Mark Holmes, PhD

• Current Projects - (5)
• Completed Projects - (25)
• Publications - (19)

Current Projects - (5)

• Alternative Methods for Defining Rural Hospital Service Area Market
  Options for describing the population served by a rural hospital are limited; geopolitical areas such as counties are convenient, but ZIP-based methods may be more accurate. In this project, we will consider multiple options that tradeoff ease, accuracy, ability to capture trends, and availability.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicare
  
• 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)
  
• 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
  
• Long-term Implications of Declining Inpatient Revenue on Bed Surge Capacity and Emergency Preparedness
  Inpatient use and key health care services offered at rural hospitals have declined over the past decade. Has the quest for efficiency in hospitals led to a dangerously low surge capacity and ability to effectively handle public health emergencies?
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicare
  
• 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 - (25)

• A Chartbook of Rural Population Health
  This project created a chartbook of population health for rural areas. This resource was designed to allow policymakers and practitioners to better understand rural-urban disparities across a wide variety of population health indicators.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Public health
  
• 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
  
• Cardiovascular & Cancer Rates for the Rural Delta Region
  This interactive tool can be used to compare county-level rates and incidence of cancer and cardiovascular related health measures for people residing in the lower Mississippi River Delta Region. Users may filter by various health measures and download images and data.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Cancer, Chronic diseases and conditions, Diabetes, Obesity
  
• Change in Service Provision at Rural Hospitals
  The purpose of this study was to compare the services offered by rural hospitals (to urban hospitals) over time (2009-2017) 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
  
• 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)
  
• Comparison of Rural Hospital Closures and the Communities Served, 1990-2020
  This project examined rural hospital closures during three decades to profile community characteristics, health status, health care services, and resources available in communities where rural hospitals have closed.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare
  
• Comprehensive Study of Swing Bed Use in Rural Hospitals
  This project will comprehensively address questions about how swing beds are used by rural hospitals. Questions to be answered include whether decision about use are driven by patient need, community resources, hospital operational concerns or some combination of these factors; the cost implications of swing bed use in critical access hospitals to the Medicare program; and whether patients served in swing beds differ in meaningful ways from those in skilled nursing facilities.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
  
• 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
  
• Do Rural Communities Have a Higher Rate of Avoidable Deaths?
  Based on some estimates, roughly half of deaths were avoidable in the sense they stem from risky behavior. What was less well known was the degree to which there was a rural-urban disparity in this rate.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Cancer
  
• Early Rural Experiences of Changes to Medicaid: Year 1
  In January 2014, some states will expand eligibility through the Medicaid program, while other states will not. Because rural residents are likely to be disproportionately affected by Medicaid expansion, understanding this interstate variation has important policy implications.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Medicaid and CHIP
  
• Exploring Regional Differences in Rural and Urban Mortality Trends
  Explores the differences in U.S. mortality rates by urban and rural location, census division, and urban and rural location within each census division. The gap in nationwide urban-rural mortality is often told as a national story, but the changes are regional. This implies different regions may need different strategies for addressing the gap.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  
• Factors Predicting Swing Bed Versus Skilled Nursing Facility Use
  This project updated our 2014 brief: Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where? In addition to examining health conditions of patients discharged from rural Prospective Payment System hospitals and Critical Access Hospitals to swing beds and skilled nursing facilities, this project also looked to see what has changed over time and whether demographic factors explain differences.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Long-term care, Medicare
  
• Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion
  Making use of the financial indicators developed by project staff, the focus of this project is a longitudinal analysis of the dimensions and indicators of financial performance. Descriptive analyses are used to capture changes in all dimensions of financial performance pre- and post-conversion.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals (CAHs), Healthcare financing, Medicare Prospective Payment System (PPS), Rural Hospital Flexibility Program
  
• How Do Costs for Rural Medicare Beneficiaries Using Swing Beds Compare to Those Using Skilled Nursing Facilities?
  This study estimated and compared total Medicare expenditures for episodes of care that include post-acute stays in either swing beds or skilled nursing facilities (SNFs). Results informed federal and state agencies, rural providers and communities as to how post-acute care in swing bed versus a SNF affects the trajectory of costs and utilization for rural Medicare beneficiaries.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Long-term care, Medicare, Post-acute care
  
• How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals?
  This two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); (3) financial performance; and (4) hospital revenue cycle management. Results will inform federal and state agencies, rural providers and communities as to how implementation of the Patient Protection and Affordable Care Act is impacting reimbursement and financial performance of rural hospitals, allowing the Office of Rural Health Policy to identify emerging challenges and develop strategies or policy changes needed to deal with any unintended consequences.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health reform, Hospitals and clinics, Private health insurance, Uninsured and underinsured
  
• How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals? (Year 2)
  The second year of this two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); and (4) financial performance.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health reform, Healthcare financing, Medicaid and CHIP, Medicare, Private health insurance, Uninsured and underinsured
  
• How Rural Communities Respond and Recover after a Hospital Closure
  Current rates of rural hospital closures are the highest seen in the last few decades. What can we learn from the experiences of communities experiencing hospital closures?
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Workforce
  
• Identifying Limitations of PPS Reimbursement for Rural Hospitals
  This project will investigate the potential financial and access consequences of returning rural hospitals to PPS payment. Characteristics of the hospitals and communities at highest risk of adverse consequences will be identified.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Healthcare financing, 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
  
• Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations
  This study will describe usual patterns of care in rural areas to determine whether rural areas are part of a single service area, or whether smaller communities utilize services from a variety of larger hubs. The results of this analysis will inform a thought piece on how the concepts of bundled payments and Accountable Care Organizations might play out in small rural areas and whether small rural communities can be assigned to a single service area without major disruption of current patterns of care.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Health services
  
• Patterns of Inpatient Care-Seeking by Rural Residents
  This study seeks to gain an understanding of inpatient care-seeking behavior by rural residents to provide insight into drivers of bypass rates, the extent to which a community uses a hospital other than its local rural hospital.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health services, Hospitals and clinics, Medicare
  
• Policy Analysis Using the Financial Distress Model: Does Medicaid Expansion Affect the Risk of Hospital Financial Distress and Closure?
  This study will build on the 2014-15 approved project entitled "Can a Model Predict Financial Distress among Rural Hospitals?" The newly developed model uses current financial performance and market characteristic data to assign rural hospitals to one of four categories of risk of financial distress. The study will use Medicare Cost Report data for 2014, if available. Otherwise, simulation will be used to estimate the effects on financial distress.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicaid and CHIP
  
• Post-Acute Care for Rural Medicare Beneficiaries
  This project described the variation in the volume, mix and financial importance of post-acute services to rural hospitals; identified hospital and community characteristics associated with variation in post-acute services provided by rural hospitals; and determined where rural Medicare beneficiaries receive post-acute services.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Long-term care, Post-acute care
  
• Rural Health Clinics: Medicare & Medicaid Profile (Year 2)
  Year 2 of a project developing a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements. RHC Medicaid data for a sample of states also will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Medicaid and CHIP, Medicare, Rural Health Clinics (RHCs)
  
• Rural Hospital Closure and Effect on Local Economies
  Several research projects have analyzed the health effects of rural hospital closures. However, highly cited evidence on the economic effects of rural hospital closures is more than a decade old. The purpose of this study was to quantify the economic impact rural hospital closures have on communities.
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare
  

Publications - (19)