospitals (CPD-CAH) to facilitate performance and quality improvement. Covers potential benefits and drawbacks of CPD-CH and identifies issues in the development and implementation of CPD-CAH.

2003

Rural-Urban Issues in the Wage Index Adjustment for Prospective Payment in Skilled Nursing Facilities (Full Report)
Date: 11/2003
Hourly wage data collected were used to examine urban/rural patterns in average hourly nursing home wages and pattern variation within the statewide rural labor markets. The data were also used to examine the adequacy of the hospital wage index as an adjuster for skilled nursing facility rates.
Impact of the Medicaid Budgetary Crisis on Rural Communities
Date: 08/2003
This paper provides an overview of the Medicaid program and options states have to reduce program costs. Steps states have proposed or taken to reduce Medicaid costs and the potential impact of these changes on rural areas are discussed. The potential impact on rural communities of federal proposals to redesign Medicaid is assessed.
Classification Change, 1999 to 2003: Office of Management and Budget Metropolitan Areas and Core Based Statistical Areas (CBSAs) Map
Date: 07/2003
This map shows the Office of Management and Budget's June 2003 Core Based Statistical Areas designations for counties that were nonmetropolitan in 1999.
Metropolitan and Micropolitan Core Based Statistical Areas (CBSAs) Map
Date: 07/2003
This map illustrates the June 2003 Office of Management and Budget's metropolitan and micropolitan Core Based Statistical Areas designations by county.
A Primer on Interpreting Hospital Margins
Date: 07/2003
This document explains the most commonly used measures of hospital profitability and how they are used to inform policy changes.
Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States
Date: 03/2003
This findings brief discusses state programs that provide enhanced benefits to Medicaid beneficiaries, such as enhanced primary care case management.
Background Paper: Rural-Urban Differences in Nursing Home and Skilled Nursing Supply
Date: 02/2003
This paper examines characteristics of nursing facilities and the supply of certified skilled nursing beds as the new PPS is being phased in, with particular reference to differences between urban and rural settings.
Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States
Date: 01/2003
This study examines three states that have implemented primary care case management and provides an overview of each program, including their strengths and weaknesses.
Unpredictable Demand and Low-Volume Hospitals
Date: 01/2003
This findings brief assesses the degree to which the annual number of patient discharges varies from year to year for low-volume hospitals.
Unstable Demand and Cost per Case in Low-Volume Hospitals
Date: 01/2003
This findings brief looks at the effects of year-to-year changes in annual inpatient discharges on costs per Medicare discharge.

2002

Arguing for Rural Health in Medicare: A Progressive Rhetoric for Rural America
Date: 09/2002
This paper examines how rural health policy is treated in the broader field of public policy, discusses the role of advocacy in developing rural health policy, and suggests ways to make advocacy more effective.
Rural Populations and Health Care Providers: A Map Book
Date: 09/2002
This book uses 2000 Census data to reassess and provide a picture of where rural people live, how the racial and ethnic nature of rural populations are changing, and whether the distribution of healthcare providers matches the population distribution.
Tracking Medicaid Managed Care in Rural Communities: A Fifty-State Follow-Up
Journal Article
Date: 08/2002
This article updates a 1997 study examining implementation of rural Medicaid-managed care programs.
Impacts of Multiple Race Reporting on Rural Health Policy and Data Analysis
Date: 05/2002
The paper examines some of the impacts to rural health analysis of new federal policy that allows people to choose one or more race categories when classifying themselves.

2001

Fewer Hospitals Close in the 1990s: Rural Hospitals Mirror This Trend
Date: 10/2001
This findings brief summarizes a study of the number and rate of hospital closures in rural areas during the 1990s. It includes graphs and a map.
The Proximity of Rural African American and Hispanic/Latino Communities to Physicians and Hospital Services
Date: 06/2001
This paper assesses how local physician concentrations and distances to hospitals differ for rural communities of varying African-American and Hispanic/Latino compositions.
If Fewer International Medical Graduates Are Allowed in the U.S., Who Might Replace Them in Rural Underserved Areas?
Date: 05/2001
This findings brief describes a study to identify rural communities that would be most affected by a decrease in availability of international medical graduates (IMGs) and perceptions of recruiters on who might replace IMGs in these areas.
Proximity of Rural African-American and Hispanic/Latino Communities to Physicians and Hospital Services
Date: 05/2001
This brief reports the findings of a study of how the African-American and Hispanic/ Latino composition of rural communities relates to local physician concentrations and relates to distances to hospitals offering various levels of services.
If Fewer International Medical Graduates Were Allowed in the U.S., Who Might Replace Them in Rural Areas?
Date: 02/2001
This paper identifies rural communities that would be most affected should restrictions on international medical graduates' (IMGs') entry into the United States be tightened and reports on the perceptions of physician recruiters and health planners about who might replace IMGs currently working in such areas.
PPS Inpatient Payment and the Area Wage Index
Date: 01/2001
This fact sheet discusses how inpatient rates are calculated, the role of the wage index, and issues surrounding the wage index and reimbursement to rural hospitals by Medicare under the Prospective Payment System.
Rural Hospital Wages and the Area Wage Index: 1990-1997
Date: 01/2001
This findings brief examines whether incremental changes to the hospital wage index have made it more equitable across regions and how these changes have impacted rural hospitals.

2000

Rural Hospital Area Wages and the PPS Wage Index: 1900-1997
Date: 10/2000
This paper examines the hospital wage index used by the Health Care Financing Administration and its effects on rural hospitals.
Background on the Wage-Related Portion of the Medicare DRG Payments
Date: 09/2000
This report discusses how to calculate Medicare diagnostic related group (DRG) payments. It includes examples and a diagram of how to calculate a DRG payment.
Race and Place: Urban-Rural Differences in Health for Racial and Ethnic Minorities
Date: 03/2000
This findings brief investigates urban-rural disparities for racial and ethnic minorities in six health areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection, and child and adult immunizations.
At-Risk Hospitals: The Role of CAH Status in Mitigating the Effects of New Prospective Payment Systems Under Medicare
Date: 02/2000
This report examines not-for-profit hospitals that potentially qualify as critical access hospitals and identifies facilities at risk as a result of Medicare's prospective payment systems to non-acute care settings.
Effect of Market Reform on Rural Public Health Departments
Date: 01/2000
This study seeks to determine how rural health departments and the populations they serve have been affected by recent health system changes, especially Medicaid managed care.
Role of CAH Status in Mitigating the Effects of New Prospective Payment Systems Under Medicare
Date: 01/2000
This findings brief examines rural hospitals that potentially qualify as critical access hospitals and identifies facilities at substantial financial risk as a result of Medicare's expansion of prospective payment systems to non-acute settings.