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Owsley KM, Karim SA. Community social vulnerability and the 340B Drug Pricing Program: Evaluating predictors of 340B participation among critical access hospital. J Rural Health 2024. [PMID: 38520681 DOI: 10.1111/jrh.12833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/08/2024] [Accepted: 03/04/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE The federal 340B Drug Pricing Program allows eligible hospitals, including critical access hospitals (CAHs), to obtain outpatient drugs at a discounted rate. CAHs likely benefit from 340B participation because they are often under-resourced and serve at-risk patient populations. The objective of this study was to understand predictors of 340B program participation among CAHs, and how participation varies with community-level social vulnerability. METHODS We used a cross-sectional study design to assess the relationship between 340B participation in 2019 and community vulnerability status using 2018 data from the CDC's social vulnerability index (SVI) among acute care CAHs. Analyses used linear probability models adjusted for hospital-level characteristics. FINDINGS In bivariate analyses, CAHs participating in the 340B program had lower overall social vulnerability scores, relative to nonparticipating, eligible, and ineligible CAHs, respectively (43.8 vs. 48.7 vs. 64.7, p < 0.10). In adjusted regression models, greater community vulnerability rankings due to socioeconomic status (-0.129, p < 0.05) and minority status and language (-0.092, p < 0.05) were associated with decreased 340B participation. Higher hospital operating margin was associated with increased 340B participation (0.163, p < 0.05). Although the number of for-profit CAHs ineligible for 340B was small, they had the highest community-level social vulnerability score and lowest hospital operating margin on average. CONCLUSIONS CAHs located in areas of high community vulnerability are less likely to participate in the 340B program. Some vulnerable patient populations served by CAHs may be excluded from 340B program benefits.
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Affiliation(s)
- Kelsey M Owsley
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Saleema A Karim
- Department of Health Administration, Virginia Commonwealth University, Richmond, Virginia, USA
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Neprash HT, McGlave CC, Rydberg K, Henning-Smith C. What happens to rural hospitals during a ransomware attack? Evidence from Medicare data. J Rural Health 2024. [PMID: 38494590 DOI: 10.1111/jrh.12834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/17/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE Hospitals are increasingly the target of cybersecurity threats, including ransomware attacks. Little is known about how ransomware attacks affect care at rural hospitals. METHODS We used data on hospital ransomware attacks from the Tracking Healthcare Ransomware Events and Traits database, linked to American Hospital Association survey data and Medicare fee-for-service (FFS) claims data from 2016 to 2021. We measured Medicare FFS volume and revenue in the inpatient, outpatient, and emergency room setting-at the hospital-week level. We then conducted a stacked event study analysis, comparing hospital volume and revenue at ransomware-attacked and nonattacked hospitals before and after attacks. FINDINGS Ransomware attacks severely disrupted hospital operations-with comparable effects observed at rural versus urban hospitals. During the first week of the attack, inpatient admissions volume fell by 14.7% at rural hospitals (P = .04) and 16.9% at urban hospitals (P = .01)-recovering to preattack levels within 2-3 weeks. Outpatient visits fell by 35.3% at rural hospitals (P<.01) and 22.0% at urban hospitals (P = .03) during the first week. Emergency room visits fell by 10.0% at rural hospitals (P = .04) and 19.3% at urban hospitals (P = .01). Travel time and distance to the closest nonattacked hospital was 4-7 times greater for rural ransomware-attacked hospitals than for urban ransomware-attacked hospitals. CONCLUSIONS Ransomware attacks disrupted hospital operations in rural and urban areas. Disruptions of similar magnitudes may be more detrimental in rural areas, given the greater distances patients must travel to receive care and the outsized impact that lost revenue may have on rural hospital finances.
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Affiliation(s)
- Hannah T Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Claire C McGlave
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katie Rydberg
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Apenteng BA, Adewoye A, Owens C, Opoku ST, Kimsey L, Peden A, Shehaj B. Examining the relationship between rural residents' satisfaction with local hospital's COVID-19 response and intention to use the hospital. J Rural Health 2024; 40:259-267. [PMID: 37468945 DOI: 10.1111/jrh.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/21/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE The COVID-19 pandemic highlighted the importance of having emergency and acute care services close to home and emerged as an opportunity for hospital-community engagement. This study examined whether rural residents' satisfaction with their local hospital's pandemic response was associated with improved community perception of the hospital and an intention to use it in the future. METHODS Data for the study were obtained from a survey of rural residents of 6 Georgia rural communities and analyzed using multivariable logistic regression and mediation analyses. RESULTS Rural residents' satisfaction with their local hospital's pandemic response was associated with an improved perception of the hospital. Improvement in the perception of rural hospitals following the pandemic was found to partially mediate a positive association between community residents' satisfaction with hospital pandemic response and the intention to use the hospital when needed. CONCLUSION The COVID-response efforts may have given rural hospitals an opportunity to influence public perception.
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Affiliation(s)
- Bettye A Apenteng
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Aishat Adewoye
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Charles Owens
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Samuel T Opoku
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Linda Kimsey
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Angie Peden
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Blerta Shehaj
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
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Reiter KL, Gurzenda S, Thompson K, Holmes GM, Pink GH. Supporting Critical Access Hospital operational and financial improvement through the Medicare Rural Hospital Flexibility Program. J Rural Health 2023; 39:710-715. [PMID: 37085885 DOI: 10.1111/jrh.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Affiliation(s)
- Kristin L Reiter
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susie Gurzenda
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristie Thompson
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - George H Pink
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, North Carolina, USA
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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PLANEY ARRIANNAMARIE, PLANEY DONALDA, WONG SANDY, MCLAFFERTY SARAL, KO MICHELLEJ. Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018. Milbank Q 2023; 101:922-974. [PMID: 37190885 PMCID: PMC10509521 DOI: 10.1111/1468-0009.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 12/19/2022] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes. CONTEXT The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. METHODS To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models. FINDINGS We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. CONCLUSIONS Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.
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Carroll C, Euhus R, Beaulieu N, Chernew ME. Hospital Survival In Rural Markets: Closures, Mergers, And Profitability. Health Aff (Millwood) 2023; 42:498-507. [PMID: 37011307 DOI: 10.1377/hlthaff.2022.01191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Financial distress among rural hospitals in the US has increased in recent years. Using national hospital data, we investigated how the decline in profitability has affected hospital survival, either independently or with a merger. The answer has direct implications for access to care and competition in rural markets. We assessed the rate of hospital closures and mergers in predominantly rural markets during the period 2010-18, focusing on hospitals that were unprofitable at baseline. A minority of unprofitable hospitals (7 percent) closed. A larger share (17 percent) merged, most commonly with organizations from outside of their local geographic market. Most unprofitable hospitals (77 percent) continued to operate through 2018 without closure or merger. About half of these hospitals returned to profitability. At the market level, 22 percent of markets served by unprofitable hospitals lost a competitor to closure or within-market merger. Out-of-market mergers affected 33 percent of markets with an unprofitable hospital. Overall, our results suggest that rural markets are experiencing meaningful rates of hospital closures and mergers, yet many hospitals have survived despite poor financial performance. Policies targeting access to care will continue to be important. Similar attention will be needed to address the competitive effects of hospital closures and mergers on prices and quality.
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Affiliation(s)
- Caitlin Carroll
- Caitlin Carroll , University of Minnesota, Minneapolis, Minnesota
| | - Rhiannon Euhus
- Rhiannon Euhus, Harvard University, Boston, Massachusetts
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Friedman HR, Holmes GM. Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals. Health Serv Res 2022; 57:1029-1034. [PMID: 35773787 PMCID: PMC9441274 DOI: 10.1111/1475-6773.14017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010. DATA SOURCES We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey. STUDY DESIGN We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression. DATA COLLECTION We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey. PRINCIPAL FINDINGS Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p < 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p < 0.001). CONCLUSIONS Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.
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Affiliation(s)
- Hannah R. Friedman
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - George Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North CarolinaChapel HillNorth CarolinaUSA
- The Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Greenwood-Ericksen M, Kamdar N, Lin P, George N, Myaskovsky L, Crandall C, Mohr NM, Kocher KE. Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries. JAMA Netw Open 2021; 4:e2134980. [PMID: 34797370 PMCID: PMC8605483 DOI: 10.1001/jamanetworkopen.2021.34980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). OBJECTIVE To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. DESIGN, SETTING, AND PARTICIPANTS This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. RESULTS The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. CONCLUSIONS AND RELEVANCE The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
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Affiliation(s)
- Margaret Greenwood-Ericksen
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Naomi George
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City
- Department of Anesthesia–Critical Care Medicine, University of Iowa, Iowa City
| | - Keith E. Kocher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
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