Rural Health
Research Gateway

George H. Pink, PhD

Deputy Director, North Carolina Rural Health Research and Policy Analysis Center

Phone: 919.966.5011
Email: gpink@email.unc.edu

University of North Carolina - Chapel Hill

Current Projects - (6)

  • Did Hospitals That Converted to Rural Emergency Hospital (REH) Avoid Closure?
    The goal of the Rural Emergency Hospital (REH) is to preserve access to essential services for rural residents, and to decrease the likelihood of hospital closures; some worry that the REH offers an option for otherwise financially strong hospitals to shed services. This study will investigate whether hospitals that converted to an REH in 2023 and 2024 would have likely closed in the absence of the REH designation.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare access, Healthcare financing, Hospitals and clinics, Medicare, Rural Emergency Hospitals (REHs)
  • Evaluating the Variation in Rural and Urban Hospital Wages and Wage Index Pre- and Post-COVID-19 Pandemic
    The primary purpose of the wage index is to address the differences in labor costs that hospitals experience based on their geographical location.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare, Workforce
  • Financial Consequences of Growth in the Number of Rural Referral Centers
    Since Centers for Medicare & Medicaid Services amended its regulations to allow hospitals in urban areas to reclassify as rural, over 400 hospitals have obtained status as a Rural Referral Center. This project will estimate the costs to hospital Medicare payment and profitability.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare
  • Medicare Advantage and Financial, Hospital, and Community Characteristics of Rural Hospitals
    This project will compare financial, hospital, and community differences among rural hospitals located in areas with lower versus higher rates of Medicare Advantage penetration.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare, Medicare Advantage (MA)
  • Medicare Disproportionate Share Hospital and Uncompensated Care Payments Since the ACA
    This project will compare disproportionate share hospital payments and uncompensated care payments to rural and urban hospitals for the years 2013-2022.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Medicare, Medicare Prospective Payment System (PPS)
  • Usual Source of Primary Care for Rural Medicare Beneficiaries Before and During COVID-19
    The global pandemic was highly disruptive to existing health care use patterns, potentially affecting rural America more than urban communities. This study will describe the usual sources of primary care (USC) for rural Medicare beneficiaries before and during COVID-19 to provide insight into how COVID-19 affected USC of Medicare beneficiaries.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Federally Qualified Health Centers (FQHCs), Healthcare access, Hospitals and clinics, Medicare, Rural Health Clinics (RHCs)

Completed Projects - (22)

  • A Comparison of 2017-2019 Uncompensated Care of Rural and Urban Hospitals and a First Look at Uncompensated Care in 2020 and 2021
    This project compared 2017-2019 uncompensated care as a percent of operating expense for rural and urban hospitals and investigated uncompensated care data for 2020 and 2021.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare
  • Ambulatory Care Provided to Rural Medicare Beneficiaries by Rural and Urban FQHCs, RHCs, and Acute Hospitals
    This project characterized the volume, cost, and case mix of ambulatory care provided to rural Medicare beneficiaries by rural and urban federally qualified health centers (FQHCs), rural health clinics (RHCs), and acute hospitals. The study included urban-rural and geographic comparisons of volume, cost, and case mix by provider type.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Health services, Hospitals and clinics, Medicare
  • Can a Model Predict Financial Distress Among Rural Hospitals?
    This project will extend an existing model of CAH financial distress to other types of rural hospitals. A valid model would be helpful to ORHP and state Offices of rural Health interested in predicting financial distress or closure of rural hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Hospitals and clinics
  • Changes in Care-Seeking After Rural Hospitals Merge
    This project seeks to understand how mergers affect the inpatient care-seeking of markets served by merging hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare access, Hospitals and clinics
  • Characteristics of Rural Hospitals at High Risk of Financial Distress
    Updates the Financial Distress Index Model with current hospital and market data. Evaluates changes in risk status and geographic distribution over time. Conducts an in-depth analysis of high risk hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics
  • Community and Financial Experience of Medicare Dependent Hospitals in Comparison to Other Rural Hospitals
    This research will investigate the community and financial experience of Medicare Dependent Hospitals (MDHs) in comparison with other rural hospitals. Analysis of the financial experience will include comparison of the long-term profitability of MDHs to other rural hospitals, estimation of the potential profitability consequences of eliminating the payment classification, and estimation of the potential consequences of maintaining the payment classification but failing to update the base year from which costs are trended forward.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
  • Current and Longer Term Challenges of Rural Hospitals: A Survey of Rural Hospital Executives
    This project involved surveying rural hospital executives about how they will respond to current and long-term challenges related to financial and regulatory burdens.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Health reform, Healthcare financing, Hospitals and clinics, Medicare
  • Decline in Inpatient Volume at Rural Hospitals
    The purpose of this study was to compare the decline in inpatient volume of rural hospitals to urban hospitals and among rural hospitals of different size, region, rurality, and payment type.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare access, Hospitals and clinics
  • Developing a Financial Performance Measurement System for Critical Access Hospitals
    This project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate bases or methods of peer comparison, investigate the relationship between quality of care and financial performance, and identify characteristics of high performing CAHs.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing
  • Developing a Post-COVID Financial Distress Index
    This project updated and improved the North Carolina Rural Health Research Program's Financial Distress Index, which uses historical data about hospital financial performance, government reimbursement, organizational characteristics, and market characteristics to predict the current risk of financial distress.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare
  • Estimating the Number of Hospitals that Might Convert to Rural Emergency Hospitals
    This project reviewed the literature to establish what is known about freestanding emergency centers (FECs) and implications for a rural community. The number and types of rural hospitals that would be eligible to convert to an FEC as an alternative to closure of acute inpatient care was estimated.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare
  • Estimation of the Fixed and Variable Costs of a Rural Emergency Hospital
    This project: 1) informed the design of CMS Rural Emergency Hospital (REH) payment methods, particularly the Medicare monthly additional facility payment; 2) estimated patient break-even volumes for the long-run financial sustainability of REHs; and; 3) provided a tool that rural hospitals can use to estimate the cost of operating a REH.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Legislation and regulation, Medicare
  • How Have the Sources of Revenue for Rural Hospitals Changed Since 2005?
    Rural hospitals have seen a steadily decreasing average acute daily census. If outpatient revenue is not expanding to fill that decrease, the decrease in patient revenue could further threaten hospital viability.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare
  • Importance of Surgery to Rural Hospital Financial Condition and Market Share
    This study explores the provision of surgical services in rural hospitals and its relationship to financial performance. The percentage of rural hospitals that offer surgical services and the number that have discontinued surgical services over the last decade will be described, and, for those that have discontinued services, the impact on financial condition will be explored.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topic: Hospitals and clinics
  • Low Volume Hospitals
    This analysis compared rural low-volume hospitals (LVHs) to non-LVH characteristics and estimate the financial impact of eliminating the LVH program and reverting to the original (2005) LVH classification and payment adjustment.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare
  • Rural Hospital Mergers and Acquisitions - Who is Being Acquired and What Happens Afterwards?
    This study compares the financial and market characteristics of recently acquired rural hospitals to other rural hospitals and investigates the post-acquisition change in services and financial performance of these hospitals. This study will inform rural advocates, federal and state agencies, and regulators as to how mergers and acquisitions (M&As) of small rural hospitals affect access to care for Medicare beneficiaries, and the potential financial consequences of M&As to small rural hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare
  • Rural-urban Comparison of Hospital Financial Performance by Medicare Payment Classification
    This project will compare the financial performance of rural and urban short term general hospitals by Medicare payment classifications (PPS only, Medicare dependent hospitals, sole community hospitals, rural referral centers, and critical access hospitals).
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare
  • The Financial and Community Experience of Sole Community Hospitals in Comparison to Other Rural Hospitals
    This research will investigate the financial and community experience of Sole Community Hospitals (SCHs) in comparison with other rural hospitals. The availability of alternative facilities, and the socioeconomic and demographic characteristics of SCH service areas will be compared to other rural hospital service areas.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS), Rural statistics and demographics
  • Three Models of a Rural Emergency Hospital
    This project used secondary data about small rural emergency departments and expert opinion to develop three clinical and operational models of a Rural Emergency Hospital (REH). The REH models were based on case mix, service mix, patient volume, clinical staffing, and technology.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Legislation and regulation, Medicare
  • What Does it Cost to Operate a Rural Free-Standing Emergency Department (RFED)?
    In recent months, there have been numerous media reports of rural hospital closures and the adverse effect on communities. In the face of hospital closure, one alternative for maintaining access to healthcare is a rural free-standing emergency department (RFED).
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Medicare
  • What Happens after Acute Inpatient Care is No Longer Provided by a Rural Hospital?
    This project will investigate the precursors to closure of acute inpatient care by rural hospitals and the post-closure configuration of health care services in the community.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topic: Hospitals and clinics
  • What Would be the Financial Consequence of Eliminating Low Volume Hospital Payments?
    Analysis will include comparison of the long-term profitability of low-volume hospitals to other rural hospitals and estimation of the potential profitability consequences of eliminating the payment classification altogether.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)

Publications - (92)

2024

  • The First Year of Rural Emergency Hospitals: REHs Serve Relatively Disadvantaged Counties
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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

2021

  • 2021 CMS Hospital Quality Star Ratings of Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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?
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • A Comparison of Rural and Urban Specialty Hospitals
    Policy Brief
    Rapid Response to Requests for Rural Data Analysis
    Date: 09/2020
    This brief describes key differences between specialty hospitals located in rural versus urban areas.
  • Urban Hospitals With a High Percentage of Inpatient Days for Rural Patients
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • 2016-18 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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.
  • Rural Hospitals With Long-Term Unprofitability
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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
    North Carolina Rural Health Research and Policy Analysis Center, Rapid Response to Requests for Rural Data Analysis
    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

2018

  • Rural Hospital Mergers From 2005 Through 2016
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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).
  • The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • CMS Hospital Quality Star Rating: For 762 Rural Hospitals, No Stars Is the Problem
    Policy Brief
    Rapid Response to Requests for Rural Data Analysis
    Date: 06/2017
    The purpose of this brief is to look more closely at the characteristics of rural hospitals with and without CMS Hospital Quality Star Ratings to help inform ongoing discussions about the usefulness of the quality star rating for comparing hospital quality and possible ways to improve the star rating initiative.
  • Predicting Financial Distress and Closure in Rural Hospitals
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 06/2017
    Examines the financial distress of rural hospitals to better predict closures within two years.

2016

  • How Would Rural Hospitals Be Affected by Loss of the Affordable Care Act's Medicare Low-Volume Hospital Adjustment?
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • 2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The Rising Rate of Rural Hospital Closures
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.
  • Do Current Medicare Rural Hospital Payment Systems Align With Cost Determinants?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The Effect of Surgery on the Profitability of Rural Hospitals
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    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

  • Rural Hospital Mergers and Acquisitions: Who Is Being Acquired and What Happens Afterward?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2013

  • Change in Profitability and Financial Distress of Critical Access Hospitals From Loss of Cost-Based Reimbursement
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Changes to Critical Access Hospitals' reimbursement, such as a reversion to prospective payment, would have marked negative effects on CAHs. About three quarters of CAHs would operate at a loss. The number of CAHs at high risk for financial distress would nearly triple, and nearly half would be at medium-high to high risk of financial distress.
  • Implications for Beneficiary Travel Time if Financially-Vulnerable Critical Access Hospitals Close
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Changes to Critical Access Hospitals' reimbursement may spur some to close. This analysis considers the communities served by the 93 CAHs with the lowest profitability and therefore most likely to close due to a change in Medicare reimbursement.
  • Rural/Urban Differences in Inpatient Related Costs and Use Among Medicare Beneficiaries
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Medicare beneficiaries who are admitted to rural hospitals tend to have lower outpatient costs than their counterparts at urban hospitals. The differences are due to multiple factors. The analysis suggests that consideration of the total cost of an acute episode of care might be considered, not just the cost of the acute inpatient stay.
  • Geographic Variation in the Profitability of Critical Access Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2012

  • Communities Served by Rural Medicare Dependent Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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

2010

2007

2006

2005

  • Financial Indicators for Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2004

  • Comparative Performance Data for Critical Access Hospitals
    Journal Article
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
    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.