Rural Health
Research Gateway

Healthcare financing

Completed Projects

Listed by project completion date. You can also view these projects alphabetically.

2024

  • Examining the Potential Impact of Multiple Payment Policies on Rural Versus Urban Home Health Agencies
    This study estimated the impact of three recent and upcoming Medicare home health payment policies (revised rural add-on payments, new prospective payment system, and value-based purchasing demonstration) on reimbursement for home health agencies based on rural-urban status, community factors, and home health agency characteristics.
    Research center: WWAMI Rural Health Research Center
    Topics: Health services, Healthcare access, Healthcare financing, Home health, Medicare, Post-acute care
  • How are Rural Health Clinics Serving Pediatric and Obstetrical Medicaid Populations?
    This project examined the roles of independent and provider-based Rural Health Clinics in serving pediatric and obstetrical patients covered by state Medicaid programs.
    Research center: Maine Rural Health Research Center
    Topics: Children and adolescents, Health services, Healthcare financing, Maternal health, Medicaid and CHIP, Rural Health Clinics (RHCs), Women

2023

  • An Innovative Approach to Targeting Rural Communities in Public Health Funding
    The Centers for Disease Control launched a new initiative to address COVID-19 related health disparities and to advance health equity among underserved and at-risk populations. This effort included state funding to address the needs of rural communities. This project was designed to better understand this initiative and its impact on rural health.
    Research center: Southwest Rural Health Research Center
    Topics: Coronavirus Disease 2019 (COVID-19), Health disparities and health equity, Healthcare financing, Public health
  • Financial Risk Assumption Among Rural Healthcare Providers
    This project assessed rural/urban providers' participation in different payment models and assumption of financial risk in the Medicare Quality Payment Program. We conducted qualitative interviews to examine rural providers' motivations and preparedness for participating in different risk-bearing payment models.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health reform, Healthcare financing, Rural Health Clinics (RHCs)
  • Following the Money: Do Block Grant Resources Reach Rural Communities?
    This project applied a mixed methods design to describe the distribution of block grant resources from federal agencies through states to the local level in rural and non-rural communities in the United States. Findings could guide federal agencies and policy makers to develop strategies to more effectively target block grant resources to ensure that the needs of vulnerable rural populations are addressed.
    Research center: Rural Health Equity Research Center
    Topics: Health services, Healthcare financing, Public health, Rural statistics and demographics
  • Inpatient Treatment Costs Associated with Substance Use Disorders
    The purposes of this project were to examine the costs and characteristics of inpatient stays associated with substance use disorders and to examine whether there are systematic differences in these stays and costs for persons residing in rural areas compared to urban areas.
    Research center: Rural Health Equity Research Center
    Topics: Health disparities and health equity, Healthcare access, Healthcare financing, Mental and behavioral health, Substance use and treatment
  • Rural Health Access: Affordability and Barriers to Care
    Rural-urban comparisons of healthcare access and affordability predate many policy reform efforts aimed at increasing access and decreasing costs—ongoing concerns of rural families. This study used national health survey data to examine rural-urban differences in access to medical care, access to insurance, and affordability of care.
    Research center: Maine Rural Health Research Center
    Topics: Health disparities and health equity, Health reform, Health services, Healthcare access, Healthcare financing, Private health insurance, Public health, Social determinants of health
  • Rural-Urban Differences in Performance of Clinicians Participating in MIPS
    This project used quantitative methods to compare MIPS performance and reported measures for clinicians working in rural and urban areas, overall, and by practice size; evaluated differences in spending per beneficiary, overall, and stratified by drugs and medical services for rural and urban clinicians participating in MIPS; and compared MIPS performance and spending for clinicians serving a large proportion of racial/ethnic minorities in rural and urban areas.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health disparities and health equity, Healthcare financing, Physicians, Quality
  • Rural/Urban Differences in Postpartum Health Insurance, Healthcare Use, and Health Outcomes
    The purpose of this project was to identify rural/urban differences in health insurance, healthcare use, and health outcomes among postpartum individuals, and to describe policy-relevant implications or strategies to improve insurance coverage, receipt of recommended healthcare, and, ultimately, health outcomes among rural residents who give birth. With a lens towards health equity, all analyses were stratified by race/ethnicity and income.
    Research center: University of Minnesota Rural Health Research Center
    Topics: American Indians and Alaska Natives, Health disparities and health equity, Healthcare access, Healthcare financing, Hispanics, Hospitals and clinics, Legislation and regulation, Maternal health, Medicaid and CHIP, Minority health, Private health insurance, Women

2022

  • How Have the Sources of Revenue for Rural Hospitals Changed Since 2005?
    Rural hospitals have seen a steadily decreasing average acute daily census. If outpatient revenue is not expanding to fill that decrease, the decrease in patient revenue could further threaten hospital viability.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare
  • Location and Characteristics of Nursing Homes in the Rural and Urban U.S.
    This project examined rural and urban nursing home availability; assessed the nursing home bed supply relative to the elderly population in rural and urban counties; summarized resident and nursing home characteristics; and analyzed the relationship between the rural location of nursing homes and resident and nursing home characteristics.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Aging, Health services, Healthcare access, Healthcare financing, Long-term care, Medicare
  • 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 disparities and health equity, Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare

2021

  • 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 disparities and health equity, Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare
  • Current and Longer Term Challenges of Rural Hospitals: A Survey of Rural Hospital Executives
    This project involved surveying rural hospital executives about how they will respond to current and long-term challenges related to financial and regulatory burdens.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Health reform, Healthcare financing, Hospitals and clinics, Medicare
  • Estimating the Number of Hospitals that Might Convert to Rural Emergency Hospitals
    This project reviewed the literature to establish what is known about freestanding emergency centers (FECs) and implications for a rural community. The number and types of rural hospitals that would be eligible to convert to an FEC as an alternative to closure of acute inpatient care was estimated.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Health reform, Healthcare access, Healthcare financing, Hospitals and clinics, Medicare
  • Evaluating the Rural Health Network Development Planning Grant Program
    This project identified factors that facilitate and impede success of Rural Health Network Development grantees, based on discussions with grantees from the 2019 cohort and surveys of prior grantees dating back more than 10 years, as well as with technical assistance providers.
    Research center: University of Minnesota Rural Health Research Center
    Topics: Health services, Healthcare access, Healthcare financing, Networking and collaboration, Public health, Quality
  • Rural and Urban Sources of Insurance Coverage: the Role of Public and Private Coverage over Time
    We estimated the percent of rural residents obtaining insurance coverage under each of the major options available to them using multiple data sets and a methodology that accounts for multiple sources of coverage. We compared rural and urban coverage sources and changes in coverage over time.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health reform, Healthcare financing, Uninsured and underinsured

2020

  • 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
  • What Factors Influence Rural Hospitals' Participation in Accountable Care Organizations?
    This project examined rural hospitals' participation in Accountable Care Organizations (ACOs), identified factors that influenced ACO participation, compared whether different factors influenced rural/urban hospital participation in ACOs, and analyzed factors influencing Critical Access Hospitals' participation in the Medicare Shared Savings Program.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Health reform, Healthcare financing, Medicare

2019

  • Cost of Running a Rural Ambulance Service
    This study will address the cost of running ambulance services in rural areas by organizational structure/source of funding, the factors contributing to differences in costs, and factors contributing to differences in financial viability.
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Emergency medical services (EMS) and trauma, Healthcare financing
  • Exploring Global Budgets as a New Reimbursement Model for Low-Volume Critical Access Hospitals
    Given the complexity of the Global Budget reimbursement model, we were interested to learn if there are aspects of the model that could be applied to consolidate reimbursement across rural and frontier health care settings, particularly for CAHs with low-volume (e.g., < 5 acute patients as a daily census).
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Hospitals and clinics
  • Financial Impact of Reimbursing CAH Swing Bed Days at the SNF PPS Rate
    This study assessed the financial impact of changing Critical Access Hospital (CAH) swing bed reimbursement from the cost-based system to the skilled nursing facility (SNF) prospective payment system (PPS).
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Long-term care, Medicare, Post-acute care
  • 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)
  • The Rural MACRA Experience
    The Rural MACRA Experience project studied rural effects of the new Medicare Quality Payment Program (QPP) implementation and operation. Rural QPP effects included provider eligibility, program preparation and data collection challenges, data analysis bias, and differential fiscal impact.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Healthcare financing, Medicare, Physicians

2017

  • Characteristics of Rural Hospitals at High Risk of Financial Distress
    Updates the Financial Distress Index Model with current hospital and market data. Evaluates changes in risk status and geographic distribution over time. Conducts an in-depth analysis of high risk hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics

2016

  • 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
  • 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

2015

  • 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
  • What Does it Cost to Operate a Rural Free-Standing Emergency Department (RFED)?
    In recent months, there have been numerous media reports of rural hospital closures and the adverse effect on communities. In the face of hospital closure, one alternative for maintaining access to healthcare is a rural free-standing emergency department (RFED).
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Medicare

2014

  • Rural Hospital Mergers and Acquisitions - Who is Being Acquired and What Happens Afterwards?
    This study compares the financial and market characteristics of recently acquired rural hospitals to other rural hospitals and investigates the post-acquisition change in services and financial performance of these hospitals. This study will inform rural advocates, federal and state agencies, and regulators as to how mergers and acquisitions (M&amp;As) of small rural hospitals affect access to care for Medicare beneficiaries, and the potential financial consequences of M&amp;As to small rural hospitals.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Healthcare financing, Hospitals and clinics, Medicare

2012

2011

  • Examining Recent Trends and Variation in Ambulatory Care Sensitive Conditions-related Hospital Expenditures of Rural Americans with Different Health Insurance Coverage and Status
    This study documents the national time-trend and regional variation of rural Ambulatory Care Sensitive Conditions (ACSC)-related hospital expenditures by patient insurance coverage/status. The study will also compare the pattern of difference in the ACSC-related expenditures of rural patients with different insurance coverage/status by patient demographic and economic characteristics as well as hospital characteristics.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Chronic diseases and conditions, Health services, Healthcare financing, Private health insurance
  • Rapid Research Response on Health Care Reform Issues
    The focus of the SC Rural Health Research Center is on investigating persistent inequities in health status within the population of the rural US, with an emphasis on inequities stemming from socioeconomic status, race and ethnicity, and access to healthcare services. Building on existing expertise, the SC Rural Health Research Center will create an internal process that allows for rapid turnaround of analysis on race/ethnicity and rural-based health disparity inquiries from policymakers.
    Research center: Rural and Minority Health Research Center
    Topic: Healthcare financing

2010

  • 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
  • Exploring the Black Box: Design and Implementation Issues of P4P for Rural Physicians
    Information about how pay-for-performance (P4P) payment systems work in ambulatory care settings, and in particular, how rural physicians might be affected, is scarce. This study employs qualitative research methods to explore the design and implementation of P4P systems and to investigate effects of P4P on rural physicians in a variety of settings.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Emergency medical services (EMS) and trauma, Healthcare financing, Physicians
  • Health Reform-Rapid Response
    This project will include several projects as requested by ORHP and DHHS as those agencies prepare for national health reform. Responses are primarily in the areas of health insurance and behavioral health.
    Research center: Maine Rural Health Research Center
    Topics: Health services, Healthcare financing, Mental and behavioral health
  • Outpatient Payment Policy Under Medicare: Recent Policy Developments from the Rural Perspective
    This study was designed to examine outpatient payment options for rural hospitals, the advantages and disadvantages of each, and their potential impact on hospital revenue and rural access to health services.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Healthcare financing, Hospitals and clinics
  • Volunteerism in Rural EMS
    Semi-structured telephone interviews will be used to examine issues facing rural emergency medical services (EMS) that have converted or are considering converting from volunteer services to paid services. Respondents will be queried regarding their conversion or consideration of conversion and the effect on their ability to recruit and retain personnel, their relationship with other agencies such as fire departments and hospitals, and the overall availability of EMS.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Emergency medical services (EMS) and trauma, Healthcare financing, Workforce

2009

  • Critical Access Hospital Readiness for CMS Value-Based Purchasing
    The purpose of this project will be to assess Critical Access Hospital readiness for participation in a Value-based Purchasing program similar to that proposed by CMS for Prospective Payment System hospitals.
    Research center: Upper Midwest Rural Health Research Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Quality
  • Impact of Expansion of Ambulatory Surgery Centers on Rural Hospitals and Communities
    This project will examine the extent of freestanding ambulatory surgery center (ASC) expansion into rural communities between 1998 and 2005, the market factors driving that expansion, and the impact of ASCs on the operational and financial viability of rural hospitals located in the same communities.
    Research center: Upper Midwest Rural Health Research Center
    Topics: Health services, Healthcare financing

2008

  • Assessment of the Mental Health Funding Marketplace in Rural vs. Urban Settings
    This study will use nationally representative data to assess how mental health (MH) services are paid for in rural areas and determine differences in payment sources between rural and urban areas. If payment sources significantly vary in rural vs. urban settings, then policies that are aimed specifically at sources of funding may have a differential impact on subsequent access to and utilization of care and point to the need for policies that are specifically targeted to rural communities.
    Research center: WICHE Center for Rural Mental Health Research
    Topics: Healthcare financing, Mental and behavioral health
  • Developing a Financial Performance Measurement System for Critical Access Hospitals
    This project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate bases or methods of peer comparison, investigate the relationship between quality of care and financial performance, and identify characteristics of high performing CAHs.
    Research center: North Carolina Rural Health Research and Policy Analysis Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing
  • Examining the Magnitudes, Geographic Variations, and Determinants Of Expenditures Due to Ambulatory Care Sensitive Conditions in Rural Hospitals
    This project will document the magnitude of and variation in ambulatory care sensitive condition (ACSC) expenditures of rural hospitals and explore the relationships between rural hospital ACSC expenditure and its key determinants in the areas of population demand, health care system supply, and provider practice style.
    Research center: RUPRI Center for Rural Health Policy Analysis
    Topics: Chronic diseases and conditions, Healthcare financing, Hospitals and clinics
  • Financial Impact of Mental Health Services on Rural Individuals and Families
    This project will use the Medical Expenditure Panel Survey (MEPS) to examine the financial burden that rural residents face in seeking mental health services, compared to urban residents. Implications of financial burden for access to needed mental health services for rural residents will be assessed.
    Research center: Maine Rural Health Research Center
    Topics: Healthcare financing, Mental and behavioral health, Private health insurance
  • Financing Rural Public Health Activities in Chronic Disease Prevention and Health Promotion
    This project describes the federal-state funding streams for selected local public health activities in the area of chronic disease prevention and health promotion, and assesses potential barriers to program implementation in less populated, local areas of a state.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Chronic diseases and conditions, Health promotion and disease prevention, Healthcare financing, Public health
  • Impact of CAH Conversion on Hospital Costs and Mix of Services
    This study examined Medicare Cost Report and claims data for hospitals before and after CAH conversion in order to better understand changes in hospital costs associated with CAH conversion, factors associated with any cost growth, and changes in the mix of services provided by the facility.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Critical Access Hospitals (CAHs), Health services, Healthcare financing
  • Quality and Financial Status of Critical Access Hospitals: A Preliminary Analysis
    The purpose of this project is to continue to investigate the relationship between Critical Access Hospital financial performance and quality of care. The University of Minnesota and the University of North Carolina will jointly develop hypotheses related to the finance-quality link and statistical models suitable for testing hypotheses.
    Research centers: North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Quality, Rural Hospital Flexibility Program

2007

  • Pay-for-Performance and Quality Improvement in Rural Hospitals
    This project will estimate the impact on rural hospitals in the U.S. of a pay-for-performance (PFP) program similar to the CMS-sponsored Premier, Inc. Hospital Quality Incentive Demonstration; synthesize the major factors that will influence the inclusion of rural hospitals in PFP programs; and make recommendations for the design of PFP programs that will appropriately reward rural hospitals for improving quality.
    Research center: Upper Midwest Rural Health Research Center
    Topics: Healthcare financing, Hospitals and clinics, Quality
  • Rapid Response: Elimination of Bad Debt Payments to Rural PPS Hospitals
    The purpose of this project is to examine: (1) the extent to which elimination of Medicare Bad Debt payments will reduce reimbursement to rural prospective payment system (PPS) hospitals and (2) how rural hospitals would respond to this reduction in reimbursement.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Healthcare financing, Hospitals and clinics, Medicare Prospective Payment System (PPS)

2006

  • Analyzing the Relationship Among Critical Access Hospital Financial Status, Organizational Linkages, and Scope of Services
    This project will systematically analyze the relationships among pre- and post-conversion Critical Access Hospital (CAH) financial performance, the organizational linkages in which the hospital participates (e.g., health care systems and/or networks), and the scope of services (i.e., the number and type of services) provided.
    Research center: University of Minnesota Rural Health Research Center
    Topics: Critical Access Hospitals (CAHs), Health services, Healthcare financing, Networking and collaboration
  • 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
  • Identifying Stakeholders to Pay for Enhanced Depression Treatment in Rural Populations
    The goal of this project is to identify stakeholders who economically benefit when rural patients receive enhanced depression treatment, which will, in turn, encourage health plans to provide enhanced depression treatment to their rural enrollees without raising premiums.
    Research center: WICHE Center for Rural Mental Health Research
    Topics: Healthcare financing, Mental and behavioral health

2005

2004

  • Evaluating the Financial Impact of Critical Access Hospital Conversion Over Time
    Using Medicare cost report data, this project will analyze changes in several key financial and organizational indicators that may be affected by CAH conversion, and produce annual reports describing the financial status of CAHs.
    Research center: University of Minnesota Rural Health Research Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Rural Hospital Flexibility Program
  • Options for Structuring Disproportionate Share (DSH) Payments to Account for Uncompensated Care: Impact on Rural Hospitals
    This study will identify options for development of an equitable DSH payment adjustment that accounts for hospital uncompensated care costs and determine the financial impact of each of these proposals on rural hospitals, using simulations with data from Washington, West Virginia, Texas, and Iowa.
    Research center: NORC Walsh Center for Rural Health Analysis
    Topics: Healthcare financing, Hospitals and clinics

2003

2002

2001