Rebecca T. Slifkin, PhD

Director, North Carolina Rural Health Research and Policy Analysis Center

Phone: 919.966.5541
Fax: 919.966.5764
E-mail: becky_slifkin@unc.edu

Rural Health Research and Policy Analysis Center
University of North Carolina - Chapel Hill
725 MLK Jr. Blvd., CB 7590
Chapel Hill, NC 27599-7590

Current Projects

Critical Access Hospital Readiness for CMS Value-Based Purchasing
Research centers: North Carolina Rural Health Research and Policy Analysis Center, Upper Midwest Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing, Quality
The purpose of this project will be to assess Critical Access Hospital readiness for participation in a Value-based Purchasing program similar to that proposed by CMS for Prospective Payment System hospitals.

Medicaid and SCHIP Participation in Rural and Urban Areas
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Medicaid and S-CHIP
This project examines state-level Medicaid and SCHIP participation rates for children in rural and urban areas. It also updates the State Profiles of Medicaid and SCHIP in Rural and Urban Areas web site and documents changes in program characteristics relevant to rural areas over the past few years.

Completed Projects

Analysis of the Cesarean Section Rates in Rural Hospitals, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Hospitals and clinics, Maternal and child health
This project will describe the practice patterns for deliveries in rural hospitals. Cesarean section rates in rural hospitals will be compared to urban hospitals and the national rate.

Analytic Capacity to Respond to Changes in Medicare and Medicaid, Data Assistance to Policy Staff at the Federal Office of Rural Health Policy, and Production of Short Policy Briefs, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health policy, Legislation and regulation, Medicaid and S-CHIP, Medicare
This project will produce short policy briefs on a variety of topics related to proposed and enacted changes in Medicare and Medicaid, as requested by policy staff at the federal Office of Rural Health Policy.

Assessing the Impact of Transfer of Pharmacy Services for Dual Eligible Beneficiaries to Medicare Part D, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Medicaid and S-CHIP, Medicare Part D, Pharmacy and prescription drugs
This project will focus on the implementation of the new Part D benefit for those dually eligible for Medicare and Medicaid. The study will examine the impact on rural dual eligibles and their local pharmacies of the transfer to Part D coverage. The project is a joint undertaking with the RUPRI Center, taking advantage of unique data sets held at each center, the analytical and programming resources of both centers, and the ability to conduct qualitative analysis in multiple states efficiently.

Background Paper on Skilled Nursing Facilities in Rural Areas, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Long term care

Community Impact Assessment, Lead researcher
Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Networking and collaboration
This project will evaluate the impact of the Flex program on local communities. Activities will focus on identifying the ways in which the program could have a measurable effect, as well as the ways in which Flex program coordinators intended to affect community health. A briefing paper that integrates information on scope of services, networking, and quality will be produced. Additionally, case studies will be conducted in six CAH communities.

Critical Access Hospital Conversion Tracking, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
Information regarding new CAH conversions will be gathered from Flex coordinators and CMS, and added to the CAH management information dataset that is housed at UNC. Flex coordinators will also be queried regarding topics of interest to the coordinators, the monitoring team, and the federal Office of Rural Health Policy.

Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GIS, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health services, Physicians
This study will use a geographically weighted regression to assess the influence of distance and travel time on the distribution of physicians in rural America. The ultimate goal of the study will be to improve our measures of access by identifying the extent to which border resources can be considered in indices of access.

Describing the Health Care Infrastructure in Rural Towns, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Federally Qualified Health Centers (FQHCs), Hospitals and clinics, Mid-level practitioners, Physicians, Rural Health Clinics (RHCs), Rural statistics and demographics

Developing a Financial Performance Measurement System for Critical Access Hospitals, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing
This project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate bases or methods of peer comparison, investigate the relationship between quality of care and financial performance, and identify characteristics of high performing CAHs.

Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing, Medicare Prospective Payment System (PPS)
Making use of the financial indicators developed by project staff, the focus of this project is a longitudinal analysis of the dimensions and indicators of financial performance. Descriptive analyses are used to capture changes in all dimensions of financial performance pre- and post-conversion.

Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health policy, Medicaid and S-CHIP
The impact of the Medicaid budgetary crisis on rural communities across the US will be assessed through a 50-state survey of state Medicaid agencies, state Offices of Rural Health and state rural health associations.

Occupational Mix Differences Across PPS Hospitals: Analysis of Hospital Occupation Mix Survey Data and Implications for Rural Hospital Payments, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS), Workforce
This study addresses the occupation-mix adjustment that has recently been added to the computation of the area wage index used to adjust Medicare prospective rates for all institutional health care providers. The study will review the policy objectives as well as the mechanics of the adjustment, and then analyze the data from the most recent occupation-mix survey to obtain a better understanding of occupation mix differences across labor markets and hospital types.

Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehicle for Expanding Health Insurance to Rural Uninsured, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Health insurance and the uninsured
This project examines the experience of states that have implemented premium assistance programs in rural areas to determine whether there are certain design features or certain types of rural communities where these programs may be more feasible.

Rapid and Flexible Analysis of Data from Centers for Medicare and Medicaid Services, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health policy, Medicare, Rural statistics and demographics
Project staff will provide rapid and flexible analysis of CMS data in response to requests from ORHP staff. Work will be ongoing throughout the contract year, with the design of individual products determined in response to ORHP staff needs.

Role of Intensive Care Units in Critical Access Hospitals, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
This project will examine the role that intensive care units (ICUs) play in Critical Access Hospitals (CAHs). The number and geographic distribution of CAH with ICUs will be described, and types of services provided in these units discussed.

Rural Emergency Medical Services: Workforce and Medical Direction, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Emergency medical services (EMS), Workforce
This two year study will examine the status of medical direction for rural EMS systems and the nature of the challenges and impediments to obtaining adequate medical direction in rural areas across the country. In addition, the study will address issues surrounding the recruitment and retention of paid and volunteer staff for rural EMS systems.

Rural Hospital Closures, 1990-2000: Community Profiles and Economic Indicators Before and After the Event, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Economic development, Hospitals and clinics
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.

Rural Hospital Participation in the 340B Drug Discount Program, Lead researcher
Research centers: North Carolina Rural Health Research and Policy Analysis Center, Walsh Center for Rural Health Analysis
Funder: Office of Rural Health Policy (ORHP)
Topics: Hospitals and clinics, Pharmacy and prescription drugs
The 340B drug discount program enables certain types of safety net organizations to obtain deeply discounted medications, at prices below the 'best price' typically offered to Medicaid agencies. This study used telephone interviews and mail surveys to explore the experiences that rural hospitals have had in seeking 340B eligibility status.

Rural Population and Providers: Mapping the 2000 Census, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Rural statistics and demographics, Workforce

State Facts about Medicaid: Rural Specific Data, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Medicaid and S-CHIP, Rural statistics and demographics
This project will develop state-specific fact sheets which will include information on the groups covered (and income eligibility), structure of the state’s SCHIP program, services covered, delivery system, some provider payment information for certain safety net providers, and percentage of the state’s rural and urban population that are enrolled in Medicaid. Additional information comparing urban and rural areas of the state will be provided, when available. The rural and urban comparisons will include total numbers of Medicaid recipients, Medicaid expenditures, and enrollment in different types of managed care plans.

Tracking the Implementation of Medicaid Managed Care in Rural Areas
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Medicaid and S-CHIP

Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals, 1996-2003, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
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 during a period of dramatic change in Medicare reimbursement, most notably the transition from cost-based reimbursement to SNF prospective payment system (PPS).

Unmet Needs for Health Care Services: An Analysis of Children with Special Health Care Needs in Rural Areas, Lead researcher
Research center: North Carolina Rural Health Research and Policy Analysis Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Children, Dental health, Disabilities, Health services
This project will study whether parents of children with special health care needs (CSHCN) who live in rural areas are less likely to perceive the need for routine and specialty medical care than their metropolitan counterparts, and whether CSHCN that live in rural areas face a greater risk of having unmet needs for health care services than their metropolitan counterparts.

Publications

• 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
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Walsh Center for Rural Health Analysis
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Report Number: Working Paper No. 88 (UNC), Working Paper 2007-01 (Walsh)
  Date: 01 / 2007
  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.
• 340B Drug Pricing Program: Results of a Survey of Participating Hospitals
  Author(s): Claudia Schur, Karen Cheung, Andrea Radford, Rebecca Slifkin, Marianne Baernholdt
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Walsh Center for Rural Health Analysis
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Report Number: Working Paper No. 2007-03 (Walsh), Working Paper No. 90 (NC)
  Date: 05 / 2007
  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.
• Area Wage Index of the Medicare Inpatient Hospital Prospective Payment System: Perspectives, Policies, and Choices
  Author(s): Anthony Wellever, Andrew Coburn, Charles Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy McBride, Keith Mueller, Rebecca Slifkin
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Health care financing, Legislation and regulation, Medicare Prospective Payment System (PPS), Medicare Wage Index
  Date: 08 / 2000
  This Policy Paper summarizes the positions of various rural health advocates and recording the actions taken by Congress and the Health Care Financing Administration (HCFA) to improve the wage index. Finally, it outlines the research needed to energize the policy discussion of the uses and methods of calculating the hospital wage index. Report produced by the RUPRI Rural Health Panel.
• Assessment of Proposals for a Medicare Outpatient Prescription Drug Benefit: The Rural Perspective
  Author(s): Andrew F. Coburn, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Legislation and regulation, Medicare, Pharmacy and prescription drugs
  Date: 01 / 2003
  This Policy Paper assesses legislative proposals to add an outpatient prescription drug benefit to the Medicare program and their implications for the delivery of services and the welfare of beneficiaries in rural areas. Report produced by the RUPRI Rural Health Panel.
• At-Risk Hospitals: The Role of Critical Access Hospital Status in Mitigating the Effects of New Prospective Payment Systems Under Medicare
  Author(s): Kathleen Dalton, Rebecca Slifkin, Hilda Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Medicare Prospective Payment System (PPS)
  Date: 02 / 2000
  This report examines not-for-profit hospitals that potentially qualify as Critical Access Hospitals and identifies those facilities that are at risk as a result of Medicare's PPS to non-acute care settings.
• Becoming an Emergency Medical Technician: Urban-Rural Differences in Motivation and Job Satisfaction
  Author(s): P. Daniel Patterson, Victoria A Freeman, Charity G. Moore, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Emergency medical services (EMS), Workforce
  Report Number: Working Paper No. 89
  Date: 03 / 2007
  This study uses cross-sectional data from the 2003 national Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) Project to explore urban-rural differences in why EMTs enter the field, what is important in their jobs, and whether they are satisfied with their profession.
• Cesarean Section Patterns In Rural Hospitals
  Author(s): Sandra B. Greene, George M. Holmes, Rebecca Slifkin, Victoria Freeman, Hilda Ann Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Maternal and child health
  Report Number: Working Paper No. 80
  Date: 11 / 2004
  Examines childbirth delivery patterns in rural hospitals and compares the cesarean section (c-section) rate in rural hospitals to that in urban hospitals. The c-section rate for rural hospitals was well above the 10-15% rate recommended by the World Health Organization, and was higher (but not statistically significant) in rural hospitals than in urban hospitals. A Findings Brief on this topic is also available.
• Cesarean Section Rates in Rural Hospitals
  Author(s): Sandra Greene, George Holmes, Rebecca Slifkin, Victoria Freeman, Hilda Ann Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Maternal and child health
  Report Number: Findings Brief No. 79
  Date: 03 / 2005
  Findings Brief examining childbirth delivery patterns in rural hospitals and comparing the C-section rate in rural hospitals to that in urban hospitals using the Nationwide Inpatient Sample (NIS). Working Paper No. 80 on this topic is also available.
• Challenges for Rural Emergency Medical Services: Medical Oversight
  Author(s): Victoria Freeman, DrPH; Rebecca Slifkin, PhD; Daniel Patterson, PhD
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Emergency medical services (EMS), Workforce
  Report Number: Findings Brief 85
  Date: 05 / 2008
  This Findings Brief examines the challenges faced by local rural EMS agencies in obtaining a medical director and ensuring medical oversight for EMS personnel, and also describes how the challenges faced in rural areas differ from those in urban ones. The data are from a national survey of 1,425 local EMS directors that was conducted in 2006-2007.
• Comments on the June 2001 Report of the Medicare Payment Advisory Commission: Medicare in Rural America
  Author(s): Andrew Coburn, Charles Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy McBride, Keith Mueller, Rebecca Slifkin
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Health policy, Medicare
  Date: 09 / 2001
  Comments on and critiques the findings in MedPAC's Medicare in Rural America. The authors believe that while the MedPAC report helps set a framework for analysis, it is not a definitive treatise on the role of Medicare in rural health. Among its findings: most of MedPAC's recommendations would have positive impacts on health care for rural beneficiaries, others would do no harm, others could be strengthened, and a few, particularly those relating to access to services, "suffer from disparities and weaknesses." Report produced by the RUPRI Rural Health Panel.
• Community Impact of Critical Access Hospitals
  Author(s): John A. Gale, Andrew F. Coburn, Victoria Freeman, Walter R. Gregg, Rebecca Slifkin
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Policy Brief No. 2
  Date: 02 / 2007
  Discusses the findings of a project to understand the community involvement and impact of Critical Access Hospitals (CAHs) and the Medicare Rural Hospital Flexibility Program (Flex Program). Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Community Involvement of Critical Access Hospitals: Results of the 2004 National CAH Survey
  Author(s): Stephanie Poley, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Flex Monitoring Team Briefing Paper No. 6
  Date: 03 / 2005
  The data reported here provide a starting point for understanding Critical Access Hospital (CAH) community involvement. Data were collected and analyzed from a national telephone survey of CAH administrators conducted in 2004. Survey respondents were asked about community involvement activities including community needs assessment, outreach and formal health promotion programs, relationships with other community organizations, free or reduced cost health care, and hospital activities in support of special populations. Most CAHs are engaged in activities that offer benefit to their community beyond hospital-based acute care services. Administrators recognize the importance of being responsive to community needs and seek the financial support necessary to maintain outreach activities. The outreach programs reported by CAH administrators resemble typical community activities for a health care facility, with a particular emphasis on health promotion and management of chronic conditions. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Comparative Performance Data for Critical Access Hospitals
  Author(s): George H. Pink, Rebecca T. Slifkin, Andrew F. Coburn, John A. Gale
  Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Quality
  Citation: Journal of Rural Health, 20(4), 374-382
  Date: 2004
  Discusses the potential use of comparative performance data for critical access hospitals (CPD-CAH) to facilitate performance and quality improvement. Covers potential benefits and drawbacks of CPD-CH and identifies issues in the development and implementation of CPD-CAH.
• 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
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, Walsh Center for Rural Health Analysis
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Medicare Advantage (MA)
  Date: 12 / 2005
  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.
• Definition of Rural in the Context of the MMA Access Standards for Prescription Drug Plans
  Author(s): Keith J. Mueller, Rebecca T. Slifkin, Michael D. Shambaugh-Miller, Randy K. Randolph
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Defining rural, Legislation and regulation, Pharmacy and prescription drugs
  Report Number: RUPRI Policy Paper P2004-7, North Carolina Working Paper No. 79
  Date: 09 / 2004
  Access to local pharmacy services is dependent upon the extent to which prescription drug plans offering the Medicare benefit incorporate local rural pharmacies into their provider networks. This will be based on market considerations and on the requirements for local access contained in the MMA and regulation, which in turn will be shaped by how "rural" is defined. This paper assesses how the definition of rural affects the potential impact of the specific access standards in the Proposed Rule to implement Title I of the MMA, and finds that the congressional objective to achieve convenient access to pharmacies (other than mail order) would be more fully realized if the Proposed Rule definition of rural is changed.
• Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States
  Author(s): Stephanie Poley, Pam Silberman, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Medicaid and S-CHIP
  Date: 03 / 2003
  Discusses state programs that provide enhanced benefits to Medicaid beneficiaries such as enhanced primary care case management (PCCM). Examples from three states: Florida, North Carolina and Oklahoma.
• Designing a Prescription Drug Benefit for Rural Medicare Beneficiaries: Principles, Criteria, and Assessment
  Author(s): Andrew F. Coburn, Erika C. Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Medicare, Medicare Part D, Pharmacy and prescription drugs
  Date: 08 / 2000
  The purpose of this paper is to offer a rural perspective on the current debate over the design and implementation of a Medicare prescription drug benefit. Background information on rural Medicare beneficiaries' need for, and access to, prescription drugs is provided, along with a set of rural-oriented principles for use in evaluating how different prescription drug proposals may meet the needs of rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
• Effect of Market Reform on Rural Public Health Departments
  Author(s): Rebecca Slifkin, Pam Silberman, Susan Reif
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Public health
  Date: 01 / 2000
  This study seeks to determine how rural health departments and populations they serve have been affected by recent health system changes, especially Medicaid managed care.
• Effect of Rural Hospital Closures on Community Economic Health
  Author(s): George M. Holmes, Rebecca T. Slifkin, Randy K. Randolph, Stephanie Poley
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Economic development, Hospitals and clinics
  Citation: Health Services Research, 41(2), 467-485
  Date: 2006
  Describes the effect of hospital closure on the local economy, based on a study of county level economic data for 1990–2000 in rural counties experiencing a hospital closure.
• Effect of Rural Residence On Dental Unmet Need for Children With Special Health Care Needs
  Author(s): Asheley Cockrell Skinner, Rebecca T. Slifkin, Michelle L. Mayer
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Children, Dental health, Disabilities
  Citation: Journal of Rural Health, 22(1), 36-42
  Date: 2006
  Unmet need for dental care is the most prevalent unmet health care need among children with special health care needs (CSHCN), even though these children are at a greater risk for dental problems. The combination of rural residence and special health care needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs. Rural CSHCN are more likely to forgo needed dental care than their urban counterparts. Results suggest that rural CSHCN have unmet needs for dental care due to both difficulty accessing care and because their parents do not recognize a need.
• Effects of Rural Residence and Other Social Vulnerabilities on Subjective Measures of Unmet Need
  Author(s): Michelle L. Mayer, Rebecca T. Slifkin, Asheley Cockrell Skinner
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Children, Disabilities, Health services, Poverty
  Citation: Medical Care Research and Review, 62(5), 617-628
  Date: 2005
  To determine whether self-reports of unmet need are biased measures of access to health care, the authors examined the relationship between rural residence and perceived need for physician services. Logistic regression analyses was performed to examine the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs. Even after controlling for factors known to be associated with evaluated need, parents of rural children were less likely to report a need for routine or specialty services. Poor children, those whose mothers had less education, and those who were uninsured in the previous year were also less likely to perceive a need for physician services. Findings suggest that rural residence and other social vulnerabilities are associated with decreased perception of need, which may bias subjective measurements of unmet need for these populations.
• Emergency Medical Services (EMS) Activities Funded by the Medicare Rural Hospital Flexibility Program
  Author(s): P. Daniel Patterson, John A. Gale, Stephenie L. Loux, Anush E. Yousefian, Rebecca Slifkin
  Research centers: Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS)
  Report Number: Flex Monitoring Team Briefing Paper No. 8
  Date: 02 / 2006
  Describes the EMS related activities that the 45 states receiving funding from the Medicare Rural Hospital Flexibility (Flex) Program proposed to conduct in fiscal year 2004-2005. Since the first full year of funding, the number and range of EMS improvement activities proposed has increased substantially states' proposals contained 239 documented EMS improvement activities. Of these, 40% focused on the Integration of Health Services attribute, 13% on Human Resource challenges, and 13% on Education Systems. Continued support of activities begun prior to 2004 was common. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Experience of Rural Independent Pharmacies With Medicare Part D: Reports From the Field
  Author(s): Andrea Radford, Rebecca Slifkin, Roslyn Fraser, Michelle Mason, Keith Mueller
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Medicare Part D, Pharmacy and prescription drugs
  Citation: Journal of Rural Health, 23(4), 286–293
  Date: 2007
  Describes first-hand reports from rural pharmacist-owners about their experiences with Medicare Part D plans in the first 7 months of 2006 in order to gain a more thorough understanding of the challenges faced by rural independent pharmacies as a result of program implementation.
• Experience of Sole Community Rural Independent Pharmacies with Medicare Part D: Reports from the Field
  Author(s): Andrea Radford, Rebecca Slifkin, Roslyn Fraser, Michelle Mason, Keith Mueller
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Medicare Part D, Pharmacy and prescription drugs
  Report Number: Working Paper No. 87 (NC), Policy Paper P2006-3 (RUPRI)
  Date: 11 / 2006
  Case study describing first-hand reports from 12 rural independent pharmacists in seven states about their experiences with Medicare Part D plans (PDPs) in the first seven months of 2006. The rural independent pharmacists interviewed are experiencing major changes in payment, administrative burden, and interaction with patients as a result of the shift of patients into Medicare Part D plans. Previously, these patients were mostly non-covered cash or Medicaid-covered clients. Two consequences are apparent in the data collected: 1) Payment per prescription is lower from Medicare PDPs than from either non-covered cash or Medicaid, and in some instances payment from PDPs is less than the combined cost of stocking the medications and dispensing them, representing a reduction in revenue; and 2)The number of plans that provide Part D benefits greatly exceeds the two payment sources pharmacists previously dealt with, representing an increase in administrative burden for independent pharmacies.
• Exploring the Community Impact of Critical Access Hospitals
  Author(s): John Gale, Andrew Coburn, Walt Gregg, Rebecca Slifkin, Victoria Freeman
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Report Number: Flex Monitoring Team Briefing Paper No. 14
  Date: 01 / 2007
  Reports on a series of site visits to six diverse rural communities and Critical Access Hospitals (CAHs) to assess the experiences and impact of these hospitals in responding to their community’s health infrastructure needs. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Financial Indicators for Critical Access Hospitals
  Author(s): George H. Pink, G. Mark Holmes, Cameron D'Alpe, Lindsay A. Strunk, Patrick McGee, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing
  Report Number: Flex Monitoring Team Briefing Paper No. 7
  Date: 05 / 2005
  The purpose of this study was to develop and disseminate comparative financial indicators specifically for Critical Access Hospitals (CAHs) using Medicare Cost Report data. Results showed that, over the six years since 1998, CAHs generally became more profitable and increased their utilization of beds. However, while on average CAHs with long-term care became more liquid and reduced their use of debt over time, those without long-term care became less liquid and increased their use of debt. In the most recent year for which we have data (2003), CAHs without long-term care generally were more profitable, were more liquid, had less debt, and had higher utilization of beds in comparison to CAHs with long-term care. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Financial Indicators for Critical Access Hospitals
  Author(s): George H. Pink, G. Mark Holmes, Cameron D'Alpe, Lindsay A. Strunk, Patrick McGee, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing
  Citation: Journal of Rural Health, 22(3), 229-36
  Date: 2006
  There is a growing recognition of the need to measure and report hospital financial performance. However, there exists little comparative financial indicator data specifically for critical access hospitals (CAHs). The authors, along with a technical advisory group, focused on twenty indicators deemed appropriate for assessment of CAH financial condition and formulas determined. Issues 1 and 2 of the CAH Financial Indicators Report were mailed to the chief executive officers of 853 CAHs in the summer of 2004 and 1,092 CAHs in the summer of 2005, respectively. Each report included indicator values specifically for their CAH, indicator medians for peer groups, and an evaluation form.
• How Might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial Viability of Rural Pharmacies? An Analysis of Pre-Implementation Prescription Volume and Payment Sources in Rural and Urban Areas
  Author(s): Erin P. Fraher, Rebecca T. Slifkin, Laura Smith, Randy Randolph, Matthew Rudolf, George M. Holmes
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health care financing, Health policy, Medicare Part D, Pharmacy and prescription drugs
  Citation: Journal of Rural Health, 21(2), 114-121
  Date: 2005
  Presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs. urban areas. Together, these data provide a baseline for evaluating how implementation of the MMA may affect the financial viability of rural independent pharmacies. The authors found that the volume of mail-order prescriptions is small. Rural providers prescribed fewer retail and mail-order prescriptions per person, but more units per person. Rural areas have a higher percentage of prescriptions paid for by cash (18% vs. 13%) and Medicaid (16% vs. 10%) and a lower percentage of third-party payers than urban areas. Significant variation in volume and payer type exists between states. The authors conclude that rural, independent pharmacies may be negatively affected by MMA implementation as business shifts from cash to third-party reimbursement. The high degree of variation between states also has potentially important implications for the implementation of Prescription Drug Plan regions under MMA.
• If Fewer International Medical Graduates are Allowed in the U.S., Who Might Replace Them in Rural Underserved Areas?
  Author(s): Leonard D. Baer, Thomas R. Konrad, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: International Medical Graduates (IMGs), Workforce
  Report Number: Findings Brief
  Date: 05 / 2001
  Describes a study to identify rural communities that would be most affected by a decrease in availability of international medical graduates (IMGs) and perceptions of recruiters on who might replace IMGs in these areas. Includes maps. A full report is also available.
• If Fewer International Medical Graduates Were Allowed in the U.S., Who Might Replace Them in Rural Areas?
  Author(s): Leonard D. Baer, Thomas R. Konrad, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: International Medical Graduates (IMGs), Workforce
  Report Number: Working Paper No. 71
  Date: 02 / 2001
  Identifies rural communities that would be most affected should restrictions on IMG entry into the United States be tightened, and reports on the perceptions of physician recruiters and health planners about who might replace IMGs currently working in such areas. Findings indicate that given the difficulty of expanding ongoing recruitment and retention efforts, many underserved rural areas would likely remain underserved in the event of a cutback in IMGs, and many rural areas that are currently adequately served could face serious problems as well. A single national solution to replace IMGs would be difficult. Recruiters and planners within states and local areas will need to expand creative and innovative approaches, and even then, many rural communities might have to make do with less.
• Impact of Conversion to Critical Access Hospital Status on Hospital Financial Performance and Condition
  Author(s): Mark Holmes, George H. Pink, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing
  Report Number: Flex Monitoring Team Findings Brief No. 1
  Date: 11 / 2006
  Policy brief analyzing financial ratios associated with Critical Access Hospitals' profitability, liquidity, and capital structure. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• Impact of Medicaid Cuts on Rural Communities
  Author(s): Pam Silberman, Matt Rudolf, Laura Brogan, Stephanie Poley, Rebecca Slifkin, Charity Moore
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Medicaid and S-CHIP, Poverty
  Report Number: Working Paper No. 82
  Date: 08 / 2005
  Medicaid is a critical program in both urban and rural areas, but it is particularly important in rural areas because of high levels of poverty and less access to employer-sponsored insurance. This study assesses the perception of state Medicaid staff and individuals from State Offices of Rural Health (SORH) and Rural Health Associations (RHA) regarding the impact on rural areas of state Medicaid policy changes that occurred between 2002 and 2004. Despite the importance of this program to rural communities, our study suggests that few people are specifically concerned with the unique challenges Medicaid changes may pose to rural communities. This study presents insight to the potential rural impact of Medicaid policy changes, especially those that could adversely affect the ability of rural residents to access services or that might potentially affect the overall rural health infrastructure.
• Impact Of The Medicaid Budgetary Crisis On Rural Communities
  Author(s): Pam Silberman, Matthew Rudolf, Cammie D'Alpe, Randy Randolph, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Medicaid and S-CHIP
  Report Number: Working Paper No. 77
  Date: 08 / 2003
  Provides an overview of the Medicaid program and options states have to reduce program costs. Steps states have proposed or taken to reduce Medicaid costs and the potential impact of these changes on rural areas are discussed. The potential impact on rural communities of federal proposals to redesign Medicaid is assessed.
• Impacts of Multiple Race Reporting on Rural Health Policy and Data Analysis
  Author(s): Randy Randolph, Rebecca Slifkin, Lynn Whitener, Anna Wulfsberg
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health policy, Minority health
  Report Number: Working Paper No. 73
  Date: 05 / 2002
  Examines some of the impacts to rural health analysis of new federal policy that allows people to choose one or more race categories when classifying themselves. Implementation of the new policy in the 2000 Census yields 63 possible combinations of race classification. Report also presents data on the number of persons choosing more than one race, discusses ways that analysts can handle the issues surrounding multiple race data, and compares several methods for bridging the change from the old single-race system to the new multiple-race system. Among its findings: rural Americans were less inclined to identify themselves as more than one race than were urban Americans; rural western residents were the only ones more inclined to choose multiple races than the rural average; and rural residents of Hawaii, Alaska, and Oklahoma were the most likely to identify with multiple races while those of Mississippi, Pennsylvania, and South Carolina were the least likely to do so.
• Improving Prescription Drug Coverage for Rural Medicare Beneficiaries: Key Rural Considerations and Objectives for Legislative Proposals
  Author(s): Andrew F. Coburn, Erika Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Legislation and regulation, Pharmacy and prescription drugs
  Date: 06 / 2000
  This Policy Paper combines the work from current projects of the Maine Rural Health Research Center (MRHRC) and the Rural Health Panel of the Rural Policy Research Institute (RUPRI) to provide a statement of specific rural considerations and objectives for any proposal that would add a prescription drug benefit to the Medicare program. Our intent is to establish a framework for assessing the effects of proposals on rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
• Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States
  Author(s): Pam Silberman, Stephanie Poley, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Medicaid and S-CHIP
  Report Number: Working Paper No. 76
  Date: 01 / 2003
  Medicaid managed care programs have been continually growing in the past decade, but this system has posed some problems to rural areas. In order to address these problems, some states have developed alternative managed care strategies, including enhanced primary care case management (PCCM). This study examines three states that have implemented PCCM and provides an overview of each program including their strengths and weaknesses. The states studied are Florida, North Carolina, and Oklahoma.
• Intensive Care In Critical Access Hospitals
  Author(s): Victoria Freeman, Joan Walsh, Matthew Rudolf, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health services, Hospitals and clinics
  Report Number: Working Paper No. 81
  Date: 03 / 2005
  Describes what officials at Critical Access Hospitals (CAHs) mean when they report that they provide intensive care and the importance of these services to the hospital and the community it serves. Semi-structured interviews were conducted with Directors of Nursing at 63 CAHs in 27 states. Respondents described the physical structure of the intensive care area, equipment and staffing available for such care, types of patients who receive intensive care, transfer patterns, the role of intensive care in the decision to convert to CAH status, and the perceived value of this service to the community and hospital.
• Intensive Care in Critical Access Hospitals
  Author(s): Victoria A. Freeman, Joan Walsh, Matthew Rudolf, Rebecca T. Slifkin, Asheley Cockrell Skinner
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Citation: Journal of Rural Health, 23(2), 116-123
  Date: 2007
  Describes the facilities, equipment, and staffing used by Critical Access Hospitals (CAHs) for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community.
• Issues in Staffing Emergency Medical Services: A National Survey of Local Rural and Urban EMS Directors
  Author(s): Victoria Freeman, DrPH; Rebecca Slifkin, PhD; Daniel Patterson, PhD
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Emergency medical services (EMS), Workforce
  Report Number: Final Report No. 93
  Date: 05 / 2008
  This report explores rural-urban differences in medical oversight and the recruitment and retention of emergency medical technicians (EMTs)and paramedics as reported by a survey of 1,425 local EMS directors.
• One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Final Report)
  Author(s): Andrea Radford, Michelle Mason, Indira Richardson, Stephan Rutledge, Stephanie Poley, Keith Mueller, Rebecca Slifkin
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Medicare Part D, Pharmacy and prescription drugs
  Report Number: Final Report No. 92 (NC), Final Report No. P2007-1 (RUPRI)
  Date: 09 / 2007
  Describes the experiences of 51 rural independently-owned pharmacies that are the sole providers of pharmacy services in their community one year after implementation of the Medicare Part D prescription drug benefit. A findings brief is also available.
• One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Findings Brief)
  Author(s): Andrea Radford, Michelle Mason, Indira Richardson, Stephan Rutledge, Stephanie Poley, Keith Mueller, Rebecca Slifkin
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Medicare Part D, Pharmacy and prescription drugs
  Report Number: Findings Brief No. 83
  Date: 10 / 2007
  Describes the experiences of 51 rural independently-owned pharmacies that are the sole providers of pharmacy services in their community one year after implementation of the Medicare Part D prescription drug benefit. A final report is also available.
• PPS Inpatient Payment and the Area Wage Index
  Author(s): Kathleen Dalton, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS), Medicare Wage Index
  Date: 01 / 2001
  Discusses how inpatient rates are calculated, the role of the wage index, and issues surrounding the wage index and reimbursement to rural hospitals by Medicare under the Prospective Payment System (PPS).
• Premium Assistance Programs for Low Income Families: How Well Does it Work in Rural Areas?
  Author(s): Pam Silberman, Laura Brogan, Charity Moore, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Children, Health insurance and the uninsured, Medicaid and S-CHIP, Poverty
  Report Number: Working Paper No. 85
  Date: 01 / 2006
  Reports results of a study on the viability in rural areas of premium assistance programs use Medicaid or State Children's Health Insurance (SCHIP) funding to subsidize the premium costs of employer-sponsored insurance or private non-group policies for eligible individuals. Because of the characteristics of rural residents and their employment markets, many stand to benefit from premium assistance programs, but there are also reasons to believe that these programs may be less successful in rural communities. Findings form the telephone survey of Medicaid or SCHIP officials in 14 of the 16 states with at least one premium assistance program indicate that premium assistance programs have not lived up to their potential. Enrollment in most of the states' programs has been small, and while positive in concept, these programs have inherent limitations that may preclude more widespread enrollment. Of particular concern is that rural residents are more likely to work for small employers who do not offer health insurance or have higher premiums or less comprehensive benefits. However, with creative program design, premium assistance programs may be a useful tool for states to expand health insurance coverage to the rural uninsured.
• Primer On Interpreting Hospital Margins
  Author(s): Kathleen Dalton, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health care financing, Hospitals and clinics
  Date: 07 / 2003
  Explains the most commonly used measures of hospital profitability, and how they are used to inform policy changes. Covers measures of overall or payer-specific profitability, total margins and operating margins. Particular emphasis on the different formulas as they impact rural versus urban hospital figures. Addresses the different ways in which these measures are commonly aggregated when they are used in descriptive studies or regulatory impact statements.
• Primer on the Occupational Mix Adjustment to the Medicare Hospital Wage Index
  Author(s): Kristin Reiter, Rebecca Slifkin, Mark Holmes
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Medicare Prospective Payment System (PPS), Medicare Wage Index
  Report Number: Working Paper No. 86
  Date: 09 / 2006
  Focuses on the occupational mix adjustment (OMA) to the labor-related share in the hospital inpatient prospective payment system. The Primer explains what the OMA is, why it is needed and how it has been calculated. In addition, reasons why the effect of the OMA has been less than some rural advocates anticipated are discussed.
• Race and Place: Urban-Rural Differences in Health for Racial and Ethnic Minorities
  Author(s): Rebecca T. Slifkin, Laurie J. Goldsmith, Thomas C. Ricketts,
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: AIDS and HIV, Chronic diseases and conditions, Health disparities, Health promotion and disease prevention, Minority health
  Date: 03 / 2000
  This findings brief investigates urban-rural disparities for racial and ethnic minorities in six health areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection, and child and adult immunizations.
• Redesigning Medicare: Considerations for Rural Beneficiaries and Health Systems
  Author(s): Andrew F. Coburn, Charles W. Fluharty, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Health policy, Medicare
  Report Number: Special Monograph
  Date: 02 / 2001
  Provides a framework to help shape proposals to redesign Medicare to the benefit of rural beneficiaries and providers. Chapters focus on equity, quality, choice, access, and cost. Each chapter outlines the current situation, analyzes the implications of various approaches to changing the program, and makes recommendations for developing a Medicare program of greatest benefit to rural residents. Report produced by the RUPRI Rural Health Panel.
• Redesigning the Medicare Program: An Opportunity to Improve Rural Health Care Systems?
  Author(s): Andrew F. Coburn, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Health policy, Medicare
  Date: 08 / 2000
  With this paper, the RUPRI Rural Health Panel is presenting a well-defined framework for what should be included in any discussion of Medicare policies.
• Role of CAH Status in Mitigating the Effects of New Prospective Payment Systems Under Medicare
  Author(s): Kathleen Dalton, Rebecca T. Slifkin, Hilda A. Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing, Medicare Prospective Payment System (PPS)
  Date: 01 / 2000
  Examines rural hospitals that potentially qualify as Critical Access Hospitals (CAH), and identifies facilities at substantial financial risk as a result of Medicare?s expansion of prospective payment systems (PPS) to non-acute settings.
• Rural and Urban Parents Report on Access to Health Care for their Children with Medicaid Managed Care
  Author(s): Victoria Freeman, Rebecca Slifkin, Asheley Skinner, Robert Schwartz
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Children, Medicaid and S-CHIP
  Report Number: Working Paper No. 84
  Date: 12 / 2005
  There has been little previous research on rural beneficiaries' perspectives on access to care under Medicaid managed care. The study reported here considers the perspective of the rural beneficiary in four states in order to broaden understanding of whether Medicaid managed care programs provide acceptable access to health care services. The study examines access to health care among rural children ages 0-17 who are enrolled in either fully capitated (New Mexico and Washington) or primary care case management (PCCM) Medicaid managed care plans (North Carolina and North Dakota), and compares this access to that of urban beneficiaries. Overall, this study finds that parents of children living in the rural areas who are enrolled in a Medicaid managed care program are almost always able to get the medical care they need. Rural children who are Medicaid enrollees have primary care providers, their parents know how to access care when needed after hours, and although rural children sometimes use the ER, they do not rely on that source of care more than urban parents do. Where barriers to medical care are reported, they are often consistent with those barriers reported for rural residents generally, and do not appear to be related to restrictions from managed care programs. Access to dental services remains a substantial problem, not just for children in rural areas, but for all Medicaid enrollees. 2004
• Rural Assessment of Leading Proposals to Redesign the Medicare Program
  Author(s): Andrew F. Coburn, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
  Research center: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
  Topics: Health policy, Medicare
  Date: 05 / 2000
  This Policy Paper provides a critique of two proposals to redesign the Medicare program: the "Medicare Preservation and Improvement Act of 1999" (S. 1895, introduced by Senator Breaux and others) and "The President's Plan to Modernize and Strengthen Medicare for the 21st Century." Rural implications of the proposals are discussed, specifically how they affect rural Medicare beneficiaries and rural providers of health care services. Report produced by the RUPRI Rural Health Panel.
• Rural Hospital Area Wages and the PPS Wage Index: 1900-1997
  Author(s): Kathleen Dalton, Rebecca Slifkin, Hilda Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Medicare Prospective Payment System (PPS), Medicare Wage Index
  Date: 10 / 2000
  
• Rural Hospital Wages and the Area Wage Index: 1990-1997
  Author(s): Kathleen Dalton, Rebecca T. Slifkin, Hilda A. Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Hospitals and clinics, Medicare Wage Index
  Date: 01 / 2001
  Examines whether incremental changes to the hospital wage index have made it more equitable across regions and how these changes have impacted rural hospitals.
• Rural Hospitals' Experience with the 340B Drug Pricing Program
  Author(s): Claudia Schur, Karen Cheung, Andrea Radford, Rebecca Slifkin
  Research centers: North Carolina Rural Health Research and Policy Analysis Center, Walsh Center for Rural Health Analysis
  Topics: Hospitals and clinics, Pharmacy and prescription drugs
  Date: 09 / 2007
  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.
• Rural Populations and Health Care Providers: A Map Book
  Author(s): Randy Randolph, Katherine Gaul, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Rural statistics and demographics, Workforce
  Date: 09 / 2002
  Uses 2000 Census data to reassess and provide a visual picture of where rural people live, how the racial and ethnic nature of rural populations is changing, and whether the distribution of health care providers matches the population distribution.
• Rural-Urban Differences in Characteristics of Local EMS Agencies
  Author(s): Victoria Freeman, DrPH; Rebecca Slifkin, PhD; Daniel Patterson, PhD
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Emergency medical services (EMS), Workforce
  Report Number: Findings Brief 84
  Date: 05 / 2008
  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 2006-2007.
• Rural-Urban Differences in Nursing Home and Skilled Nursing Supply
  Author(s): Kathleen Dalton, Courtney Harold VanHoutven, Rebecca Slifkin, Stephanie Poley, Ann Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Long term care
  Report Number: Working Paper No. 74
  Date: 02 / 2003
  Examines characteristics of nursing facilities and the supply of certified skilled nursing beds as the new PPS is being phased in, with particular reference to differences between urban and rural settings. Finds that rural-urban differences in the supply of long-term care beds and in the characteristics of long-term facilities are less pronounced, in general, than rural-urban differences in acute care capacity. Among the differences between urban and rural nursing facilities are: the most rural counties are the most likely to have no certified nursing homes; as counties become more rural, swing beds account for an increasing percentage of Medicare SNF discharges; and long-term care facilities in the most rural counties are more likely to be hospital based. Overall, the supply of nursing facilities does not appear to be a problem in rural areas, with the possible exception of the most rural counties.
• Rural-Urban Issues In The Wage Index Adjustment For Prospective Payment In Skilled Nursing Facilities (Brief Report)
  Author(s): Kathleen Dalton, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Long term care, Medicare Prospective Payment System (PPS), Medicare Wage Index
  Report Number: Findings Brief
  Date: 01 / 2004
  The hourly wage data collected from Medicare-participating nursing homes were used to examine urban and rural patterns in average hourly nursing home wages and patterns of wage variation within the statewide rural labor markets defined by CMS. The data were also used to examine the adequacy of the hospital wage index as an adjuster for skilled nursing facility rates. Working Paper No. 78 also addresses this topic.
• Rural-Urban Issues In The Wage Index Adjustment For Prospective Payment In Skilled Nursing Facilities (Full Report)
  Author(s): Kathleen Dalton, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Long term care, Medicare Prospective Payment System (PPS), Medicare Wage Index
  Report Number: Working Paper No. 78
  Date: 11 / 2003
  The hourly wage data collected from Medicare-participating nursing homes were used to examine urban and rural patterns in average hourly nursing home wages and patterns of wage variation within the statewide rural labor markets defined by CMS. The data were also used to examine the adequacy of the hospital wage index as an adjuster for skilled nursing facility rates. A findings brief on this topic is also available.
• Rural/Urban Differences in Barriers to and Burden of Care for Children With Special Health Care Needs
  Author(s): Asheley Cockrell Skinner, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Children, Disabilities
  Citation: Journal of Rural Health, 23(2), 150-157
  Date: 2007
  Examines the barriers and difficulties experienced by rural families of children with special health care needs in caring for their children. Covers rural-urban differences in types of providers used, reasons for unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care.
• State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program
  Author(s): John Gale, Jennifer Lenardson, Walt Gregg, Michelle Casey, Indira Richardson, Stephen Rutledge, Rebecca Slifkin
  Research centers: Maine Rural Health Research Center, Minnesota Rural Health Research Center , North Carolina Rural Health Research and Policy Analysis Center
  Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  Report Number: Flex Monitoring Team Briefing Paper No. 15
  Date: 10 / 2007
  Explores activities funded by the Medicare Rural Hospital Flexibility Program (Flex Program) to strengthen the rural health care infrastructure and discusses which activities were considered most successful by State Flex Coordinators. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
• State Profiles of Medicaid and SCHIP in Rural and Urban Areas
  Author(s): Jennifer King, Leslie Geiger, Pam Silberman, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Medicaid and S-CHIP, Rural statistics and demographics
  Report Number: Final Report No. 91
  Date: 08 / 2007
  This final report is one component of a larger project that includes the development of web-based State Profiles of Medicaid and SCHIP in Rural and Urban Areas. The report provides national data comparing Medicaid enrollment and expenditures in rural and urban counties. A summary of these and other data found in the State Profiles is included.
• Tracking Medicaid Managed Care in Rural Communities: A Fifty-State Follow-Up
  Author(s): Pam Silberman, Stephanle Poley, Kerry James, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Medicaid and S-CHIP
  Citation: Health Affairs, 21(4), 255-263
  Date: 08 / 2002
  Updates a 1997 study examining implementation of rural Medicaid managed care programs. Among its findings are that there have been significant state-level changes in the types of programs offered; there has been an overall increase in the percentage of urban and rural counties with Medicaid managed care programs; and SCHIP expansion has had little impact on the operation of fully capitated Medicaid managed care programs in rural areas because the increased number of children covered has not been large enough to affect health plans' participation. Concludes that looking only at the increase in rural Medicaid managed care since 1997 could lead to a false impression. While the number of rural counties with fully capitated programs has increased, states' more recent experiences suggest that health plans are pulling out of rural areas just as they are pulling out of urban ones. States may find it difficult to find commercial HMOs willing to participate in Medicaid managed care at prices that states can afford.
• Trends in Skilled Nursing and Swing-bed Use in Rural Areas, 1996-2003
  Author(s): Kathleen Dalton, Jeongyoung Park, Ann Howard, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Health services, Hospitals and clinics, Medicare
  Report Number: Working Paper No. 83
  Date: 12 / 2005
  Examines trends in the delivery of skilled nursing facility (SNF) services in rural areas during a period of dramatic change in Medicare payments for both acute and post-acute care, focusing on the role of rural hospitals in providing SNF services as they respond to the new reimbursement environment. The authors examined changes in the number and types of facilities providing this level of care, and computed comparative statistics on Medicare utilization, case mix, ancillary service use and per diem costs across the three different institutional settings where inpatient skilled nursing services can be provided-freestanding SNFs, hospital-based units, and swing beds in acute care hospitals.
• Trends over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
  Author(s): Kathleen Dalton, Rebecca Slifkin, Jeongyoung Park, and Hilda Ann Howard
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  Report Number: Findings Brief No. 81
  Date: 02 / 2006
  Examines trends in the delivery of skilled nursing facility services in both hospital-based units and swing beds during a period of dramatic change in Medicare payments for post-acute care, focusing on Critical Access Hospitals (CAHs).
• Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff
  Author(s): Keith J. Mueller, Andrew F. Coburn, A. Clinton MacKinney, Timothy D. McBride, Rebecca T. Slifkin, Mary K. Wakefield
  Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, Upper Midwest Rural Health Research Center
  Topics: Health policy, Legislation and regulation, Medicare, Pharmacy and prescription drugs
  Citation: Journal of Rural Health, 21(3), 194-197
  Date: 2005
  The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in September 2004 to identify a set of researchable questions concerning the impact of the MMA on rural health care. This paper presents research questions in the following areas that congressional staff identified as having the highest priority: access to health plans and pharmacy services, beneficiary outreach and enrollment, technology capacity, provider payment policy, and demonstration projects.
• Unpredictable Demand and Low-Volume Hospitals
  Author(s): Kathleen Dalton, Mark Holmes, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Hospitals and clinics
  Report Number: Findings Brief 75
  Date: 01 / 2003
  This Findings Brief assesses the degree to which the annual number of patient discharges varies from year to year for low volume hospitals. The study finds that low volume hospitals face more instability from year to year in demand for inpatient services than larger hospitals. Also, the average variability over time for the smallest hospitals, defined as less than 500 or fewer discharges a year, is nearly 60% higher than the average for all hospitals. Finally, the study concluded that even though low volume, rather than rurality, is the important factor, hospitals in extremely rural counties must contend with more fluctuation than other hospitals, primarily because they tend to be smaller.
• Unstable Demand and Cost per Case in Low-Volume Hospitals
  Author(s): Kathleen Dalton, Mark Holmes, Rebecca Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topic: Hospitals and clinics
  Report Number: Findings Brief 76
  Date: 01 / 2003
  This Findings Brief looks at the effects of year-to-year changes in annual inpatient discharges on costs per Medicare discharge. The analysis finds that small hospital costs are more vulnerable to change than larger hospital costs. As a result, average costs per discharge are less stable, making it difficult for these facilities to predict and manage profitability under fixed payment schemes. The study finds that among the lowest volume hospitals, there is a 10% decrease in discharges with every 3% increase in the cost per Medicare case. In addition, the study found that hospitals allowed to use swing-beds for long-term care patients are not less sensitive to volume fluctuations.
• Variations in Financial Performance Among Peer Groups of Critical Access Hospitals
  Author(s): George H. Pink, George M. Holmes, Roger E. Thompson, Rebecca T. Slifkin
  Research center: North Carolina Rural Health Research and Policy Analysis Center
  Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health care financing
  Citation: Journal of Rural Health, 23(4), 299–305
  Date: 2007
  Reports findings from a study that investigated whether indicators of financial performance and condition systematically vary among peer groups of Critical Access Hospitals (CAHs). Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.