Mark Holmes, PhD

Director, North Carolina Rural Health Research and Policy Analysis Center

Phone: 919.966.7101
Email: mark_holmes@unc.edu

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


Current Projects - (3)

How Do Costs for Rural Medicare Beneficiaries Using Swing Beds Compare to Those Using Skilled Nursing Facilities?
This study will estimate and compare total Medicare expenditures for episodes of care that include post-acute stays in either swing beds or skilled nursing facilities (SNFs). Results will inform federal and state agencies, rural providers and communities as to how post-acute care in swing bed versus a SNF affects the trajectory of costs and utilization for rural Medicare beneficiaries.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Long term care, Medicare
How Rural Communities Respond and Recover after a Hospital Closure
Current rates of rural hospital closures are the highest seen in the last few decades. What can we learn from the experiences of communities experiencing hospital closures?
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Workforce
Post-Acute Care for Rural Medicare Beneficiaries
This project will describe the variation in the volume, mix and financial importance of post-acute services to rural hospitals; identify hospital and community characteristics associated with variation in post-acute services provided by rural hospitals; and determine where rural Medicare beneficiaries receive post-acute services.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Long term care

Completed Projects - (12)

Can a Model Predict Financial distress among Rural Hospitals?
This project will extend an existing model of CAH financial distress to other types of rural hospitals. A valid model would be helpful to ORHP and state Offices of rural Health interested in predicting financial distress or closure of rural hospitals.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Hospitals and clinics
Community and Financial Experience of Medicare Dependent Hospitals in Comparison to Other Rural Hospitals
This research will investigate the community and financial experience of Medicare Dependent Hospitals in comparison with other rural hospitals. Analysis of the financial experience will include comparison of the long-term profitability of MDHs to other rural hospitals, estimation of the potential profitability consequences of eliminating the payment classification, and estimation of the potential consequences of maintaining the payment classification but failing to update the base year from which costs are trended forward.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
Comprehensive Study of Swing Bed Use in Rural Hospitals
This project will comprehensively address questions about how swing beds are used by rural hospitals. Questions to be answered include whether decision about use are driven by patient need, community resources, hospital operational concerns or some combination of these factors; the cost implications of swing bed use in critical access hospitals to the Medicare program; and whether patients served in swing beds differ in meaningful ways from those in skilled nursing facilities.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS)
Early Rural Experiences of Changes to Medicaid: Year 1
In January 2014, some states will expand eligibility through the Medicaid program, while other states will not. Because rural residents are likely to be disproportionately affected by Medicaid expansion, understanding this interstate variation has important policy implications.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health policy, Medicaid and S-CHIP
Exploring Regional Differences in Rural and Urban Mortality Trends
Explores the differences in U.S. mortality rates by urban and rural location, census division, and urban and rural location within each census division. The gap in nationwide urban-rural mortality is often told as a national story, but the changes are regional. This implies different regions may need different strategies for addressing the gap.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topic: Health disparities
Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion
Making use of the financial indicators developed by project staff, the focus of this project is a longitudinal analysis of the dimensions and indicators of financial performance. Descriptive analyses are used to capture changes in all dimensions of financial performance pre- and post-conversion.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Healthcare financing, Medicare Prospective Payment System (PPS)
How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals?
This two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); (3) financial performance; and (4) hospital revenue cycle management. Results will inform federal and state agencies, rural providers and communities as to how implementation of the Patient Protection and Affordable Care Act is impacting reimbursement and financial performance of rural hospitals, allowing the Office of Rural Health Policy to identify emerging challenges and develop strategies or policy changes needed to deal with any unintended consequences.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health insurance and the uninsured, Hospitals and clinics
How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals? (Year 2)
The second year of this two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); and (4) financial performance.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health insurance and the uninsured, Healthcare financing, Medicaid and S-CHIP, Medicare
Identifying Limitations of PPS Reimbursement for Rural Hospitals
This project will investigate the potential financial and access consequences of returning rural hospitals to PPS payment. Characteristics of the hospitals and communities at highest risk of adverse consequences will be identified.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health policy, Healthcare financing, Hospitals and clinics
Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations
This study will describe usual patterns of care in rural areas to determine whether rural areas are part of a single service area, or whether smaller communities utilize services from a variety of larger hubs. The results of this analysis will inform a thought piece on how the concepts of bundled payments and Accountable Care Organizations might play out in small rural areas and whether small rural communities can be assigned to a single service area without major disruption of current patterns of care.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health policy, Health services
Policy Analysis Using the Financial Distress Model: Does Medicaid Expansion Affect the Risk of Hospital Financial Distress and Closure?
This study will build on the 2014-15 approved project entitled “Can a Model Predict Financial Distress among Rural Hospitals?” The newly developed model uses current financial performance and market characteristic data to assign rural hospitals to one of four categories of risk of financial distress. The study will use Medicare Cost Report data for 2014, if available. Otherwise, simulation will be used to estimate the effects on financial distress.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Hospitals and clinics, Medicaid and S-CHIP
Rural Health Clinics: Medicare & Medicaid Profile (Year 2)
Year 2 of a project developing a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements. RHC Medicaid data for a sample of states also will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Medicaid and S-CHIP, Medicare, Rural Health Clinics (RHCs)

Publications - (47)

  • 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.
  • The 21st Century Rural Hospital: A Chart Book
    Chartbook
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2015

    Hospitals have changed over recent decades. Hospital stays are shorter. Procedures once requiring hospitalization are now done in an outpatient setting. Hospitals have moved beyond providing mainly inpatient and emergency department care. They have become vertically integrated systems with “one-stop shopping” for all of one’s health care needs.

    The transformation of hospitals has also occurred in rural areas where the presence of a hospital with traditional inpatient and emergency department services may also ensure that other healthcare is available. Even with a cursory scan of rural hospital websites, one can see that rural hospitals offer a variety of services that range from traditional inpatient medical, surgical and obstetric care to advanced imaging, laboratory, and rehabilitation services. Outpatient primary and specialty care are available, and hospitals provide important health promotion and wellness services for the community. Hospitals vary, however, based on their resources and the needs of the populations they serve. As is often said about many things, “if you’ve seen one hospital, you’ve seen one hospital.”

    This Chart Book uses available data to present a broad profile of the 21st century rural hospital and includes such descriptors as: Where are they located? Whom do they serve? What traditional hospital services do they provide? How do they ensure outpatient services for their community? What other community benefits do they provide or enable for citizens in their area? How are they doing financially? How are they supported by federal programs?

    The pages of The 21st Century Rural Hospital: A Chart Book are each designed as a pull-out document and describe many aspects of today’s rural hospital. Each page includes charts comparing rural hospitals to each other and to urban hospitals across different dimensions such as levels of rurality, US Census region, and hospital size. Important data points are emphasized and an illustrative rural hospital is highlighted. Those who are unfamiliar with today’s rural hospital may be surprised by many data points shown here; others may use this document to research a particular data point.

  • 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

    The Affordable Care Act provided coverage through the Health Insurance Marketplace to nearly seven million people during the first open enrollment period. Yet, research suggests that the enrollment rates for eligible individuals living in rural areas was less than enrollment rates for those living in urban areas. That may be due, in part, to specific challenges in rural communities, including lack of internet access, low population density, travel barriers to obtaining help, or strong political opposition to “Obamacare.”

    Among rural communities, there was considerable variation in the enrollment rate. The North Carolina Rural Health Research Program conducted key informant interviews of navigators, health centers, Certified Application Counselors (CACs), and other partner organizations in nine rural counties with high enrollment rates in seven states to try to identify best practices for marketing, outreach and education, in-reach (identifying eligible current clients), and enrollment in rural communities.

  • 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.
  • 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.
  • Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Reports that changes to Critical Access Hospitals (CAHs) reimbursement, such as a reversion to prospective payment, would have marked negative effects on CAH profitability and financial health. Roughly three quarters of CAHs would operate at a loss. The number of CAHs at high risk for financial distress would nearly triple and nearly half of CAHs would be at medium-high to high risk of financial distress.
  • 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.
  • 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.
  • CMS Hospital Quality Star Rating: For 762 Rural Hospitals, No Stars is the Problem
    Policy Brief
    Rapid Response to Requests for Rural Data Analysis
    Date: 06/2017
    The purpose of this brief is to look more closely at the characteristics of rural hospitals with and without CMS Hospital Quality Star Ratings to help inform ongoing discussions about the usefulness of the quality star rating for comparing hospital quality and possible ways to improve the star rating initiative.
  • 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.
  • 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

    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).

  • 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

    The financial performance of small, rural hospitals has long been a concern to federal and state agencies. Federal law makers have enacted legislation authorizing the Medicare program to develop reimbursement methods that provide higher payments to hospitals that serve rural communities (Critical Access Hospitals, Sole Community Hospitals, Medicare-Dependent Hospitals, and Standard Prospective Payment Systems hospitals). Current payment methods reflect legislative changes that have occurred since the rural hospital Medicare payment classifications were created more than 15-20 years ago. As a result, current rural hospital payment methods differ in eligibility criteria, adjustment factors, formulae, and timeliness of data. These differences may contribute to the variation in financial condition that has been found across the four types of rural hospitals. 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. Results are reported in the Findings Brief: Do Current Medicare Rural Hospital Payment Systems Align with Cost Determinants?

  • 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.
  • The Effect of Surgery on the Profitability of Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 2015
    Presents research on the effect of providing surgery in rural hospitals. Examines the availability of surgery’s effect on trauma outcomes and economies in rural communities.
  • 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.
  • Financially Fragile Hospitals: Mergers and Closures
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2015
    Evaluates the causes of financial stress in rural hospitals, and describes the impact rural hospitals have on their communities. Also discusses the ways in which rural hospitals and communities have responded to this financial stress.
  • Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2014

    Combines the recently released data on plan selection in the Federally Facilitated Marketplaces with estimates of the population likely to qualify for the marketplace (i.e. “eligibles”) to calculate the percent of potential eligible individuals who chose a health insurance plan (the “uptake rate”). Contains a heat map that shows variation in uptake rates across the country.

  • 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.
  • 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.
  • How Does Medicaid Expansion Affect Insurance Coverage of Rural Populations?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2014

    Examines how states’ decisions on Medicaid expansion are impacting rural areas in the United States. Used population estimates, current status of state expansion, and state-level insurance estimates to answer two primary questions including how is Medicaid expansion affecting rural populations and how would it differ if every state were to expand Medicaid.

  • How Might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial Viability of Rural Pharmacies? An Analysis of Pre-Implementation Prescription Volume and Payment Sources in Rural and Urban Areas
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 2005
    Presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs. urban areas. Together, these data provide a baseline for evaluating how implementation of the MMA may affect the financial viability of rural independent pharmacies.
  • 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.
  • 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.
  • Implications for Beneficiary Travel Time if Financially-Vulnerable Critical Access Hospitals Close
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Reports that changes to Critical Access Hospitals (CAHs) reimbursement may spur some CAHs to close, with the most financially vulnerable more likely to close. The average resident of these communities would experience an 80% increase in distance to the nearest hospital if the CAH were to close. This analysis considers the communities served by the 93 CAHs with the lowest profitability and therefore most likely to close due to a change in Medicare reimbursement.
  • 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.
  • Minimum Distance Requirements Could Harm High-Performing CAHs and Rural Communities
    North Carolina Rural Health Research and Policy Analysis Center, University of Minnesota Rural Health Research Center
    Date: 04/2015
    Compares the effect of location on critical access hospitals’ size, quality of care, and financial strength. Discusses implications of minimum distance requirements on critical access hospitals.
  • Predicting Financial Distress and Closure in Rural Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 06/2016
    Examines the financial distress of rural hospitals to better predict closures within two years.
  • 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.
  • 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.
  • Profile of Rural Health Clinics: Clinic & Medicare Patient Characteristics
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2013
    Presents a summary of the geographic distribution and clinic-level characteristics of rural health clinics, as well as an overview of the Medicare beneficiaries they served.
  • 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.
  • 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.
  • 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

    Examines the implications of mergers and acquisitions for small rural hospitals. Addresses the characteristics of rural hospitals that merged and the changes in hospital financial performance, staffing or services following a merger.

  • Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Post-discharge
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2015
    Compares rates of post hospital discharge care among Medicare beneficiaries in rural and urban settings. Discusses the effect on policies for follow-up care and readmission penalties.
  • 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

    The Affordable Care Act (ACA) expanded health insurance coverage to previously uninsured populations by allowing states to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level (FPL) as well as by creating health insurance marketplaces to subsidize affordable coverage. However, states with a higher number or proportion of rural residents were less likely to expand Medicaid than were more urban states. In addition, rural residents eligible for insurance coverage through the new health insurance market place were less likely to enroll in coverage compared to eligible urban residents.

    Expanding health insurance coverage to the uninsured, through both Medicaid and the new health insurance marketplaces, may improve the financial well-being of rural hospitals and Federally Qualified Health Centers (FQHCs) by reducing the provision of uncompensated care. Even a small increase in revenues due to expanded coverage may have a meaningful impact for rural prospective payment system (PPS) hospitals and critical access hospitals (CAHs), which generally have lower median operating margins than do urban hospitals or larger rural referral centers.

    In order to inform timely policy development, the North Carolina Rural Health Research Program surveyed rural providers’ early experiences of the ACA in four states: two that chose to expand Medicaid (Arizona and North Dakota), and two that chose not to expand Medicaid (Georgia and Maine). Our findings brief, Rural Provider Perceptions of the ACA: Case Studies in Four States summarizes perceptions from these states regarding the early effects of the ACA, including changes to patient populations, financial health, and capacity for rural hospitals and rural FQHCs.

  • 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.
  • 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 Affordable Care Act and other reforms in the healthcare market, new models of care are being tested and implemented across the country. Care and payment models such as patient-centered medical homes, Accountable Care Organizations (ACOs), and bundled payments depend on linkages between different types of healthcare providers to ensure continuity of care. To addresses concerns that healthcare in rural areas may be more fractured and thus a difficult place for these models to succeed, we measured continuity of care using detailed data on a sample of Medicare beneficiaries from 2000-2009.

  • Rural-Urban Variations in Medicare Live Discharge Patterns from Hospice, 2012-2013
    Policy Brief
    Rapid Response to Requests for Rural Data Analysis
    Date: 09/2017
    This brief 1) provides an overview of the geographic distribution of “freestanding” (i.e., rather than those co-located in a hospital, home health agency, or skilled nursing facility) rural and urban hospices and, 2) explores live discharge rates for hospices operating in rural versus urban areas.
  • Rural/Urban Differences in Inpatient Related Costs and Use among Medicare Beneficiaries
    Rapid Response to Requests for Rural Data Analysis
    Date: 12/2013
    Reports that Medicare beneficiaries who are admitted to rural hospitals tend to have lower outpatient costs than Medicare beneficiaries admitted to urban hospitals. These differences are due to multiple factors, some of which were adjusted in the comparison. The analysis suggests that consideration of the total cost of an acute episode of care might be considered, not just the cost of the acute inpatient stay.
  • 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

    Uses data extracted from 2009 Medicare outpatient provider claims to look at the location of clinics, the number of beneficiaries served, and the number of and cost per claim for each type of rural safety net clinic. We further examined characteristics of Medicare beneficiaries comparing their age, the health problems for which they sought care, and the distance they travelled to obtain care. Because Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) are similar in mission but may be different in practice, understanding their respective Medicare patient profiles is important. This findings brief is the third and final in a series on RHCs which draws on a large, national dataset that includes claims data on the approximately 90% of RHCs that billed Medicare in 2009.

  • 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.
  • The Rising Rate of Rural Hospital Closures
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 07/2015
    Discusses the increase in rural hospital closure rates, including the causes of closures and its impact on rural communities.
  • 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.
  • 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.
  • Variations in Financial Performance Among Peer Groups of Critical Access Hospitals
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 2007
    Reports findings from a study that investigated whether indicators of financial performance and condition systematically vary among peer groups of Critical Access Hospitals (CAHs).