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

2024

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 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.
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.
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.

2022

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.
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.
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.
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

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.
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.
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

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.
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.
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.

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.

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.
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

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.
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.
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.

2015

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.
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.
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.

2007

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 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.
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

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

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.

2002

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.