The NC Rural Health Research Program brief, [Download not found], provides a preliminary look at the types of communities with hospitals that converted to Rural Emergency Hospitals (REHs) in 2023. We: 1) describe the socio-economic, race and ethnicity, and health status and access characteristics of… Read more »

The NC Rural Health Research Program wrote the brief, News Media Coverage of Rural Hospital Closures and the Causes . to augment previous research with findings from a structured framework of attributed causes of closures through the analysis of news media reports. Media reports of closures offer a… Read more »

Profitability is a determinant of hospital financial distress and closure. Operating margin is one of the key measures of hospital profitability. Accurate use of the measure relies on the quality of data, and previous studies found inconsistencies in how operating margin is calculated and reported…. Read more »

Using a recent revision of the Financial Distress Index (FDI) model, the NC Rural Health Research Program brief, Using the Updated Financial Distress Index to Describe Relative Risk of Hospital Financial Distress describes the relative risk of experiencing financial distress for rural hospitals and… Read more »

The NC Rural Health Research Program’s brief, A Comparison of 2017-19 Uncompensated Care of Rural and Urban Hospitals by Net Patient Revenue, System Affiliation, and Ownership , extends our 2018 study of geographic variation in uncompensated care between rural and urban hospitals. In this study, we… Read more »

Based on findings from a literature review and consultation with practitioners, the NC Rural Health Research Program developed a conceptual framework and checklist to organize and guide conversations about key considerations for conversion a Rural Emergency Hospital.  The brief, [Download not found]… Read more »

In the brief, Small Rural Hospitals with Low Volume ED that May Convert to a Rural Emergency Hospital , the NC Rural Health Research Program examines Critical Access Hospitals (CAHs) and Prospective Payment System (PPS) hospitals with no more than 50 beds in rural areas that are eligible to convert… Read more »

The purpose of this brief is to explore changes in the availability and provision of different health care services among rural CAHs and PPS hospitals in 2009 compared to 2017.

Abstract Background Surgical bypass occurs when rural residents receive surgical care at a nonlocal hospital. Given limited knowledge of current bypass rates, we evaluated rates and predictors of bypass for common procedures. Methods We used 2014 to 2016 all-payer claims data from the Healthcare Cos… Read more »

Y Zhang, TL Malone, CD Scales, and GH Pink. Predictors of hospital bypass for rural residents seeking common elective surgery, Surgery, August 2022. https://doi.org/10.1016/j.surg.2022.06.009.

Recognizing that many rural hospitals are the only health care facility in their communities and that their survival is vital to ensure access to health care, Federal policymakers in the 1980s and 1990s created five special payment designations under Medicare: Critical Access Hospital (CAHs), Medica… Read more »

The purpose of the brief, Association between Rural Hospital Service Changes and Community Demographics, was to investigate the association between the proportion of a rural community belonging to an AHRQ-identified priority population and local hospital service changes. Our results suggest that rec… Read more »

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 »

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 »

The NC Rural Health Research Program tracks and studies rural hospital closures. Our most recent brief, [Download not found], describes the socio‐economic, demographic, and health system characteristics for rural counties with and without hospital closures between 1990 and 2020. For the purposes of… Read more »

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 »

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 »

For decades, health care has been shifting from inpatient care to outpatient care. As hospitals reduce inpatient care, revenue from outpatient care becomes critically important. In most rural hospitals, the greatest portion of net patient revenue is from outpatient services versus urban hospitals th… Read more »

  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 »

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 »

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 »

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 »

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 »

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. Abstract Purpose: To investigate (1) all-payer inpatient volume changes at rural hospitals and (2) whether trends in inpatient volume differ… Read more »

Rural hospitals are being adversely affected by short-term and long-term challenges related to financial and regulatory burdens such as sequestration, 340B payment reductions, declining patient volumes, and increases in the under and uninsured.

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 »

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 »

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. On December 15, 2020, the U.S. DHHS published weekly data on each individual hospital’s status on key indicators for acute management of COVID-19… Read more »

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 »

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 »

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 Acu… Read more »

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 »

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 »

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… Read more »

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 »

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 »

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, [Download… Read more »

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 »

Overview 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 ofte… Read more »

The [Download not found] 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 challenges with rural data analysis.

Abstract Purpose: Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home. Methods: The population includes Medica… Read more »

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 »

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 Research staff: Kristie Thompson, MA Project funded: September 2014 Project completed: December 2015 In the face of hospital cl… Read more »

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 »

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 »

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 »

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 »

Background 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… Read more »

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 »

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 »

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 »

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 »

Abstract As rural hospital closures become more common, many patients are left without sources of care, raising ethical questions about hospitals’ and clinicians’ responsibilities during and after closures. In many cases, such as the one considered in this article, hospitals have been economic hubs… Read more »

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 »

Background One of the primary drivers of health is being covered by health insurance. A review of available literature found a wide range of effects of health insurance, including a 20% relative reduction in mortality among previously uninsured people who become eligible for Medicare [1]. Many facto… Read more »

Abstract For most health professions, rural North Carolina has lower relative supply than urban parts of the state. Although there are plenty of innovative models addressing this disparity, a holistic approach is necessary if we want to effect real change.

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 »

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 »

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 »

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 »

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 »

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 »

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 »

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 »

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 »

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 »

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 Project funded: September 2017 Project completed:… Read more »

“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 »

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 »

Abstract Purpose: Annual rates of rural hospital closure have been increasing since 2010, and hospitals that close have poor financial performance relative to those that remain open. This study develops and validates a latent index of financial distress to forecast the probability of financial distr… Read more »

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 »

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 »

“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 »

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 »

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 »

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. R… Read more »

Abstract Purpose: The low-volume hospital (LVH) payment adjustment established in the Patient Protection and Affordable Care Act (ACA) of 2010 is scheduled to sunset on October 1, 2017. The purpose of this analysis was: (1) to estimate the effect of the ACA LVH adjustment on qualifying hospitals’ pr… Read more »

Purpose: Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities. Methods: The 2009 financial performance and market characteristics… Read more »

BACKGROUND 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 reasonabl… Read more »

Abstract From January 2005 through December 2015, 105 rural hospitals closed. This study examined associations between community characteristics and rural hospital closure. Compared with other rural hospitals that were at high risk of financial distress but remained open over the same time period, c… Read more »

Background In response to the widening gap between rural and urban hospital profitability margins, the Medicare Payment Advisory Commission (MedPAC) asserted that Medicare payment policies penalized small-scale hospital operations and recommended that Congress authorize a Low Volume Hospital (LVH) p… Read more »

About this project Lead researcher: Mark Holmes, PhD Contact: Mark Holmes, PhD Project funded: September 2016 Project completed: August 2017 This brief builds upon previous research and explores the differences in mortality trends between urban and rural locations by census division from 1999 to 201… Read more »

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 »

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 Project funded: September 2016 Project completed: July 2019 What is less understood is the longer-term recovery period: does th… Read more »

Abstract Rural hospitals differ from urban hospitals in many ways. For example, rural hospitals are more reliant on public payers and have lower operating margins. In addition, enrollment in the health insurance Marketplaces of the Affordable Care Act (ACA) has varied across rural and urban areas. T… Read more »

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 »

About this project Lead researcher: Mark Holmes, PhD 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 hospitals. In particular, the purpose… Read more »

BACKGROUND Implementing the Patient Protection and Affordable Care Act (ACA) is changing hospital reimbursement in important ways.1 The most significant changes stem from increasing access to health insurance coverage for previously uninsured or under-insured populations. Since rural residents are m… Read more »

BACKGROUND 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 compl… Read more »

BACKGROUND 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.1 S… Read more »

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 Project funded: September 2016 Pro… Read more »

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 »

OVERVIEW 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 ne… Read more »

OVERVIEW From 2005 to 2015, 112 rural hospital closures have been identified (North Carolina Rural Health Research Program, 2015)1 . Although six of these closed hospitals have since reopened, the remaining closures impact millions of rural residents in communities that are typically older and poore… Read more »

BACKGROUND From 2005 through 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services.1 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 economi… Read more »

Abstract The number of stand-alone rural hospitals has been shrinking as larger health systems target these hospitals for mergers and acquisitions (M and As). However, little research has focused specifically on rural hospital M and A transactions. Using data from Irving Levin Associates’ Healthcare… Read more »

OVERVIEW Since 2005, more than 100 rural hospitals have closed and more are at risk.1,2 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 emergenc… Read more »

Background 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… Read more »

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 Project funded: September 2015 Project completed: October 2… Read more »

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 »

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 »

Abstract Background: Hospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but lit… Read more »

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 »

Abstract Purpose: This study assessed the association between homicide rates in northern Mexico and potentially avoidable use of emergency departments (ED) in the US-Mexico border region. The border region is largely rural and underserved, making the identification and correction of potential barrie… Read more »

Abstract Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical-access hospitals, which entitles them to Medicare cost-based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). S… Read more »

BACKGROUND From 2010 through 2014, 47 rural hospitals,1 ceased providing inpatient services in 23 states across the country (“closed”2 ). 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 i… Read more »

Purpose 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 Prospectiv… Read more »

Read the PDF.

Background 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.1… Read more »

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 »

Abstract Rural hospitals serve as major sources of health care and employment for their communities, but recently they have been under increased financial stress. What are the causes of this stress, and how have hospitals and their communities responded?

Background 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… Read more »

The Affordable Care Act provided coverage through the Health Insurance Marketplace to nearly seven million people during the first open enrollment period.1 Yet, research suggests that the enrollment rates for eligible individuals living in rural areas was less than enrollment rates for those living… Read more »

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 Project funded: September 2014 Project completed: August 2015 Publicatio… Read more »

Background One of the central and most visible components of the Affordable Care Act is the Health Insurance Marketplace (known as the Federally Facilitated Marketplace when administered by the federal government), which provides consumers a method to enroll in non-group health insurance coverage. I… Read more »

Background   Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are important primary care providers in rural communities. These safety net programs are similar in that they both are located in areas with inadequate access to health care services. In addition, RHCs and F… Read more »

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 »

Background Swing beds are one option for post-acute skilled care in rural communities, and they are more likely to be the only option in the most rural areas.1 These transitional care beds allow a patient to be discharged from an acute hospital stay but remain in the hospital for skilled after care…. Read more »

Background Policy makers have recently focused on the relative locations of Critical Access Hospitals (CAHs), whether changes are needed to current mileage requirements and the impact changes would have on how Medicare pays for services in smaller, low-volume hospitals. CAHs can have no more than 25… Read more »

About this project This brief is part of a series of three briefs providing information for policy makers and stakeholders as policy changes for Critical Access Hospitals (CAHs) are considered. This one focuses on the projected financial impact that a reduction in Medicare payments might have on CAH… Read more »

Background A recent Institute of Medicine report suggests that care received after a hospitalization is a primary driver of regional variation in health care costs in the United States. 1 While evidence suggests that health care utilization varies by rural setting, 2 it is unknown how pre- and post-… Read more »

Researchers at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research have introduced a new way of thinking about how to determine physician supply and medical specialty configurations in order to meet health care needs. In an article published in Academic Medicine (No… Read more »

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 Project funded: September 2013 Project completed: March 2016 RHC Medicaid data for a sample of states also will be r… Read more »

About this project Contact: Mark Holmes, PhD 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 Medicaid expansion, understanding this i… Read more »

About this project Contact: Mark Holmes, PhD 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 communities at highest risk of adv… Read more »

Abstract Purpose: To conduct a preliminary assessment of the quality of uncompensated care data included in Medicare Cost Report (MCR) Worksheet S-10 for rural hospitals and to identify the implications of data quality issues for research and policy decisions. Methods: 2011 MCR Worksheet S-10 data f… Read more »

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 »

OVERVIEW In 1977, Public Law 95-210 created the Rural Health Clinic (RHC) Medicare and Medicaid reimbursement designation for qualified primary care practices. With over 3,900 certified sites located across the county, RHCs are an important component of the rural health care infrastructure.1 RHCs ca… Read more »

Overview In 1977, Public Law 95-210 created the Rural Health Clinic (RHC) Medicare and Medicaid reimbursement designation for qualified primary care practices. With over 3,900 certified sites located across the county, RHCs are an important component of the rural health care infrastructure.1 RHCs re… Read more »

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 Project funded: Septe… Read more »

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 »

About this article Purpose Medicare cost reports (MCR), Internal Revenue Service form 990s (IRS 990), and audited financial statements (AFS) vary in their content, detail, purpose, timeliness, and certification. The purpose of this study was to compare selected financial data elements and characteri… Read more »

Overview Repaying education loans is the most popular incentive now used to attract early-career healthcare practitioners into rural and other shortage areas. The federal National Health Service Corps Loan Repayment Program (NHSC LRP), by far the largest loan repayment program for health professiona… Read more »

Overview Swing beds are one option for post-acute skilled care in rural communities; they are more likely to be the only option in the most rural areas.1 How are they being used? What do they mean for the hospital and the community? We explored these issues with hospital staff to inform our analytic… Read more »

Abstract CEOs and CFOs of 19 critical access hospitals (CAHs) that achieved benchmark financial performance over three years were interviewed regarding the strategies they use. The interviews identified nine success factors for exemplary financial performance that were common to all or most of the 1… Read more »

Overview The Medicare Dependent Hospital (MDH) program provides enhanced reimbursement to support rural health infrastructure and to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This greater dependence on Medicare may mak… Read more »

Purpose: To ascertain the use and perceived success of strategies to improve the financial performance of Critical Access Hospitals (CAHs). Methods: Information about the use and perceived effectiveness of 44 specific strategies to improve financial performance was collected from an online survey of… Read more »

Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals Critical Access Hospitals (CAHs) receive cost-based reimbursement from Medicare for inpatient care, including post-acute skilled care provided in swing beds (skilled swing days). Because the reimbur… Read more »

Background of trends in skilled nursing facility and swing bed use in rural areas Reimbursement for facility-based post-acute skilled care has been affected by multiple regulatory changes, particularly during the period from 1997 to 2003. Payment for post-acute skilled care received in freestanding… Read more »

Background of “Trends in the Provision of Surgery by Rural Hospitals” Surgery is an important health service in rural communities. In addition to providing routine surgical services, surgeons also serve as backup for other medical specialities such as obstetrics and are essential for the treatment o… Read more »

Overview of “Recent Changes in Health Insurance Coverage in Rural and Urban Areas” There has been concern about the impact of the recent economic downturn on health insurance coverage in the U.S. From 2007 to 2009, an additional 5.6 million adults became uninsured as a result of decreases in the num… Read more »

Rural Hospital Support for Emergency Medcial Services overview Prehospital emergency care is an important component of a comprehensive health care system. Rural EMS agencies face continual challenges to ensure a qualified workforce to meet prehospital emergency care needs. While most EMS agencies fu… Read more »

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 »

Rural Volunteer EMS: Reports from the Field overview Prehospital emergency care services (EMS) are an essential component of a comprehensive health care system. Rural residents and visitors to rural areas rely on EMS for treatment and transport in the event of an injury or other health emergency. In… Read more »

Profitability of Rural Hospitals Paid Under Prospective Payment Compared to Rural Hospitals with Special Medicare Payment Provisions overview The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1983. Under PPS, hospitals are paid a pre-determined rate f… Read more »

About this project Lead researcher: Victoria Freeman, DrPH, RN Project completed: May 2010 In 2006, the Institute of Medicine published its report “Emergency Care for Children: Growing Pains” as part of its Future of Emergency Care series. Children comprise 27% of all emergency room admissions; yet,… Read more »

Pediatric Care in Rural Hospital Emergency Departments overview Optimal emergency care for children may be difficult for rural hospitals to provide. Rural hospitals have less access to pediatric and emergency medicine trained physicians and a low volume of pediatric ED patients makes it difficult fo… Read more »

A Financial Comparison of Rural Hospitals With Special Medicare Payment Provisions to Hospitals Paid Under Prospective Payment overview The financial performance of rural hospitals has long been a concern to federal and state agencies as well as banks, creditors, bond rating firms, and regulators. F… Read more »

States’ Use of Cost-Based Reimbursement for Medicaid Services at Critical Access Hospitals overview Critical Access Hospitals (CAH) are reimbursed by Medicare at 101% of allowable cost for both inpatient and outpatient services. State Medicaid agencies, however, are not required to reimburse CAHs on… Read more »

The Effect of Medicare Part D Plan Switching and Formulary Changes on Sole Community Pharmacies and the Patients They Serve overview Sole community independent pharmacies (i.e., those located at least 10 miles from the next closest retail pharmacy) are the primary access point to pharmacy services f… Read more »

Learn more about Medicaid and CHIP in our mini-studies Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2009 Project completed: December 2010 Medicaid and the Children’s Health Insurance Program (CHIP) are important sources of health insurance coverage, especially in rural communit… Read more »

About this project Project funded: September 2009 Project completed: August 2011 Characteristics of rural residents, combined with challenges faced by rural providers, make rural health care systems far more vulnerable to changes in federal health care policy than are those in urban areas. Because o… Read more »

Examining the impact of surgery on rural hospital market share 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 Project funded: September 2009 Project completed: March 2011 Recent… Read more »

Profile of Sole Community Pharmacists’ Prescription Sales and Overall Financial Position overview Sole community independent pharmacists provide essential services to residents of small towns and isolated communities. In an effort to document the role sole community pharmacies play in their local he… Read more »

Workforce Issues Among Sole Community Pharmacies overview In just over one thousand small rural communities throughout the United States, pharmacy services are delivered through a single independently owned retail outlet. In recent years this group of pharmacies has been subject to increased financi… Read more »

Medicaid & CHIP Participation Among Rural & Urban Children overview Public Health Insurance Programs Are Especially Important For Rural Children Compared to urban residents, rural families have less access to job-based coverage and may be less able to afford non-group private plans. Medicaid… Read more »

Characteristics of Rural & Urban Children Who Qualify For Medicaid or CHIP But Are Not Enrolled overview Substantial Portions of Children Who Are Eligible to Enroll in Medicaid or CHIP Are Uninsured About three-quarters of children who qualify for Medicaid or CHIP are enrolled, with slightly hig… Read more »

The Key Role of Sole Community Pharmacists in Their Local Healthcare Delivery Systems project overview Sole community independent pharmacists provide essential services to residents of small towns and isolated communities. Anecdotal reports indicate their role within the local health care community… Read more »

Sole Community Pharmacies and Part D Participation: Implications for rural residents BACKGROUND The Medicare Part D Drug Plan (Part D), which was implemented on January 1, 2006, allows Medicare’s 44 million elderly and disabled beneficiaries to join a private Prescription Drug Plan (PDP) or join a M… Read more »

About this project Lead researcher: Jennifer King 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 found empirical… Read more »

Learn more about rural hospital ambulance services factors Lead researcher: Victoria Freeman, DrPH, RN Project funded: September 2008 Project completed: August 2010 Rural emergency medical services (EMS) agencies face continual challenges to ensure a trained workforce to meet the prehospital emergen… Read more »

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 »

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

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 »

BACKGROUND This Findings Brief describes the general characteristics of local rural EMS agencies and important ways that they differ from the characteristics of agencies located in urban areas. The data are from a national survey of 1,425 local EMS directors that was conducted in 2006-07. KEY FINDIN… Read more »

Background The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established funding to allow up to 43 million Medicare beneficiaries to enroll in plans providing comprehensive outpatient prescription drug coverage, beginning in January 2006. The new Medicare Part D progra… Read more »

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 »

Understanding volunteerism in rural EMS Project funded: September 2007 Project completed: August 2010 Emergency medical services (EMS) providers are continually challenged to maintain an adequate workforce. A survey of state EMS directors in 2004 suggests that volunteerism is declining in rural area… Read more »

Overview The 340B Drug Pricing Program (hereafter referred to as the 340B program) enables certain types of safety net organizations to obtain deep discounts on medications delivered during outpatient care, at prices below what is typically offered to Medicaid agencies. Prior to the 2003 Medicare Mo… Read more »

About this project Lead researchers: Claudia Schur, PhD and Rebecca T. Slifkin, PhD Project completed: August, 2007 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… Read more »

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) has take… Read more »

Assessing the impact of transfer of pharmacy services for dual eligible Medicare Part D beneficiaries   Project funded: September 2006 Project completed: October 2008 With the implementation of the Medicare prescription drug benefit (Part D) in January 2006, full-benefit dual eligible beneficia… Read more »

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 »

Trends over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals executive summary This study examines trends in the delivery of skilled nursing facility (SNF) services in both hospital-based units and swing beds during a period of dramatic change in Medicare payments for post-… Read more »

Contracting With Medicare Advantage Plans: A Brief for Critical Access Hospital Administrators overview This document summarizes the experience of CAH administrators with contracts offered by Medicare Advantage (MA) plans. Telephone surveys were conducted with CAH administrators across the country t… Read more »

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed: August 2005 Topics: Aging, Hospitals and clinics, Long-term care, Medicare Prospective Payment System (PPS) This study will examine trends in the distribution of skilled nursing facility (SNF) services in rural hospitals… Read more »

Understanding how the Medicaid budget crisis affects communities 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 eligibl… Read more »

Executive summary Childbirth by cesarean section (c-section) is major abdominal surgery that carries risk to both mother and baby. There are reasons to suggest that c-section rates at rural hospitals might be different than c-section rates at urban hospitals. The diffusion of best practices, such as… Read more »

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 »

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 »

About this project Lead researcher: Rebecca T. Slifkin, PhD Project completed:December 2004 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 Service… Read more »

About this project Lead researcher: Victoria Freeman, DrPH, RN 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 program, and compared this access across type… Read more »

About this project Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2004 Project completed: February 2007 This study addresses the occupation-mix adjustment that has recently been added to the computation of the area wage index used to adjust Medicare prospective rates for all inst… Read more »

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 »

About this project Contact: Thomas C. Ricketts, PhD Project funded: September 2004 Project completed: May 2007 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 America. The Medicar… Read more »

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 »

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 hospital… Read more »

About this project Lead researcher: Erin Fraher, MPH Project completed: August 2004 This study examined the supply, distribution, workload, and reimbursement patterns of pharmacists in rural areas. Pharmacist licensure data from five geographically diverse states with high rural populations were ana… Read more »

About this project Research center: North Carolina Rural Health Research and Policy Analysis Center Lead researcher: Rebecca T. Slifkin, PhD Project funded: April 2004 Project completed: August 2006 This project provides rapid and flexible analysis of Centers for Medicare and Medicaid Services (CMS)… Read more »

In July of 1998, the method for determining payments for Medicare services in skilled nursing facilities (SNFs) began a three-year transition from retrospective cost-based reimbursement to a SNF prospective payment system (SNF PPS). SNF PPS is based on national rates with an adjustment for differenc… Read more »

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 »

Understanding critical access hospital (CAH) conversion tracking Lead researcher: Rebecca T. Slifkin, PhD Project funded: September 2003 Project completed: August 2008 This multi-year project will continue the tracking of Critical Access Hospital (CAH) conversions. A CAH management information datas… Read more »

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 »

About this project George H. Pink, PhD, lead investigator Project funded: September 2003 Project completed: August 2008 This multi-year project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate methods of peer comparison, and identify… Read more »

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 »

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 »

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 »

Executive summary States are beginning to develop alternative managed care strategies for their Medicaid populations, including enhanced primary care case management (PCCM) programs that incorporate features originally developed for fully capitated managed care programs, such as care coordination an… Read more »

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 »

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 »

About this project Lead researcher: Pam Silberman, JD, DrPH 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 specifically at how these… Read more »

Unpredictable Demand and Low-Volume Hospitals background This Findings Brief assesses the degree to which the annual number of patient discharges varies from year to year for low volume hospitals. To the extent that demand for inpatient services is unpredictable, it is hard for administrators to set… Read more »

About this project This Findings Brief looks at the effects of year-to-year changes in annual inpatient discharges on costs per Medicare discharge. Low-volume hospitals, regardless of location, experience significantly greater total variability in inpatient demand across years, and greater changes i… Read more »

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 »

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 »

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 »

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 »

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 »

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 »

About this project Lead researcher: Randy Randolph, MRP 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 Administrative Reporting, a revision… Read more »

About this project Research staff: Thomas C. Ricketts & 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 conducted… Read more »

Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals Friedman HR, Holmes GM. Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals. Health Services Research. 2022 Oct;57(5):1029-1034. doi: 10.1111/1475-6773.14017. Epub 2022 Jul 13. P… Read more »

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 »

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 »

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 »

Abstract   OBJECTIVE: The purpose of this research study is to determine the effect of surgery on the profitability of rural hospitals. BACKGROUND: Small rural hospitals are often the sole health care provider in their communities and the only source of care for many people.  The provision of s… Read more »

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 »

Access to care in many communities has been reduced by rural hospital closures. The causes of rural hospital closures are complex and multifaceted, but unprofitability has been identified as a major contributor. In this study, the NC Rural Health Research Program focuses on system affiliation and ow… Read more »

The NC Rural Health Research Program has been tracking profitability of rural hospitals more than a decade. In a 2020 study, we found that: overall, profitability of rural hospitals decreased while the profitability of urban hospitals increased between 2016 and 2018.  Since our 2020 study was publis… Read more »

Access to care in many communities has been reduced by rural hospital closures. The causes of rural hospital closures are complex and multifaceted, but unprofitability has been identified as a major contributor. In this study, the NC Rural Health Research Program focuses on whether hospitals operate… Read more »

The NC Rural Health Research Program has been tracking the Low Volume Hospital (LVH) adjustment’s impact on rural hospitals. As policy makers consider legislation to maintain or alter the LVH adjustment before its expiration on December 31, 2024, the impact on more vulnerable communities is a releva… Read more »