North Carolina Rural Health Research and Policy Analysis Center

Completed Projects

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

2017

  • Exploring Regional Differences in Rural and Urban Mortality Trends
    Explores the differences in U.S. mortality rates by urban and rural location, census division, and urban and rural location within each census division. The gap in nationwide urban-rural mortality is often told as a national story, but the changes are regional. This implies different regions may need different strategies for addressing the gap.
    Topic: Health disparities

2016

  • Can a Model Predict Financial distress among Rural Hospitals?
    This project will extend an existing model of CAH financial distress to other types of rural hospitals. A valid model would be helpful to ORHP and state Offices of rural Health interested in predicting financial distress or closure of rural hospitals.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Hospitals and clinics
  • How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals?
    This two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); (3) financial performance; and (4) hospital revenue cycle management. Results will inform federal and state agencies, rural providers and communities as to how implementation of the Patient Protection and Affordable Care Act is impacting reimbursement and financial performance of rural hospitals, allowing the Office of Rural Health Policy to identify emerging challenges and develop strategies or policy changes needed to deal with any unintended consequences.
    Topics: Health insurance and the uninsured, Hospitals and clinics
  • How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals? (Year 2)
    The second year of this two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); and (4) financial performance.
    Topics: Health insurance and the uninsured, Healthcare financing, Medicaid and S-CHIP, Medicare
  • Policy Analysis Using the Financial Distress Model: Does Medicaid Expansion Affect the Risk of Hospital Financial Distress and Closure?
    This study will build on the 2014-15 approved project entitled “Can a Model Predict Financial Distress among Rural Hospitals?” The newly developed model uses current financial performance and market characteristic data to assign rural hospitals to one of four categories of risk of financial distress. The study will use Medicare Cost Report data for 2014, if available. Otherwise, simulation will be used to estimate the effects on financial distress.
    Topics: Hospitals and clinics, Medicaid and S-CHIP
  • Rural Health Clinics: Medicare & Medicaid Profile (Year 2)
    Year 2 of a project developing a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements. RHC Medicaid data for a sample of states also will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
    Topics: Medicaid and S-CHIP, Medicare, Rural Health Clinics (RHCs)
  • What Would be the Financial Consequence of Eliminating Low Volume Hospital Payments?
    Analysis will include comparison of the long-term profitability of LVHs to other rural hospitals and estimation of the potential profitability consequences of eliminating the payment classification altogether.
    Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)

2015

  • 21st Century Rural Hospital: Outpatient Services and Access to Care
    The rural hospital has changed dramatically with hospitals becoming increasingly outpatient-centered. This project is designed to inform policymakers about rural hospitals' provision of outpatient care, including publication of a Primer, detailing the variability in outpatient services provision by key characteristics that can be used to examine the potential impact of proposed policy changes on patients' ability to access different services.
    Topics: Health policy, Hospitals and clinics
  • Early Rural Experiences of Changes to Medicaid
    This project will 1) develop baseline state-level snapshots of rural enrollment in Medicaid and 2) estimate and model enrollment expansion in each state. We will also conduct a baseline provider key informant interviews in late 2013 to gauge expected effects, with follow up interviews in Summer 2014 as a sentinel warning system of early effects of changes to Medicaid in order to inform timely policy development.
    Topics: Federally Qualified Health Centers (FQHCs), Health insurance and the uninsured, Health policy, Hospitals and clinics, Medicaid and S-CHIP
  • Identifying Limitations of PPS Reimbursement for Rural Hospitals
    This project will investigate the potential financial and access consequences of returning rural hospitals to PPS payment. Characteristics of the hospitals and communities at highest risk of adverse consequences will be identified.
    Topics: Health policy, Healthcare financing, Hospitals and clinics
  • Rural Health Clinics: Medicare & Medicaid Profile
    This study builds on our work with the 2009 RHC Medicare claims. This project will result in the development of a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements (provider-based cost reports only at this point in time). RHC Medicaid data for a sample of states will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
    Topics: Medicare, Rural Health Clinics (RHCs)
  • What Does it Cost to Operate a Rural Free Standing Emergency Department (FED)?
    In recent months, there have been numerous media reports of rural hospital closures and the adverse effect on communities. In the face of hospital closure, one alternative for maintaining access to health care is rural free-standing emergency department (RFEDs).
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health policy, Healthcare financing, Medicare
  • What Happens after Acute Inpatient Care is No Longer Provided by a Rural Hospital?
    This project will investigate the precursors to closure of acute inpatient care by rural hospitals and the post-closure configuration of health care services in the community.
    Topic: Hospitals and clinics

2014

  • Comprehensive Study of Swing Bed Use in Rural Hospitals
    This project will comprehensively address questions about how swing beds are used by rural hospitals. Questions to be answered include whether decision about use are driven by patient need, community resources, hospital operational concerns or some combination of these factors; the cost implications of swing bed use in critical access hospitals to the Medicare program; and whether patients served in swing beds differ in meaningful ways from those in skilled nursing facilities.
    Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
  • Early Rural Experiences of Changes to Medicaid: Year 1
    In January 2014, some states will expand eligibility through the Medicaid program, while other states will not. Because rural residents are likely to be disproportionately affected by Medicaid expansion, understanding this interstate variation has important policy implications.
    Topics: Health policy, Medicaid and S-CHIP
  • Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations
    This study will describe usual patterns of care in rural areas to determine whether rural areas are part of a single service area, or whether smaller communities utilize services from a variety of larger hubs. The results of this analysis will inform a thought piece on how the concepts of bundled payments and Accountable Care Organizations might play out in small rural areas and whether small rural communities can be assigned to a single service area without major disruption of current patterns of care.
    Topics: Health policy, Health services
  • Rural Hospital Mergers and Acquisitions - Who is Being Acquired and What Happens Afterwards?
    This study compares the financial and market characteristics of recently acquired rural hospitals to other rural hospitals and investigates the post-acquisition change in services and financial performance of these hospitals. This study will inform rural advocates, federal and state agencies, and regulators as to how mergers and acquisitions (M&As) of small rural hospitals affect access to care for Medicare beneficiaries, and the potential financial consequences of M&As to small rural hospitals.
    Topics: Healthcare financing, Hospitals and clinics, Medicare

2013

  • Use of Rural Health Clinics by Medicare Beneficiaries
    Determination of Medicare beneficiaries utilization of available RHCs and development of a descriptive profile of Medicare beneficiaries who utilize RHCs including both geographic and diagnostic elements and a comparison to Medicare beneficiaries who utilize FQHCs.
    Topics: Medicare, Rural Health Clinics (RHCs)

2012

2011

  • Importance of Surgery to Rural Hospital Financial Condition and Market Share
    This study explores the provision of surgical services in rural hospitals and its relationship to financial performance. The percentage of rural hospitals that offer surgical services and the number that have discontinued surgical services over the last decade will be described, and, for those that have discontinued services, the impact on financial condition will be explored.
    Topic: Hospitals and clinics
  • Mini-Studies to Inform Health Reform Efforts
    Rural health care systems are far more vulnerable to changes in federal health care policy than are those in urban areas. The purpose of this project is to conduct rapid turnaround mini-studies that will be essential to maintain an effective rural voice in both the ongoing adjustments to current policies and the development of new policies.
    Topics: Health policy, Health services

2010

  • Factors Associated with Provision of Ambulance Services by Rural Hospitals
    This two-part study will use existing national data to determine how many hospitals have regularly offered ambulance services as well as how many have recently acquired or discontinued such services. In-depth interviews with selected rural hospital administrators will explore the factors related to a hospital's decision regarding these important health care services.
    Topic: Emergency medical services (EMS)
  • Medicaid and SCHIP Participation in Rural and Urban Areas
    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.
    Topic: Medicaid and S-CHIP
  • Rural Emergency Department Preparedness for Pediatric Care
    While many large cities have dedicated children's hospitals or facilities with pediatric emergency departments, many general hospitals do not have either the equipment necessary to provide optimal pediatric emergency care nor staff that is specifically trained in the care of pediatric emergencies. This project will use secondary data analysis and semi-structured interviews with emergency room directors in order to address how the availability of pediatric services, expertise and supplies in U.S. emergency departments differs between urban and rural facilities, and to determine which factors impede the availability of pediatric services, expertise, and supplies in rural emergency departments.
    Topics: Children, Health services, Hospitals and clinics
  • Rural Medicaid and CHIP Mini-Studies
    Medicaid and the Children's Health Insurance Program (CHIP) are important sources of health insurance coverage in rural communities and it is likely that the importance of Medicaid/CHIP will grow as job-based health insurance coverage continues to erode and policymakers pursue the goal of expanding coverage. This project is composed of three mini-studies that: 1) Update our State Profiles of Medicaid and CHIP in Rural and Urban Areas website, adding information on Medicaid Disproportionate Share Hospital (DSH) payments to rural hospitals; 2) Analyze trends in Medicaid/CHIP enrollment in rural and urban areas over the past two to three years; and 3) Explore the future role of CHIP given increasing levels of childhood poverty.
    Topics: Children, Medicaid and S-CHIP
  • Rural-urban Comparison of Hospital Financial Performance by Medicare Payment Classification
    This project will compare the financial performance of rural and urban short term general hospitals by Medicare payment classifications (PPS only, Medicare dependent hospitals, sole community hospitals, rural referral centers, and critical access hospitals).
    Topics: Hospitals and clinics, Medicare
  • Volunteerism in Rural EMS
    Semi-structured telephone interviews will be used to examine issues facing rural EMS services that have converted or are considering converting from volunteer services to paid services. Respondents will be queried regarding their conversion or consideration of conversion and the effect on their ability to recruit and retain personnel, their relationship with other agencies such as fire departments and hospitals, and the overall availability of EMS services.
    Topics: Emergency medical services (EMS), Healthcare financing, Workforce

2008

  • Assessing the Impact of Transfer of Pharmacy Services for Dual Eligible Beneficiaries to Medicare Part D
    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.
    Topics: Medicaid and S-CHIP, Medicare Part D, Pharmacy and prescription drugs
  • Critical Access Hospital Conversion Tracking
    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.
    Topic: Critical Access Hospitals and Rural Hospital Flexibility Program
  • Developing a Financial Performance Measurement System for Critical Access Hospitals
    This project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate bases or methods of peer comparison, investigate the relationship between quality of care and financial performance, and identify characteristics of high performing CAHs.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Healthcare financing
  • Move Toward Clinical Doctorates in the Allied Health Professions: Implications for Rural Areas
    Allied health occupations play a major role in health care delivery and comprise a significant proportion of the health care workforce in the United States. Researchers have found empirical evidence of allied health shortages in many states. Given the longstanding history of health professional shortages facing rural areas, there are concerns that the existing and impending shortages in allied health professions may be particularly acute in rural areas. This study will synthesize information on allied health professions, such as credentialing requirements and wage comparisons, with telephone and in-person interviews of rural health care employers, educators, and practitioners in order to assess the degree of alignment between community needs for allied health care services and existing and proposed certification and educational training for these health care providers.
    Topics: Allied health professionals, Workforce
  • Quality and Financial Status of Critical Access Hospitals: A Preliminary Analysis
    The purpose of this project is to continue to investigate the relationship between CAH financial performance and quality of care. UMN and UNC will jointly develop hypotheses related to the finance-quality link and statistical models suitable for testing hypotheses.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Healthcare financing, Quality
  • Rural Hospital Flexibility Performance Monitoring Project- Grant Years 2003-2008
    Under contract with the federal Office of Rural Health Policy, the Rural Health Research Centers at the Universities of Minnesota, North Carolina, and Southern Maine are cooperatively conducting a performance monitoring project for the Medicare Rural Hospital Flexibility Program (Flex Program). The monitoring project will assess the impact of the Flex Program on rural hospitals and communities and the role of states in achieving overall program objectives, including improving access to and the quality of health care services; improving the financial performance of Critical Access Hospitals; and engaging rural communities in health care system development.
    Topic: Critical Access Hospitals and Rural Hospital Flexibility Program

2007

  • Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GIS
    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.
    Topics: Health services, Physicians
  • Occupational Mix Differences Across PPS Hospitals: Analysis of Hospital Occupation Mix Survey Data and Implications for Rural Hospital Payments
    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.
    Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS), Workforce
  • Rural Emergency Medical Services: Workforce and Medical Direction
    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.
    Topics: Emergency medical services (EMS), Workforce
  • Rural Hospital Participation in the 340B Drug Discount Program
    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.
    Topics: Hospitals and clinics, Pharmacy and prescription drugs
  • State Facts about Medicaid: Rural Specific Data
    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.
    Topics: Medicaid and S-CHIP, Rural statistics and demographics

2006

  • Community Impact Assessment
    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.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Networking and collaboration
  • Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion
    Making use of the financial indicators developed by project staff, the focus of this project is a longitudinal analysis of the dimensions and indicators of financial performance. Descriptive analyses are used to capture changes in all dimensions of financial performance pre- and post-conversion.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Healthcare financing, Medicare Prospective Payment System (PPS)
  • Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehicle for Expanding Health Insurance to Rural 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.
    Topic: Health insurance and the uninsured
  • Rapid and Flexible Analysis of Data from Centers for Medicare and Medicaid Services
    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.
    Topics: Health policy, Medicare, Rural statistics and demographics

2005

  • Access to Health Care for Young Rural Medicaid Beneficiaries
    This study examined access to health care among rural children ages 0-17 who are enrolled in some type of Medicaid managed care program, and will compare this access across types of programs and, within program type, to that of urban beneficiaries.
    Topics: Children, Dental health, Health services, Medicaid and S-CHIP
  • Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey
    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.
    Topics: Health policy, Medicaid and S-CHIP
  • Role of Intensive Care Units in Critical Access Hospitals
    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.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Health services
  • Special Study of EMS Issues
    This study will focus on state, community, and hospital level initiatives designed to build the infrastructure to support EMS service capacity and encourage the integration of these services into the rural healthcare infrastructure in the areas of quality improvement, financing, staffing, medical control, and networking and integration.
    Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Networking and collaboration
  • Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals, 1996-2003
    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).
    Topics: Aging, Hospitals and clinics, Long term care, Medicare Prospective Payment System (PPS)

2004

2003

2002

2001