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Title
Rural Hospital Profitability during the Global COVID-19 Pandemic Requires Careful Interpretation

The North Carolina Rural Health Research Program has been tracking rural hospital profitability for more than a decade, as many small rural hospitals struggle with profitability compared to their urban counterparts. The findings brief, Rural Hospital Profitability during the Global COVID-19 Pandemic… Read more »

Findings Brief
2022
Predictors of Hospital Choice among Rural Patients Seeking Elective Surgery: A Scoping Review

Hospital choice for surgery affects both patient outcomes and hospital viability, a greater understanding of rural patients’ surgical care-seeking behavior could enhance rural health and rural hospital financial stability. Specifically, insight on modifiable determinants of care-seeking behavior can… Read more »

Findings Brief
2022
Rural Hospitals that Closed between 2017‐20: Profitability and Liquidity in the Year Before Closure

In a 2017 article, we presented the Financial Distress Index (FDI). The FDI is an algorithm that uses historical data about hospital financial performance, government reimbursement, organizational characteristics, and market characteristics to predict the current risk of financial distress. The mode… Read more »

Findings Brief
2022
Since 1990, Rural Hospital Closures Have Increasingly Occurred in Counties that Are More Urbanized, Diverse, and Economically Unequal

The NC Rural Health Research Program tracks and studies rural hospital closures. Our most recent brief,  Since 1990, Rural Hospital Closures Have Increasingly Occurred in Counties that Are More Urbanized, Diverse, and Economically Unequal, describes the socio‐economic, demographic, and health system… Read more »

Findings Brief
2022
How Many Hospitals Might Convert to a Rural Emergency Hospital (REH)?

  The Consolidated Appropriations Act of 2021 establishes a Rural Emergency Hospital (REH) designation under the Medicare program. It is difficult to predict rural hospital interest in conversion to REH because conditions of participation through rulemaking and guidance have yet to be establish… Read more »

Findings Brief
2021
Current and Longer Term Challenges of Rural Hospitals: A Survey of Rural Hospital Executives

About this project Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded: September 2018 Project completed: February 2021 Rural hospitals are being adversely affected by short-term and long-term challenges related to financial and regulatory burdens such as sequestration, 34… Read more »

2021
Hospital Readmission Following Care in a Swing Bed

About this project Lead researcher: Mark Holmes, PhD Project funded: September 2012 Project completed: July 2021 Preventable hospital readmissions are a significant problem for patients and insurers. Swing beds are the only post-acute care in many very rural communities but research on the ability o… Read more »

2021
The Effect of Medicare Payment Standardization Methods on the Perceived Cost of Post-Acute Swing Bed Care in Critical Access Hospitals

The Centers for Medicare & Medicaid (CMS) use standardized payments to compare Medicare resource use across locations and settings. Currently, CMS uses different payment systems to reimburse post-acute care provided in CAH swing beds versus inpatient prospective payment system (IPPS) hospital sw… Read more »

Findings Brief
2021
Analysis of Options for Criteria to Determine Underservice

About this project Lead researcher: Thomas C. Ricketts, PhD Project completed: December 2002 This project extends existing work on the analysis of options for criteria to determine underservice. The research will: Complete additional analyses of options for revisions to the criteria for designation… Read more »

2021
Medicaid Managed Care in Rural Areas: Innovative Case Management Strategies

About this project Lead researcher: Pam Silberman, JD, DrPH, 919.966.4525 , Project completed: January 2003 Continuing the work on tracking and assessing the extent of Medicaid-managed care in rural areas, the project will focus on states with innovative case management strategies and look specifica… Read more »

2021
Labor Costs and the Area Wage Index in Skilled Nursing Facilities

About this project Lead researcher: Kathleen Dalton, PhD Project completed: February 2003 This project will examine regional patterns in Skilled Nursing Facility (SNF) hourly wages, using data from Fiscal Year 1997 cost reports for all freestanding and hospital-based facilities. We will analyze wage… Read more »

2021
Information Technology Engineering Support for Health Resources and Services Administration Data Systems/Geospatial Data Warehouse, GIS Technologies, GEMS Support and General Office of Information Technology Systems Support

About this project Lead researcher: Thomas C. Ricketts, PhD Project completed: October 2003 This project will develop or update a comprehensive national data set that describes the supply and distribution of primary care professionals in the United States and related need factors for use by the Heal… Read more »

2021
Changes in Provision of Selected Services by Rural and Urban Hospitals between 2009 and 2017

During the past decade, access to health care services provided by rural hospitals has changed in two major ways. First, there has been a substantial increase in the number of rural hospitals that have completely closed or converted (provide some health care services, but not inpatient care). Second… Read more »

Findings Brief
2021
Factors Contributing to Unit Cost Instability in the Low-Volume Hospital

About this project This project will study year-to-year variation in Medicare inpatient costs within rural hospitals, with a special focus on factors affecting unit costs in low-volume providers. Lead researcher: Kathleen Dalton, PhD Project completed: January 2003 We propose to analyze panel data c… Read more »

2021
Unmet Needs for Health Care Services: An Analysis of Children with Special Health Care Needs in Rural Areas

About this project Parental report of having an unmet need for care is frequently used as a measure of poor access to medical services; however, this unvalidated measure is usually dependent on parental perceptions of the need for care. Lead researcher: Rebecca T. Slifkin, PhD Project completed: Aug… Read more »

2021
Rural Hospital Closures, 1990-2000: Community Profiles and Economic Indicators Before and After the Event

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: December 2004 This study investigated the economic impact of hospital closures in non- metropolitan counties, taking into account the economic characteristics and employment trends that may have preceded the event. Betwee… Read more »

2021
Arguing for Rural Health: Justice and Fairness in Advocating for Rural Health Policy

About this project Lead researcher: Thomas C. Ricketts, PhD Project completed: June 2002 The development of policy for rural health care in the United States has occurred in a reactive manner. Within rural health advocacy, there little attention has been paid to the structure of the arguments that a… Read more »

2021
Analysis of Options for Revisions to the Criteria for Designation for Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs)

About this project Lead researcher: Laurie Goldsmith, MSc Project completed: April 2002 This project has several activities related to the development of new indices of underserviced for rural areas: Apply the existing Medically Underserved Areas/Populations (MUA/P) and Health Professional Shortage… Read more »

2021
National Rural Hospital Flexibility Program Review

About this project Lead researcher: Melissa A. Fruhbeis, MSPH Project completed: August 2003 The North Carolina Rural Health Research and Policy Analysis Center and the UNC Department of Health Policy and Administration are collaborating with the other rural health research and policy analysis cente… Read more »

2021
Rural Hospital Wages and the Prospective Payment System Wage Index: 1990-1997

About this project Lead researcher: Kathleen Dalton, PhD Project completed: January 2001 The hospital wage index is used by HCFA to adjust hospital DRG payments for regional variation in the cost of labor. There has been concern among rural policy analysts that the index is biased against rural mark… Read more »

2021
Background Paper on Skilled Nursing Facilities in Rural Areas

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: January 2002 This study will synthesize existing literature on skilled nursing facilities (SNFs) and present an overview of the issues and legislation relevant to SNFs in rural areas. The general characteristics of SNFs (… Read more »

2021
Creating a Culture of Health in Appalachia: Disparities and Bright Spots

“Creating a Culture of Health in Appalachia: Disparities and Bright Spots” is an innovative research initiative that aims to identify factors that support a culture of health in Appalachian communities. This multi-part health research project will produce a series of reports. The first report  measu… Read more »

2021
Impacts of Multiple Race Reporting

About this project Lead researcher: Randy Randolph, MRP, 919.966.7113, randy_randolph@unc.edu Project completed: August 2001 This project will investigate the following questions regarding the 1997 revisions to Statistical Policy Directive No. 15, Race and Ethnic Standards for Federal Statistics and… Read more »

2021
Describing the Health Care Infrastructure in Rural Towns

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: February 2001 The goal of this project is to incorporate information from multiple data sources in order to describe more fully the health care infrastructure in rural towns. Provider data, used to place providers within… Read more »

2021
Tracking the Implementation of Medicaid Managed Care in Rural Areas

About this project Research staff: Rebecca T. Slifkin, PhD Project completed: August 2002 More than half of all Medicaid recipients are enrolled in some form of managed care, but participation in rural areas remains behind that of urban areas. In 1997, the North Carolina Rural Health Research Progra… Read more »

2021
Policy Analysis Using the Financial Distress Model: Does Medicaid Expansion Affect the Risk of Hospital Financial Distress and Closure?

About this project Lead researcher: Mark Holmes, PhD Project funded: September 2015 Project completed: August 2016 The NC RHRC has recently developed a model to predict financial distress in rural hospitals. This study will demonstrate the use of this model to analyze policies affecting rural hospit… Read more »

2021
Rural Health Clinics: Medicare & Medicaid Profile

About this project Contact: Andrea Radford, DrPH Project funded: September 2012 Project completed: August 2015 Rural health clinics are a critical element of the rural healthcare system with approximately 3800 located throughout the United States, but due to limited reporting requirements relatively… Read more »

2021
Comprehensive Study of Swing Bed Use in Rural Hospitals

About this project Lead researcher: Mark Holmes, PhD Project funded:September 2010 Project completed:February 2014 Under the Medicare program, rural hospitals with 100 or fewer licensed routine care beds are eligible to participate in the swing bed program, meaning that a bed can be used for either… Read more »

2021
Use of Rural Health Clinics by Medicare Beneficiaries

About this project Contact: Andrea Radford, DrPH Project funded: September 2011 Project completed: April 2013 With approximately 3800 located across the nation, RHCs are an important component of the rural health infrastructure. Using Medicare outpatient claims data the degree to which Medicare bene… Read more »

2021
Evaluation of the Rural Hospital Flexibility Act and the Critical Access Hospital Program

About this project Lead researcher: William N. Zelman, PhD Project completed: August 2002 The North Carolina Rural Health Research Program at the University of North Carolina’s (UNC) Cecil G. Sheps Center for Health Services Research and the Department of Health Policy and Administration, also at UN… Read more »

2021
Rural Population and Providers: Mapping the 2000 Census

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: August 2002 For this project we will create a monograph that uses maps to illustrate population location and changes at both the state and national level, and overlays these changes with provider supply. Using the 1990 an… Read more »

2021
Early Rural Experiences of Changes to Medicaid: Year 1

About this project Contact: Mark Holmes, PhD, 919.966.7100, mark_holmes@unc.edu Project funded: September 2013 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 Medic… Read more »

2021
Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations

About this project Contact: Mark Holmes, PhD, 919.966.7100, mark_holmes@unc.edu Project funded: September 2010 Project completed: December 2014 Recent health reform has included a number of models of care provision and/or payment, for example, bundled payments and Accountable Care Organizations (ACO… Read more »

2021
Early Rural Experiences of Changes to Medicaid

About this project   Lead researcher:Pam Silberman, JD, DrPH Project completed: February 2015 The Affordable Care Act included provisions for a substantial expansion in Medicaid, but the Supreme Court ruled that states could not be compelled to expand. Many states decided not to expand. These states… Read more »

2021
Identifying Limitations of PPS Reimbursement for Rural Hospitals

About this project Contact: Mark Holmes, PhD, 919.966.7100, mark_holmes@unc.edu Project funded:September 2013 Project completed:January 2015 This project will investigate the potential financial and access consequences of returning rural hospitals to PPS payment. Characteristics of the hospitals and… Read more »

2021
2021 CMS Hospital Quality Star Ratings of Rural Hospitals

In July of 2016, the Centers for Medicare & Medicaid Services (CMS) released a new Hospital Quality Star Rating system on the Hospital Compare website.  Under this system, performance on a series of quality metrics is used to assign between one and five stars to a hospital, with a higher number… Read more »

Findings Brief
2021
Medicare Rural Hospital Flexibility Program Evaluation (Flex Program)

About the Flex Program Lead researcher:Melissa A. Fruhbeis, MSPH Project completed:August 2002 The North Carolina Rural Health Research and Policy Analysis Center and the UNC Department of Health Policy and Administration are collaborating with the other rural health research and policy analysis cen… Read more »

2021
North Carolina Rural Health Research and Policy Analysis Center

About the North Carolina Rural Health Research and Policy Analysis Center The North Carolina Rural Health Research and Policy Analysis Center extends and expands the work of the North Carolina Rural Health Research Program at UNC-CH.  This center, one of seven federally-designated rural health resea… Read more »

2021
Rapid Response Project

About the project The Rapid Response Project, in conjunction with the RUPRI Center, provides rapid rural data analysis and issue-specific rural research studies in response to emerging policy issues.

2021
Ambulatory Care Provided to Rural Medicare Beneficiaries by Rural and Urban FQHCs, RHCs, and Acute Hospitals

About the project In the Rural Healthy People 2020 survey, 78% of respondents identified “access” as the top rural health priority. Research center: North Carolina Rural Health Research and Policy Analysis Center Lead researcher: George H. Pink, PhD Contact: George H. Pink, PhD, 919.843.2728, gpink@… Read more »

2021
Financial Impact of Reimbursing CAH Swing Bed Days at the SNF PPS Rate

About this project Under current reimbursement methods, the Medicare program pays more per day for a skilled nursing patient in a Critical Access Hospital (CAH) swing bed than it does for a similar patient who is in a skilled nursing facility. Lead researcher: Kristin Reiter, PhD, 919.843.8619, reit… Read more »

2021
How Rural Communities Respond and Recover after a Hospital Closure

About this project Previous research has shown hospital closures have immediate negative health and economic effects on a rural community. Lead researcher: Mark Holmes, PhD Contact: Mark Holmes, PhD, 919.966.7100, mark_holmes@unc.edu Project funded: September 2016 Project completed: July 2019 What i… Read more »

2021
Post-Acute Care for Rural Medicare Beneficiaries

About this project Increasingly, attention on Medicare payment policy has turned to post-acute services. Research has shown that discharges to post-acute care (PAC) facilities have increased substantially over the past two decades. Lead researcher: Mark Holmes, PhD Contact: Mark Holmes, PhD, 919.966… Read more »

2021
Characteristics of Rural Hospitals at High Risk of Financial Distress

About this project The project updates the Financial Distress Index Model (FDI) with current hospital and market data and evaluates changes in risk status and geographic distribution over time. Research center: North Carolina Rural Health Research and Policy Analysis Center Lead researcher: George H… Read more »

2021
Exploring Regional Differences in Rural and Urban Mortality Trends

About this project Previous research has established both that there is a gap in nationwide urban-rural mortality and that this gap is increasing over time. Existing and ongoing work has found that the urban-rural mortality gap may vary regionally. Lead researcher: Mark Holmes, PhD Contact: Mark Hol… Read more »

2021
The Financial and Community Experience of Sole Community Hospitals in Comparison to Other Rural Hospitals

About this project The standard mechanism for Medicare payment for hospital services is the Prospective Payment System (PPS), but a hospital classification available to hospitals that maintain health services in isolated areas is the Sole Community Hospital (SCH). Lead researcher: George H. Pink, Ph… Read more »

2021
Can a Model Predict Financial Distress Among Rural Hospitals?

About this project This project will extend an existing model of CAH financial distress to other types of rural hospitals. Lead researcher: Mark Holmes, PhD Project funded: September 2014 Project completed: August 2016 A valid model would be helpful to ORHP and state Offices of rural Health interest… Read more »

2021
How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals?

About this project 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 ma… Read more »

2021
How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals? (Year 2)

About this project The implementation of the Patient Protection and Affordable Care Act (ACA) is changing hospital reimbursement in important ways. Lead researcher: Mark Holmes, PhD Project funded: September 2015 Project completed: August 2016 One of the most significant changes is the expansion of… Read more »

2021
Rural Health Clinics: Medicare & Medicaid Profile (Year 2)

About this project Year 2 of a project developing a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements. Contact:Mark Holmes, PhD, 919.966.7100, mark_holmes@unc.edu Project funded: September 2013 Project completed: March 2016 RHC Medicaid data for… Read more »

2021
What Would be the Financial Consequence of Eliminating Low Volume Hospital Payments?

About this project The standard mechanism for Medicare payment for hospital services is the Prospective Payment System, but hospitals receive an additional payment if they qualify as a low-volume hospital (LVH). Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded: Septembe… Read more »

2021
21st Century Rural Hospital: Outpatient Services and Access to Care

About this project The services rural hospitals provide have changed dramatically over the past decades as they have expanded to provide outpatient services that are both needed by their communities and that support their financial viability. Contact: Victoria Freeman, DrPH, RN, 919.966.6168, victor… Read more »

2021
What Does it Cost to Operate a Rural Free-Standing Emergency Department (RFED)?

About this project In recent months, there have been numerous media reports of rural hospital closures and their adverse effect on communities. Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.eduResearch staff: Kristie Thompson, MA Project funded: September 2014 Project completed: Decemb… Read more »

2021
What Happens after Acute Inpatient Care is No Longer Provided by a Rural Hospital?

About this project This project will investigate the precursors to the closure of acute inpatient care by rural hospitals and the post-closure configuration of health care services in the community. Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded: September 2014 Projec… Read more »

2021
Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research

About this project Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research. Lead researcher: Rebecca T. Slifkin, PhD Project funded: January 2006 Project completed: August 2012 Publications 2012-14 Profitability of Urban and Rural Hospitals by Medicar… Read more »

2021
Importance of Surgery to Rural Hospital Financial Condition and Market Share

About this project Anecdotal evidence supports the notion that the viability of many rural hospitals is strongly affected by their offering surgical services. Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded:September 2009 Project completed:March 2011 Recent studies sho… Read more »

2021
Factors Associated with Provision of Ambulance Services by Rural Hospitals

Lead researcher: Victoria Freeman, DrPH, RN Contact: Victoria Freeman, DrPH, RN, 919.966.6168, victoria_freeman@unc.edu Project funded: September 2008 Project completed: August 2010 Topic: Emergency medical services and trauma Rural emergency medical services (EMS) agencies face continual challenges… Read more »

2021
Medicaid and SCHIP Participation in Rural and Urban Areas

Lead researcher: Rebecca T. Slifkin, PhD Contact: Rebecca T. Slifkin, PhD Project funded: September 2008 Project completed: August 2010 Topic: Medicaid and CHIP Medicaid and SCHIP are an important source of health insurance coverage in rural communities. The programs also are vital sources of income… Read more »

2021
Rural Emergency Department Preparedness for Pediatric Care

Lead researcher: Victoria Freeman, DrPH, RN, 919.966.6168, victoria_freeman@unc.edu Project funded: September 2007 Project completed: May 2010 Topics: Children and adolescents, Health services, Hospitals and clinics In 2006, the Institute of Medicine published its report “Emergency Care for Children… Read more »

2021
Rural Medicaid and CHIP Mini-Studies

Contact: Rebecca T. Slifkin, PhD Project funded: September 2009 Project completed: December 2010 Topics: Children and adolescents, Medicaid and CHIP Medicaid and the Children’s Health Insurance Program (CHIP) are important sources of health insurance coverage, especially in rural communities. In 200… Read more »

2021
Rural-urban Comparison of Hospital Financial Performance by Medicare Payment Classification

Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded: September 2008 Project completed: August 2010 Topics: Hospitals and clinics, Medicare The standard mechanism for Medicare payment for hospital services is the Prospective Payment System, but four specific hospital classi… Read more »

2021
Volunteerism in Rural EMS

Project funded: September 2007 Project completed: August 2010 Topics: Emergency medical services and trauma, Healthcare financing, Workforce Emergency medical services (EMS) providers are continually challenged to maintain an adequate workforce. A survey of state EMS directors in 2004 suggests that… Read more »

2021
Assessing the Impact of Transfer of Pharmacy Services for Dual Eligible Beneficiaries to Medicare Part D

Project funded: September 2006 Project completed: October 2008 Topics: Medicaid and CHIP, Medicare Part D, Pharmacy and prescription drugs With the implementation of the Medicare prescription drug benefit (Part D) in January 2006, full-benefit dual eligible beneficiaries no longer have their prescri… Read more »

2021
Critical Access Hospital Conversion Tracking

Lead researcher: Rebecca T. Slifkin, PhD Contact: Indira Richardson Project funded: September 2003 Project completed: August 2008 Topic: Critical Access Hospitals This multi-year project will continue the tracking of Critical Access Hospital (CAH) conversions. A CAH management information dataset, h… Read more »

2021
Developing a Financial Performance Measurement System for Critical Access Hospitals

Contact: George H. Pink, PhD, 919.843.2728, gpink@email.unc.edu Project funded: September 2003 Project completed: August 2008 Topics: Critical Access Hospitals, Healthcare financing This multi-year project uses research and expert opinion to select dimensions and indicators of financial performance,… Read more »

2021
Move Toward Clinical Doctorates in the Allied Health Professions: Implications for Rural Areas

About this project Lead researcher: Jennifer King, 919.966.9985, Project funded: September 2007 Project completed: August 2008 Allied health occupations play a major role in healthcare delivery and comprise a significant proportion of the health care workforce in the United States. Researchers have… Read more »

2021
Quality and Financial Status of Critical Access Hospitals: A Preliminary Analysis

About this project   Contact: Ira Moscovice, PhD Project start date: September 2006 Project completed: October 2008 The Flex Monitoring Team has worked to develop financial and quality performance measurement systems for Critical Access Hospitals (CAHs). The University of North Carolina (UNC) h… Read more »

2021
Rural Hospital Flexibility Performance Monitoring Project- Grant Years 2003-2008

About this project Lead researcher: Ira Moscovice, PhD Project funded: September 2003 Project completed: August 2008 Under contract with the federal Office of Rural Health Policy, the Rural Health Research Centers at the Universities of Minnesota, North Carolina, and Southern Maine (the Flex Monitor… Read more »

2021
Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GIS

Contact: Thomas C. Ricketts, PhD Project funded: September 2004 Project completed: May 2007 Topics: Health services, Physicians This study is testing the use of geographically weighted regression (GWR) to assess the influence of distance and travel time on the distribution of physicians in rural Ame… Read more »

2021
Occupational Mix Differences Across PPS Hospitals: Analysis of Hospital Occupation Mix Survey Data and Implications for Rural Hospital Payments

Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2004 Project completed: February 2007 Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS), Workforce This study addresses the occupation-mix adjustment that has recently been added to the computation of the area… Read more »

2021
Rural Emergency Medical Services: Workforce and Medical Direction

About this project Contact: Victoria Freeman, DrPH, RN Project funded: September 2005 Project completed: August 2007 This two-year study will examine the status of medical direction for rural Emergency Medical Services (EMS) systems, the nature of the challenges and impediments to obtaining adequate… Read more »

2021
Rural Hospital Participation in the 340B Drug Discount Program

About this project The 340B drug pricing program enables certain types of safety net organizations to obtain deeply discounted medications, at prices below the “best price” typically offered to Medicaid agencies. In the past, few rural hospitals qualified for the 340B program, but the 2003 Medicare… Read more »

2021
State Facts about Medicaid: Rural Specific Data

About this project Lead researcher: Rebecca T. Slifkin, PhD Medicaid is an important source of health insurance coverage for both rural residents and rural providers. Rural residents are more likely to live in poverty than urban residents, and are less likely to have employer-sponsored health insura… Read more »

2021
Community Impact Assessment

About this project This project will evaluate the impact of the Flex program on local communities. Activities will focus on identifying the ways in which the program could have a measurable effect, as well as the ways in which Flex program coordinators intended to affect community health. In Year 2… Read more »

2021
Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion

About this project Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2003 Project completed: August 2006 One of the objectives of the Flex program is to provide a greater degree of financial stability for CAHs through the use of cost-based reimbursement. Making use of the financial… Read more »

2021
Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehicle for Expanding Health Insurance to Rural Uninsured

About this project Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2004 Project completed: February 2006 Many states have created public-private partnerships to expand health insurance coverage to the uninsured. Among these, one group of programs, “premium assistance programs,” ar… Read more »

2021
Rapid and Flexible Analysis of Data from Centers for Medicare and Medicaid Services

Research center: North Carolina Rural Health Research and Policy Analysis Center Phone: 919.966.5541 Lead researcher: Rebecca T. Slifkin, PhD Project funded: April 2004 Project completed: August 2006 Topics: Medicare, Rural statistics and demographics This project provides rapid and flexible analysi… Read more »

2021
Access to Health Care for Young Rural Medicaid Beneficiaries

About this project Lead researcher: Victoria Freeman, DrPH, RN, 919.966.6168, victoria_freeman@unc.edu Project funded: September 2004 Project completed: December 2005 This study examined access to health care among rural children ages 0-17 who are enrolled in some type of Medicaid managed care progr… Read more »

2021
Analysis of the Cesarean Section Rates in Rural Hospitals

About this project Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2003 Project completed: August 2006 The purpose of this study is to examine practice patterns for deliveries in rural hospitals, with a focus on cesarean section (c-section) rates, which are rising nationally. The… Read more »

2021
Analytic Capacity to Respond to Changes in Medicare and Medicaid, Data Assistance to Policy Staff at the Federal Office of Rural Health Policy, and Production of Short Policy Briefs

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed:December 2004z Medicare payment rates to a variety of providers are constantly evolving, both through new legislation proposed in the Congress and regulatory changes proposed by the Centers for Medicare and Medicaid Servic… Read more »

2021
Changes in the Supply, Distribution, Workload and Reimbursement Patterns of Pharmacists in Rural Areas

Research center: North Carolina Rural Health Research and Policy Analysis Center Phone: 919.966.5541 Lead researcher: Erin Fraher, MPH Project completed: August 2004 Topics: Pharmacy and prescription drugs, Workforce This study examined the supply, distribution, workload, and reimbursement patterns… Read more »

2021
Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey

About this project Lead researcher:Rebecca T. Slifkin, PhD Most states are facing severe budget crises, forcing them to reduce Medicaid program costs. States have many different options to reduce Medicaid expenditures, including cutting optional eligibles or optional services, reducing provider paym… Read more »

2021
Role of Intensive Care Units in Critical Access Hospitals

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: February 2005 The number of small rural hospitals that have chosen to convert to CAH status has been greater than many people had anticipated, and concern has been voiced by some individuals about whether the provision of… Read more »

2021
Special Study of EMS Issues

About this project   Lead researcher: Andrew F. Coburn, PhD The University of Southern Maine and the University of North Carolina at Chapel Hill will collaborate to conduct a special study of EMS issues during Year 2 of the Flex Project (2004-05). The study will focus on state, community, and h… Read more »

2021
Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals, 1996-2003

Research center: North Carolina Rural Health Research and Policy Analysis Center Phone: 919.966.5541 Lead researcher: Rebecca T. Slifkin, PhD Contact: Kathleen Dalton, PhD Project completed: August 2005 Topics: Aging, Hospitals and clinics, Long-term care, Medicare Prospective Payment System (PPS) T… Read more »

2021
Rural Informal Safety Net: The Development of a Research and Evaluation Design and a Preliminary Assessment

About this project Research staff: Thomas C. Ricketts, PhD & Kerry James Project completed: May 2001 This is a continuation of a multi-center assessment of the Rural Informal Safety Net. During January through August 1999, the North Carolina Rural Health Research and Policy Analysis Program cond… Read more »

2021
Decline in Inpatient Volume at Rural Hospitals

About this project Authors: Tyler L Malone, George H Pink, George M Holmes This article was originally published in the Journal of Rural Health in March, 2021. doi: 10.1111/jrh.12553. Epub 2020 Dec 31. Abstract Purpose: To investigate (1) all-payer inpatient volume changes at rural hospitals and (2)… Read more »

2021
Occupancy Rates in Rural and Urban Hospitals: Value and Limitations in Use as a Measure of Surge Capacity

As policymakers deal with the effects of the novel coronavirus pandemic on the hospital infrastructure, understanding the differences in occupancy rates between rural and urban hospitals may help state and local officials in their planning for dealing with surge demand. Historically, rural hospitals… Read more »

Findings Brief
2020
Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents

Hospital bypass, the tendency of local rural residents to not seek care at their closest hospital, is thought to be a contributing factor for rural hospital closure. To to update the knowledge base of determinants of bypass behavior, the NC Rural Health Research Program produced the brief, Patterns… Read more »

Findings Brief
2020
Rural Health 101: An Overview of Rural Health Research

The Rural Health 101–An Overview of Rural Health Research PDF is a shorter primer on rural health for researchers in health and health services. It provides information on: a spectrum of rural definitions and the importance of selecting a standardized definition; rural mortality; and some common ch… Read more »

Other
2020
Understanding the Broader Context of Rural Hospitals and Profitability

Rural hospital closures remain a worrisome issue for policy makers and communities. Since 2005, 170 rural hospitals closed. The North Carolina Rural Health Research Program and Policy Analysis Center tracks these closures and studies potential predictors. Profitability (revenue greater than expenses… Read more »

Other
2020
2016‐18 Profitability of Urban and Rural Hospitals by Medicare Payment Classification

To remain open, businesses generally need to be profitable (have revenues greater than expenses). Hospitals are no different. Hospitals use profits to pay for new and upgraded buildings, equipment, technology, programs, and other patient care needs. To assess hospital profitability, we often look at… Read more »

Findings Brief
2020
Geographic Variation in the 2018 Profitability of Urban and Rural Hospitals

Rural hospital closures remain a worrisome issue for policy makers and communities. Since 2005, 170 rural hospitals closed. The North Carolina Rural Health Research Program and Policy Analysis Center tracks these closures and studies potential predictors. Profitability (revenue greater than expenses… Read more »

Findings Brief
2020
Most Rural Hospitals Have Little Cash Going into COVID-19

In the infographic, Most Rural Hospitals Have Little Cash Going into COVID, The North Carolina Rural Health Research Program uses recent Medicare Cost Report data to illustrate the type of rural hospitals most likely to struggle financially during the pandemic as measured by lower median days cash o… Read more »

Findings Brief
2020
Changes in Care‐Seeking after Rural Hospitals Merge

Rural hospital mergers have increased significantly since 2010. Enhanced financial performance and improved quality are often cited as benefits, but hospital mergers can also lead to changes in the services provided by acquired hospitals. This brief estimates the use of inpatient services delivered… Read more »

Findings Brief
2020
A Comparison of Rural and Urban Specialty Hospitals

Specialty hospitals are important providers in both urban and rural areas. However, they are not evenly distributed across these areas. The NC Rural Health Research Program in the brief, A Comparison of Rural and Urban Specialty Hospitals, addresses three types of specialty hospitals: Long Term Acut… Read more »

Findings Brief
2020
Rural Hospitalizations for COVID-19: A Snapshot for December10, 2020

Since the onset of COVID-19, public health leaders have emphasized reducing the rate of viral spread to ensure that hospitals did not become overwhelmed. The U.S. DHHS publishes weekly data on individual hospital’s indicators for management of COVID-19 patients. The NC Rural Health Research Program… Read more »

Other
2020
CMS Hierarchical Condition Category (HCC) 2014 Risk Scores Are Lower for Rural Medicare Beneficiaries than for Urban Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) use Hierarchical Condition Categories (HCC) and demographic information to calculate beneficiary risk scores, which predict expected Medicare spending by beneficiaries. CMS-HCC risk scores may be underestimating expected health care utilization… Read more »

Findings Brief
2020
Rural Hospitals Have Higher Percentages of Patients with COVID-19 than Urban Hospitals (October-December 2020)

Since the onset of COVID-19, public health leaders have emphasized reducing the rate of viral spread to ensure that hospitals did not become overwhelmed. The U.S. DHHS publishes weekly data on individual hospital’s indicators for management of COVID-19 patients. The NC Rural Health Research Program… Read more »

Other
2020
Alternatives to Hospital Closure: Findings from a National Survey of CAH Executives

Despite the numerous challenges of operating a CAH, there is little research examining the perspectives of CAH executives on potential community health care options if the CAH were to close. The NC Rural Health Research Program produced the brief, Alternatives to Hospital Closure: Findings from a Na… Read more »

Findings Brief
2020
Health System Challenges for Critical Access Hospitals: Findings from a National Survey of CAH Executives

Despite the numerous challenges of operating a CAH, there is little research examining the perspectives of CAH executives on potential community health care options if the CAH were to close. This brief presents a subset of results from a national survey of CAH executive perspectives on pressing chal… Read more »

Findings Brief
2020
Facility-Based Ambulatory Care Provided to Rural Medicare Beneficiaries in 2014: A Chartbook

For decades, health care has been shifting from inpatient to outpatient settings. Ambulatory care refers to medical services performed same day on an outpatient basis (without admission to a hospital or other facility) and includes services ranging from wellness and disease management to surgical tr… Read more »

Other
2019
Trends in Risk of Financial Distress among Rural Hospitals, 2015 to 2019

In 2016, the NC Rural Health Research Program developed and utilized the Financial Distress Index (FDI) model to identify hospitals at high risk of financial distress and assess trends in varying risk of financial distress over time to help inform strategies to prevent or mitigate the effects of clo… Read more »

Findings Brief
2019
Geographic Variation in the 2019 Risk of Financial Distress among Rural Hospitals

In 2016, the NC Rural Health Research Program developed and utilized the Financial Distress Index (FDI) model to identify hospitals at high risk of financial distress and assess trends in varying risk of financial distress over time to help inform strategies to prevent or mitigate the effects of clo… Read more »

Findings Brief
2019
Cost-Sharing as a Barrier to Accessing Care at FQHCs and RHCs for Rural Medicare Beneficiaries

Cost is often a significant barrier to accessing care for the rural Medicare population, so having a better understanding of the variations in cost-sharing at different types of safety-net facilities is important. The purpose of this study was to empirically investigate cost as a barrier to accessin… Read more »

Working Paper
2019
Risk Factors and Potentially Preventable Deaths in Rural Communities

As the rural-urban mortality gap continues to expand, researchers have been exploring the reasons why the gap exists and how some of the deaths might be prevented. Studies show a higher percentage of rural residents die from preventable causes, specifically heart disease, cancer, unintentional injur… Read more »

Findings Brief
2019
Delineating Rural Areas in the United States

One challenge in addressing rural-urban disparities is the lack of a common definition. Multiple federal systems exist using different levels of geography (e.g, county versus census tract). Multiple definitions of the “rurality” of a place or population means that the degree of the disparity may var… Read more »

Other
2019
A Rural Urban Comparison of the Proposed 2020 Wage Index

On April 23, 2019, the Centers for Medicare & Medicaid Services (CMS) released its annual proposed update for the hospital Inpatient Prospective Payment System for fiscal year 2020 that starts in October 2019.  In the proposed update, CMS recognizes that the current wage index system perpetuates… Read more »

2018
Access to Care: Populations in Counties with No FQHC, RHC, or Acute Care Hospital

Rural areas have more limited access to health care than urban areas. In 2013, there were 79.3 primary care physicians per 100,000 people in metropolitan counties, compared to only 55.1 per 100,000 people in non-metropolitan counties. To help provide a quick understanding of how many people may have… Read more »

Findings Brief
2018
Range Matters: Rural Averages Can Conceal Important Information

Researchers often use averages to describe data.  The average (or the mean) of a data set can be used to identify the central value of the group, or what is typical. While valuable, it’s also important to understand the range of data—the highs and lows.  What might we miss by focusing on the average… Read more »

Findings Brief
2018
Rural Health Care Costs: Are They Higher and Why Might They Differ from Urban Health Care Costs?

  Do health care costs differ between rural and urban populations, and if so, why might that be? Rural Americans are more vulnerable than their urban counterparts, which could lead us to suspect rural health care costs are higher. However, the answer may differ depending on how costs are measur… Read more »

2018
Geographic Variation in the 2016 Profitability of Urban and Rural Hospitals

Rural hospital closures remain a worrisome issue for policy makers and communities: between 2010 and 2017, 83 rural hospitals closed. The NC Rural Health Research Program tracks these closures and studies potential predictors. Profitability is not the only predictor, but it is one of the main predic… Read more »

Findings Brief
2018
Market Characteristics Associated with Rural Hospitals’ Provision of Post-Acute Care

Post-acute care (PAC) in rural hospitals, particularly Critical Access Hospitals (CAHs), represents an important source of PAC access in rural areas. In addition, a rural hospital’s financial health often depends on providing services that meet local need.  Over time, some changes in Medicare paymen… Read more »

Findings Brief
2018
Rural and Urban Provider Market Share of Inpatient Post-Acute Care Services Provided to Rural Medicare Beneficiaries

As new Medicare payment models are implemented, there is some concern about how it will affect inpatient post-acute care in rural areas.  Changes in referral patterns and utilization could make maintaining these services financially difficult in rural areas, which could ultimately reduce access to l… Read more »

Findings Brief
2018
Senate Finance Committee Testimony: Rural Health Care in America: Challenges and Opportunities

On May 24, 2018, George Pink, PhD, Humana Distinguished Professor in the Department of Health Policy and Management at the Gillings School of Global Public Health, Deputy Director of the North Carolina Rural Health Research Program, and Senior Research Fellow at the Cecil G. Sheps Center for Health… Read more »

Other
2018
Geographic Variation in Uncompensated Care between Rural and Urban Hospitals

Rural residents are less likely than urban residents to have health care coverage through their employer, more likely to be low-income, and oftentimes are unable to afford coverage on their own. For hospitals that serve rural residents, this often means higher rates of uncompensated care compared to… Read more »

Findings Brief
2018
Rural Hospital Mergers from 2005 through 2016

Hospital mergers and acquisitions are changing the face of health care in both rural and urban communities across the country. There are many factors driving mergers, such as cost savings, increased access to capital, increased access to technology, etc., but concerns about rural hospital mergers ha… Read more »

Findings Brief
2018
Average Beneficiary CMS Hierarchical Condition Category (HCC) Risk Scores for Rural and Urban Providers

Risk adjustment mechanisms predict whether a given patient, or group of patients, is likely to be more or less costly to treat than the average population and provides a way to adjust payment accordingly. The Centers for Medicare & Medicaid Services (CMS) risk adjustment model is a hierarchical… Read more »

Findings Brief
2018
Rural/Urban and Regional Variation in the 2019 CMS Hospital Wage Index

The Medicare hospital Inpatient Prospective Payment System (IPPS) is designed to pay hospitals for services provided to Medicare beneficiaries based on a national standardized amount adjusted for the patient’s condition and related treatment. Further, Social Security Act Section 1886(d)(3)(E) requir… Read more »

2018
Association of CMS‐HCC Risk Scores with Health Care Utilization among Rural and Urban Medicare Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) use Hierarchical Condition Categories (HCC) and demographic information to calculate beneficiary risk scores, which predict expected Medicare spending by beneficiaries. CMS-HCC risk scores may be underestimating expected health care utilization… Read more »

2018
Rural Health Snapshot (2017)

Disparities in health status and access to health care exist between people living in rural areas and those in urban areas.   The Rural Health Snapshot 2017 displays selected indicators of access to health care, health behavior/risk factors, and mortality rates, comparing rural to urban residents.

Other
2017
CMS Hospital Quality Star Rating: for 762 Rural Hospitals, No Stars Is the Problem

In April 2017, the Centers for Medicare & Medicaid Services (CMS) released their fourth Hospital Quality Star Rating list. Since the first release, stakeholders have been publicly debating the star rating scale’s usefulness in comparing hospital quality, but little focus has been given to the la… Read more »

Findings Brief
2017
The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals

The provision of post-acute (PAC) and hospice care by rural hospitals allows patients to receive such care locally, avoiding unnecessary travel and staying close to family and friends.  Typically, rural residents discharged from an acute care facility receive PAC either locally or in the urban cente… Read more »

Findings Brief
2017
Regional Differences in Urban and Rural Mortality Trends

Previous research has established both that there is a gap in nationwide urban-rural mortality and that this gap is increasing over time. Existing and ongoing work has found that the urban-rural mortality gap may vary regionally. This brief builds upon previous research and explores the differences… Read more »

Findings Brief
2017
Rural-Urban Variations in Medicare Live Discharge Patterns from Hospice, 2012-2013

For the last decade-and-a-half, the proportion of patients discharged from the Medicare hospice program prior to death – known as a “live discharge” – has increased across the country with significant hospice-level geographic variations. Despite clear geographic variations in live discharge rates an… Read more »

Findings Brief
2017
Health Disparities in Appalachia

“Creating a Culture of Health in Appalachia: Disparities and Bright Spots” is an innovative research initiative that aims to identify factors that support a culture of health in Appalachian communities. “Health Disparities in Appalachia” is the first report in a series exploring health issues in App… Read more »

Final Report
2017
Differences in Community Characteristics of Sole Community Hospitals

In 1983, Congress created the Sole Community Hospital (SCH) program to support small rural hospitals for which “by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals, is the sole source of inpatient hospital services reasonably available… Read more »

Findings Brief
2017
Characteristics of Communities Served by Hospitals at High Risk of Financial Distress

Since 2005, there have been 124 rural hospital closures in the United States.  Rural hospital closures can intensify already challenging health and economic issues for rural communities. People served by rural hospitals tend to be older, poorer, have access to fewer health care professionals, and ha… Read more »

Findings Brief
2017
Prediction of Financial Distress among Rural Hospitals

From 2005 through 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services. Though a handful of these closed hospitals have since reopened, the remaining closures leave millions of rural residents at greater risk of negative health and economic hardship d… Read more »

Findings Brief
2016
Geographic Variation in Risk of Financial Distress among Rural Hospitals

From 2005 to 2015, 112 rural hospital closures have been identified (North Carolina Rural Health Research Program, 2015). Although six of these closed hospitals have since reopened, the remaining closures impact millions of rural residents in communities that are typically older and poorer, more dep… Read more »

Findings Brief
2016
2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification

More Americans are now aware of the financial challenges faced by rural hospitals. Media coverage of the 66 rural hospital closures between January 2010 and January 2016 has highlighted the health care access and economic challenges facing rural America. Rural hospital closures are not a new phenome… Read more »

Findings Brief
2016
Geographic Variation in the Profitability of Urban and Rural Hospitals

The popular business quote “No margin, no mission” succinctly states the importance of profitability. The notion that if a hospital doesn’t make enough money to keep its doors open, its higher purpose is moot may be a simplistic view, but historic and recent evidence suggest that unprofitability can… Read more »

Findings Brief
2016
Identifying Rural Health Clinics in Medicaid Data

In 1977, Public Law 95-210 created the Rural Health Clinic (RHC) Medicare and Medicaid reimbursement designation for qualified primary care practices. RHCs must be located in non-urban areas with documented health care shortages. There are currently more than 4,100 RHCs across the U.S. Some RHCs ope… Read more »

Findings Brief
2016
Characteristics of Medicaid Beneficiaries Who Use Rural Health Clinics

For almost four decades, Rural Health Clinics (RHCs) (currently numbering about 4,100) have served patients from underserved rural areas. Although Medicaid is an important payer for RHCs, little is known about Medicaid patients and the services provided to them partly because of the complexity of id… Read more »

Findings Brief
2016
Profitability of Rural and Urban Hospitals (Infographic)

More Americans are now aware of the financial challenges faced by rural hospitals. Media coverage of the 76 rural hospital closures between January 2010 and July 2016 has highlighted the health care access and economic challenges facing rural America. Rural hospital closures are not a new phenomenon… Read more »

Other
2016
Trends in Risk of Financial Distress among Rural Hospitals

From January 2005 to July 2016, 118 rural hospitals have closed permanently, not including seven others that closed and subsequently reopened. The number of closures has increased each year since 2010, and in the first half of 2016, the closure rate surpassed two closures per month. Hospital closure… Read more »

Findings Brief
2016
The Impact of the Low Volume Hospital (LVH) Program on the Viability of Small, Rural Hospitals

Thanks to a temporary, but substantial expansion of the Centers for Medicare & Medicaid Services (CMS) Low Volume Hospital (LVH) Program, around 500 rural hospitals benefit from LVH payment adjustment. When it was originally implemented in 2005 only five rural hospitals qualified. Under the prog… Read more »

Findings Brief
2016
The Financial Importance of the Sole Community Hospital Payment Designation

In 1983, Congress created the Sole Community Hospital (SCH) program to support small rural hospitals for which “by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals, is the sole source of inpatient hospital services reasonably available… Read more »

Findings Brief
2016
U.S. Hospital List (2016)

The North Carolina Rural Health Research Program produces a list of rural and urban U.S. hospitals each year.  This list includes 4,768 acute and 1,373 specialty hospitals that were reported open on January 1, 2016. U.S. Hospital List (2016)  

Other
2016
Do Current Medicare Rural Hospital Payment Systems Align with Cost Determinants?

The financial performance of small, rural hospitals has long been a concern to federal and state agencies. Federal law makers have enacted legislation authorizing the Medicare program to develop reimbursement methods that provide higher payments to hospitals that serve rural communities (Critical Ac… Read more »

Findings Brief
2015
Rural Provider Perceptions of the ACA: Case Studies in Four States

The Affordable Care Act (ACA) expanded health insurance coverage to previously uninsured populations by allowing states to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level (FPL) as well as by creating health insurance marketplaces to subsidize affordable covera… Read more »

Findings Brief
2015
The 21st Century Rural Hospital: A Chart Book

Hospitals have changed over recent decades. Hospital stays are shorter. Procedures once requiring hospitalization are now done in an outpatient setting. Hospitals have moved beyond providing mainly inpatient and emergency department care. They have become vertically integrated systems with “one-stop… Read more »

Other
2015
A Critique of the Office of the Inspector General’s Report on Swing Beds in Critical Access Hospitals

In March 2015, the Office of the Inspector General (OIG) issued a report on Medicare’s expenditures on swing beds in Critical Access Hospitals (“Medicare Could Have Saved Billions At Critical Access Hospitals If Swing Bed Services Were Reimbursed Using The Skilled Nursing Facility Prospective Paymen… Read more »

Other
2015
A Comparison of Closed Rural Hospitals and Perceived Impact

From 2010 through 2014, 47 rural hospitals,  ceased providing inpatient services in 23 states across the country (“closed”). Among the 47 closed hospitals, 26 hospitals no longer provide any health care services (“abandoned”), and 21 continue to provide a mix of health services but no inpatient care… Read more »

Findings Brief
2015
Estimating Eligibility and Uptake of Federally Facilitated Marketplace Insurance in North Carolina in the Second Open Enrollment Period

As the Federally Facilitated Marketplace (FFM) enters its third open enrollment period, focus is shifting toward examining which communities have lower uptake in coverage and how to increase enrollment. In national analysis of the first open enrollment period, Holmes and colleagues found that rural… Read more »

Findings Brief
2015
Estimated Costs of Rural Freestanding Emergency Departments

Since 2005, more than 100 rural hospitals have closed and more are at risk. Rural hospital closures jeopardize access to emergency services in the affected communities. As communities react to and/or prepare for closures, providers and policy makers seek a viable alternative for emergency services p… Read more »

Findings Brief
2015
Rural and Urban Hospitals in the United States

The table below shows the number of rural and urban hospitals in the United States as of January 1, 2016. The source of the data is the 2016 Provider of Services file produced by the Centers for Medicare and Medicaid Services.  Hospitals are classified as rural by using the definition provided by th… Read more »

2015
Rural Hospital Mergers and Acquisitions: Who Is Being Acquired and What Happens Afterward?

Hospital mergers and acquisitions are changing the face of health care in both rural and urban communities across the country. Declining reimbursement levels, increased capital needs, a weak economy and easier access to credit have all contributed to a level of mergers not seen in more than a decade… Read more »

Findings Brief
2014
How Does Medicaid Expansion Affect Insurance Coverage of Rural Populations?

The NC Rural Health Research Program’s Findings Brief: How Does Medicaid Expansion Affect Insurance Coverage of Rural Populations? examines how states’ decisions on Medicaid expansion are impacting rural areas in the U.S., we used population estimates, current status of state expansion, and state-le… Read more »

Findings Brief
2014
Medicaid Managed Care in Rural Areas: A Ten-State Follow-Up Study

Medicaid Managed Care in Rural Areas: A Ten-State Follow-Up Study. (March, 1999). Health Affairs. Felt-Lisk, Suzanne, Pam Silberman, Sheila Hoag, and Rebecca Slifkin.

Other
2014
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… Read more »

Article
2014
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013

Map
2013
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013 (Puerto Rico included)

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013 (Puerto Rico included)

Map
2013
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013 (2013 and 2009)

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2013 (2013 and 2009)

Map
2013
Rural-Urban Continuum Codes by County, 2013

Rural-Urban Continuum Codes by County, 2013  

Map
2013
Background on the Wage-related Portion of the Medicare DRG Payments

Background on the Wage-related Portion of the Medicare DRG Payments. (September, 2000). ORHP. Dalton, Kathleen.

Other
2012
Cartographic Defining Rural Maps – Frontier Counties 2000

Cartographic Defining Rural Maps – Frontier Counties 2000

Map
2012
A comparative study of financial data sources for critical access hospitals: audited financial statements, the Medicare cost report, and the Internal Revenue Service form 990

A Comparative Study of Financial Data Sources for Critical Access Hospitals: Audited Financial Statements, the Medicare Cost Report, and the Internal Revenue Service Form 990

Article
2012
Rural Populations and Health Care Providers: A Map Book

Rural Populations and Health Care Providers: A Map Book (September, 2002). ORHP. Randy Randolph, Katherine Gaul, Rebecca Slifkin.

Other
2010
Tracking Medicaid Managed Care in Rural Communities: A 50-State Follow Up

Tracking Medicaid Managed Care in Rural Communities: A 50-State Follow Up (July, 2002). Health Affairs. Silberman, Pam, Stephanie Poley, Kerry James, and Rebecca Slifkin.

Other
2010
2010 Rural-Urban Commuting Area Codes by Census Tract

2010 Rural-Urban Commuting Area Codes by Census Tract

Map
2010
Urbanized Areas and Urbanized Clusters 2010

Urbanized Areas and Urbanized Clusters 2010

Map
2010
A Primer on Interpreting Hospital Margins

A Primer on Interpreting Hospital Margins. (July, 2003). ORHP. Dalton, Kathleen, Rebecca Slifkin.

Other
2009
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2003

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2003

Map
2009
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) June, 2003

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) June, 2003

Map
2009
County-level Estimates of the Number of Uninsured in North Carolina 2004 Update

This report provides county-level estimates of the number and percentage of people under the age of 65 who are uninsured in 2004.

Findings Brief
2008
Core Based Statistical Areas and the Medicare Wage Index

Core Based Statistical Areas and the Medicare Wage Index. (February, 2004). ORHP. Dalton, Kathleen, Rebecca Slifkin.

Other
2008
Cartographic Defining Rural Maps – Frontier Counties 2004

Cartographic Defining Rural Maps – Frontier Counties 2004

Map
2008
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2004

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2004

Map
2008
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2005

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2005

Map
2007
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2006

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2006

Map
2006
The Effect of Rural Hospital Closures on Community Economic Health

The purpose of this work was to examine the effect of rural hospital closures on the local economy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1702512/

Article
2006
Cartographic Defining Rural Maps – Frontier Counties 2007

Cartographic Defining Rural Maps – Frontier Counties 2007

Map
2005
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2007

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) December, 2007

Map
2005
The Occupational Mix Adjustment to the Medicare Hospital Wage Index

The Occupational Mix Adjustment to the Medicare Hospital Wage Index: Why the rural impact is less than expected. The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association 24 (2): 148-54. A94

Article
2004
The Trend Towards the Clinical Doctorate in Allied Health

The Trend Towards the Clinical Doctorate in Allied Health: Implications for Rural Communities. (August, 2008). ORHP. Freburger, J., King, J., Slifkin, R. FR94

Final Report
2004
Issues in Staffing Emergency Medical Services

Issues in Staffing Emergency Medical Services: Results from a National Survey of Local Rural and Urban EMS Directors. (May, 2008). ORHP. Freeman, V., Slifkin, R., Patterson, D. FR93

Final Report
2004
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2008

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2008

Map
2004
Designated Medical Directors for Emergency Medical Services

Designated medical directors for emergency medical services: Recruitment and roles. The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association 25 (4): 392. A98

Article
2003
Developing Financial Benchmarks for Critical Access Hospitals

Developing financial benchmarks for critical access hospitals. Health Care Financing Review 30 (3): 55-69. A97

Article
2003
Continuing Effects of Medicare Part D on Rural Independent Pharmacies

Continuing effects of medicare part D on rural independent pharmacies who are the sole retail provider in their community. Research in Social & Administrative Pharmacy: RSAP 5 (1): 17-30. A96

Article
2003
Recruitment and Retention in Rural and Urban EMS

Recruitment and retention in rural and urban EMS: Results from a national survey of local EMS directors. Journal of Public Health Management and Practice : JPHMP 15 (3): 246. A95

Article
2003
Profile of Sole Community Pharmacists’ Prescription Sales and Overall Financial Position

Profile of Sole Community Pharmacists’ Prescription Sales and Overall Financial Position (August, 2009). Radford, A., Lampman, M., Richardson, I., Rutledge, S. FB92

Findings Brief
2003
Characteristics of Rural & Urban Children Who Qualify For Medicaid or CHIP But Are Not Enrolled

Characteristics of Rural & Urban Children Who Qualify For Medicaid or CHIP But Are Not Enrolled (July, 2009). King, J., Slifkin, R., Holmes, G. FB91

Findings Brief
2003
Medicare Beneficiaries’ Access to Pharmacy Services in Small Rural Towns

Medicare Beneficiaries’ Access to Pharmacy Services in Small Rural Towns: Implications of Contracting Patterns of Sole Community Pharmacies with Part D Plans. (January, 2009). ORHP. Freeman, V., Richardson, I., Slifkin, R. FR95

Final Report
2003
Medicaid & CHIP Participation Among Rural & Urban Children

Medicaid & CHIP Participation Among Rural & Urban Children (July, 2009). King, J., Slifkin, R., Holmes, M. FB90

Findings Brief
2003
Workforce Issues Among Sole Community Pharmacies

Workforce Issues Among Sole Community Pharmacies (July, 2009). Klepser, D., Lampman, M., Radford, A., Richardson, I., Rutledge, S. FB89

Findings Brief
2003
The Key Role of Sole Community Pharmacists in Their Local Healthcare Delivery Systems

The Key Role of Sole Community Pharmacists in Their Local Healthcare Delivery Systems (March, 2009). Radford, A., Richardson, I., Mason, M., Rutledge, S. FB88

Findings Brief
2003
Sole Community Pharmacies and Part D Participation: Implications for Rural Residents

Sole Community Pharmacies and Part D Participation: Implications for Rural Residents (February, 2009). Freeman, V., Richardson, I., Slifkin, R. FB87

Findings Brief
2003
A Case Study of Rural Health Care in the Economic Downturn

A Case Study of Rural Health Care in the Economic Downturn. (2009). ORHP. No author.

Other
2003
Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2009

Defining Rural Maps OMB Core Based Statistical Areas (CBSAs) November, 2009

Map
2003
Projected Changes in North Carolina Health Insurance Coverage Due to Health Reform

Running the numbers: Projected changes in North Carolina health insurance coverage due to health reform. North Carolina Medical Journal 71 (3): 306-308. A102

Article
2002
A Rural-Urban Comparison of Allied Health Professionals’ Average Hourly Wage

A Rural-Urban comparison of allied health professionals’ average hourly wage. Journal of Allied Health 39 (3): E91. A104

Article
2002
What Does the Clinical Doctorate in Physical Therapy Mean for Rural Communities?

What does the clinical doctorate in physical therapy mean for rural communities? Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy 15 (1): 24,n/a. A100

Article
2002
Rural and Urban Differences in Children’s Medicaid and CHIP Participation

Rural and urban differences in children’s medicaid and CHIP participation. Inquiry 47 (2): 150-61. A101

Article
2002
Rural Hospital Support for Emergency Medical Services

Rural Hospital Support for Emergency Medical Services (November, 2010). Freeman, V., Howard, H.A., Lavergne, R. FB99

Findings Brief
2002
Rural Volunteer EMS: Reports from the Field

Rural Volunteer EMS: Reports from the Field (September, 2010). Freeman, V., Rutledge, S., Hamon, M., Slifkin, R. FB98

Findings Brief
2002
Prospective Payment Compared to Special Medicare Payment Provisions

Profitability of Rural Hospitals Paid Under Prospective Payment Compared to Rural Hospitals with Special Medicare Payment Provisions (September, 2010). Holmes, G.M., Pink, G.H., Howard, H.A. FB97

Findings Brief
2002
Pediatric Care in Rural Hospital Emergency Departments

Pediatric Care in Rural Hospital Emergency Departments (May, 2010). Freeman, V., Randolph, R., Poley, S., Friedman, S., Slifkin, R. FB96

Findings Brief
2002
States’ Use of Cost-Based Reimbursement for Medicaid Services at Critical Access Hospitals

States’ Use of Cost-Based Reimbursement for Medicaid Services at Critical Access Hospitals (April, 2010). Radford, A., Hamon, M., Nelligan, C. FB94

Findings Brief
2002
The Effect of Medicare Part D Plan Switching on Sole Community Pharmacies and the Patients

The Effect of Medicare Part D Plan Switching and Formulary Changes on Sole Community Pharmacies and the Patients They Serve (March, 2010). Lampman, M., Radford, A., Nguyen, A. FB93

Findings Brief
2002
Rural Hospital Support for Emergency Medcial Services

Rural Hospital Support for Emergency Medcial Services. (November, 2010). ORHP. Freeman, V., Howard A., Lavergne, R. FR100

Final Report
2002
Rural Volunteer EMS: Reports from the Field

Rural Volunteer EMS: Reports from the Field. (August, 2010). ORHP. Freeman, V., Rutledge, S., Hamon, M., Slifkin, R. FR99

Final Report
2002
Comparison of Rural Hospitals with Special Medicare Payment Provisions to Urban and Rural Hospitals Paid Under Prospective Payment

A Comparison of Rural Hospitals with Special Medicare Payment Provisions to Urban and Rural Hospitals Paid Under Prospective Payment. (August, 2010). ORHP. Holmes, M., Pink, G., Friedman, S., Howard, A. FR98

Final Report
2002
Pediatric Care in Rural Hospital Emergency Departments

Pediatric Care in Rural Hospital Emergency Departments. (May, 2010). ORHP. Freeman, V., Randolph, R., Poley, S., Friedman, S., Slifkin, R. FR97

Final Report
2002
Comparison of Rural Hospitals With Special Medicare Payment Provisions to Hospitals Paid Under Prospective Payment

A Financial Comparison of Rural Hospitals With Special Medicare Payment Provisions to Hospitals Paid Under Prospective Payment (April, 2010). Pink, G., Slifkin, R., Howard, H.A. FB95

Findings Brief
2002
Rural Health Snapshots

Rural Health Snapshot 2010 Disparities in health status and access to health care exist between people living in rural areas and those in urban areas. Rural Health Snapshot 2010 displays selected indicators of access to health care, health behavior/risk factors, and mortality rates, comparing rural… Read more »

Other
2002
Financial Status of Independent Pharmacies and Rural Providers

The relationship between the financial status of sole community independent pharmacies and their broader involvement with other rural providers. The Journal of Rural Health 27 (2): 176-83. A105

Article
2001
Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals

Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals

Findings Brief
2001
Trends in the Provision of Surgery by Rural Hospitals

Trends in the Provision of Surgery by Rural Hospitals (July, 2011). Holmes, G.M., Karim, S., Pink, G. FB101

Findings Brief
2001
Recent Changes in Health Insurance Coverage in Rural and Urban Areas

Recent Changes in Health Insurance Coverage in Rural and Urban Areas (May, 2011). King, J., Holmes, G.M. FB100

Findings Brief
2001
Trends in Skilled Nursing Facility and Swing Bed Use (Post Medicare Modernization Act of 2003)

Trends in Skilled Nursing Facility and Swing Bed Use in Rural Areas Following the Medicare Modernization Act of 2003. (April, 2011). ORHP. Reiter, K., Freeman, V. FR101

Final Report
2001
Profile of Rural Health Clinics: Medicare Payments & Common Diagnoses

Profile of Rural Health Clinics: Medicare Payments & Common Diagnoses (December, 2012). Radford, D., Kirk, D., Howard, H.A. FB107

Findings Brief
2000
Flux in Loan Repayment Programs for Healthcare Professionals With States’ Budget Cuts and National Health Service Corps Budget Increases

Flux in Loan Repayment Programs for Healthcare Professionals With States’ Budget Cuts and National Health Service Corps Budget Increases (May, 2012). Pathman, D., Goldberg, L., Konrad, T., Kerwin, K., Morgan, J. FB106

Findings Brief
2000
Why Use Swing Beds? Conversations with Hospital Administrators and Staff

Why Use Swing Beds? Conversations with Hospital Administrators and Staff (April, 2012). Freeman, V., Radford, A. FB105

Findings Brief
2000
Communities Served by Rural Medicare Dependent Hospitals

Communities Served by Rural Medicare Dependent Hospitals (March, 2012). Reiter, K., Holmes, G.M., Karim, S., Pink, G.H. FB104

Findings Brief
2000
Adoption and perceived effectiveness of financial improvement strategies in Critical Access Hospitals

Adoption and perceived effectiveness of financial improvement strategies in Critical Access Hospitals. The Journal of Rural Health 28 (1): 92-100. A108

Article
2000
Achieving benchmark financial performance in Critical Access Hospitals

Achieving benchmark financial performance in Critical Access Hospitals: Lessons from high performers. Healthcare Financial Management : Journal of the Healthcare Financial Management Association 66 (4): 116. A107

Article
2000
Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement

The North Carolina Rural Health Research Program released their Findings Brief, Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement.  It looks at how changes to Critical Access Hospitals (CAHs) reimbursement – notably a reversion to prosp… Read more »

Findings Brief
1999
Rural and Urban Differences in Inpatient Related Costs and Use among Medicare Beneficiaries

This recent Findings Brief from the North Carolina Rural Health Research Program finds that Medicare beneficiaries who are admitted to rural hospitals tend to have lower outpatient costs than Medicare beneficiaries admitted to urban hospitals. These differences are due to multiple factors,  some of… Read more »

Findings Brief
1999
Profitability in Rural Hospitals

The North Carolina Rural Health Research Program recently released Profitability in Rural Hospitals, authored by George H. Pink, PhD; Victoria Freeman, RN, DrPH; Randy Randolph, MRP; and G. Mark Holmes, PhD. This new findings brief compares the profitability between 2010 and 2012 for urban and rural… Read more »

Findings Brief
1999
Geographic Variation in the Profitability of Critical Access Hospitals

The NC Rural Health Research Program’s Findings Brief, Geographic Variation in the Profitability of Critical Access Hospitals, examines how the profitability of Critical Access Hospitals (CAHs) varies greatly across states and U.S. Census divisions. The decertification of CAHs and the loss of cost-b… Read more »

Findings Brief
1999
Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement

Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement. (December, 2013). Holmes, G.M. and Pink, G. FB112

Findings Brief
1999
Implications for Beneficiary Travel Time if Financially-Vulnerable Critical Access Hospitals Close

Implications for Beneficiary Travel Time if Financially-Vulnerable Critical Access Hospitals Close. (December, 2013). Freeman, V., Randolph, R., Pink, G., Holmes, G.M. FB111

Findings Brief
1999
NC Rural Health Research Program December 2013 Newsletter

NC Rural Health Research Program December 2013 Newsletter

Other
1999
Rural/Urban Differences in Inpatient Related Costs and Use Among Medicare Beneficiaries

Rural/Urban Differences in Inpatient Related Costs and Use Among Medicare Beneficiaries. (December, 2013). Toth, M., Holmes, G.M., Freeman, V., Pink, G. FB113

Findings Brief
1999
Using “Plasticity” to Model a Community’s Need for Health Care Services

Using “Plasticity” to Model a Community’s Need for Health Care Services. (November, 2013). Beavers, L. Post

Other
1999
Provision of Uncompensated Care by Rural Hospitals

Provision of Uncompensated Care by Rural Hospitals: A Preliminary Look at Medicare Cost Report Worksheet S-10. (August, 2013). WP-

Other
1999
Profile of Rural Health Clinics: Clinic & Medicare Patient Characteristics

Profile of Rural Health Clinics: Clinic & Medicare Patient Characteristics (March, 2013). Radford, A., Kirk, D., Howard, A., Holmes, G.M. FB108

Findings Brief
1999
Metropolitan and Micropolitan CBSAs

Metropolitan and Micropolitan Core Based Statistical Areas (CBSAs) November 2013 Office of Management and Budget CBSA Designations by County

Map
1999
Metropolitan and Micropolitan CBSAs (2013 and 2009)

Metropolitan and Micropolitan Core Based Statistical Areas (CBSAs) November 2013 Office of Management and Budget CBSA Designations by County

Map
1999
Metropolitan and Micropolitan CBSAs (Puerto Rico included)

Metropolitan and Micropolitan Core Based Statistical Areas (CBSAs) November 2013 Office of Management and Budget CBSA Designations by County

Map
1999
2013 Metropolitan/Micropolitan Status by County

Defining Rural: 2013 Metropolitan/Micropolitan Status by County

Map
1999
Location of CAHs, June 30, 2014

Location of CAHs, June 30, 2014

Map
1998
County-level Estimates of the Number of Uninsured in North Carolina 2002 Update

This report provides annual county-level estimates of the number and percentage of people under the age of 65 who are uninsured for 2002.

Findings Brief
1998
Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where?

The NC Rural Health Research Program’s Findings Brief, Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where, examines health conditions of patients discharged from rural Prospective Payment System (PPS) hospitals and Critical Access Hospitals (CAHs) to swing beds and skilled nursing fa… Read more »

Findings Brief
1998
Rural-Urban Differences in the Rate of Health Insurance Coverage

Although national estimates of health insurance coverage rates typically show little or no difference between rural and urban areas in the per cent of residents with health insurance, if only individuals below the age of 65 are considered, rural residents are more likely to lack health insurance. Wh… Read more »

Article
1998
Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace

On September 18, 2014, the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (HHS) released data showing that nearly five and a half million individuals had selected an insurance plan in the 36 states where the Federally Facilitated Marketplac… Read more »

Findings Brief
1998
Safety Net Clinics Serving the Elderly in Rural Areas

Safety Net Clinics Serving the Elderly in Rural Areas: Rural Health Clinic Patients Compared to Federally Qualified Health Center Patients. (May, 2014). Radford, A., Freeman, V., Kirk, D., Howard, A., Holmes, G.M. FB115

Findings Brief
1998
Location of Critical Access Hospitals (February, 2014)

Location of Critical Access Hospitals.(February, 2014). Cartographic.

Map
1998
Medicaid Managed Care Programs in Rural Areas: A Fifty State Overview

Medicaid Managed Care Programs in Rural Areas: A Fifty State Overview. (November, 1998). Health Affairs. Slifkin, Rebecca, Sheila D. Hoag, Pam Silberman, Suzanne Felt-Lisk, and Benjamin Popkin.

Other
1998
State Medicaid Profiles

Nationally, Medicaid provides health insurance to a larger share of the population in rural areas than in urban areas. Both Medicaid and the Children’s Health Insurance Program (CHIP) are also critical sources of income for rural health care providers and help contribute to economic development with… Read more »

Final Report
1998
Best Practices for Health Insurance Marketplace Outreach and Enrollment in Rural Areas

The Affordable Care Act provided coverage through the Health Insurance Marketplace to nearly seven million people during the first open enrollment period. Yet, research suggests that the enrollment rates for eligible individuals living in rural areas was less than enrollment rates for those living i… Read more »

Findings Brief
1998
Rural-Urban Differences in Continuity of Care among Medicare Beneficiaries

In response to the Affordable Care Act and other reforms in the health care market, new models of care are being tested and implemented across the country. Care and payment models such as patient-centered medical homes, Accountable Care Organizations (ACOs), and bundled payments depend on linkages b… Read more »

Findings Brief
1998