RUPRI Center for Rural Health Policy Analysis

Research Products & Journal Articles

Browse the full list of research publications from this Rural Health Research Center.

Products – Freely accessible products include policy briefs, fact sheets, full reports, chartbooks, and interactive data websites.

Journal Articles – Articles in peer-reviewed journals may require a subscription or affiliation with a subscribing library. For these publications, Gateway lists the article citation, a brief summary, a link to additional information and access to the full-text of the article, if available.

2021

2020

  • Telepharmacy Rules and Statutes: A 3-Year Update for all 50 States
    Policy Brief
    Date: 07/2020
    This policy brief analyzed administrative rules and legislative statutes governing each state's pharmacy practice. Key features of telepharmacy regulations were investigated for comparative analysis. Twenty-one states currently authorize retail telepharmacy, but between these states the regulatory activity varies considerably.
  • Access to Medicare Part D Plans: A Comparison of Metropolitan and Nonmetropolitan Areas
    Policy Brief
    Date: 05/2020
    This policy brief updates previous reports on rural activity in the Medicare Part D program. Comparisons are made across county type, within type of Part D plan (standalone and part of Medicare Advantage plans), and between the types of plans within county classifications.
  • County-Level 14-Day COVID-19 Case Trajectories
    Date: 05/2020
    Many locations in the U.S. are relaxing their community-level COVID-19 mitigation measures. But one of the key "gating" indicators for doing this is a downward trajectory of new cases during a 14-day period. The rural data brief examines county-level 14-day trajectories for new confirmed COVID-19 cases.
  • Metropolitan/Nonmetropolitan COVID-19 Confirmed Cases and General and ICU Beds
    Policy Brief
    Date: 05/2020
    The spread of COVID-19 across rural areas has fueled concern about the availability of healthcare resources for dealing with the pandemic. This brief looks at a single measure of healthcare resources – hospital beds – and reports of current COVID-19 cases in a single week to assess the impact on rural facilities.
  • Health Care Professional Workforce Composition Before and After Rural Hospital Closure
    Policy Brief
    Date: 04/2020
    This policy brief examines the composition of the local healthcare workforce before and after rural hospital closure to reveal any associations with discontinuation of inpatient services in rural communities.
  • Rural Hospital Participation in Medicare Accountable Care Organizations
    Policy Brief
    Date: 04/2020
    This policy brief summarizes national and regional rates of rural hospital participation in Medicare Shared Savings Program Accountable Care Organizations (ACOs) and identifies factors associated with ACO participation.

2019

2018

  • Changes to the Merit-based Incentive Payment System Pertinent to Small and Rural Practices, 2018
    Policy Brief
    Date: 11/2018
    This policy brief highlights key regulatory changes to the Merit-based Incentive Payment System that occurred in 2018. It discusses the implications of these changes with an emphasis on how these changes may affect small and rural practices.
  • The Rural Hospital and Health System Affiliation Landscape – A Brief Review
    Policy Brief
    Date: 11/2018
    The shift from traditional fee-for-service to value-based payment requires major capital investment. In this paper, we examine rural hospital and health system motivations for affiliation and present a non-exhaustive list of common affiliation structures with representative examples.
  • Trends in Hospital System Affiliation, 2007-2016
    Policy Brief
    Date: 11/2018
    This policy brief updates a RUPRI Center brief published in 2014 and documents the continued growth in system affiliation by both metropolitan and non-metropolitan hospitals.
  • Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018
    Policy Brief
    Date: 08/2018
    This brief assesses changes from 2014 to 2018 in average Health Insurance Marketplace plan participation and pre-subsidy premiums in rural and urban places. Insurance carriers reduced participation across both, while the gap between average premiums in expansion and non-expansion states is widening at a similar rate in rural and urban counties.
  • Spread of Medicare Accountable Care Organizations in Rural America
    Policy Brief
    Date: 08/2018
    This policy brief describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2016 to 2017. This brief, which includes data through December 2017, follows a similar analysis released in October 2016 that described ACO trends from 2013 to 2015.
  • Organizational Attributes Associated with Medicare ACO Quality Performance
    Date: 07/2018
    Peer-reviewed paper evaluating associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance.
  • Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018
    Policy Brief
    Date: 07/2018
    Rural pharmacies play an important role in health service delivery to rural populations. This RUPRI Center brief updates previous findings on the continued decline in the number of independently owned rural pharmacies since the implementation of Medicare Part D. This brief provides follow-up data on rural pharmacy closures through March 2018.
  • Organizational Attributes with Medicare ACO Quality Performance
    Date: 05/2018
    Cross-sectional and longitudinal analyses of Medicare Shared Savings Program Accountable Care Organizations' (ACOs') quality performance found rural ACOs' score was comparable to those in other categories. ACOs with hospital-system sponsorship, larger beneficiary panels, and higher post-hospitalization follow-up rates had better performance.
  • Telepharmacy Rules and Statutes: A 50-State Survey (Journal Article)
    Date: 05/2018
    Peer-reviewed paper identifying state-enacted regulations and legislation authorizing use of community telepharmacy initiatives and describing implications for patients in underserved rural communities. Also provides a table listing states that permit telepharmacy, and pilot programs and waivers that enable telepharmacy initiatives.
  • Medicare Accountable Care Organization Growth in Rural America, 2014-2016
    Policy Brief
    Date: 03/2018
    This RUPRI Center data report describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2014 to 2016. ACOs are the most widespread of the Centers for Medicare & Medicaid Services (CMS) value-based payment programs and demonstrations.
  • Distance and Networks: A Regional Analysis of Health Insurance Marketplaces
    Policy Brief
    Date: 02/2018
    Using 2015-16 data on 15 Midwestern states, we examine the possibility that geographic distance to care plays a role in insurance issuer participation, premiums, and enrollment success through its effect on network adequacy and assess the moderating role that state-level policies on network adequacy standards and Rating Area design may have.

2017

  • Rural-Urban Enrollment in Part D Prescription Drug Plans: June 2017 Update
    Policy Brief
    Date: 12/2017
    As of June 2017, the percentage of rural enrollment in Part D plans, which include stand-alone prescription drug plans (PDPs) and Medicare Advantage with Prescription Drug (MA-PD) plans, lags urban enrollment despite significant growth overall in the number of Medicare beneficiaries with prescription drug coverage through Medicare Part D plans.
  • Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals
    Policy Brief
    Date: 11/2017
    This policy brief provides information about the potential impact of scheduled changes in Medicaid Disproportionate Share Hospital (DSH) payment on hospitals in 47 states. We expect variation across states, because of differences in state policies allocating DSH payments, as well as geographic variation by census region.
  • Financial Issues Challenging Sustainability of Rural Pharmacies
    Date: 08/2017
    Findings from a survey of rural lone community retail pharmacies about issues perceived as a threat to their sustainability. Reimbursement issues were cited as being most immediate and of highest magnitude.
  • Medicare Advantage Enrollment Update 2017
    Policy Brief
    Date: 08/2017
    Reports on the percentage of rural Medicare beneficiaries enrolled in Medicare Advantage (MA) plans and other prepaid enrollment plans. Compares national and rural MA enrollment, and variability by state.
  • Rural/Urban Analysis on Individual Insurance Market Topics
    Fact Sheet
    Date: 08/2017
    Some special challenges face the development and sustainability of marketplace plans in rural areas. This data release provides some additional detail on some important topics, with particular importance to rural people, places, and providers.
  • The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries
    Date: 07/2017
    Uses 2007-2010 Medicare data to examine the relationship between Rural Health Clinic (RHC) use and potentially preventable hospitalizations and emergency department (ED) visits. RHC use was associated with an increase in both preventable hospitalizations and ED visits among all Medicare enrollees, regardless of their reason for eligibility.
  • Issues Confronting Rural Pharmacies after a Decade of Medicare Part D
    Policy Brief
    Date: 04/2017
    This brief reports on a survey of very rural independent pharmacies designed to assess threats to their sustainability. Major, immediate issues included delays in updates to maximum allowable costs (MACS), charges for remuneration fees, competition from mail order pharmacies; and, status as a "non-preferred pharmacy" for Medicare Part D plans.
  • Telepharmacy Rules and Statutes: A 50-State Survey
    Policy Brief
    Date: 04/2017
    This is summary analysis reviews administrative rules and legislative statutes governing the practice of telepharmacy in all 50 states. Telepharmacy is specifically authorized in 23 states and 16 states have no rules or legislation authorizing telepharmacy. Other states have pilot programs or waivers that would enable telepharmacy.
  • 2016 Rural Enrollment in Health Insurance Marketplaces, by State
    Policy Brief
    Date: 01/2017
    Cumulative county-level enrollment rates in Health Insurance Marketplaces (HIMs) in metropolitan and non-metropolitan areas of each state, defined as the percentage of "potential market" participants selecting plans, are presented as of March 2016. States are separated by Medicaid expansion status.
  • Changing Rural and Urban Enrollment in State Medicaid Programs
    Policy Brief
    Date: 01/2017
    Medicaid enrollment growth in 36 states is analyzed by rural and expansion status, pre- and post-Affordable Care Act (ACA). Enrollment growth was larger in expansion states but did take place in most states, with significant state-level variation in both groups. Metropolitan areas generally had higher growth than micropolitan and rural areas.

2016

  • Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
    Policy Brief
    Date: 11/2016
    Provides an analysis of the differences in Accountable Care Organization (ACO) performance on the quality measures among the Medicare Shared Saving Program ACOs with varying levels of rural presence. Findings suggest that ACOs with significant rural presence have performed as well as, if not better than, urban ACOs in delivering quality care.
  • Spread of Accountable Care Organizations in Rural America
    Policy Brief
    Date: 10/2016
    This brief updates a RUPRI Center analysis of the presence of Medicare Accountable Care Organizations (ACOs) in rural areas of the US in 2013. Using participation data through 2015, the current brief finds that there has been broad growth in the number of places where ACO participating providers can be found, including rural locations.
  • Medicare Advantage Enrollment Update 2016
    Policy Brief
    Date: 09/2016
    This annual brief examines Medicare Advantage (MA) enrollment data from March 2015 and March 2016. It shows that enrollment in MA and other prepaid plans increased, both nationally and in non-metropolitan areas, but the rate of growth has slowed compared to previous years.
  • Financial Performance of Rural Medicare ACOs
    Date: 08/2016
    Assesses the financial performances of rural accountable care organizations (ACOs) based on different levels of rural presence.
  • Rural Medicare Advantage Market Dynamics and Quality: Historical Context and Current Implications
    Policy Brief
    Date: 07/2016
    There is significant variation in the quality ratings of MA plans that are available to rural beneficiaries. This brief suggests that policy interventions may be necessary to improve the quality of MA plans in rural areas.
  • Health Insurance Marketplaces: Premium Trends in Rural Areas
    Policy Brief
    Date: 06/2016
    Total Health Insurance Marketplace premiums have grown disproportionately in rural places in 2016. Urban counties have an average of 4.2 firms, while rural counties average 3.2 firms offering coverage through the HIMs. This causes concern since, at the county level, we find that as the number of firms increases, premiums increase at a slower rate.
  • Medicare Accountable Care Organizations: Beneficiary Assignment Update
    Policy Brief
    Date: 06/2016
    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services Accountable Care Organization regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Understanding ACO beneficiary assignment policies is dire in managing ACO providers and beneficiaries.
  • Variation in Primary Care Service Patterns by Rural-Urban Location
    Date: 03/2016
    Examines primary care physician service patterns by rural-urban location and discusses effect on recruitment strategies for primary care providers in rural communities.
  • Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?
    Date: 02/2016
    Examines how Critical Access Hospitals perform compared to Prospective Payment System hospitals on measures of quality.
  • Rural Medicare Advantage Plan Payment in 2015
    Policy Brief
    Date: 01/2016
    Payment to Medicare Advantage (MA) plans was fundamentally altered by the Patient Protection and Affordable Care Act of 2010 (ACA). This brief finds that while plans operating in both rural and urban areas have experienced a reduction in MA payment, the reduction in rural payment overall has been less significant.

2015

  • Rural Bypass for Elective Surgeries
    Date: 11/2015
    Describes the elective surgical bypass rate, the procedures most commonly bypassed by rural residents, the distribution of volume among Critical Access Hospitals (CAHs) that offer elective surgical services, and factors predictive of bypass.
  • Rural Enrollment in Health Insurance Marketplaces, by State
    Policy Brief
    Date: 10/2015
    This brief compares cumulative enrollment totals in Health Insurance Marketplaces in metropolitan and non-metropolitan areas by state and the percentages of potential market participants enrolled. Non-metropolitan enrollment rates were higher in several states. The analysis shows how well outreach/enrollment efforts targeting rural areas work.
  • Rural Enrollment in Health Insurance Marketplaces
    Policy Brief
    Date: 07/2015
    This brief analyzes Health Insurance Marketplace enrollment outcomes for 2015 at rating area/county levels. Enrollment rates are reported by number of firms participating and for multiple geographic categories: population density, census region, and metropolitan status of the county. Rural/urban rates are often similar, but areas of concern exist.
  • Characteristics of Rural Accountable Care Organizations (ACOs) - A Survey of Medicare ACOs with Rural Presence
    Policy Brief
    Date: 05/2015
    In this policy brief, we present the findings of a survey of 27 rural accountable care organizations, focusing on characteristics important to their formation and operation.
  • Characteristics of Rural Communities with a Sole, Independently Owned Pharmacy
    Policy Brief
    Date: 05/2015
    This brief describes the populations of rural communities with single independently owned pharmacies. About 2.7 million people, more than 25% of whom live below the poverty level, live in 663 rural communities with sole independently owned pharmacies. For about 70% of these rural communities, the next closest pharmacy is more than 10 miles away.
  • Health Insurance Marketplaces: Early Findings on Changes in Plan Availability and Premiums in Rural Places, 2014-2015
    Policy Brief
    Date: 05/2015
    Analysis of national county-level Health Insurance Marketplace (HIM) plan data for 2014 and 2015 shows there is no systematic pattern to rural experiences of HIMs, although some isolated places may be at risk for weak outcomes.
  • Hospital Views of Factors Affecting Telemedicine Use
    Policy Brief
    Date: 04/2015
    This brief expands upon previous research by examining hospital-based use of telemedicine by determining the type of use by hospitals, whether it be providing services as a hub or receiving services as a spoke, and then identifying factors from the hospitals' perspectives that affect use.
  • A Rural Taxonomy of Population and Health-Resource Characteristics
    Policy Brief
    Date: 04/2015
    This brief reports the newly developed taxonomy of rural places based on relevant population and health-resource characteristics and discusses how this classification tool can be utilized by policymakers and rural communities.
  • Developmental Strategies and Challenges for Rural Accountable Care Organizations
    Policy Brief
    Date: 02/2015
    This brief offers insights into the initial strategic decisions and challenges of four accountable care organizations (ACOs) with rural presences. These ACOs were formed as a step toward a value-driven rural delivery system. While several challenges need to be addressed, these insights can inform development of other rural ACOs.
  • Surgical Services in Critical Access Hospitals, 2011
    Policy Brief
    Date: 02/2015
    This brief describes the types and volume of major surgical services provided in critical access hospitals across four regionally representative states in 2011.
  • 2014: Rural Medicare Advantage Enrollment Update
    Policy Brief
    Date: 01/2015
    Rural Medicare Advantage (MA) and other prepaid plan enrollment in March 2014 was about 1.95 million, an increase of more than 216,000 from March 2013. Enrollment increased to 1.99 million in October 2014. Rural and urban enrollment increased despite reductions in payment and the conclusion of the MA bonus payment demonstration at 2014's end.

2014

2013

2012

2011

2010

2009

2008

2007

2006

  • The Experience of Sole Community Rural Independent Pharmacies with Medicare Part D: Reports from the Field
    Date: 11/2006
    This case study describes firsthand reports from 12 rural independent pharmacists in seven states about their experiences with Medicare Part D plans in the first seven months of 2006.
  • Medicare Physician Payment: Impacts of Changes on Rural Physicians
    Policy Brief
    Date: 09/2006
    This policy brief provides an overview of the effects of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 on physician payment rates in rural areas. The brief discusses the effects of the Medicare incentive payment for providing services in shortage areas and of the bonus for practicing in a physician scarcity area.
  • Elements of Successful Rural Diabetes Management Programs
    Date: 07/2006
    This report shares findings from a study about local innovations implemented by rural chronic disease management programs. Using diabetes as a proxy for all chronic diseases, the authors explored how local innovations overcame challenges of the rural setting to provide effective and efficient disease management.
  • Chronic Disease Management Systems (Registries) in Rural Health Care
    Policy Brief
    Date: 05/2006
    A Chronic Disease Management System (CDMS) is a tool that helps providers collect and analyze patient information to promote quality care. This study shows that CDMSs are readily available to rural clinics and are being implemented and maintained by clinic staff with minimal expenditures for technology.
  • Medicare Part D: Early Findings on Enrollment and Choices for Rural Beneficiaries
    Policy Brief
    Date: 04/2006
    This policy brief provides a first snapshot of enrollment in Medicare Part D in rural and urban areas across the United States and outlines the early findings from an analysis of plans available to rural persons under this program.
  • Care Across the Continuum: Access to Health Care Services in Rural America (2006)
    Date: 2006
    The article is divided into 3 sections: 1) basic principles that determine services to be included in the continuum and how success in providing those services is judged; 2) definition of the continuum and its basic stages based on the health systems research literature; 3) applications of the continuum and policy implications of the framework.

2005

2004

2003

2002

2001

2000