Rural Health
Research Gateway

Keith J. Mueller, PhD

Director, RUPRI Center for Rural Health Policy Analysis

Phone: 319.384.3832
Email: keith-mueller@uiowa.edu

Health Management and Policy
University of Iowa
145 N. Riverside Drive
Iowa City, IA 52242

Current Projects - (6)

  • Causal Effect of Nursing Home Closure on Resident Outcomes in Rural Areas
    We will evaluate the causal impact of nursing home closure on two key outcomes: distance to the transitioned nursing home, and resident physical and mental health outcomes. We will compare the effect of closures on outcomes for rural and urban areas using resident-level data from 2010-2019 and advanced difference-in-differences regression methods.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Aging, Health services, Healthcare access, Long-term care, Post-acute care, Quality
  • Retention and Expansion of Hospital Services Offered by Rural Hospitals After Enrollment in 340B
    The 340B Federal program is designed to provide hospitals with financial stability through provision of drug discounts which may, in turn, allow hospitals to maintain or expand their service line offerings. Using a series of event study analyses over an 11-year period, this study will examine the impact of enrollment in the 340B program on discontinuing services, maintaining services, and adding new services in eligible rural hospitals.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Health services, Hospitals and clinics, Pharmacy and prescription drugs
  • RHCs and CAHs Participating in SSP: Characteristics of the Providers and Communities
    This project describes characteristics of Rural Health Clinics (RHCs) and Critical Access Hospitals (CAHs) participating in the Medicare Shared Savings Program (SSP), and the communities they serve. Comparisons will be made to RHCs and CAHs not participating in the SSP.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Medicare, Rural Health Clinics (RHCs)
  • Rural Implications of Increased Medicare Beneficiary Enrollment in ACOs and MA Plans
    This project will leverage Centers for Medicare & Medicaid Services data showing the number of Medicare beneficiaries assigned to Accountable Care Organizations, in combination with enrollment in Medicare Advantage in rural counties, to describe implications for rural health care organizations.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health reform, Healthcare financing, Medicare, Medicare Advantage (MA)
  • Rural-based Accountable Care Organizations Accepting Downside Risk
    The RUPRI Center will update its studies of rural provider participation in accountable care organizations, including differences between those who exit the program, those who remain, and those who enter. In particular, this project will address participation decisions made after a rule change in July 2019 that requires conversion to two-sided risk.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), Health reform, Hospitals and clinics, Legislation and regulation, Medicare
  • Rural-Urban Differences in Medicare Advantage Plan Quality Scores
    This project updates previous RUPRI Center publications focused on rural-urban differences in access to, and enrollment in, Medicare Advantage plans with four- and five-star quality ratings.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Healthcare financing, Medicare, Medicare Advantage (MA)

Completed Projects - (43)

  • Access to Services Across a Continuum of Care for Rural Beneficiaries
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Health services
  • After Hospital Closure: Pursuing High Performance Rural Health Systems without Inpatient Care
    This paper describes opportunities for rural communities to develop a high performance rural health system after hospital closure, including three case studies that describe real-world transitions from centering on inpatient hospital-based care to new models of care delivery in rural places.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Hospitals and clinics, Quality
  • Analysis of the Effects of Federal Debt Reduction and Long Term Budget Adjustment on Rural Health Care Delivery
    The RUPRI Center for Rural Health Policy Analysis will examine suggested changes in Medicare and Medicaid as stated in proposals to reduce spending as part of achieving deficit reduction.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Medicaid and CHIP, Medicare
  • Analysis Related to Health Care Reform Issues
    The RUPRI Center is prepared to provide analysis of elements and/or effects of proposed or enacted health reform legislation and/or regulations to implement changes mandated by legislation.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Healthcare financing
  • Analyzing the Variation in the Performance of Accountable Care Organizations Serving Rural Medicare Beneficiaries
    The goals of this project are to characterize ACOs that operate in rural areas, describe the models being used to organize those ACOs, and to test relationships of those characteristics to performance measures related to financial success and quality. The study will identify potential changes in legislative and regulatory policies that could strengthen the utility of the ACO model to achieve high performing rural healthcare delivery organizations.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Healthcare financing, Legislation and regulation, Medicare, Quality
  • Assessing Rural Implications of Changes in Insurance Markets
    The goal of this project is to understand and predict changes in the insurance market in which rural people will participate and how state and national policies might influence activity in that market. The specific objectives of the project are to analyze state policies designing and implementing health insurance exchanges and to model the behavior of health insurance plans as regards entering and exiting rural markets.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Private health insurance
  • Assessing the Community Impact of the MMA
    This project will measure the community-level impacts of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and will provide feedback to policymakers regarding the impact of the MMA on its policy targets (providers and beneficiaries), in the context of rural places.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Legislation and regulation, Medicare, Medicare Part D
  • Assessing the Impact of Medicaid Policy Changes
    Goals of this project included: 1) clearly articulating the rural considerations in Medicare reform by synthesizing information on the impact of Medicare on rural people, places, and providers; 2) assessing the impact of specific proposals to reform Medicare; and 3) analyzing the effects of market-based reform on rural populations, focusing on specific provisions of Medicare reform proposals.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Medicaid and CHIP
  • Assessing the Stability of Rural Pharmacy Services
    This project's goals include deepening our understanding of economic forces beyond the immediate control of local pharmacies that are affecting their ability to remain in business, assessing the future of sole community retail pharmacies in rural places, and exploring alternative modalities for delivering pharmacy services in the absence of retail pharmacy businesses.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Pharmacy and prescription drugs, Telehealth
  • Assessment of Small Rural Hospital Activities to Report Medication Errors
    This research will determine how small rural hospitals have responded to the environmental pressure to improve patient safety and quality by implementing safe medication practices and by reporting and monitoring medication errors.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Hospitals and clinics, Pharmacy and prescription drugs, Quality
  • Changes in Hospital Services Offered After Mergers, Acquisition and Affiliations
    Hospitals have affiliated with systems in increasing numbers since 2007, as of 2016 reaching 56.1 percent of nonmetropolitan prospective payment system hospitals and 42.8 percent of critical access hospitals. This project examined resulting changes in services offered by rural hospitals, hypothesizing shifts of some services to regional hospitals and growth in some service lines.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Hospitals and clinics, Networking and collaboration
  • Changing the Medicare Program According to the Principles of Managed Competition
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Medicare
  • Characteristics of Low-volume Communities
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Healthcare financing, Legislation and regulation, Medicare
  • Comments on Regulatory and Contractor Reform Legislation
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Legislation and regulation, Medicare
  • Continuous Services in the Absence of Retail Pharmacies in Rural Communities
    This project identified communities with and without pharmacies by rurality and described the differences in population and market characteristics of communities with and without any pharmacies. Research findings regarding "pharmacy deserts" informed alternative methods of securing services based on community characteristics.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Healthcare access, Medicare Part D, Pharmacy and prescription drugs
  • Developing and Using a Classification Schema to Identify Sentinel Communities in the U.S.
    This project will enable rural researchers to track the effect of current policies on rural communities, anticipate the effect of proposed policies, and demonstrate policy effects that link one sector to another.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Public health, Transportation
  • Engagement of Rural Providers in Accountable Care Organizations (ACOs)
    The RUPRI Center's work assessing the development of ACOs in rural places including updating our data base showing the location of Medicare ACOs and using the data to create maps for each Census Region showing the counties in which Medicare ACOs have assigned beneficiaries.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Care management, Health services
  • Establishing a Fair Payment for Rural Physicians
    This project will analyze differences in physician payment as a function of practice location and simulate policy choices that change the current payment formula.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Physicians, Workforce
  • How Would Health Insurance Exchanges Work in Rural America?
    The passage of the Patient Protection and Affordable Care Act (PPACA) of 2010 has created the potential for states to create Health Insurance Exchanges (HIEs). This project will assess the potential of these plans to meet the needs of rural residents. Empirical work will establish baseline measures of choices available to rural residents and literature reviews will yield prospective analysis of how exchanges could operate to benefit rural residents.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health reform, Private health insurance
  • Impact of Capping Medicare Disproportionate Share Hospital Payments on Rural Hospitals
    Rural hospitals receiving Medicare prospective payment system payment and receiving disproportionate share hospital payments are subject to a 12% cap on those payments. This project provided information on the number and location of rural hospitals subject to this cap and the fiscal impact.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Healthcare financing, Medicare, Medicare Prospective Payment System (PPS)
  • Impact of Changing Medicare Advantage Landscape on Rural Enrollees
    This project will explore three important questions related to Medicare Advantage (MA) plans. What is the impact of recent changes in the MA market on rural Medicare beneficiaries, providers and communities? In particular, how have recent changes in markets and payment policy led to changes in the choices of plans facing beneficiaries, and the quality of those plans (as defined by the coverage offered by the plans)? Finally, what is the likely impact of changes made in Medicare Advantage payment rates passed in the Patient Protection Affordable Care Act of 2010 (PPACA) on rural enrollment in MA plans in 2011 and beyond?
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Advantage (MA)
  • Impact of Payment Policy on Access to Physician Care in Rural America
    Profiles of physician practices will be constructed that specify the percent of payments derived from specific current procedural terminology (CPT) codes, dichotomized into evaluation and management (often considered to define primary care) or procedural. Differences across rural practices and between rural and urban practices will be analyzed, with implications for payment policies intended to reward rural primary care.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Medicare, Physicians
  • Implementation of Health Reform Legislation in Rural America
    The RUPRI Center has developed particular expertise, including the use of simulations, in how changes in public policy that are now part of the Patient Protection and Affordable Care Act (PPACA) affect the rural health care providers and communities. We have published policy briefs and papers related to Medicare Advantage and Part D plans, effects of insurance reform on the percentage of uninsured in rural areas, and effects of changes in physician payment on projected total income of rural primary care physicians. The purpose of this project is to take advantage of RUPRI's capacity for further simulation analysis and empirically based analyses of changes occurring as a result of the PPACA.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Uninsured and underinsured
  • Is Medicare Beneficiary Access to Primary Care Physicians At Risk?
    This project examined the impact of changes in Medicare payment to physicians on access to care for rural beneficiaries.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Physicians
  • J-1 Visa Project
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: International Medical Graduates (IMGs), Workforce
  • Medicare Advantage and Medicare Prescription Drug Plans in Rural Areas
    The rapid growth in Medicare Advantage (MA) plans, as well as evidence that MA plans are being paid significantly more than traditional fee-for-service Medicare, has created the impetus for reform of the MA program, especially reductions in payment to MA plans. This project will continue the RUPRI Center's work in tracking and analyzing the trends in MA plan enrollment in rural areas, including changes in types of plans.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Advantage (MA)
  • Medicare Advantage Plan Growth in Rural America: Opportunities for Beneficiaries?
    County Medicare Advantage enrollment data and plan characteristic data were used to create a model accounting for the availability of plans offering benefits addressing social determinants of health. Analyses compared rural and urban counties, and examined county characteristics to explore potential equitable opportunities for rural beneficiaries because of geography and other factors.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Advantage (MA), Medicare Part D, Social determinants of health, Telehealth, Transportation
  • Medicare Beneficiary Access to Prescription Drugs Under Part D
    This study built on RUPRI Center work describing patterns of enrollment into Medicare Part D plans (including access to zero deductible plans) by using transaction files to analyze how medications are actually acquired and implications for access to local pharmacy services.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Part D
  • Medicare Modernization Act: Reality for Rural Beneficiaries and Providers
    This project will focus on two areas of new activity in Medicare beneficiary participation in Medicare Advantage (MA) plans and prescription drug plans and implementation of the new Part D benefit through private health plans. We will describe enrollment into specific types of MA prescription drug plans and other prescription drug plans, and analyze differences across regions, states, and types of counties. We will also examine the impact of the transfer to Part D coverage on rural dual eligibles and their local pharmacies.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare Advantage (MA), Medicare Part D
  • Medicare Reform: Rural Considerations
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Prospective Payment System (PPS)
  • National Rural Hospital Flexibility Program Tracking Project Dissemination
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Rural Hospital Flexibility Program
  • Nationwide Analysis of New Entrants into Medicare+Choice Demonstrations
    This project will examine the effects of recent changes in the Medicare+Choice program on enrollment in rural areas and on activities of rural-based health plans.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Medicare
  • Patient-Centered Medical Home: A Model for Rural Physician Practices and Communities?
    Rural practices will need to meet the expectations inherent in the patient-centered medical home (PCMH) model or lose any payment advantage that comes with participating as a PCMH. The goal of this project is to assess rural readiness to adopt services seen as part of a PCMH.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Physicians
  • Pharmacy Services in Communities After the Only Local Pharmacy Closes
    This project will investigate patterns of utilization of prescription drug and other health care services in rural communities in the years since the only local pharmacy closed. We will also examine changes in local economies and Medicare spending, trended to include time before closure through as many years possible after closure.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Pharmacy and prescription drugs
  • Quality of Surgical Care services in Critical Access Hospitals (CAHs)
    This project builds on prior work examining rural residents' bypass behavior of their local CAH to hospitals outside their community. Using recently identified inpatient surgical procedures that are commonly performed in CAHs, we will examine and compare outcomes (e.g. post-surgical complication rates, adverse events) of these procedures between CAHs and non-CAHs.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Critical Access Hospitals (CAHs), Hospitals and clinics
  • Rural Community Response to Hospital Closure
    The Rural Community Response to Hospital Closure project will study how rural communities adapt to local hospital closure. Within selected communities, the project will evaluate the impact of hospital closure on multiple community health-related services and characteristics.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Healthcare financing, Hospitals and clinics
  • Rural Inclusion in the Development of Health Insurance Exchanges
    State plans for developing Health Insurance Exchanges (HIEs) will be analyzed to determine likely benefits for rural residents and communities. Three elements of each plan will be described and assessed: strategies to seek out and enroll rural residents eligible for subsidized insurance coverage or categorically eligible for plans offered through exchanges; minimum standards for participating health plans, including access to essential services; and simulations of impact on availability of plans and enrollment of currently uninsured rural residents.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Private health insurance, Uninsured and underinsured
  • Rural Provider Participation in a Statewide Health Information Project
    Nebraska has recently constructed a communication infrastructure that links all the hospitals in the state with broadband, high-speed systems (using T1 lines to the Critical Access Hospitals). That infrastructure is considered to be the backbone for a statewide health information network being designed by a coalition of organizations. The aim of this project is to delineate reasons for rural providers to participate in the coalition by assessing the associated costs and benefits.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health information technology, Hospitals and clinics, Networking and collaboration
  • System Integration and Rural Provider Participation in Accountable Care Organizations (ACOs)
    This project will develop a national descriptive database of both rural providers and larger (often urban) health systems participating in Medicare ACOs and health system networks. Case studies of four ACOs will generate an awareness of decisions being made that affect configuration of services in rural places and provide suggestions for further research with representative samples of ACOs.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Medicare
  • The Availability of Optional Benefits in Medicare Advantage (MA) Plans in Rural and Urban Areas and the Implications for MA Payment Policy
    Enrollment and landscape files containing data regarding Medicare Advantage plan activities by county were used to describe the geographic differences in what is available to beneficiaries in benefit design and total out-of-pocket liability. Findings revealed potential for policy actions to address equity of benefits and cost to beneficiaries.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Medicare Advantage (MA), Medicare Prospective Payment System (PPS)
  • What Does Healthcare Delivery System Reconfiguration Portend for Rural Health?
    The purpose of this project was to understand the dynamic relationships between healthcare system changes and healthcare network configurations that involve rural providers.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topic: Quality
  • What Factors Explain Rural Residents Seeking Care Outside of the Rural Community?
    This project will examine factors that explain rural residents seeking care outside of the rural community.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health services, Hospitals and clinics
  • What Makes Successful Rural Accountable Care Organizations Successful?
    The U.S. Department of Health and Human Services plans to shift at least 50% of traditional Medicare spending into alternative payment models by 2018. Accountable Care Organizations (ACOs) represent a popular model in both the Medicare and Medicaid programs. This study used multiple methods to find what makes a successful ACO.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Medicare, Quality

Publications - (215)

2024

2023

2022

  • The Evolution of Hospital Designations and Payment in the U.S.: Implications for Rural Hospitals
    Report
    RUPRI Center for Rural Health Policy Analysis, RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 12/2022
    Medicare hospital payment policies affecting rural hospitals play a significant role in the financial viability of rural hospitals. This report provides an overview of historic and current Medicare rural hospital payment policies and alternative payment models to understand their impact on rural hospitals and the communities they serve.
  • An Insurance Profile of Rural America: Chartbook
    Chartbook
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2022
    Over the past decade, health insurance coverage has changed in major ways in rural areas with shifts towards public and publicly subsidized coverage among the nonelderly – Medicaid, Marketplace plans – and a shift towards Medicare Advantage among those eligible for Medicare. This chartbook describes these trends in detail.
  • The Impact of Medicare Shared Savings Program Participation on Hospital Financial Performance: An Event-Study Analysis
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2022
    This study evaluated the extent to which Medicare Shared Savings Program participation affected hospital financial outcomes, including patient revenue, operating margin, different revenue source shares, and allowance and discount rate.
  • Health Insurance Marketplaces: Issuer Participation Trends in Non-Metropolitan Places, 2014-22
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 08/2022
    Since the 2014 implementation of Health Insurance Marketplaces (HIMs), considerable changes have been observed in the number of insurance companies offering plans across the United States. This policy brief describes changes in HIM plan issuers over the 2014-2022 period with an emphasis on variation across metropolitan and non-metropolitan places.
  • Medicare Beneficiary Access to Prescription Drugs in Rural Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2022
    Declines in the number of retail pharmacies in rural areas have raised concerns about beneficiary access to prescription medications when their local pharmacy closes. The purpose of this policy brief is to identify the types of pharmacies used by beneficiaries in rural areas with limited or no access to local pharmacies.
  • Rural and Urban Pharmacy Presence – Pharmacy Deserts
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2022
    This policy brief continues the RUPRI Center's ongoing examination of the availability of community pharmacies and their provided services in rural areas of the U.S. The brief also provides a deeper analysis of counties with no retail pharmacies (i.e. pharmacy deserts) based on metropolitan/nonmetropolitan locations.
  • Update on Rural Independently Owned Pharmacy Closures in the United States, 2003-2021
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 08/2022
    Independently owned retail pharmacies in rural areas experienced a higher rate of closure than micropolitan and metropolitan areas. Closures have raised concerns about access to prescription medications as well as pharmacist-provided primary care services, which are often the sole source in rural areas for obtaining health services.
  • Nursing Homes in Rural America: A Chartbook
    Chartbook
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2022
    Closure of nursing homes and hospitals with swing beds in recent years has changed the availability of post-acute and long-term care services in rural areas. This study examines the availability of post-acute and long-term care services as well as characteristics of residents and nursing homes in noncore, micropolitan, and metropolitan counties.
  • Medicare Accountable Care Organization Characteristics Associated With Participation in 2‐Sided Risk
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2022
    This study examined the associations of accountable care organization (ACO) characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program. Small and rural ACOs were found to be less prepared to transition into 2-sided risk tracks than their urban counterparts.
  • Meeting the Behavioral Health Needs of Farm Families in Times of Economic Distress
    Policy Brief
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 02/2022
    Economic fluctuations and periods of distress in farming cannot be eliminated, however, their impact on communities and individuals can be mitigated. Strategies for meeting the behavioral health needs of farm families by supporting community-based services, and expanding behavioral health services in rural contexts are highlighted in this work.
  • High-Performing Rural Health System
    Policy Brief
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2022
    This document updates the RUPRI Health Panel's framework, for a high-performing rural health system, originally published in 2011. It offers a revised vision statement and updates the high-performing rural health system pillars (access, affordability, community health, and quality) and describes an underlying base of equity considerations.

2021

  • COVID-19 Cases and Vaccination Rates
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 09/2021
    This data brief examines the relationship between vaccination rates, COVID-19 one-week incidence and metropolitan/nonmetropolitan location. Additional information is provided for Census regions and individual states.
  • Medicare Advantage Enrollment Update 2021
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 09/2021
    The RUPRI Center's annual update on Medicare Advantage (MA) shows that both metropolitan and nonmetropolitan enrollment has continued to grow for more than 10 years. However, between 2020 and 2021 the rate of growth in nonmetropolitan counties was more than twice as large as that in metropolitan counties.
  • Confirmed COVID-19 Cases, Metropolitan and Nonmetropolitan Counties
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 08/2021
    This data brief shows the spread of COVID-19 confirmed cases across the U.S., highlighting metropolitan and nonmetropolitan counties with confirmed cases of, and deaths from, COVID-19.
  • County-Level 14-Day COVID-19 Case Trajectories
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 08/2021
    Many locations in the U.S. are relaxing their community-level COVID-19 mitigation measures. But one of the key "gating" indicators for doing this is a downward trajectory of new cases during a 14-day period. The rural data brief examines county-level 14-day trajectories for new confirmed COVID-19 cases.
  • COVID-19 Cases and Deaths, Metropolitan and Nonmetropolitan Counties Over Time (Update)
    Report
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 08/2021
    This data brief compares seven-day moving average COVID-19 incidence and mortality rates between metropolitan, micropolitan, and noncore counties in the U.S. The brief is updated twice a month.
  • Medicare Advantage Enrollment Update 2020
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 05/2021
    This annual update on Medicare Advantage (MA) shows that both metropolitan and nonmetropolitan enrollment has continued to grow for more than 10 years. The percent of nonmetropolitan MA enrollees in Health Maintenance Organization (HMO) plans has increased every year since 2017. Metropolitan HMO enrollment has decreased every year since 2016.
  • Geographic Expansion of Medicaid Managed Care Organizations: Assessing Access to Primary Care in Nonmetropolitan Counties
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2021
    This brief evaluates the degree to which Medicaid beneficiaries in nonmetropolitan counties that were newly served by managed care organizations in 2012-2018 are able to access primary care, as determined by travel time. The study also examined the association between their primary care access and the strength of network adequacy state policies.
  • Sources of Insurance Coverage in Nonmetropolitan Areas: The Role of Public and Private Insurance Since 2009
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2021
    This brief uses 2009-13 and 2013-17 American Community Survey five-year estimates to compare types of health insurance coverage for the nonelderly in metropolitan and nonmetropolitan areas. The significant growth in public insurance rates due to Medicaid expansion was larger for those living in nonmetropolitan areas compared to metropolitan areas.
  • Availability of Supplemental Benefits in Medicare Advantage Plans in Rural and Urban Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2021
    This brief identifies differences in Medicare Advantage (MA) plans that include supplemental benefits available to rural and urban enrollees. By better understanding the variation in MA plan offerings across the country, policymakers can take appropriate action to improve the value of plans available in rural regions.
  • High-Functioning Rural Medicare ACOs – A Qualitative Review
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2021
    This brief identifies common success factors among four high-performing rural Medicare Accountable Care Organizations.
  • Pharmacy Vaccination Service Availability in Nonmetropolitan Counties
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 02/2021
    Pharmacies will play a role in administering the COVID-19 vaccination to the general public. But there are many rural locations in the U.S. where pharmacy resources are limited. This rural data brief examines the availability of pharmacies capable of delivering COVID-19 vaccinations in nonmetropolitan areas.
  • Trends in Nursing Home Closures in Metropolitan and Nonmetropolitan Counties in the United States, 2008-2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2021
    Nursing home closures have raised concerns about access to long-term services and supports in rural areas. This study examines trends in closures and characteristics of open and closed nursing homes in metropolitan and nonmetropolitan counties. Furthermore, this study identifies metropolitan and nonmetropolitan counties without any nursing homes.
  • Advancing Population Health in Rural Places: Key Lessons and Policy Opportunities
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2021
    This paper advances policy discussion of population health in rural places, focusing on the role of rural healthcare organizations. Lessons from ongoing programs provide policy considerations. Medicare and Medicaid programs should prioritize staff and infrastructure development, flexibility in covered benefits, and further expansion of telehealth.
  • Characteristics and Challenges of Rural Ambulance Agencies – A Brief Review and Policy Considerations
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2021
    There are 23,272 ambulance agencies in the U.S., and 73% of those agencies report serving rural areas. This paper examines current rural ambulance agency characteristics and challenges and identifies public policy considerations designed to stabilize rural ambulance agencies.

2020

  • Medicare Advantage Enrollment Update 2019
    Policy Brief
    Rapid Response to Requests for Rural Data Analysis
    Date: 10/2020
    The annual update on Medicare Advantage (MA) shows that both metropolitan and nonmetropolitan enrollment has continued to grow for more than 10 years. However, the rate of growth has been higher in nonmetropolitan counties for the past two years. Local Preferred Provider Organization plans account for nearly half of nonmetropolitan MA enrollment.
  • Telepharmacy Rules and Statutes: A 3-Year Update for All 50 States
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis, Rapid Response to Requests for Rural Data Analysis
    Date: 07/2020
    This policy brief analyzed administrative rules and legislative statutes governing each state's pharmacy practice. Key features of telepharmacy regulations were investigated for comparative analysis. Twenty-one states currently authorize retail telepharmacy, but between these states the regulatory activity varies considerably.
  • Access to Medicare Part D Plans: A Comparison of Metropolitan and Nonmetropolitan Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2020
    This policy brief updates previous reports on rural activity in the Medicare Part D program. Comparisons are made across county type, within type of Part D plan (standalone and part of Medicare Advantage plans), and between the types of plans within county classifications.
  • Considerations for Defining Rural Places in Health Policies and Programs
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 05/2020
    Rural definitions in statute and policy are used to direct resources to underserved people. But changes in population behavior and census processes have led to concern about historic methods of defining rural. This paper identifies key questions, reviews rural definitions, and discusses options for reconsidering rural definitions.
  • Metropolitan/Nonmetropolitan COVID-19 Confirmed Cases and General and ICU Beds
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2020
    The spread of COVID-19 across rural areas has fueled concern about the availability of healthcare resources for dealing with the pandemic. This brief looks at a single measure of healthcare resources – hospital beds – and reports of current COVID-19 cases in a single week to assess the impact on rural facilities.
  • Health Care Professional Workforce Composition Before and After Rural Hospital Closure
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2020
    This policy brief examines the composition of the local healthcare workforce before and after rural hospital closure to reveal any associations with discontinuation of inpatient services in rural communities.
  • Rural Hospital Participation in Medicare Accountable Care Organizations
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2020
    This policy brief summarizes national and regional rates of rural hospital participation in Medicare Shared Savings Program Accountable Care Organizations (ACOs) and identifies factors associated with ACO participation.

2019

  • Impact of the Medicare Disproportionate Share Hospital Payment Cap on Urban and Rural Hospitals
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2019
    The Medicare Disproportionate Share Hospital payment adjustment is intended to compensate hospitals serving a disproportionate number of low-income patients. This policy brief describes the number and location of urban and rural hospitals affected by a 12% payment cap established by the Medicare Modernization Act of 2003.
  • Strategic Choice in Developing Telemedicine - Observations From Three Organizations
    Report
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2019
    Advances in technology have made it easier to provide telemedicine services, but the actual value of telemedicine programs for health systems providing those services or for patients has not been firmly established. This paper explores organizational motivations of three large health systems for incorporating telemedicine patient care services.
  • Insurer Participation in Rural Health Insurance Marketplaces: Are Some Markets Intrinsically More Competitive Than Others?
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2019
    We examine insurer participation changes in three health insurance (Federal Employees Health Benefits Program, Medicare Advantage, and Health Insurance Marketplaces) markets over time in rural counties.
  • Medicare Advantage Enrollment Update 2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2019
    This annual report on Medicare Advantage (MA) enrollment shows growth in the program in nonmetropolitan and metropolitan areas. The rate of metro enrollment is higher than in nonmetro areas, but the growth rate in the nonmetropolitan population is higher. There are also significant differences in metro/nonmetro MA enrollment by plan type.
  • Primary Care Clinician Participation in the CMS Quality Payment
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2019
    Approximately 10% of primary care clinicians participate in Advanced Alternative Payment Models (A-APMs) and less than 30% of primary care clinicians participate in the Merit-Based Incentive Payment System. Metropolitan primary care clinicians are more likely to participate in A-APMs than nonmetropolitan primary care clinicians.
  • Comparing Rural and Urban Medicare Advantage Beneficiary Characteristics
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2019
    This brief reports few rural and urban differences in observed demographic characteristics among enrollees in the Medicare Advantage program. Issuers often exclude rural counties from their service areas, but we find no evidence that this is due to such demographics, suggesting that other reasons relating to population size may be more likely.
  • The Market Mechanism and Health Insurance in Rural Places: Lessons Learned From an Economics and Policy Perspective
    Report
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2019
    This paper focuses on unique challenges in health insurance markets facing rural people, providers, and places, identifying their origins in what economists call "market failures," defined narrowly or broadly. We conclude with observations about the current landscape of rural insurance markets and identify issues policy makers should consider.

2018

  • Assessing the Unintended Consequences of Health Policy on Rural Populations and Places
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 12/2018
    This paper explores the unintended consequences of health policy through an analysis of policy actions that have affected, or had the potential to affect, rural people, places, and/or providers in ways counteractive to policy intent.
  • Changes to the Merit-Based Incentive Payment System Pertinent to Small and Rural Practices, 2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2018
    This policy brief highlights key regulatory changes to the Merit-based Incentive Payment System that occurred in 2018. It discusses the implications of these changes with an emphasis on how these changes may affect small and rural practices.
  • The Rural Hospital and Health System Affiliation Landscape – A Brief Review
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2018
    The shift from traditional fee-for-service to value-based payment requires major capital investment. In this paper, we examine rural hospital and health system motivations for affiliation and present a non-exhaustive list of common affiliation structures with representative examples.
  • Trends in Hospital System Affiliation, 2007-2016
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2018
    This policy brief updates a RUPRI Center brief published in 2014 and documents the continued growth in system affiliation by both metropolitan and non-metropolitan hospitals.
  • Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2018
    This brief assesses changes from 2014 to 2018 in average Health Insurance Marketplace plan participation and pre-subsidy premiums in rural and urban places. Insurance carriers reduced participation across both, while the gap between average premiums in expansion and non-expansion states is widening at a similar rate in rural and urban counties.
  • Spread of Medicare Accountable Care Organizations in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2018
    This policy brief describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2016 to 2017. This brief, which includes data through December 2017, follows a similar analysis released in October 2016 that described ACO trends from 2013 to 2015.
  • Insuring Rural America: Health Insurance Challenges and Opportunities
    Policy Brief
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 07/2018
    This brief discusses a series of policy considerations in three main categories: policies related to rural insurance risk, policies related to provider networks, and policies related to rural payment rates and structures.
  • Organizational Attributes Associated With Medicare ACO Quality Performance
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2018
    Peer-reviewed paper evaluating associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance.
  • Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2018
    Rural pharmacies play an important role in health service delivery to rural populations. This RUPRI Center brief updates previous findings on the continued decline in the number of independently owned rural pharmacies since the implementation of Medicare Part D. This brief provides follow-up data on rural pharmacy closures through March 2018.
  • Organizational Attributes With Medicare ACO Quality Performance
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2018
    Cross-sectional and longitudinal analyses of Medicare Shared Savings Program Accountable Care Organizations' (ACOs') quality performance found rural ACOs' score was comparable to those in other categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher post-hospitalization follow-up rates had better performance.
  • Telepharmacy Rules and Statutes: A 50-State Survey (Journal Article)
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2018
    Peer-reviewed paper identifying state-enacted regulations and legislation authorizing use of community telepharmacy initiatives and describing implications for patients in underserved rural communities. Also provides a table listing states that permit telepharmacy, and pilot programs and waivers that enable telepharmacy initiatives.
  • Medicare Accountable Care Organization Growth in Rural America, 2014-2016
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2018
    This RUPRI Center data report describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2014 to 2016. ACOs are the most widespread of the Centers for Medicare & Medicaid Services (CMS) value-based payment programs and demonstrations.
  • Distance and Networks: A Regional Analysis of Health Insurance Marketplaces
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2018
    Using 2015-16 data on 15 Midwestern states, we examine the possibility that geographic distance to care plays a role in insurance issuer participation, premiums, and enrollment success through its effect on network adequacy and assess the moderating role that state-level policies on network adequacy standards and Rating Area design may have.

2017

  • Rural-Urban Enrollment in Part D Prescription Drug Plans: June 2017 Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2017
    As of June 2017, the percentage of rural enrollment in Part D plans, which include stand-alone prescription drug plans (PDPs) and Medicare Advantage with Prescription Drug (MA-PD) plans, lags urban enrollment despite significant growth overall in the number of Medicare beneficiaries with prescription drug coverage through Medicare Part D plans.
  • Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2017
    This policy brief provides information about the potential impact of scheduled changes in Medicaid Disproportionate Share Hospital (DSH) payment on hospitals in 47 states. We expect variation across states, because of differences in state policies allocating DSH payments, as well as geographic variation by census region.
  • Rural Long-Term Services and Supports: A Primer
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 11/2017
    This paper provides policymakers and other interested stakeholders a primer on the fundamentals of the rural LTSS system, rural access to and use of LTSS, and the opportunities and limitations of current federal and state LTSS policy for advancing rural health system transformation toward a high-performing rural health delivery system.
  • Financial Issues Challenging Sustainability of Rural Pharmacies
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2017
    Findings from a survey of rural lone community retail pharmacies about issues perceived as a threat to their sustainability. Reimbursement issues were cited as being most immediate and of highest magnitude.
  • Medicare Advantage Enrollment Update 2017
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2017
    Reports on the percentage of rural Medicare beneficiaries enrolled in Medicare Advantage (MA) plans and other prepaid enrollment plans. Compares national and rural MA enrollment, and variability by state.
  • Rural/Urban Analysis on Individual Insurance Market Topics
    Fact Sheet
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2017
    Some special challenges face the development and sustainability of marketplace plans in rural areas. This data release provides some additional detail on some important topics, with particular importance to rural people, places, and providers.
  • The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2017
    Uses 2007-2010 Medicare data to examine the relationship between Rural Health Clinic (RHC) use and potentially preventable hospitalizations and emergency department (ED) visits. RHC use was associated with an increase in both preventable hospitalizations and ED visits among all Medicare enrollees, regardless of their reason for eligibility.
  • After Hospital Closure: Pursuing High Performance Rural Health Systems Without Inpatient Care
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 06/2017
    A new paper describing opportunities for rural communities to develop a high performance rural health system after hospital closure, including three case studies that describe real-world transitions from hospital-based locus of care to new models of care delivery in rural places.
  • Issues Confronting Rural Pharmacies After a Decade of Medicare Part D
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2017
    This brief reports on a survey of very rural independent pharmacies designed to assess threats to their sustainability. Major, immediate issues included delays in updates to maximum allowable costs (MACS), charges for remuneration fees, competition from mail order pharmacies; and, status as a "non-preferred pharmacy" for Medicare Part D plans.
  • Telepharmacy Rules and Statutes: A 50-State Survey
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2017
    This is summary analysis reviews administrative rules and legislative statutes governing the practice of telepharmacy in all 50 states. Telepharmacy is specifically authorized in 23 states and 16 states have no rules or legislation authorizing telepharmacy. Other states have pilot programs or waivers that would enable telepharmacy.
  • 2016 Rural Enrollment in Health Insurance Marketplaces, by State
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2017
    Cumulative county-level enrollment rates in Health Insurance Marketplaces (HIMs) in metropolitan and non-metropolitan areas of each state, defined as the percentage of "potential market" participants selecting plans, are presented as of March 2016. States are separated by Medicaid expansion status.
  • Changing Rural and Urban Enrollment in State Medicaid Programs
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2017
    Medicaid enrollment growth in 36 states is analyzed by rural and expansion status, pre- and post-Affordable Care Act (ACA). Enrollment growth was larger in expansion states but did take place in most states, with significant state-level variation in both groups. Metropolitan areas generally had higher growth than micropolitan and rural areas.

2016

  • Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2016
    Provides an analysis of the differences in Accountable Care Organization (ACO) performance on the quality measures among the Medicare Shared Saving Program ACOs with varying levels of rural presence. Findings suggest that ACOs with significant rural presence have performed as well as, if not better than, urban ACOs in delivering quality care.
  • Spread of Accountable Care Organizations in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2016
    This brief updates a RUPRI Center analysis of the presence of Medicare Accountable Care Organizations (ACOs) in rural areas of the US in 2013. Using participation data through 2015, the current brief finds that there has been broad growth in the number of places where ACO participating providers can be found, including rural locations.
  • Medicare Advantage Enrollment Update 2016
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2016
    This annual brief examines Medicare Advantage (MA) enrollment data from March 2015 and March 2016. It shows that enrollment in MA and other prepaid plans increased, both nationally and in non-metropolitan areas, but the rate of growth has slowed compared to previous years.
  • Financial Performance of Rural Medicare ACOs
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2016
    Assesses the financial performances of rural accountable care organizations (ACOs) based on different levels of rural presence.
  • Rural Medicare Advantage Market Dynamics and Quality: Historical Context and Current Implications
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2016
    There is significant variation in the quality ratings of MA plans that are available to rural beneficiaries. This brief suggests that policy interventions may be necessary to improve the quality of MA plans in rural areas.
  • Health Insurance Marketplaces: Premium Trends in Rural Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    Total Health Insurance Marketplace premiums have grown disproportionately in rural places in 2016. Urban counties have an average of 4.2 firms, while rural counties average 3.2 firms offering coverage through the HIMs. This causes concern since, at the county level, we find that as the number of firms increases, premiums increase at a slower rate.
  • Medicare Accountable Care Organizations: Beneficiary Assignment Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services Accountable Care Organization regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Understanding ACO beneficiary assignment policies is dire in managing ACO providers and beneficiaries.
  • Variation in Primary Care Service Patterns by Rural-Urban Location
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2016
    Examines primary care physician service patterns by rural-urban location and discusses effect on recruitment strategies for primary care providers in rural communities.
  • Rural Medicare Advantage Plan Payment in 2015
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2016
    Payment to Medicare Advantage (MA) plans was fundamentally altered by the Patient Protection and Affordable Care Act of 2010 (ACA). This brief finds that while plans operating in both rural and urban areas have experienced a reduction in MA payment, the reduction in rural payment overall has been less significant.

2015

  • Medicare Value-Based Payment Reform: Priorities for Transforming Rural Health Systems
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 11/2015
    As Medicare moves to value-based payment, healthcare groups are made more accountable for patient health. But the changes have been concentrated in urban areas. Policies meant to strengthen rural health systems are complicating payment and delivery system reform in rural areas. This study examines ways to include rural areas in the changes.
  • Rural Enrollment in Health Insurance Marketplaces, by State
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2015
    This brief compares cumulative enrollment totals in Health Insurance Marketplaces in metropolitan and non-metropolitan areas by state and the percentages of potential market participants enrolled. Non-metropolitan enrollment rates were higher in several states. The analysis shows how well outreach/enrollment efforts targeting rural areas work.
  • Rural Enrollment in Health Insurance Marketplaces
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2015
    This brief analyzes Health Insurance Marketplace enrollment outcomes for 2015 at rating area/county levels. Enrollment rates are reported by number of firms participating and for multiple geographic categories: population density, census region, and metropolitan status of the county. Rural/urban rates are often similar, but areas of concern exist.
  • Care Coordination in Rural Communities Supporting the High Performance Rural Health System
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 06/2015
    This paper examines care coordination programs and processes that affect rural areas to discover what is happening in rural communities, how various programs and approaches are working, who benefits, and to make policy recommendations that will facilitate care coordination efforts in support of high performance rural health system development.
  • Characteristics of Rural Accountable Care Organizations (ACOs) - A Survey of Medicare ACOs With Rural Presence
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2015
    In this policy brief, we present the findings of a survey of 27 rural accountable care organizations, focusing on characteristics important to their formation and operation.
  • Characteristics of Rural Communities With a Sole, Independently Owned Pharmacy
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2015
    This brief describes the populations of rural communities with single independently owned pharmacies. About 2.7 million people, more than 25% of whom live below the poverty level, live in 663 rural communities with sole independently owned pharmacies. For about 70% of these rural communities, the next closest pharmacy is more than 10 miles away.
  • Health Insurance Marketplaces: Early Findings on Changes in Plan Availability and Premiums in Rural Places, 2014-2015
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2015
    Analysis of national county-level Health Insurance Marketplace (HIM) plan data for 2014 and 2015 shows there is no systematic pattern to rural experiences of HIMs, although some isolated places may be at risk for weak outcomes.
  • Hospital Views of Factors Affecting Telemedicine Use
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2015
    This brief expands upon previous research by examining hospital-based use of telemedicine by determining the type of use by hospitals, whether it be providing services as a hub or receiving services as a spoke, and then identifying factors from the hospitals' perspectives that affect use.
  • A Rural Taxonomy of Population and Health-Resource Characteristics
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2015
    This brief reports the newly developed taxonomy of rural places based on relevant population and health-resource characteristics and discusses how this classification tool can be utilized by policymakers and rural communities.
  • Developmental Strategies and Challenges for Rural Accountable Care Organizations
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2015
    This brief offers insights into the initial strategic decisions and challenges of four accountable care organizations (ACOs) with rural presences. These ACOs were formed as a step toward a value-driven rural delivery system. While several challenges need to be addressed, these insights can inform development of other rural ACOs.
  • Surgical Services in Critical Access Hospitals, 2011
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2015
    This brief describes the types and volume of major surgical services provided in critical access hospitals across four regionally representative states in 2011.
  • 2014: Rural Medicare Advantage Enrollment Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2015
    Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was about 1.95 million, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million in October 2014. Rural and urban enrollment increased despite reductions in payment and the conclusion of the MA bonus payment demonstration at 2014's end.

2014

  • Rural Implications of the Blueprints for State-Based Health Insurance Marketplaces
    Report
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2014
    This report presents various states' approaches to the Health Insurance Marketplace, including service and rating areas, network adequacy requirements, rural consumer outreach, rural representation on the marketplace governing board, certification and oversight of Qualified Health Plans, and design of the Small Business Health Options Program.
  • Geographic Variation in Premiums in Health Insurance Marketplaces
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2014
    This policy brief analyzes the 2014 premiums of health insurance plans available in the new marketplaces created by the Affordable Care Act.
  • The Effect of Medicare Payment Policy Changes on Rural Primary Care Practice Revenue
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2014
    This policy brief describes the impact of recent Medicare payment updates to the Geographic Practice Cost Indices portion of the Medicare Physician Fee Schedule on rural primary care providers' practice revenue from Medicare.
  • Facilitating the Formation of Accountable Care Organizations in Rural Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2014
    This brief shows characteristics contributing to the formation of four accountable care organizations (ACOs) that serve rural Medicare beneficiaries, one each of the four census regions. The findings can help rural providers interested in forming/participating in an ACO assess the status and potential gaps of their core structures and capabilities.
  • Update: Independently Owned Pharmacy Closures in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2014
    This brief examines the closure of independently owned rural pharmacies in the United States from 2003 to 2013 and its effects on rural Americans' access to medications and other pharmacy services. This report is an update to past publications from RUPRI.
  • A Guide to Understanding the Variation in Premiums in Rural Health Insurance Marketplaces
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2014
    This brief provides a framework for assessing variations in the premiums of plans offered in the Health Insurance Marketplaces across geography.
  • Extent of Telehealth Use in Rural and Urban Hospitals
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014
    This brief provides discussion with statistics on the use of telehealth in rural hospitals and the opportunities telehealth can bring to supporting healthcare in rural communities.
  • From Health Care Volume to Health Care Value - Success Strategies for Rural Health Care Providers
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014
    Examines strategies that rural healthcare providers can use to improve healthcare quality for patients.
  • Medicare Accountable Care Organizations: Program Eligibility, Beneficiary Assignment, and Quality Measures
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014
    This brief discusses Medicare Shared Savings Program eligibility, participation requirements, and quality measures relative to accountable care organization formation.
  • The Uninsured: An Analysis by Age, Income, and Geography
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2014
    This brief analyzes the rural/urban uninsured populations by age. Furthermore, we discuss the potential for age differences between rural and urban uninsured populations to drive Health Insurance Marketplace premiums upward, an effect which may be mitigated or compounded by various other factors.
  • 2012 Rural Medicare Advantage Quality Ratings and Bonus Payments
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2014
    This brief analyzes differences in rural Medicare Advantage (MA) quality ratings and payments and suggests reasons why quality ratings vary by geography. Overall, the quality rating of MA plans in rural areas is lower than in urban areas, a result of the availability of, and enrollment in, different types of MA plans.
  • Trends in Hospital Network Participation and System Affiliation, 2007-2012
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 2014
    Network participation and system affiliation are two ways for hospitals to build and/or access necessary capacities to engage in the transformation to an integrated, patient-centered, pay-for-value care delivery model. This brief tracks trends in network participation and system affiliation among U.S. general community hospitals from 2007 to 2012.

2013

2012

  • The Current and Future Role and Impact of Medicaid in Rural Health
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 09/2012
    This report outlines and describes the current Medicaid program and its importance to rural America. It also discusses rural implications of program expansion, including whether and how states choose to implement changes.
  • Stand-Alone Prescription Drug Plans Dominated the Rural Market in 2011
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2012
    This report shows that as of May 2011, 59.1% of rural Medicare beneficiaries were enrolled in Medicare Part D through insurance plans that provide coverage for prescription medications. It also provides further detail, including urban and rural enrollment by type of plan and by state.
  • March 2012: Rural Medicare Advantage Enrollment Update
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2012
    This policy brief presents key findings on rural Medicare Advantage enrollment and on rural Preferred Provider Organization enrollment.
  • Affordable Insurance Exchanges and Enrollment: Meeting Rural Needs
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2012
    This report reviews the principal characteristics of exchanges that will affect how well they meet the needs of rural residents, including the structure, governance, and process for enrollment.

2011

2010

  • Securing High Quality Health Care in Rural America: The Impetus for Change in the Affordable Care Act
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 12/2010
    The Affordable Care Act calls for the development of a National Health Care Quality Strategy and Plan (National Quality Strategy) that will affect healthcare that is delivered to millions of Americans who live in rural areas and thousands of healthcare providers who care for them.
  • September 2010: Rural Medicare Advantage Enrollment Update
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2010
    Rural enrollment in Medicare Advantage (MA) plans grew to nearly 1.5 million enrollees in September 2010 (15% of eligible Medicare beneficiaries), while national MA enrollment grew to more than 11.5 million (25%). Rural Medicare beneficiaries will find fewer options for MA health insurance coverage in 2011.
  • The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A First Look
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 09/2010
    This report summarizes six issue areas of the Affordable Care Act and discusses implications for access to services and improving the health status of rural residents. The issue areas are health insurance coverage; Medicare and Medicaid payment; quality, financing, and delivery system reform; public health; healthcare workforce; and long-term care.
  • Rural Medicare Advantage: Modest Enrollment Growth in 2010
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2010
    Despite a slight drop in enrollment and a dramatic shift in the landscape of the rural Medicare Advantage (MA) market in early 2010, MA plans have experienced modest growth in enrollment in rural areas during the last two quarters of 2010. The majority of the growth is concentrated in preferred provider organization plans.
  • The Patient Protection and Affordable Care Act: A Summary of Provisions Important to Rural Health Care Delivery
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2010
    This paper provides a summary of legislative provisions contained in the Patient Protection and Affordability Act of 2010 (PPACA) that have particular meaning to rural residents and to the delivery of services in rural areas.
  • February 2010: A Dramatic Shift Away From Private Fee-for-Service Plans in Rural Medicare Advantage Enrollment
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2010
    Private fee-for-service (PFFS) enrollment fell in rural areas in early 2010. As a result, Medicare Advantage (MA) enrollment in rural areas fell. Nationwide, enrollment in preferred provider organization and health maintenance organization plans grew, offsetting the decline in PFFS enrollment and contributing to growth in total MA enrollment.
  • December 2009: Rural Medicare Advantage Enrollment Grows 15% in 2009
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2010
    Rural enrollment in Medicare Advantage (MA) and other prepaid plans grew by 15% from December 2008 to December 2009. Preferred provider organization plans drove the increased enrollment in MA plans in rural areas in 2009, while private fee-for-service plans continued to dominate the market with over 50% of enrollment.

2009

  • Rural Primary Care Physician Payment 2006-2009: What a Difference Three Years Doesn't Make
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2009
    The analysis in this brief shows the impact of Medicare's Evaluation and Management (E&M) service valuation adjustment (implemented January 1, 2007) on two prototypical primary care practices—one providing only E&M services and the other providing a mix of procedures and E&M services.
  • A Case Study of Developments in Rural Health in Difficult Economic Times: Leake County, Mississippi
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2009
    The U.S. healthcare crisis is especially strong in rural communities. The experience of Leake County, a rural Mississippi county, embodies these problems.
  • A Case Study of Developments in Rural Health in Difficult Economic Times: Nemaha County, Nebraska
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2009
    The U.S. healthcare crisis is especially strong in rural communities. The experience of Nemaha County, a small county located in southeastern Nebraska, illustrates the reach of these problems into counties that are somewhat stable during times of economic turbulence.
  • A Case Study of Developments in Rural Health in Difficult Economic Times: Walthall County, Mississippi
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2009
    The U.S. healthcare crisis is especially strong in rural communities. The experience of Walthall County, a small county located in southwestern Mississippi, exemplifies these problems.
  • July 2009: Rural Enrollment in Medicare Advantage Continues to Grow
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2009
    Rural enrollment in Medicare Advantage continues to increase, with growth in the last 18 months led by the growth of preferred provider organization (PPO) plans. Despite the growth in PPO plans, private fee-for-service plans continue to dominate enrollment in rural areas and have accounted for much of the program's growth since 2005.
  • May 2009: PPOs Driving Growth in Rural Medicare Advantage Enrollment
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2009
    Rural Medicare Advantage (MA) enrollment had rapid growth in preferred provider organization (PPO) plans and a decline in the growth rate of private fee-for-service (PFFS) plans. MA enrollment has continued to climb, but it has been impacted by the slowed rate of growth in PFFS plans, which cover more than half of MA enrollees in rural areas.
  • April 2009 Rural Enrollment in Medicare Advantage: Growth in PPOs Outpacing Growth in PFFS
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2009
    Private fee-for-service (PFFS) plans dominate enrollment in rural areas and have accounted for much of the program's expansion since 2005. However, from December 2008 through April 2009 enrollment growth of preferred provider organization (PPO) plans, both nationally and in rural areas, was double the enrollment growth of PFFS plans.
  • Loss of Community Pharmacies Since 2006: State Experiences
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2009
    This brief presents the latest data from a continuous monitoring of the status of rural pharmacies by the RUPRI Center. The brief includes a table showing the data by state.
  • Rural Enrollment in Medicare Advantage: Growth Slows in 2008
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2009
    The rate of growth of enrollment in the Medicare Advantage program decreased significantly in 2008, compared to previous years. The growth rate in preferred provider organization plans in rural areas now exceeds that in private fee-for-service plans. This updates earlier findings from analysis of the MA program reported by the RUPRI Center.

2008

2007

2006

  • The Experience of Sole Community Rural Independent Pharmacies With Medicare Part D: Reports From the Field
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    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.
  • Medicare Physician Payment: Impacts of Changes on Rural Physicians
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2006
    This policy brief provides an overview of the effects of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 on physician payment rates in rural areas. The brief discusses the effects of the Medicare incentive payment for providing services in shortage areas and of the bonus for practicing in a physician scarcity area.
  • Elements of Successful Rural Diabetes Management Programs
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2006
    This report shares findings from a study about local innovations implemented by rural chronic disease management programs. Using diabetes as a proxy for all chronic diseases, the authors explored how local innovations overcame challenges of the rural setting to provide effective and efficient disease management.
  • Chronic Disease Management Systems (Registries) in Rural Health Care
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2006
    A Chronic Disease Management System (CDMS) is a tool that helps providers collect and analyze patient information to promote quality care. This study shows that CDMSs are readily available to rural clinics and are being implemented and maintained by clinic staff with minimal expenditures for technology.
  • Medicare Part D: Early Findings on Enrollment and Choices for Rural Beneficiaries
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2006
    This policy brief provides a first snapshot of enrollment in Medicare Part D in rural and urban areas across the United States and outlines the early findings from an analysis of plans available to rural persons under this program.
  • Care Across the Continuum: Access to Health Care Services in Rural America (2006)
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 2006
    The article is divided into 3 sections: 1) basic principles that determine services to be included in the continuum and how success in providing those services is judged; 2) definition of the continuum and its basic stages based on the health systems research literature; 3) applications of the continuum and policy implications of the framework.

2005

2004

2003

2002

2001

2000