Rural Health
Research Gateway

RUPRI Center for Rural Health Policy Analysis

Completed Projects

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

2024

  • Clinical-Community Linkages in Non-Metropolitan and Metropolitan Hospitals: COVID-19 Impacts and Trends
    This study examined trends in partnerships between hospitals and public health departments and other community linkages in both non-metropolitan and metropolitan hospitals with a particular focus on the impact of the COVID-19 pandemic.
    Topics: Coronavirus Disease 2019 (COVID-19), Critical Access Hospitals (CAHs), Health services, Hospitals and clinics, Networking and collaboration, Public health, Social determinants of health
  • Rural Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces: An Updated Analysis
    The project described variations in Health Insurance Marketplace plan design and availability, total and net-of-subsidy premium trends, and enrollment over time between rural and urban areas and identified associations between these factors and several key policy differences and changes, controlling for economic and demographic variation.
    Topics: Health disparities and health equity, Health reform, Healthcare access, Private health insurance, Rural statistics and demographics, Uninsured and underinsured

2023

  • Changes in Hospital Services Offered After Mergers, Acquisition and Affiliations
    Hospitals have affiliated with systems in increasing numbers since 2007, as of 2016 reaching 56.1 percent of nonmetropolitan prospective payment system hospitals and 42.8 percent of critical access hospitals. This project examined resulting changes in services offered by rural hospitals, hypothesizing shifts of some services to regional hospitals and growth in some service lines.
    Topics: Critical Access Hospitals (CAHs), Hospitals and clinics, Networking and collaboration
  • Financial Risk Assumption Among Rural Healthcare Providers
    This project assessed rural/urban providers' participation in different payment models and assumption of financial risk in the Medicare Quality Payment Program. We conducted qualitative interviews to examine rural providers' motivations and preparedness for participating in different risk-bearing payment models.
    Topics: Health reform, Healthcare financing, Rural Health Clinics (RHCs)
  • Rural and Racial/Ethnic Disparities in COVID-19 Mortality Rates and Associations with Community Characteristics
    This project examined rural and racial/ethnic disparities in COVID-19 mortality rates during the peak of COVID-19 deaths (December 2020-January 2021). Researchers examined mortality rates across non-metropolitan and metropolitan counties overall and stratified by racial/ethnic composition and U.S. census region, and spatial regression methods were used to identify community characteristics (e.g., rurality, sociodemographic, health conditions, and health care access) associated with mortality rates at the county level.
    Topics: Coronavirus Disease 2019 (COVID-19), Health disparities and health equity, Healthcare access
  • Rural-Urban Differences in Performance of Clinicians Participating in MIPS
    This project used quantitative methods to compare MIPS performance and reported measures for clinicians working in rural and urban areas, overall, and by practice size; evaluated differences in spending per beneficiary, overall, and stratified by drugs and medical services for rural and urban clinicians participating in MIPS; and compared MIPS performance and spending for clinicians serving a large proportion of racial/ethnic minorities in rural and urban areas.
    Topics: Health disparities and health equity, Healthcare financing, Physicians, Quality

2022

  • An Insurance Profile of Rural America: A Chartbook
    This chartbook describes current conditions and recent trends in rural health insurance by drawing from census data and other sources. Tables and maps, accompanied by bulleted policy takeaways, compare rural and urban coverage sources, the degree of competition among issuers, and the share of the population who are underinsured.
    Topic: Uninsured and underinsured
  • Continuous Services in the Absence of Retail Pharmacies in Rural Communities
    This project identified communities with and without pharmacies by rurality and described the differences in population and market characteristics of communities with and without any pharmacies. Research findings regarding "pharmacy deserts" informed alternative methods of securing services based on community characteristics.
    Topics: Health services, Healthcare access, Medicare Part D, Pharmacy and prescription drugs
  • Location and Characteristics of Nursing Homes in the Rural and Urban U.S.
    This project examined rural and urban nursing home availability; assessed the nursing home bed supply relative to the elderly population in rural and urban counties; summarized resident and nursing home characteristics; and analyzed the relationship between the rural location of nursing homes and resident and nursing home characteristics.
    Topics: Aging, Health services, Healthcare access, Healthcare financing, Long-term care, Medicare
  • Medicare Beneficiary Access to Prescription Drugs Under Part D
    This study built on RUPRI Center work describing patterns of enrollment into Medicare Part D plans (including access to zero deductible plans) by using transaction files to analyze how medications are actually acquired and implications for access to local pharmacy services.
    Topics: Medicare, Medicare Part D

2021

  • Rural and Urban Sources of Insurance Coverage: the Role of Public and Private Coverage over Time
    We estimated the percent of rural residents obtaining insurance coverage under each of the major options available to them using multiple data sets and a methodology that accounts for multiple sources of coverage. We compared rural and urban coverage sources and changes in coverage over time.
    Topics: Health reform, Healthcare financing, Uninsured and underinsured
  • Rural Nursing Home Closures - Trends, Characteristics, and Impact on Access
    This project built a database of nursing home closures across rural and urban areas in the U.S. and evaluated the changes in access to post-acute and/or long-term care providers. It also described the differences in organizational, financial, and market characteristics between open vs. closed nursing homes in rural vs. urban areas.
    Topics: Aging, Healthcare access, Long-term care, Medicare
  • The Availability of Optional Benefits in Medicare Advantage (MA) Plans in Rural and Urban Areas and the Implications for MA Payment Policy
    Enrollment and landscape files containing data regarding Medicare Advantage plan activities by county were used to describe the geographic differences in what is available to beneficiaries in benefit design and total out-of-pocket liability. Findings revealed potential for policy actions to address equity of benefits and cost to beneficiaries.
    Topics: Medicare, Medicare Advantage (MA), Medicare Prospective Payment System (PPS)
  • The Geographic Expansion of Medicaid MCOs
    This project characterized the counties into which Medicaid Managed Care Organizations (MCOs) expanded in 2012-18, focusing on population and provider density, sociodemographics, and health indicators. We assessed the extent to which MCO geographic expansion occurred in compliance with previous network adequacy standards and evaluated how well MCOs were performing in rural areas.
    Topic: Medicaid and CHIP
  • What Makes Successful Rural Accountable Care Organizations Successful?
    The U.S. Department of Health and Human Services plans to shift at least 50% of traditional Medicare spending into alternative payment models by 2018. Accountable Care Organizations (ACOs) represent a popular model in both the Medicare and Medicaid programs. This study used multiple methods to find what makes a successful ACO.
    Topics: Medicare, Quality

2020

  • Rural Community Response to Hospital Closure
    The Rural Community Response to Hospital Closure project will study how rural communities adapt to local hospital closure. Within selected communities, the project will evaluate the impact of hospital closure on multiple community health-related services and characteristics.
    Topics: Healthcare financing, Hospitals and clinics
  • What Factors Influence Rural Hospitals' Participation in Accountable Care Organizations?
    This project examined rural hospitals' participation in Accountable Care Organizations (ACOs), identified factors that influenced ACO participation, compared whether different factors influenced rural/urban hospital participation in ACOs, and analyzed factors influencing Critical Access Hospitals' participation in the Medicare Shared Savings Program.
    Topics: Health reform, Healthcare financing, Medicare

2019

  • An Empirical Study of Health Insurance Firm Participation over Time in Rural Counties
    We examined changes in firm participation in multiple health insurance markets (FEHBP, MA, HIMs) over time in rural counties. We had hypothesized that participation would be related inversely to population density, because it becomes more difficult to spread risk, and network formation becomes more challenging when primary and specialty care becomes less available.
    Topics: Medicare Advantage (MA), Private health insurance
  • Analysis of Trends in Characteristics of Rural Beneficiaries Enrolling in Medicare Advantage Plans
    This study compared characteristics of rural and urban beneficiaries enrolling in Medicare Advantage (MA) plans, including their age, health status, income, and race/ethnicity. We analyzed the consequences of increasing use, promoted by policy choices, of a market-based approach in the Medicare program.
    Topics: Medicare Advantage (MA), Rural statistics and demographics
  • Impact of Capping Medicare Disproportionate Share Hospital Payments on Rural Hospitals
    Rural hospitals receiving Medicare prospective payment system payment and receiving disproportionate share hospital payments are subject to a 12% cap on those payments. This project provided information on the number and location of rural hospitals subject to this cap and the fiscal impact.
    Topics: Healthcare financing, Medicare, Medicare Prospective Payment System (PPS)
  • The Rural MACRA Experience
    The Rural MACRA Experience project studied rural effects of the new Medicare Quality Payment Program (QPP) implementation and operation. Rural QPP effects included provider eligibility, program preparation and data collection challenges, data analysis bias, and differential fiscal impact.
    Topics: Healthcare financing, Medicare, Physicians
  • The Rural/Urban Impact of Insurance Coverage Changes
    We examined the impacts of changes in health insurance coverage during the last several years on use of health services and health outcomes separately for rural and urban areas. Due to differences in demand and supply level factors, we hypothesized that the effects of coverage changes differ by rural/urban status.
    Topics: Health services, Private health insurance

2018

2017

  • After Hospital Closure: Pursuing High Performance Rural Health Systems without Inpatient Care
    This paper describes opportunities for rural communities to develop a high performance rural health system after hospital closure, including three case studies that describe real-world transitions from centering on inpatient hospital-based care to new models of care delivery in rural places.
    Topics: Hospitals and clinics, Quality
  • Assessing the Impact of Medicaid Policy Changes
    Goals of this project included: 1) clearly articulating the rural considerations in Medicare reform by synthesizing information on the impact of Medicare on rural people, places, and providers; 2) assessing the impact of specific proposals to reform Medicare; and 3) analyzing the effects of market-based reform on rural populations, focusing on specific provisions of Medicare reform proposals.
    Topic: Medicaid and CHIP
  • Assessing the Stability of Rural Pharmacy Services
    This project's goals include deepening our understanding of economic forces beyond the immediate control of local pharmacies that are affecting their ability to remain in business, assessing the future of sole community retail pharmacies in rural places, and exploring alternative modalities for delivering pharmacy services in the absence of retail pharmacy businesses.
    Topics: Health services, Pharmacy and prescription drugs, Telehealth
  • Do Rural Health Clinics (RHCs) Provide Services that Lower Rates of Preventable Hospitalizations?
    This project uses 3 years of individual-level Medicare claims data to analyze the relationship between receiving care at a Rural Health Clinic (RHC) and the likelihood of potentially preventable hospitalization and/or potentially preventable emergency department (ED) visits. The project will explore this relationship among both fee-for-service Medicare enrollees and Medicare-Medicaid dual eligibles.
    Topics: Hospitals and clinics, Rural Health Clinics (RHCs)
  • State Policy Issues That May Impact HIMs' Success in Rural Places: A Regional Analysis
    Goals of this project include gathering detailed data and providing analysis and policy recommendations on issues relating to network adequacy and service areas for HIMs, with additional investigation of other state-level policy variables (such as the Medicaid expansion decision) which may have a confounding or moderating effect on the relationship between network adequacy and enrollees' choices and premiums.
    Topics: Health information technology, Legislation and regulation, Medicaid and CHIP, Private health insurance, Telehealth

2016

  • Analyzing the Variation in the Performance of Accountable Care Organizations Serving Rural Medicare Beneficiaries
    The goals of this project are to characterize ACOs that operate in rural areas, describe the models being used to organize those ACOs, and to test relationships of those characteristics to performance measures related to financial success and quality. The study will identify potential changes in legislative and regulatory policies that could strengthen the utility of the ACO model to achieve high performing rural healthcare delivery organizations.
    Topics: Healthcare financing, Legislation and regulation, Medicare, Quality
  • Trends in Medicare Advantage Quality and Enrollment: The Effects of Quality Based Payment Incentives on Rural People and Places
    This research will analyze the quality of Medicare Advantage (MA) plans offered to rural MA beneficiaries currently, in relation to urban beneficiaries, and how it has evolved over the past four years. In addition, the effect of quality-based payment incentives will be measured by: 1) changes that have been made to improve the quality of existing plans in rural areas or to encourage the entry of high quality plans into rural areas, and 2) the movement of plans' entry and exit into the MA market by plan type and rural/urban location.
    Topics: Medicare, Medicare Advantage (MA)

2015

2014

  • Analysis of Medicare Advantage Quality in Rural Areas: Historically and Moving Forward
    This project examines the role that geography and demographics play in the success and quality of different types of MA plans in particular regions of the country.
    Topics: Medicare, Medicare Advantage (MA)
  • Effects of Changing Medicare Advantage Landscape on Rural Enrollees
    The goal of this project is to assess the impact of changes in Medicare payment policy on the availability of choices for rural Medicare beneficiaries. The objectives are quantify the impact of payment policy on the number of competing plans in strata of rural counties and the effects of using quality star ratings on choices in rural counties.
    Topics: Medicare, Medicare Advantage (MA)
  • Engagement of Rural Providers in Accountable Care Organizations (ACOs)
    The RUPRI Center's work assessing the development of ACOs in rural places including updating our data base showing the location of Medicare ACOs and using the data to create maps for each Census Region showing the counties in which Medicare ACOs have assigned beneficiaries.
    Topics: Care management, Health services
  • Rural Inclusion in the Development of Health Insurance Exchanges
    State plans for developing Health Insurance Exchanges (HIEs) will be analyzed to determine likely benefits for rural residents and communities. Three elements of each plan will be described and assessed: strategies to seek out and enroll rural residents eligible for subsidized insurance coverage or categorically eligible for plans offered through exchanges; minimum standards for participating health plans, including access to essential services; and simulations of impact on availability of plans and enrollment of currently uninsured rural residents.
    Topics: Private health insurance, Uninsured and underinsured
  • Use of Telehealth to Deliver Services to Rural People and Implications for Public Policy
    This project analyzes national datasets to examine the extent of use of inpatient telehealth services, organizational factors contributing to use, and payment and other policies that limit uptake. This project will identify approaches that could aid spread of this effective delivery approach throughout rural service areas.
    Topics: Health information technology, Networking and collaboration, Telehealth
  • Will Health Insurance Marketplaces Deliver Affordable Options in Rural America
    This project analyzes early Health Insurance Marketplaces plan and premium data by geographic region, controlling for state policy decisions, to assess the degree to which affordable health insurance will be available through individual and/or small business marketplaces.
    Topics: Health reform, Private health insurance

2013

  • Assessing Rural Implications of Changes in Insurance Markets
    The goal of this project is to understand and predict changes in the insurance market in which rural people will participate and how state and national policies might influence activity in that market. The specific objectives of the project are to analyze state policies designing and implementing health insurance exchanges and to model the behavior of health insurance plans as regards entering and exiting rural markets.
    Topics: Health services, Private health insurance
  • Impact of Payment Policy on Access to Physician Care in Rural America
    Profiles of physician practices will be constructed that specify the percent of payments derived from specific current procedural terminology (CPT) codes, dichotomized into evaluation and management (often considered to define primary care) or procedural. Differences across rural practices and between rural and urban practices will be analyzed, with implications for payment policies intended to reward rural primary care.
    Topics: Health services, Medicare, Physicians
  • Pharmacy Services in Communities After the Only Local Pharmacy Closes
    This project will investigate patterns of utilization of prescription drug and other health care services in rural communities in the years since the only local pharmacy closed. We will also examine changes in local economies and Medicare spending, trended to include time before closure through as many years possible after closure.
    Topic: Pharmacy and prescription drugs
  • System Integration and Rural Provider Participation in Accountable Care Organizations (ACOs)
    This project will develop a national descriptive database of both rural providers and larger (often urban) health systems participating in Medicare ACOs and health system networks. Case studies of four ACOs will generate an awareness of decisions being made that affect configuration of services in rural places and provide suggestions for further research with representative samples of ACOs.
    Topics: Health services, Medicare

2012

  • Analysis of the Effects of Federal Debt Reduction and Long Term Budget Adjustment on Rural Health Care Delivery
    The RUPRI Center for Rural Health Policy Analysis will examine suggested changes in Medicare and Medicaid as stated in proposals to reduce spending as part of achieving deficit reduction.
    Topics: Health services, Medicaid and CHIP, Medicare
  • Assessing the Community Impact of the MMA
    This project will measure the community-level impacts of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and will provide feedback to policymakers regarding the impact of the MMA on its policy targets (providers and beneficiaries), in the context of rural places.
    Topics: Legislation and regulation, Medicare, Medicare Part D
  • Do Communities Make a Difference in Access? A National Study
    This project will examine the effect of community-level resources on an individual's access to healthcare, particularly whether urban and rural individuals' access to healthcare differs, given community differences.
    Topic: Health services
  • Examining the Applicability of the AHRQ's Inpatient Quality Indicators to Rural Hospitals and the Implications of the Relationship Between the Indicators and Financial Measures for Medicare Payment Policies
    This study will investigate how the Agency for Healthcare Research and Quality's inpatient quality indicators can be applied to rural hospitals and will explore the application of those indicators in answering relevant policy questions.
    Topics: Healthcare financing, Hospitals and clinics, Quality
  • How Would Health Insurance Exchanges Work in Rural America?
    The passage of the Patient Protection and Affordable Care Act (PPACA) of 2010 has created the potential for states to create Health Insurance Exchanges (HIEs). This project will assess the potential of these plans to meet the needs of rural residents. Empirical work will establish baseline measures of choices available to rural residents and literature reviews will yield prospective analysis of how exchanges could operate to benefit rural residents.
    Topics: Health reform, Private health insurance
  • Impact of Changing Medicare Advantage Landscape on Rural Enrollees
    This project will explore three important questions related to Medicare Advantage (MA) plans. What is the impact of recent changes in the MA market on rural Medicare beneficiaries, providers and communities? In particular, how have recent changes in markets and payment policy led to changes in the choices of plans facing beneficiaries, and the quality of those plans (as defined by the coverage offered by the plans)? Finally, what is the likely impact of changes made in Medicare Advantage payment rates passed in the Patient Protection Affordable Care Act of 2010 (PPACA) on rural enrollment in MA plans in 2011 and beyond?
    Topics: Medicare, Medicare Advantage (MA)
  • Medicare Advantage and Medicare Prescription Drug Plans in Rural Areas
    The rapid growth in Medicare Advantage (MA) plans, as well as evidence that MA plans are being paid significantly more than traditional fee-for-service Medicare, has created the impetus for reform of the MA program, especially reductions in payment to MA plans. This project will continue the RUPRI Center's work in tracking and analyzing the trends in MA plan enrollment in rural areas, including changes in types of plans.
    Topics: Medicare, Medicare Advantage (MA)
  • Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
    Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
    Topic: Pharmacy and prescription drugs

2011

  • Examining Recent Trends and Variation in Ambulatory Care Sensitive Conditions-related Hospital Expenditures of Rural Americans with Different Health Insurance Coverage and Status
    This study documents the national time-trend and regional variation of rural Ambulatory Care Sensitive Conditions (ACSC)-related hospital expenditures by patient insurance coverage/status. The study will also compare the pattern of difference in the ACSC-related expenditures of rural patients with different insurance coverage/status by patient demographic and economic characteristics as well as hospital characteristics.
    Topics: Chronic diseases and conditions, Health services, Healthcare financing, Private health insurance
  • Implementation of Health Reform Legislation in Rural America
    The RUPRI Center has developed particular expertise, including the use of simulations, in how changes in public policy that are now part of the Patient Protection and Affordable Care Act (PPACA) affect the rural health care providers and communities. We have published policy briefs and papers related to Medicare Advantage and Part D plans, effects of insurance reform on the percentage of uninsured in rural areas, and effects of changes in physician payment on projected total income of rural primary care physicians. The purpose of this project is to take advantage of RUPRI's capacity for further simulation analysis and empirically based analyses of changes occurring as a result of the PPACA.
    Topics: Medicare, Uninsured and underinsured
  • Patient-Centered Medical Home: A Model for Rural Physician Practices and Communities?
    Rural practices will need to meet the expectations inherent in the patient-centered medical home (PCMH) model or lose any payment advantage that comes with participating as a PCMH. The goal of this project is to assess rural readiness to adopt services seen as part of a PCMH.
    Topics: Health services, Physicians

2010

  • Analysis Related to Health Care Reform Issues
    The RUPRI Center is prepared to provide analysis of elements and/or effects of proposed or enacted health reform legislation and/or regulations to implement changes mandated by legislation.
    Topics: Health services, Healthcare financing

2009

  • Expanding Rural Health Insurance Coverage: How Do Insurance Reform Strategies Stack Up?
    This purpose of this study is to inform policymakers about the current state of health insurance coverage in rural America, and to assess how specific reform strategies may differentially affect rural residents. Using a combination of analytic strategies, we will provide policymakers and rural health advocates with the necessary tools to develop reform strategies that meet the needs of rural residents.
    Topics: Health reform, Private health insurance, Uninsured and underinsured

2008

  • Examining the Magnitudes, Geographic Variations, and Determinants Of Expenditures Due to Ambulatory Care Sensitive Conditions in Rural Hospitals
    This project will document the magnitude of and variation in ambulatory care sensitive condition (ACSC) expenditures of rural hospitals and explore the relationships between rural hospital ACSC expenditure and its key determinants in the areas of population demand, health care system supply, and provider practice style.
    Topics: Chronic diseases and conditions, Healthcare financing, Hospitals and clinics
  • Impact of Medicare Advantage Plan Concentration on Choices and Competition in Rural Areas
    This project focuses on the analysis of Medicare Advantage (MA) plan choices for rural beneficiaries and what the concentration of plan choices in rural areas may mean in the context of how rural beneficiaries are making their choices. Using measures of concentration from the economics literature, this project will explore the relationship between market concentration in MA plans and the generosity of MA plans, and how it varies by the location of residence of Medicare beneficiaries.
    Topics: Medicare, Medicare Advantage (MA)
  • Medicare Modernization Act: Reality for Rural Beneficiaries and Providers
    This project will focus on two areas of new activity in Medicare beneficiary participation in Medicare Advantage (MA) plans and prescription drug plans and implementation of the new Part D benefit through private health plans. We will describe enrollment into specific types of MA prescription drug plans and other prescription drug plans, and analyze differences across regions, states, and types of counties. We will also examine the impact of the transfer to Part D coverage on rural dual eligibles and their local pharmacies.
    Topics: Medicare Advantage (MA), Medicare Part D
  • Rural Provider Participation in a Statewide Health Information Project
    Nebraska has recently constructed a communication infrastructure that links all the hospitals in the state with broadband, high-speed systems (using T1 lines to the Critical Access Hospitals). That infrastructure is considered to be the backbone for a statewide health information network being designed by a coalition of organizations. The aim of this project is to delineate reasons for rural providers to participate in the coalition by assessing the associated costs and benefits.
    Topics: Health information technology, Hospitals and clinics, Networking and collaboration

2007

2006

  • Implementation of the Medicare Prescription Drug Benefit: What is Available to Rural Beneficiaries?
    This study will focus on the impact of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 on rural beneficiaries, based on actual prescription drug plan contracts, comparing the impact of the legislation on rural beneficiaries to their urban counterparts.
    Topics: Legislation and regulation, Medicare Part D
  • Rural-Urban Physician Payment Differences Across the Nation: Methodological Changes
    This project will simulate the effects of changes to the methodologies used to calculate the three geographic practice cost indices currently used to adjust physician payment across the 89 Medicare payment areas in the U.S. and territories. Changes to the payment formula will be analyzed to determine potential impact on payment across areas and revenues for rural physician practices.
    Topics: Medicare, Physicians, Workforce
  • Uninsurance and Welfare Reform in Rural America
    This project used widely accepted databases to examine the recent history of uninsurance rates in the U.S., focusing on the low-income population that could be eligible for welfare. Additionally, the project concentrated on how welfare reform has impacted the health insurance coverage of welfare recipients and other low-income persons over the period when welfare reform was phased in.
    Topics: Poverty, Uninsured and underinsured
  • Why Are Health Care Costs Increasing and Is There a Rural Differential in National Data?
    This project will determine whether growth in health insurance premiums and out-of-pocket spending differs in rural areas as compared to urban areas.
    Topic: Private health insurance

2005

2004

  • Establishing a Fair Payment for Rural Physicians
    This project will analyze differences in physician payment as a function of practice location and simulate policy choices that change the current payment formula.
    Topics: Physicians, Workforce

2003

2002

2001