North Carolina Rural Health Research and Policy Analysis Center

Products

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

For a complete list of publications from the Center, which may include older publications and publications funded by other sources, please see the Center's website.

2017

  • Regional Differences in Rural and Urban Mortality Trends
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2017
    This brief explores the differences in mortality rates over time by (1) urban and rural location, (2) census division, and (3) urban and rural location within each census division.
  • The Financial Importance of Medicare Post-Acute and Hospice Care to Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2017
    This brief describes Medicare post-acute and hospice care provided by hospitals in rural areas by characterizing the variation in the number of rural hospitals that provide PAC and hospice care, the average amount of Medicare revenue rural hospitals receive for these services, and the financial importance of PAC and hospice care to rural hospitals.

2016

  • The Financial Importance of the Sole Community Hospital Payment Designation
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2016
    Assesses the financial importance of the Sole Community Hospital (SCH) program by: the proportion of SCHs that was reimbursed at the hospital specific rate between 2006 and 2015; the profitability of providing services to Medicare patients in SCHs between 2006 and 2015, and; the financial consequences if the SCH program had not existed in 2015.
  • The Impact of the Low Volume Hospital (LVH) Program on the Viability of Small, Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2016
    This brief compares rural Low Volume Hospital (LVH) to non-LVH characteristics and estimates the financial impact of eliminating the LVH program and reverting to the original (2005) LVH classification and payment adjustment.
  • Trends in Risk of Financial Distress among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2016
    From January 2005 to July 2016, 118 rural hospitals have closed permanently, and the rate of rural hospital closures is increasing. Hospital closures impact millions of rural residents. Identifying hospitals at high risk of closure and assessing the trends over time may inform strategies to prevent or mitigate the effects of closures.
  • Characteristics of Medicaid Beneficiaries Who Use Rural Health Clinics
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2016
    The RHC role varies by state. While we don’t have an understanding of what this looks like for each state, we can see that RHCs are an important provider for Medicaid beneficiaries. One of the most important differences is by age groups. All states tend to cater RHC services toward children, with a minimum of 39% of the RHC population < 18.
  • Identifying Rural Health Clinics in Medicaid Data
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2016
    Identifying RHCs in Medicaid claims across states is challenging, but this brief recommends methods for identifying the majority of these claims in four states.
  • Does ACA Insurance Coverage Expansion Improve the Financial Performance of Rural Hospitals?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2016
    Views on how the implementation of the ACA’s expanded insurance coverage is affecting the financial performance of rural hospitals. The study found that while respondents believe the expanded insurance coverage was the right thing to do for patients, they worried coverage may not be adequate to ensure access to care.
  • 2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2016
    The profitability of urban hospitals to that of rural hospitals are compared for fiscal years 2012-2014 based on size and rural Medicare payment classifications.
  • Geographic Variation in the Profitability of Urban and Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2016
    Historic and recent evidence suggest that unprofitability can reduce hospital services and quality, or worse, lead to closure. This study describes the current geographic variability of hospital profitability by comparing the 2014 profitability of CAHs, other rural hospitals, and urban hospitals by census region, census division, and state.
  • Geographic Variation in Risk of Financial Distress among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2016
    From 2005 to 2015, 112 rural hospital closures have been identified. The closures impact millions of rural residents. This brief describes the geographic variation in the proportion of rural hospitals forecasted to be at high risk of distress in 2015.
  • Prediction of Financial Distress among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2016
    From 2005 to 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services. To understand factors affecting rural hospital financial distress and to develop an early warning system to identify hospitals at risk, the North Carolina Rural Health Research Program developed the Financial Distress Index.

2015

  • Estimated Costs of Rural Freestanding Emergency Departments
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2015
    A rural freestanding emergency department (RFED) is one potential model for providing emergency services in areas where hospitals have closed. The North Carolina Rural Health Research Program’s Findings Brief, Estimated Costs of Rural Freestanding Emergency Departments explains the RFED concept and estimates RFED costs in three scenarios.
  • A Comparison of Closed Rural Hospitals and Perceived Impact
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2015
    This policy brief compares selected characteristics of abandoned rural hospitals and their markets to those of converted rural hospitals.
  • The 21st Century Rural Hospital: A Chart Book
    Chartbook
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2015
    This chartbook presents a broad profile of rural hospitals and includes information on location, who they serve, services they provide, how they ensure outpatient services for their communities, other community benefits they provide, and financial performance. Each page includes charts comparing rural hospitals to each other and to urban hospitals.
  • Do Current Medicare Rural Hospital Payment Systems Align with Cost Determinants?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2015
    To inform policy discussions on how complex current payment models may affect rural hospitals, the North Carolina Rural Health Research Program studied differences in financial condition among rural hospitals and important determinants of differences in rural hospital costs.
  • Rural Provider Perceptions of the ACA: Case Studies in Four States
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2015
    This brief summarizes the perceptions from rural providers in four states regarding the early effects of the Affordable Care Act, including changes to patient populations, financial health, and capacity for rural hospitals and rural federally qualified health centers.

2014

  • Best Practices for Health Insurance Marketplace Outreach and Enrollment in Rural Areas
    Fact Sheet
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2014
    Research suggests enrollment rates for those in rural areas was less than urban areas during the first Health Insurance Marketplace enrollment period. Interviews of navigators, health centers, and others in rural counties with high enrollment rates were conducted to uncover best practices for marketing, outreach/education, in-reach, and enrollment.
  • Rural-Urban Differences in Continuity of Care among Medicare Beneficiaries
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2014
    In response to the ACA and other reforms in the healthcare market, new care models are being tested and implemented. To addresses concerns that healthcare in rural areas may be more fractured and thus a difficult place for the models to succeed, we measured continuity of care using detailed data on a sample of Medicare beneficiaries from 2000-2009.
  • Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2014
    This brief combines the data on plan selection in the federally facilitated marketplaces with estimates of those likely to qualify for the marketplace to calculate the percentage of potential eligible individuals who chose a health insurance plan (the uptake rate). It contains a heat map showing the variation in uptake rates across the country.
  • Rural Hospital Mergers and Acquisitions: Who Is Being Acquired and What Happens Afterward?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2014
    A brief from the North Carolina Rural Health Research and Policy Analysis Center examines the implications of mergers and acquisitions for small rural hospitals. The brief addresses the characteristics of rural hospitals that merged and the changes in hospital financial performance, staffing, or services following a merger.
  • How Does Medicaid Expansion Affect Insurance Coverage of Rural Populations?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2014
    This brief examines how states’ decisions on Medicaid expansion are impacting rural areas in the United States. Population estimates, current state expansion status, and state-level insurance estimates were used to answer two main questions—how is expansion affecting rural populations and how would it differ if every state were to expand Medicaid.
  • Safety Net Clinics Serving the Elderly in Rural Areas: Rural Health Clinic Patients Compared to Federally Qualified Health Center Patients
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2014
    This brief, the third and final in a series on rural health centers (RHC), uses data from 2009 Medicare outpatient provider claims to look at clinic locations, number of beneficiaries served, and number of/cost per claim for each type of rural safety net clinic, as well as beneficiaries’ ages, health problems, and distance travelled for care.
  • Discharge to Swing Bed or Skilled Nursing Facility: Who Goes Where?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2014
    This brief examines health conditions of patients discharged from rural prospective payment system (PPS) hospitals and critical access hospitals (CAHs) to swing beds and skilled nursing facilities (SNFs).

2013

2012

2011

2010

  • Rural Hospital Support for Emergency Medical Services (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2010
    This study uses Medicare Hospital Cost Reports to identify rural hospitals, with and without Emergency Medical Services (EMS) units, to answer the following questions: what proportion of rural hospitals support or operate EMS units; has this changed in last five years; what are the characteristics of rural hospitals that support or operate EMS; what are the financial investments made by these hospitals in EMS; and what describes the communities in which these hospitals are located.
  • Rural Hospital Support for Emergency Medical Services (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2010
    This study uses Medicare Hospital Cost Reports to identify rural hospitals, with and without Emergency Medical Services (EMS) units, to answer the following questions: what proportion of rural hospitals support or operate EMS units; has this changed in last five years; what are the characteristics of rural hospitals that support or operate EMS; what are the financial investments made by these hospitals in EMS; and what describes the communities in which these hospitals are located.
  • Profitability of Rural Hospitals Paid Under Prospective Payment Compared to Rural Hospitals with Special Medicare Payment Provisions (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2010
    This study compares the profitability of urban and rural hospitals paid under PPS (U-PPS and R-PPS, respectively) to rural hospitals with special Medicare payment provisions between 2007 and 2009. R-PPS hospitals are subdivided by bed size (<26, 26-50 and >50) to assess differences within the group. Financial ratios are used to compare the profitability of hospital groups, and percentages of hospitals with negative total margins are used as a sign of financial distress.
  • Rural Volunteer EMS: Reports from the Field (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2010
    This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondent agencies were considered to be rural if they were located in a nonmetropolitan county or within a metropolitan county in an area with a Rural Urban Commuting Area (RUCA) code of four or higher. A semi-structured interview format encouraged respondents to speculate on the future viability of their local service, describe the challenges they face and what they need to ensure continuance. The descriptions presented represent the perceptions of those interviewed, but are also likely to resonate with other rural EMS administrators.
  • A Comparison of Rural Hospitals with Special Medicare Payment Provisions to Urban and Rural Hospitals Paid Under Prospective Payment (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2010
    This final report compares the financial performance and condition of rural hospitals with special Medicare payment provisions to urban and rural hospitals paid under prospective payment (UPPS and R-PPS hospitals, respectively). Nine ratios from the three most common categories of ratios used in financial statement analysis (profitability, liquidity, and capital structure) as well as four other ratios that are commonly used to evaluate rural hospital financial performance are assessed.
  • Rural Volunteer EMS: Reports from the Field (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2010
    This report explores the current state of rural EMS by interviewing 49 local directors from all-volunteer rural services in 23 states. Respondent agencies were considered to be rural if they were located in a nonmetropolitan county or within a metropolitan county in an area with a Rural Urban Commuting Area (RUCA) code of four or higher. A semi-structured interview format encouraged respondents to speculate on the future viability of their local service, describe the challenges they face and what they need to ensure continuance. The descriptions presented represent the perceptions of those interviewed, but are also likely to resonate with other rural EMS administrators.
  • Pediatric Care in Rural Hospital Emergency Departments (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2010
    Analyzes data from the Emergency Pediatric Services and Equipment Supplement (EPSES) to the National Hospital Ambulatory Medicare Care Survey to compare rural and urban hospitals' responses on various dimensions of pediatric Emergency Department care.
  • Pediatric Care in Rural Hospital Emergency Departments (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2010
    Analyzes data from the Emergency Pediatric Services and Equipment Supplement(EPSES) to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Rural and urban hospitals' responses were compared on various dimensions of pediatric ED care. We also surveyed 65 ED directors at rural hospitals in a separate process to explore rural pediatric ED care in more detail and to obtain the opinion of rural ED administrators regarding ways to assure quality emergency care for children.
  • A Financial Comparison of Rural Hospitals With Special Medicare Payment Provisions to Hospitals Paid Under Prospective Payment (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2010
    Compares the profitability of hospitals with the four classifications of rural hospitals that can qualify for special payment provisions under Medicare (Critical Access Hospitals, Medicare Dependent Hospitals, Sole Community Hospitals, and Rural Referral Centers) to urban and rural hospitals paid under prospective payment over a recent three-year period.
  • States' Use of Cost-Based Reimbursement for Medicaid Services at Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2010
    Critical Access Hospitals (CAH) are reimbursed by Medicare at 101% of allowable cost for both inpatient and outpatient services. State Medicaid agencies however are not required to reimburse CAHs on a cost-basis and have flexibility in determining how CAHs are paid for providing services to Medicaid enrollees. This brief documents which states utilize a cost-based reimbursement methodology for Medicaid.
  • Effect of Medicare Part D Plan Switching and Formulary Changes on Sole Community Pharmacies and the Patients They Serve
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    Date: 03/2010
    Presents findings from a 2008 survey of 401 pharmacist-owners of sole community independent pharmacies.

2009

  • A Case Study of Rural Health Care in the Economic Downturn
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2009
    Many rural communities face persistent challenges with healthcare access and cost. These problems have been amplified by the current economic downturn. This report describes the economic and healthcare environment in Ashe County, a rural community in the mountains of western North Carolina. The experience in Ashe County exemplifies the healthcare challenges faced in many rural areas across the country.
  • Characteristics of Rural & Urban Children Who Qualify For Medicaid or CHIP But Are Not Enrolled (Policy Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2009
    About three-quarters of children who qualify for Medicaid or CHIP are enrolled, with slightly higher rates in rural areas than in urban areas. This leaves one in four qualified children without insurance coverage.
  • Medicaid & CHIP Participation Among Rural & Urban Children (Policy Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2009
    Describes the characteristics of rural and urban children who qualify for Medicaid or CHIP but are uninsured.
  • Workforce Issues Among Sole Community Pharmacies
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    Date: 07/2009
    Pharmacy services are delivered through a sole community pharmacy in over 1000 small rural communities nationwide. This brief presents the findings from 401 telephone interviews of sole community pharmacist-owners nationwide about their current staffing and future plans. Thirty-three percent of those interviewed have one or fewer pharmacist FTEs on staff. Thirty percent of those interviewed would like to retire in five years or fewer, and most would like to sell their pharmacies upon retirement. This brief explores the shared experiences of sole community pharmacist-owners regarding the challenges facing the pharmacy workforce in their communities and their concerns about their pharmacy's future.
  • The Key Role of Sole Community Pharmacists in Their Local Healthcare Delivery Systems
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2009
    This findings brief presents findings from a 2008 survey of 401 community pharmacists that are the only retail provider in their community to document their extended relationships with other health care providers and the additional health care services these pharmacists provide to their patients. Pharmacist-owners in independent pharmacies located at least 10 miles from the next closest retail pharmacy were interviewed to determine the presence in their community of other types of health care organizations that require pharmaceutical support(such as hospitals, long-term care facilities, hospice providers, home health agencies and community health centers), their level of involvement with those facilities, and the types of clinical services (other than dispensing and counseling) the pharmacists offered to their own patients.
  • Sole Community Pharmacies and Part D Participation: Implications for Rural Residents (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2009
    This findings brief describes the contracting rates of sole rural community pharmacies in 16 states to assess the extent to which each pharmacy contracts with the most commonly used PDPs available in their state.
  • Medicare Beneficiaries' Access to Pharmacy Services in Small Rural Towns: Implications of Contracting Patterns of Sole Community Pharmacies with Part D Plans
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2009
    Describes the contracting patterns of sole rural community pharmacies to assess the extent to which each pharmacy contracts with the most commonly used PDPs available in their state.
  • A Rural-Urban Comparison of Allied Health Average Hourly Wages
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2009
    This report uses data from the Bureau of Labor Statistics to describe the extent to which rural-urban differentials exist in wages for eleven allied health professions, focusing on professions that are both likely to be found in rural communities and have adequate data to support hourly wage estimates.

2008

2007

  • One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Findings Brief)
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    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. Funded by the Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
  • State Initiatives Funded by the Medicare Rural Hospital Flexibility Grant Program
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.
  • One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Final Report)
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    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. Funded by the Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
  • Rural Hospitals' Experience with the 340B Drug Pricing Program
    NORC Walsh Center for Rural Health Analysis, North Carolina Rural Health Research and Policy Analysis Center
    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.
  • State Profiles of Medicaid and SCHIP in Rural and Urban Areas
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • 340B Drug Pricing Program: Results of a Survey of Participating Hospitals
    NORC Walsh Center for Rural Health Analysis, North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The State Flex Program at 10 Years: Strengthening Critical Access Hospitals and Rural Communities
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 04/2007
    To understand the priorities and accomplishments of state Flex Grant Programs, members of the Flex Monitoring Team asked Flex Coordinators to identify and discuss their states' three most successful initiatives in the past two years. Interviews were conducted during February 2007 with Flex Coordinators and State Office of Rural Health staff (SORH) in all 45 states. The listed publication is a policy brief; the full report will be available in the fall of 2007. Report produced by the Flex Monitoring Project, funded by the Office of Rural Health Policy.
  • Becoming an Emergency Medical Technician: Urban-Rural Differences in Motivation and Job Satisfaction
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.
  • 340B Drug Pricing Program: Results of a Survey of Eligible but Non-Participating Rural Hospitals
    NORC Walsh Center for Rural Health Analysis, North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Exploring the Community Impact of Critical Access Hospitals
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    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.

2006

  • The Experience of Sole Community Rural Independent Pharmacies with Medicare Part D: Reports from the Field
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    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. Funded by the Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
  • Impact of Conversion to Critical Access Hospital Status on Hospital Financial Performance and Condition
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • A Primer on the Occupational Mix Adjustment to the Medicare Hospital Wage Index
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Allied Health Job Vacancy Tracking Report
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2006
    Quantifies workforce demand for selected allied health professions in North Carolina, tracks job vacancy advertisements in print and online sources, summarizes vacancy advertisements by profession, region, and employer type, and describes the types of sign-on bonuses offered by employers.
  • The Effect of Rural Hospital Closures on Community Economic Health
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2006
    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.
  • Emergency Medical Services (EMS) Activities Funded by the Medicare Rural Hospital Flexibility Program
    Maine Rural Health Research Center, North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Trends over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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).
  • Premium Assistance Programs for Low Income Families: How Well Does it Work in Rural Areas?
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2005

  • Contracting with Medicare Advantage Plans: A Brief for Critical Access Hospital Administrators
    NORC Walsh Center for Rural Health Analysis, North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    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.
  • Rural and Urban Parents Report on Access to Health Care for their Children with Medicaid Managed Care
    North Carolina Rural Health Research and Policy Analysis Center
    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 healthcare services. The study examines access to healthcare 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
  • Trends in Skilled Nursing and Swing-bed Use in Rural Areas, 1996-2003
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The Impact of Medicaid Cuts on Rural Communities
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Financial Indicators for Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Cesarean Section Rates in Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Community Involvement of Critical Access Hospitals: Results of the 2004 National CAH Survey
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Intensive Care In Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • The Effects of Rural Residence and Other Social Vulnerabilities on Subjective Measures of Unmet Need
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 2005
    Are self-reports of unmet need a biased measure of access to healthcare? We examined the relationship between rural residence and perceived need for physician services. Examined 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.

2004

  • Reducing Mortality from Motor Vehicle Crashes for Children 0 through 14 Years of Age: Success in New York and North Dakota
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2004
    Reviews effective interventions to reduce motor vehicle crash mortality among children. Explores what is happening in New York and North Dakota that contributes to their success in being among the best performing states in regard to this measure of child health.
  • Cesarean Section Patterns In Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Definition of Rural in the Context of the MMA Access Standards for Prescription Drug Plans
    North Carolina Rural Health Research and Policy Analysis Center, RUPRI Center for Rural Health Policy Analysis
    Date: 09/2004
    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.
  • Core Based Statistical Areas And The Medicare Wage Index
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2004
    Discusses the potential impact of the 2003 Office of Management and Budget (OMB) statistical area standards on the hospital wage index and Medicare payments to rural providers. Additionally, three other possible options for defining labor markets using the 2003 classifications are presented.
  • Rural-Urban Issues In The Wage Index Adjustment For Prospective Payment In Skilled Nursing Facilities (Brief Report)
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2003

  • Rural-Urban Issues In The Wage Index Adjustment For Prospective Payment In Skilled Nursing Facilities (Full Report)
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Impact Of The Medicaid Budgetary Crisis On Rural Communities
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Classification Change, 1999 to 2003: Office of Management and Budget Metropolitan Areas and Core Based Statistical Areas (CBSAs) Map
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2003
    Map of the Office of Management and Budget's June 2003 Core Based Statistical Areas (CBSAs) Designations for Counties that were Nonmetropolitan in 1999.
  • Metropolitan and Micropolitan Core Based Statistical Areas (CBSAs) Map
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2003
    Map of the June 2003 Office of Management and Budget's metropolitan and micropolitan Core Based Statistical Areas (CBSA) Designations by County.
  • Primer On Interpreting Hospital Margins
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Rural-Urban Differences in Nursing Home and Skilled Nursing Supply
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Unpredictable Demand and Low-Volume Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    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
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2002

  • Arguing for Rural Health in Medicare: A Progressive Rhetoric for Rural America
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2002
    Examines how rural health policy is treated in the broader field of public policy, discusses the role of advocacy in developing rural health policy, and suggests ways to make that advocacy more effective. Specifically, the report explores the types of claims that rural advocates make, focusing in the context of Medicare policy, and determines to what extent those claims reflect a central them of fairness and inclusiveness in national polices versus claims that benefit special interests.
  • Rural Populations and Health Care Providers: A Map Book
    North Carolina Rural Health Research and Policy Analysis Center
    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 healthcare providers matches the population distribution.
  • Tracking Medicaid Managed Care in Rural Communities: A Fifty-State Follow-Up
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Impacts of Multiple Race Reporting on Rural Health Policy and Data Analysis
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2001

  • Fewer Hospitals Close in the 1990s: Rural Hospitals Mirror This Trend
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2001
    Summarizes a study of the number and rate of hospital closures in rural areas during the 1990s. Includes graphs and a map.
  • The Proximity of Rural African American and Hispanic/Latino Communities to Physicians and Hospital Services
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 06/2001
    Assesses how local physician concentrations and distances to hospitals differ for rural communities of varying African American and Hispanic/Latino compositions. Uses data at the town-area level for nine southern and six western states to compare town-areas with low, medium, and high proportions of African Americans and Hispanics on their local physician-to-population ratios and distances to nearest hospital offering each of four levels of services. Among the findings are that rural Hispanics, but not African Americans, face longer travel distances to physicians, and both groups face longer distances to some types of hospital services than do non-minority rural individuals.
  • If Fewer International Medical Graduates are Allowed in the U.S., Who Might Replace Them in Rural Underserved Areas?
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • Proximity of Rural African-American and Hispanic/Latino Communities to Physicians and Hospital Services
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2001
    This brief reports the findings of a study of how the African American and Hispanic/ Latino composition of rural communities relates to local physician concentrations, and relates to distances to hospitals offering various levels of services.
  • If Fewer International Medical Graduates Were Allowed in the U.S., Who Might Replace Them in Rural Areas?
    North Carolina Rural Health Research and Policy Analysis Center
    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.
  • PPS Inpatient Payment and the Area Wage Index
    North Carolina Rural Health Research and Policy Analysis Center
    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).
  • Rural Hospital Wages and the Area Wage Index: 1990-1997
    North Carolina Rural Health Research and Policy Analysis Center
    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.

2000