Walsh Center for Rural Health Analysis

Publications

Listed by publication date. You can also view these publications alphabetically.

2008

• Experiences of Critical Access Hospitals in the Provision of Emergency Medical Services (Policy Brief)
  Author(s): Janet P. Sutton, June Eichner
  Report Number: W Series No.15
  Date: 10 / 2008
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS)
  This brief presents NORC Walsh Center for Rural Health Analysis research conducted to better understand the experiences of CAHs in operating an EMS unit. Using key informant interviews, researchers examined motivations for acquiring EMS services and the effect of these services on the level of emergency care available in the community. The benefits and challenges that CAH providers face in operating EMS services are discussed.
• Impact of CAH Conversion on Hospital Finances and Mix of Inpatient Services (Final Report)
  Author(s): Julie Schoenman and Janet Sutton
  Date: 08 / 2008
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing, Health services
  This study examined Medicare Cost Report and claims data for hospitals before and after CAH conversion in order to better understand changes in hospital costs associated with CAH conversion, factors associated with any cost growth, and changes in the mix of services provided by the facility.
• Urban-to-Rural Evacuation: Planning for Population Surge (Final Report)
  Author(s): Michael Meit, Alene Kennedy, Thomas Briggs
  Date: 08 / 2008
  Topic: Emergency preparedness
  To date, rural emergency planning efforts have focused more on addressing the needs of rural residents and have not accounted for potential population surge from neighboring urban areas in the event of disaster. In many areas, rural infrastructure and capacities are likely to be stretched thin or possibly overwhelmed. This study assessed the likelihood of urban evacuation to rural areas and provides recommendations for rural planning and response.
• Financing Rural Public Health Activities in Prevention and Health Promotion (Final Report)
  Author(s): Michael Meit, Lorraine Ettaro, Benjamin Hamlin, Bhumika Piya
  Date: 06 / 2008
  Topics: Chronic diseases and conditions, Health care financing, Health promotion and disease prevention, Public health
  Final Report of a study to determine whether the flow of federal resources, from federal agencies, through states, and to communities, is influenced by state and local level public health infrastructure.
• Rural Public Health Financing: The Relationship Between Infrastructure and Local Program Funding (Policy Brief)
  Author(s): Michael Meit, Lorraine Ettaro, Benjamin Hamlin, Bhumika Piya
  Report Number: W Series No. 14
  Date: 06 / 2008
  Topics: Chronic diseases and conditions, Health care financing, Health promotion and disease prevention, Public health
  The purpose of this study was to describe how federal funds for selected chronic disease prevention and health promotion activities are distributed to local health departments and non-governmental organizations at the local level and to identify infrastructure-related barriers that rural agencies may face in securing and using funds for such purposes. A central hypothesis was that the availability of federal funding for chronic disease prevention and health promotion activities may vary based on state and local public health infrastructural differences.
• Critical Access Hospitals' Experience with Medicare Advantage Plans
  Date: 03 / 2008
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Hospitals and clinics, Medicare Advantage (MA)
  This report details findings from a survey of 60 critical access hospital (CAH) administrators regarding their experiences with Medicare Advantage (MA) plans. Findings from this research identify concerns of CAH administrators that, as the MA program evolves, may be addressed through technical assistance and changes in regulation or legislation.

2007

• Spontaneous Evacuation Following a Dirty Bomb or Pandemic Influenza: Highlights from a National Survey of Urban Residents’ Intended Behavior
  Author(s): Michael Meit, Thomas Briggs, Alene Kennedy, Janet Sutton, Jacob Feldman
  Report Number: W Series No. 12
  Date: 11 / 2007
  Topic: Emergency preparedness
  Reports results of a national survey to assess the evacuation intentions of urban citizens following emergency scenarios. Includes information on how likely it would be for evacuees to go to a rural or urban area. Discusses the potential impact of an urban evacuation on rural areas.
• Rural Hospitals' Experience with the 340B Drug Pricing Program
  Author(s): Claudia Schur, Karen Cheung, Andrea Radford, Rebecca Slifkin
  Date: 09 / 2007
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Policy brief describing the results of surveys of rural hospitals participating in the 340B drug pricing program and of rural eligible but non-participating hospitals. Includes information on factors affecting participation in the program and the benefits and challenges of participation.
• How Will Elimination of Hospital Bad Debt Reimbursement Affect Rural PPS Hospitals?
  Author(s): Janet P. Sutton, Alene Kennedy, Lucia Hammer, Grace Yang
  Report Number: Walsh W Series No. 11
  Date: 07 / 2007
  Topics: Health care financing, Hospitals and clinics, Medicare Prospective Payment System (PPS)
  Policy brief examining the financial effect that changes in current Medicare bad debt payment policy, as proposed in the FY2007 budget, might have on rural hospitals.
• Why Are Fewer Hospitals in the Delivery Business?
  Author(s): Lan Zhao
  Date: 06 / 2007
  Topics: Health services, Hospitals and clinics, Maternal and child health
  Examines the declining availability of hospital-based obstetric services in rural areas from the mid-1980s to the early 2000s. Examines potential causes for this trend and explores the effects of medical malpractice reforms. Report available on request.
• 340B Drug Pricing Program: Results of a Survey of Participating Hospitals
  Author(s): Claudia Schur, Karen Cheung, Andrea Radford, Rebecca Slifkin, Marianne Baernholdt
  Report Number: Working Paper No. 2007-03 (Walsh), Working Paper No. 90 (NC)
  Date: 05 / 2007
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Presents the results of a survey of pharmacy directors at rural hospitals currently buying discounted outpatient drugs through the 340B program. The purpose was to understand the perspectives of pharmacy directors on the 340B program in general, the financial impact of the program, and which specific program features presented barriers to its broader implementation.
• Small, Stand-Alone, and Struggling: The Adoption of Health Information Technology by Rural Hospitals (Policy Brief)
  Author(s): Julie A. Schoenman
  Report Number: Policy Analysis Brief W Series No. 10
  Date: 04 / 2007
  Topics: Health information technology, Hospitals and clinics
  Reports findings from a national survey of rural hospitals designed to investigate how differences among the hospitals affect their implementation of health IT. A full report is also available.
• Urban-to-Rural Evacuation: Planning for Population Surge (Policy Brief)
  Author(s): Michael Meit, Alene Kennedy, Thomas Briggs
  Report Number: Policy Analysis Brief W Series No. 9
  Date: 04 / 2007
  Topic: Emergency preparedness
  Discusses disaster planning and how rural preparedness officials face significant informational, organizational, and infrastructural constraints in their abilities to prepare for a potential population surge from urban areas.
• Delivering the U.S. Preventive Services Task Force Recommendations in a Rural Health Plan
  Author(s): Alycia Infante, Michael Meit
  Report Number: Research Brief, W Series No. 8
  Date: 02 / 2007
  Topics: Health promotion and disease prevention, Health services
  Explores the challenges that one health plan faces in delivering the U.S. Preventive Services Task Force (USPSTF) recommendations to its rural patient population.
• Evaluation of the U.S. Preventive Services Task Force Recommendations for Clinical Preventive Services
  Author(s): Alycia Infante, Michael Meit, Thomas Briggs, Caitlin Oppenheimer, Jennifer Benz
  Report Number: Final Report
  Date: 02 / 2007
  Topics: Health promotion and disease prevention, Health services
  Reports findings addressing the adoption, integration, delivery, and dissemination of the U.S. Preventive Services Task Force (USPSTF) recommendations for clinical preventive services in different types of health plans.
• Small, Stand-Alone, and Struggling: The Adoption of Health Information Technology by Rural Hospitals (Full Report)
  Author(s): Julie A. Schoenman
  Date: 02 / 2007
  Topics: Health information technology, Hospitals and clinics
  Reports the full findings from a national survey of rural hospitals designed to investigate how differences among the hospitals affect their implementation of health IT.
• 340B Drug Pricing Program: Results of a Survey of Eligible but Non-Participating Rural Hospitals
  Author(s): Andrea Radford, Rebecca Slifkin, Claudia Schur, Karen Cheung
  Report Number: Working Paper No. 88 (UNC), Working Paper 2007-01 (Walsh)
  Date: 01 / 2007
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Summarizes the results of a 2006 survey of pharmacy directors at rural hospitals that are eligible but currently not participating in the 340B Drug Pricing Program, which enables certain types of safety-net organizations to obtain discounted outpatient medications.

2006

• Roadmap for the Adoption of Health Information Technology in Rural Communities
  Author(s): Julie A. Schoenman, Joy Keeler, Adil Moiduddin, Benjamin N. Hamlin
  Date: 08 / 2006
  Topic: Health information technology
  Assists rural providers who are just beginning their investigation of using health IT, and its applicability to their organization.
• Attention from the Top? Roles of State Offices of Rural Health Policy in Preparing for Bioterrorism and Other Health System Emergencies
  Author(s): Curt D. Mueller, A. Ketchel, L. Silver
  Date: 07 / 2006
  Topic: Emergency preparedness
  Presents results from a follow-up survey of directors of state offices of rural health on emergency preparedness in rural communities. A telephone survey was used to identify state office involvement with emergency preparedness (EP) activities. Findings indicate that the nature of involvement varied considerably across states. Among the most pressing needs were for improvements in communication and for additional EP training, especially for EMS and hospital personnel. Most offices were involved in activities related to development of an emergency preparedness response plan encompassing the state (71 percent) or development of a plan for regions within the state (55 percent). Over half of state office directors reported involvement in assessment of training needs of emergency personnel and in assessing EP of rural hospitals. Almost half of state offices participated in assessment of rural public health system preparedness capabilities. Sixty-one percent of offices assisted in development of capabilities for the electronic exchange of information among health care providers and public health officials serving rural areas, and 48 percent of rural offices were engaged in activities in support of development of a system for receipt of urgent reports or information by providers on a 24-hour-7-day basis.
• Performance of Rural and Urban Home Health Agencies in Improving Patient Outcomes
  Author(s): Janet P. Sutton
  Date: 05 / 2006
  Topics: Home health, Medicare
  This study was conducted to determine whether rural and urban home care agencies differ in terms of patient care outcomes, and to ascertain whether there are agency characteristics that are associated with better or worse outcomes. This study found rather small differences in the quality of care provided by home health agencies in rural and urban areas. Findings from the multivariate analyses indicated that rural agencies performed better on measures of improvement in walking, transferring, and dressing, whereas urban agencies performed better on measures of improvement in pain frequency and medication management. Rural or urban location had only a modest effect on functional performance scores. Rural and urban agency differences in rates of unplanned urgent care and hospital admissions were not statistically significant after controlling for other agency characteristics, region of country and characteristics of the health care market.
• Rural Public Health Infrastructure: Case Studies to Assess the Impact of Structure on Service Delivery
  Author(s): Leigh Ann White, Lauren Silver
  Date: 01 / 2006
  Topic: Public health
  The purpose of this study is to contribute to a more thorough understanding of how public health governance affects how states structure and organize the delivery of public health services, and how this, in turn, influences the strategies adopted for meeting community public health needs in rural areas. Using a case study approach, the study examined three themes: 1) lines of reporting and accountability among public health entities, 2) provision of public health services, and 3) public health funding for localities. This work suggests that it would be of value to develop a comprehensive profile of state' public health systems, which would include specific aspects of each state's public health infrastructure, as well as community population and health statistics. Report available on request.

2005

• Contracting with Medicare Advantage Plans: A Brief for Critical Access Hospital Administrators
  Author(s): Michelle Mason, Roslyn Fraser-Maginn, Keith Mueller, Jennifer King, Andrea Radford, Rebecca Slifkin, Jennifer Lenardson, Lauren Silver, Curt Mueller
  Date: 12 / 2005
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Medicare Advantage (MA)
  Summarizes the experience of Critical Access Hospital (CAH) administrators with contracts offered by Medicare Advantage (MA) plans. Telephone surveys were conducted with CAH administrators across the country to learn about their experiences with MA plans. This brief includes information about the contract terms administrators have been offered, their experiences negotiating with MA plans, and their advice for others dealing with this issue.
• Revisions to Medicare's Disproportionate Share Payment Policy to Incorporate Bad Debt and Charity Care
  Author(s): Julie A. Schoenman, Janet P. Sutton, Lan Zhao
  Date: 09 / 2005
  Topics: Health care financing, Hospitals and clinics, Medicare
  Investigates the impact of possible changes to the Medicare disproportionate share (DSH) payment policy, designed to incorporate information on the hospital's uncompensated care burden as well as to improve the payment formulae. DSH payments were computed for individual study hospitals under six alternative models, and compared to the payments now made under current law. For each alternative, the authors examined the overall financial impact by type of hospital and the characteristics of hospitals that would experience either large payment increases or decreases relative to the current system. These analyses are intended to help policymakers evaluate the likely impact of revising the DSH payment methodology.
• Utilization of Home Health Services Among Rural Medicare Beneficiaries Before and After the PPS
  Author(s): Janet P. Sutton
  Date: 08 / 2005
  Topics: Home health, Medicare Prospective Payment System (PPS), Rural statistics and demographics
  Describes a study conducted to gather information on the rural effects of the PPS, including whether the PPS contributed to changes in: (1) the demographic and clinical characteristics of home care users; (2) the likelihood of using each of six home care disciplines (aide, skilled nursing, physical therapy, occupational therapy, speech therapy and medical social work); and (3) the intensity of services. A total of 99,367 home health episodes were represented in the two years of Medicare data examined. In both study years, urban residents accounted for three-quarters of episodes, while residents of large rural counties and those of remote rural counties accounted for approximately 21 percent and 3 percent of episodes, respectively. Findings suggest that the PPS has had a mixed effect on access to home care in rural counties. Study results indicated an association between implementation of the PPS and admitting home health diagnoses, utilization and intensity of home care episodes and, for the subset of home health users admitted from an acute hospital, readmission rates.
• Home Health Payment Reform: Trends In The Supply Of Rural Agencies And Availability Of Home-Based Skilled Services
  Author(s): Janet P. Sutton
  Report Number: Policy Analysis Brief, W Series No. 6
  Date: 03 / 2005
  Topics: Home health, Medicare
  Findings from this study suggest that changes in home health reimbursement were associated with dramatic reductions in the supply of home care agencies; however those reductions appear to have occurred primarily during the time in which the Interim Payment System was in place. Although proportionately fewer rural agencies closed between 1998 and 2000, the closure of a rural agency may have a greater impact on access since many communities are experiencing critical shortages of providers. In the post-PPS period, agency supply became more stable, but closure rates were higher among rural agencies.
• Patterns Of Post-Acute Utilization In Rural And Urban Communities: Home Health, Skilled Nursing, and Inpatient Medical Rehabilitation
  Author(s): Janet P. Sutton
  Date: 03 / 2005
  Topics: Home health, Long term care
  Describes rural Medicare beneficiaries' patterns of post-acute utilization of home health services, skilled nursing facilities, and inpatient rehabilitation facilities. This study provides baseline data that policymakers, researchers, and others who are interested in rural health care issues may use to monitor how changes in Medicare policies affect access to post-acute care in rural areas.
• Rural Implications of Medicare's Post-Acute-Care Transfer Payment Policy
  Author(s): Julie A. Schoenman, Curt D. Mueller
  Citation: Journal of Rural Health, 21(2), 122-130
  Date: 2005
  Topics: Health care financing, Long term care, Medicare
  Examines how the initial policy change affected rural and urban hospitals and investigates the likely impact of the FY2004 expansion and other possible future expansions. The authors conclude that rural hospitals are not disproportionately harmed by the post-acute-care transfer policy. An expanded policy may even benefit rural hospitals by recognizing their lower use of post-acute-care and readjusting DRG weights so that they are paid more appropriately when providing the full course of inpatient care.

2004

• Rural Perspective Regarding Regulations Implementing Titles I and II of the Medicare Prescription Drug, Improvement, and Modernization Act Of 2003 (MMA)
  Author(s): Curt Mueller, Keith Mueller, Janet Sutton
  Report Number: Walsh W Series No. 6, RUPRI P2004-6
  Date: 08 / 2004
  Topics: Legislation and regulation, Medicare, Medicare Part D
  Provides in chart form sections of the MMA which were identified as having special concern to rural Medicare beneficiaries, medical care providers, and policymakers. The particular sections are cited and implications for rural health services are indicated. Most of the sections identified are concerned with access to prescription drug coverage and the impact of the proposed legislation on rural pharmacies. The primary focus is on rules that will affect providers of drug coverage; this policy paper does not focus on rural dimensions of coverage from the insurance providers' perspective.
• Exploring the Impact of Medicare's Post-Acute Care Transfer Payment Policy on Rural Hospitals
  Author(s): Julie A. Schoenman
  Report Number: Policy Analysis Brief W Series No. 5
  Date: 07 / 2004
  Topics: Health care financing, Hospitals and clinics, Medicare
  Describes a change in Medicare post-acute transfer payment policy and its impact on rural and urban hospitals. Includes data on the financial impact and hospital discharge behavior before and after the change. A full report is also available.
• Access To Primary Care And Quality Of Care In Rural America
  Date: 06 / 2004
  Topics: Health services, Quality
  Provides findings from a population-based study addressing the impact of the availability of health care resources on the rate of potentially avoidable hospitalizations. It suggests shortcomings with previous research conducted in communities that experienced problems accessing primary care services. Report available on request.
• Rural Implications of Medicare's Post-Acute Care Transfer Payment Policy
  Author(s): Julie A. Schoenman
  Date: 06 / 2004
  Topics: Health care financing, Long term care, Medicare
  Beginning in October 1998, Medicare began to pay acute-care hospital cases in 10 DRGs as transfers instead of discharges when the patient is discharged to a targeted post-acute care (PAC) provider after a short inpatient stay. This study examines the behavioral and financial impacts of the initial 10-DRG policy, and projects the likely financial impact of extending the policy to cover additional DRGs or discharges to swing beds. Key findings: 1) Hospitals' discharge behavior did not change significantly in ways that would suggest a strategic response to the PAC transfer payment policy; 2) Based on simulation, less than 5 percent of all cases discharged from the additional DRGs would receive the PAC transfer payment instead of the full DRG payment. Medicare revenue earned by rural hospitals would fall by more than $1,100 for each transfer case.; and 3) Expanding the transfer policy to cover swing beds would result in a relatively small financial impact. A policy brief is also available.
• Perspectives Of Rural Hospitals On Bioterrorism Preparedness Planning
  Author(s): Claudia L. Schur, Marc L. Berk, Curt D. Mueller
  Report Number: Policy Analysis Brief W Series No. 4
  Date: 04 / 2004
  Topics: Emergency preparedness, Hospitals and clinics
  Representatives from several rural hospitals met to discuss various aspects of bioterrorist preparedness in terms of workforce and training, physical capacity and supplies, communication, and coordination with other entities. Three main themes emerged from the discussion: 1) Bioterrorism resources have the potential to improve the rural health care delivery system, 2) A "cookie-cutter" model does not work for rural hospitals, and 3) Strategies for coping with a bioterrorist event need to be practical and have dual use.
• Understanding The Role Of The Rural Hospital Emergency Department In Responding To Bioterrorist Attacks And Other Emergencies: A Review Of The Literature And Guide To The Issues
  Author(s): Claudia L. Schur
  Date: 04 / 2004
  Topics: Emergency medical services (EMS), Emergency preparedness, Hospitals and clinics
  Reviews issues affecting rural hospitals' level of readiness for bioterrorist attack. Issues examined include physical capacity, sufficiency of health personnel, preparedness plans, disease surveillance systems, and communication/coordination. Concerns about funding cut across all the issues of preparedness.
• Rural Hospitals' Strategies for Achieving Compliance with HIPAA Privacy Requirements
  Report Number: Policy Analysis Brief W Series No. 3
  Date: 03 / 2004
  Topics: Hospitals and clinics, Technology
  Rural hospitals in this study recognized the importance of ensuring the confidentiality of patient health information, and have made substantial progress in achieving compliance with HIPAA privacy standards. Although these rural hospitals were using the flexibility afforded to them under HIPAA to develop common-sense approaches, each recognized that additional work will be required to effectively secure patient privacy, particularly as technology and the need for information advance. A full report is also available.
• Financially Distressed Rural Hospitals In Four States
  Report Number: Policy Analysis Brief W Series No. 2
  Date: 01 / 2004
  Topics: Health care financing, Hospitals and clinics, Medicare Prospective Payment System (PPS)
  The effect of the outpatient prospective payment system (OPPS) on the financial performance of rural hospitals was simulated in four states-Iowa, Texas, Washington, and West Virginia. Findings suggest that the profitability and cash position of small, government-owned, and Medicare-dependent hospitals will be adversely impacted by the OPPS. Results also suggest that the number of financially distressed rural hospitals will increase significantly. The small rural hospitals currently protected by the hold harmless provision are those most likely to be hardest hit by OPPS.
• Medicare Home Health Care in Rural America (Brief)
  Author(s): Sheila J. Franco
  Report Number: Policy Analysis Brief W Series No. 1
  Date: 01 / 2004
  Topics: Home health, Medicare
  This study looked at the characteristics of rural Medicare beneficiaries served by urban home health agencies as compared with those served by rural agencies. Findings demonstrate that urban agencies, either directly or through their branch offices, play an important role in providing home health care to rural Medicare beneficiaries. A full report is also available.

2003

• Survey of Critical Access Hospital (CAH)-Affiliated Emergency Medical Service (EMS) Providers
  Date: 09 / 2003
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS)
  To provide a description of EMS providers in rural communities, particularly those with CAHs
• Rural Hospitals' Strategies for Achieving Compliance With HIPAA Privacy Regulations: Case Studies Of Rural Hospitals
  Date: 08 / 2003
  Topics: Hospitals and clinics, Technology
  Rural hospitals in this study recognized the importance of ensuring the confidentiality of patient health information, and have made substantial progress in achieving compliance with HIPAA privacy standards. Although these rural hospitals were using the flexibility afforded to them under HIPAA to develop common-sense approaches, each recognized that additional work will be required to effectively secure patient privacy, particularly as technology and the need for information advance. A policy brief is also available. Report available on request.
• Who Receives Inpatient Charity Care in California?
  Date: 08 / 2003
  Topics: Health services, Hospitals and clinics
  Results of a study regarding how California hospitals determine charity care. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Medicare Home Health Care in Rural America (Full Report)
  Date: 06 / 2003
  Topics: Home health, Medicare
  This study looked at the characteristics of rural Medicare beneficiaries served by urban home health agencies as compared with those served by rural agencies. Findings demonstrate that urban agencies, either directly or through their branch offices, play an important role in providing home health care to rural Medicare beneficiaries. Report available on request. A policy brief is also available.
• Rural Beneficiaries' Projected Drug Coverage Under Three Medicare Prescription Drug Proposals
  Report Number: P 2003-1
  Date: 06 / 2003
  Topics: Medicare, Medicare Part D
  Estimates the expected increase in urban and rural Medicare beneficiaries eligible for drug coverage under three current Medicare prescription drug proposals. Also gives an estimate of the urban and rural per capita federal payments for drug coverage under the three proposals. Finds that total dollar impact of the three proposals is driven by their generosity. The costliest offers the greatest taxpayer-funded benefits. Per dollar of spending, the urban/rural division of federal drug outlays differs across the proposals. The Administration proposal would result in much higher per-capita federal drug spending in rural areas than urban ones. Congressional Republican and Democratic proposals show smaller rural-urban differences. Concludes that higher poverty and lower current drug coverage in rural areas affect projected spending under Medicare drug proposals. Per dollar of spending, the Administration's proposal to focus spending on near-poor without current coverage strongly favors rural areas. Congressional Democratic and Republican proposals subsidize coverage for all, including those currently with and without coverage. The urban-rural split of federal spending under those proposals depends on the extent to which the currently uninsured are willing to take up the newly offered benefit.
• Designing a Medicare Drug Benefit: Balancing Government-Based and Market-Based Approaches, the Implications for Rural Beneficiaries
  Date: 01 / 2003
  Topics: Legislation and regulation, Medicare, Medicare Part D
  Examines the relationship between a variety of design characteristics of a Medicare prescription drug benefit and their likely impact on rural areas. The research is based on an analysis of three competing legislative proposals, the House passed proposal (HR 4954), the "Tripartisan" proposal (S 2729), and the Graham proposal (S 2625). In addition, there is an analysis of data from the Medicare Current Beneficiary Survey, pharmacy benefit managers, discussions with various state and federal policy makers, and reviews of published literature. The study finds that the different prescription drug proposals will have positive implications for rural areas and address the lack of access to Medicare+Choice drug coverage in rural areas. Rural pharmacies may see a change in revenue, but the actual result of the changes has not been studied.
• 2003 Index of Hospital Quality
  Author(s): Colm O'Muircheartaigh
  Date: 2003
  Topics: Hospitals and clinics, Quality
  Published annually by U.S. News & World Report. Describes a series of factors regarding ranking of measuring hospital quality.

2002

• Rural Dimensions of Medicare Reimbursement for Inpatient and Outpatient Institutional and Physician Services
  Date: 12 / 2002
  Topics: Medicare, Physicians
  Examines major Medicare payment policies from the rural perspective. Specifically, it summarizes major payment policies with explicit rural dimensions that directly affect physicians and hospitals, examines existing evidence on whether there are direct rural impacts of the policy, and looks at whether direct rural impacts are consistent with legislative and regulatory inten
• Federal Funding for Emergency Medical Services
  Author(s): Penny E. Mohr, Julie A. Schoenman
  Date: 07 / 2002
  Topic: Emergency medical services (EMS)
  Includes recent trend data from 1994 to the present on aggregate Federal spending on EMS and funding targeted explicitly to rural areas. Also discusses the role various Federal agencies have played and traces the history of Federal legislation to support EMS programs. Activities funded under Title XII of the Public Health Service Act. Discussion of pending EMS-related legislation and future goals specified by the agencies included in the study. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Are Fundamental Changes to Medicare's Disproportionate Share Methodology Needed?
  Date: 06 / 2002
  Topic: Medicare
  Examines whether the Medicare disproportionate share percentage (DPP) is a useful predictor of Medicare costs per adjusted discharge and whether it is a good predictor of uncompensated care burdens. Findings indicate that the DPP is not a useful predictor of differences in the cost of treating Medicare patients (and is a statistically significant but weak predictor of uncompensated care burdens); the analysis does not support the contention that treatment of substantial numbers of low-income patients with public insurance directly causes hospitals to incur higher costs per discharge. It finds no support for basing DSH payments on DPP levels. The study concludes that if its results were confirmed in a national study of DSH payments, operating costs, and uncompensated care costs, there would be justification for fundamentally changing DSH payment methodology. Furthermore, since the results indicate that patient needs per adjusted discharge unit are unrelated to the DPP at both rural and urban hospitals, the authors see no rationale for differential treatment between rural and urban providers.
• Achieving Equity in Medicare DSH Payments to Rural Hospitals: An Assessment of the Financial Impact of Recent and Proposed Changes to the DSH Payment Formula
  Author(s): Janet Sutton, Jeffrey Stensland, Lan Zhao, Michael Cheng
  Date: 05 / 2002
  Topics: Health care financing, Hospitals and clinics, Medicare
  Examines how Benefits Improvement and Protection Act revisions to the qualifying and distribution formulas of the Medicare disproportionate share hospital (DSH) program are likely to affect rural hospital financial performance as measured by hospital operating and total margins. Also considers the effect of establishing a uniform DSH formula. The study shows that paying rural hospitals based on the rules used for urban hospitals would produce financial benefits that could improve access to care in rural communities. Notably, nearly one-fifth of financially distressed rural hospitals could have remained "in the black" and an even greater proportion could have received additional funds to cover costs incurred by treating indigent members of the community if rural hospitals had been paid in 1998 under the same DSH formula. Among the chief economic winners would be the smallest rural hospitals, which generally are in worse financial condition than other hospitals. Findings suggest that elimination of rural and urban disparities in DSH payment could strengthen the rural health care safety net. Report available on request.
• Capital Needs of Small Rural Hospitals
  Author(s): Jeffrey Stensland, Julie Schoenman, Curt Mueller, Andrew Singer
  Date: 05 / 2002
  Topics: Capital funding, Hospitals and clinics
  Examines the capital situation of rural hospitals with fewer than 50 beds to determine the total cost of bringing each facility into compliance with current laws, as well as the facilities' cost of borrowing and ability to borrow. Key results include: 38 percent report having deficiencies that, by law, require renovation or remodeling; the median cost of correcting those deficiencies is $1,000,000; most hospitals will need to, and have the ability to, borrow funds to correct the deficiencies; and the hospitals that report being unable to obtain loans tend to be older, low-volume hospitals with operating losses. Study concludes that due to the poor financial condition of hospitals that lack the ability to borrow, a new federal loan program does not appear to be the answer to their capital needs. Rather, improving access to capital depends on improving hospital profitability. The authors offer three options. 1) Medicare policy could provide hospitals in regions with very few patients an adjustment that would allow low-volume hospitals to earn a profit on Medicare patients. 2) Medicare policy could be adjusted to allow Medicare to directly pay a portion of hospitals' charity care and bad debt burdens. 3) Policy makers could set up a technical assistance program operated at the state level to assist rural hospitals in improving their financial condition.
• Variance in the Profitability of Small-Town Rural Hospitals (Policy Brief)
  Author(s): Jeffrey Stensland, Meredith Milet
  Date: 04 / 2002
  Topics: Health care financing, Hospitals and clinics
  This policy brief discusses why some rural small-town hospitals are financially successful and others struggle with persistent financial difficulties.
• Essential Research Issues in Rural Health: The State Rural Health Directors' Perspective
  Author(s): Michael J. O'Grady, Curt D. Mueller, Gail R. Wilensky
  Report Number: Policy Analysis Brief W Series, Vol. 5 No. 1
  Date: 03 / 2002
  Topic: Health policy
  Policy brief describes the key issues confronting state rural health directors. Five issues were repeatedly raised by directors from a wide variety of states: workforce, telemedicine, emergency medical services, mental health, and lack of local data.
• How State Rural Health Directors Obtain Policy-Relevant Research Information
  Author(s): Michael J. O'Grady, Curt D. Mueller, Gail R. Wilensky
  Report Number: Policy Analysis Brief W Series, Vol. 5 No. 2
  Date: 03 / 2002
  Topic: Health policy
  Policy brief summarizes how information pertinent to rural health policy activities of the state offices is obtained. The primary sources of policy-relevant information identified by directors are: the Internet, information sharing with others, and strategic partnerships with organizations outside the traditional health policy arena. The study also found that the organizational location of the state's office of rural health may affect the level of resources available for information gathering. The brief identifies steps to ensure that needed information can be accessed in the future: 1) state offices should have and maintain adequate resources to ensure ready access to electronic forms of information; 2) state offices should continue to share information on sources of health policy research; and 3) study further the implications of organizational form of state offices on resources available for getting needed information.
• Variance in the Profitability of Small-Town Rural Hospitals (Full Report)
  Author(s): Jeffrey Stensland, Meredith Milet
  Date: 02 / 2002
  Topics: Health care financing, Hospitals and clinics
  Documents the variance in profitability among small-town rural hospitals and evaluates the characteristics that distinguish highly profitable small-town hospitals from struggling ones. It also reports on strategies that small-town hospital administrators are using to achieve financial success and discusses public policy priorities for assisting small-town hospitals in rural America. Among the findings are that patient volumes appear to explain a significant portion of the difference in small-town hospital profitability. No small-town hospital with fewer than 300 admissions was able to generate significant profits and no small-town hospital with more than 2,500 admissions generated significant losses. Among the hospitals with between 300 and 2,500 admissions, there is a wide variance in profitability. The case studies suggest that lower staffing levels and higher levels of visiting specialists can improve profitability. They also suggest that bad debt burdens can create significant financial strain. Report available on request.

2001

• Quality of Medicare Outpatient Claims Data and Its Implications for Rural Outpatient Payment Policy
  Author(s): Penny E. Mohr
  Date: 12 / 2001
  Topic: Medicare Prospective Payment System (PPS)
  Analyzes Medicare outpatient claims to see if relatively poor quality of small rural hospitals' claims data have amplified the negative effects of the new payment system on small hospitals. Compares three indicators of quality across urban, rural, and small rural hospitals: 1) proportion of claims with missing procedure codes, 2) proportion of claims with multiple procedures codes, and 3) proportion of "low-intensity" versus higher intensity evaluation and management or emergency room services. Finds no significant differences among urban, rural, and low-volume rural hospitals with respect to missing codes; urban hospitals were more likely to have multiple codes; and small rural hospitals were substantially more likely to submit low intensity claims. Study does not refute the possibility that undercoding played a role in CMS's forecasts of negative impact of the outpatient PPS for small rural hospitals. Report available on request.
• Establishing a Fair Medicare Reimbursement for Low-Volume Rural Ambulance Providers
  Author(s): Penny E. Mohr, C. Michael Cheng, Curt D. Mueller
  Date: 07 / 2001
  Topics: Emergency medical services (EMS), Health care financing, Medicare
  National study of ambulance transport costs looks at the advantages and disadvantages of several options for Medicare to compensate low-volume rural ambulance providers. Among its conclusions: many low-volume rural volunteer EMS providers will benefit from the new Medicare fee schedule; a volume-based premium offers a disincentive for small providers to grow and take advantage of economies of scale; and cost-based reimbursement for a select class of rural providers would not over- or under-pay vulnerable providers. Report available on request.
• Is the Rural Safety Net at Risk? Analyses of Charity and Uncompensated Care Provided by Rural Hospitals in Washington, West Virginia, Texas, Iowa, and Vermont
  Author(s): Janet Sutton, Bonnie B. Blanchfield, Andrew Singer, Meredith Milet
  Date: 01 / 2001
  Topics: Health insurance and the uninsured, Hospitals and clinics
  Examines recent trends in the provision of both charity care and uncompensated care by rural hospitals in five states. Also identifies rural communities whose charity and uncompensated care may diminish if their hospitals face more intense financial pressures as a result of the Balanced Budget Act. Two major findings: 1) differences in hospitals' expenditures on charity and uncompensated care vary dramatically across states; and 2) hospital financial health may have a limited effect on charity and uncompensated care expenditures. Concludes that future access to hospital services in many rural communities will depend upon how the uncompensated care burden is shared between hospitals and the state. Report available on request.
• Will the Outpatient Prospective Payment System Increase the Number of Distressed Rural Hospitals in Iowa, Texas, Washington, and West Virginia?
  Date: 01 / 2001
  Topics: Health care financing, Hospitals and clinics, Medicare Prospective Payment System (PPS)
  Simulates the financial impact of the outpatient prospective payment system rates and estimates the number and type of rural hospitals in the five states likely to become financially distressed as a result of its implementation. Results clearly suggest that the outpatient PPS will have a significant negative impact on the profitability and cash position of many rural hospitals, especially those that are small, government owned, and classified as Medicare dependent. The results also suggest that this negative impact may lead to a significant increase in the number of financially distressed rural hospitals. Given these findings, a permanent exemption to outpatient prospective payment to small hospitals may be a policy alternative that would benefit rural communities and cost the Medicare program relatively little. Report available on request.

2000

• Data Sources for Studying Uncompensated Care Provided by Rural Hospitals
  Author(s): Bonnie B. Blanchfield, Emily Randall
  Date: 08 / 2000
  Topics: Health care financing, Health insurance and the uninsured, Hospitals and clinics
  This policy analysis brief discusses data sources related to hospitals' provision of charity and uncompensated care. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Potential Supply-Side Implications of the BBA Limits on Reimbursement to Provider-Based Rural Health Clinics
  Author(s): Julie A. Schoenman, C. Michael Cheng, Bonnie B. Blanchfield, Curt D. Mueller
  Date: 06 / 2000
  Topic: Rural Health Clinics (RHCs)
  This policy analysis brief examines whether provider-based (typically hospital operated) rural health clinics are likely to close due to the reimbursement cap introduced by the Balanced Budget Act of 1997 (BBA). For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Medicare Reforms: The Rural Perspective
  Author(s): Curt Mueller, Sheila J. Franco, Gail Wilensky
  Date: 04 / 2000
  Topics: Medicare, Pharmacy and prescription drugs
  Discusses Medicare reforms considered by the National Bipartisan Commission on the Future of Medicare (created by the Balanced Budget Act of 1997 - BBA), including prescription drug coverage, funding graduate medical education, and increasing the eligibility age. To request a copy, contact the Walsh Center at 301-951-5070.
• Rural Home Health Agencies: The Impact of the Balanced Budget Act
  Author(s): Sheila J. Franco, Joel Leon
  Date: 04 / 2000
  Topics: Home health, Medicare Prospective Payment System (PPS)
  This policy analysis brief examines how the characteristics of rural and urban Medicare-certified home health agencies differ, estimates the impact of interim payment system (IPS) on these agencies, and discusses policy implications for a Medicare home health prospective payment system (PPS). For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Rural and Urban Patterns of Home Health Use: Implications for Access Under the Interim Payment System
  Author(s): Janet P. Sutton
  Date: 03 / 2000
  Topics: Home health, Medicare
  This policy analysis brief compares patterns of home health utilization among rural and urban Medicare beneficiaries in order to estimate the potential impact of an interim payment system (IPS) on access to home care in rural areas of the country. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.

1999

• Implementation of the State Children's Health Insurance Program: Outreach, Enrollment, and Provider Participation in Rural Areas (Full Report)
  Author(s): Jennifer L. Dunbar, Harvey I. Sloane, Curt D. Mueller
  Date: 11 / 1999
  Topics: Children, Health insurance and the uninsured, Medicaid and S-CHIP, Poverty
  The State Children's Health Insurance Program (CHIP) provides states with an important source of funding for helping low-income, uninsured children overcome financial barriers to medical care. There is considerable interest among federal policy makers and rural advocates that CHIP may be especially important in providing coverage to children living in rural areas. This study qualitatively assesses CHIP outreach, enrollment, and provider issues in Colorado, Kansas, Oklahoma, Pennsylvania, and West Virginia. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.
• Implementation of the State Children's Health Insurance Program: Outreach, Enrollment, and Provider Participation in Rural Areas (Policy Brief)
  Author(s): Jennifer L. Dunbar, Harvey I. Sloane, Curt D. Mueller
  Date: 11 / 1999
  Topics: Children, Health insurance and the uninsured, Medicaid and S-CHIP, Poverty
  The State Children's Health Insurance Program (CHIP) provides states with an important source of funding for helping low-income, uninsured children overcome financial barriers to medical care. This policy analysis brief assesses CHIP outreach, enrollment, and provider issues in Colorado, Kansas, Oklahoma, Pennsylvania, and West Virginia. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.

1998

• Anticipating the 1997 State Children's Health Insurance Program: What's Current in Five Rural States?
  Author(s): Jennifer Dunbar, Curt Mueller
  Date: 01 / 1998
  Topics: Children, Health insurance and the uninsured, Medicaid and S-CHIP, Poverty
  This study examines aspects of of existing children's health insurance or health services to low-income, uninsured children. For a print copy of publications prior to 2004, please contact the Walsh Center at 301-951-5070.