Access To Obstetric, Behavioral Health, And Surgical Inpatient Services After Hospital Mergers In Rural Areas

Rural Hospitals Experienced More Patient Volume Variability Than Urban Hospitals During The COVID-19 Pandemic, 2020-21

Fluctuations in patient volume during the COVID-19 pandemic may have been particularly concerning for rural hospitals. We examined hospital discharge data from the Healthcare Cost and Utilization Project State Inpatient Databases to compare data from the COVID-19 pandemic period (March 8, 2020-December 31, 2021) with data from the prepandemic period (January 1, 2017-March 7, 2020). Changes in average daily medical volume at rural hospitals showed a dose-response relationship with community COVID-19 burden, ranging from a 13.2 percent decrease in patient volume in periods of low transmission to a 16.5 percent increase in volume in periods of high transmission. Overall, about 35 percent of rural hospitals experienced fluctuations exceeding 20 percent (in either direction) in average daily total volume, in contrast to only 13 percent of urban hospitals experiencing similar magnitudes of changes. Rural hospitals with a large change in average daily volume were more likely to be smaller, government-owned, and critical access hospitals and to have significantly lower operating margins. Our findings suggest that rural hospitals may have been more vulnerable operationally and financially to volume shifts during the pandemic, which warrants attention because of the potential impact on these hospitals' long-term sustainability.

Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey

INTRODUCTION

We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India.

METHODS

A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant.

RESULTS

Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas.

CONCLUSIONS

Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

A comparison of critical access hospitals and other rural acute care hospitals in Pennsylvania

PURPOSE

As the Flex Program celebrates its 25th anniversary, we examined changes in critical access hospital (CAH) financial performance, investigated whether CAH status has reduced hospitals' financial vulnerability, and identified factors influencing financial performance.

METHODS

We collected data on acute care hospitals in Pennsylvania's rural counties for 2000-20. Our sample contained 1,444 hospital-year observations. We used trend analysis to compare the financial performance of CAHs and rural prospective payment system (PPS) hospitals (non-CAHs). We investigated the effect of CAH status on financial performance and identified the time-variant factors impacting financial performance using fixed-effects regression analysis.

RESULTS

The median total margin of CAHs lagged behind that of non-CAHs. When compared to non-CAH costs over the same period, the median cost per patient day incurred by CAHs has increased, with the rate of increase being significantly higher in the most recent decade. Our findings show that while CAH status does not appear to have a direct impact on the total margin, it is significantly associated with a higher cost per patient day.

CONCLUSIONS

CAHs in Pennsylvania appear to be facing a double whammy of declining margins and rising costs compared to non-CAHs. Our findings demonstrate how crucial the Flex program has been in sustaining CAHs in Pennsylvania ever since its inception. Our findings have implications for rural health care delivery as well. While providing financial support and operational flexibility to CAHs should be a continuing policy priority, a long-term policy goal should be to envision an economic development strategy that capitalizes on the unique strengths of each of the rural archetypes.

Considerations for state-imposed conditions on healthcare provider transactions

The widespread consolidation of health systems, hospitals, and physicians has contributed to the high price of healthcare across the United States. While federal antitrust enforcers continue to play an important role in overseeing large mergers, acquisitions, and other consolidating transactions of major healthcare providers, state oversight over healthcare markets is essential to slow consolidation more broadly and address market failures across the country. State laws govern the scope of authority held by state attorneys general and other state agencies to receive notice of, review, and approve, conditionally approve, or block healthcare provider transactions, which can significantly impact the breadth and content of oversight. While blocking potentially anticompetitive transactions can help states maintain any competitive forces that remain in the market, in some situations, approving a transaction with conditions may be the best path forward. Applying conditions to transactions may allow state officials to oversee and govern the behavior of providers post-transaction while states pursue other legislative fixes. Although the use of conditions is a relatively common practice at the state level, little research has been done to explore their use among states. Following a search in all 50 states, this paper examines decisions from state officials imposing conditions intended to address the impacts of transactions on healthcare price, access, and quality and provides recommendations for the effective use of conditions moving forward.

Hospital Survival In Rural Markets: Closures, Mergers, And Profitability

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.

Proposed Solutions for Improving Maternal Health Care in Rural America

Increasing hospital and labor & delivery (L&D) closures have led to declining access to hospital obstetric care in rural areas across the country. These closures increase the burden on women and families living in rural communities, who often must drive long distances for prenatal visits and delivery. The lack of maternal health care in rural America can also result in several adverse maternal and infant outcomes including premature birth, low birth weight, out of hospital births, maternal and infant morbidity and mortality, and increased risk of postpartum depression. The reasons for these closures are multifactorial, and include, workforce shortages, financial viability, low volume of patients, concerns over maintaining the knowledge base and skill sets of the obstetrical health care team required to provide high quality and safe care, as well as medical-legal concerns. The problems of providing and accessing quality maternal and obstetrical care in rural America have not happened overnight, Likewise, the solutions to these problems will also not occur overnight and must also address the multifactorial nature of the problem. However, there are several opportunities to improve access to maternal health care in rural communities. Programs, policies, and funding need to be designed and provided to make these opportunities a reality.

Relationship between sleep apnea and hospital readmission in rural and urban populations

OBJECTIVES

The aims of this study were to evaluate geographic differences in obstructive sleep apnea (OSA) prevalence, to determine if readmissions were more likely among rural patients with OSA than others, and to model predictors, including diagnosed OSA, of 30, 60, and 90-day acute-care readmissions.

DESIGN

This cohort study employed a secondary analysis of data extracted from the electronic health record shared by all hospitals in a north Texas healthcare system.

SAMPLE

The sample consisted of records associated with 472,503 adult patients admitted to any of the study system's acute-care facilities from 2016 through 2019.

MEASUREMENTS

Measurements consisted of case-level health information, including admissions, demographic variables, payors, diagnoses, screens, and physician orders.

RESULTS

OSA was significantly related to hospital readmission when considered in isolation but did not significantly predict readmission when modeled with plausible covariates. Screening rates for OSA did not vary by geography. Differences in rural/urban-suburban OSA prevalence were not statistically significant.

CONCLUSIONS

Findings contrast with previous suggestions that OSA plays an independent role in hospital readmissions or that rural resident may be disadvantaged regarding services that support the OSA diagnosis. Prevalence and screening rates were almost identical in urban and rural populations.

Risk of Closure Among Independent and Multihospital-Affiliated Rural Hospitals

Question

Is affiliation with another hospital or multihospital system associated with lower risk of closure in rural areas?

Findings

In this 13-year cohort study from 2007 to 2019 among rural US hospitals that faced financial distress in 2007, affiliation was associated with a lower risk of closure compared with being independent. Conversely, among hospitals with financial stability in 2007, affiliation was associated with a higher risk of closure compared with being independent.

Meaning

The study results suggest that affiliation may protect some financially distressed rural hospitals from closure, but the higher risk of closure among hospitals that were initially financially stable potentially raises concerns about the consequences of affiliation for some types of hospitals.

Importance

The increase in rural hospital closures has strained access to inpatient care in rural communities. It is important to understand the association between hospital system affiliation and access to care in these communities to inform policy on this issue.

Objective

To examine the association between affiliation and rural hospital closure.

Design, Setting, and Participants

This cohort study used survival models with a time-dependent variable for affiliation vs independent status to assess risk of closure among a national cohort of US rural hospitals from January 2007 through December 2019. Data analysis was conducted from March to October 2021. Hospital affiliations were identified from the American Hospital Association Annual Survey and Irving Levin Associates and closures from the University of North Carolina Sheps Center (Chapel Hill). Additional covariates came from the Healthcare Cost and Utilization Project State Inpatient Databases and other national sources.

Exposures

Affiliation with another hospital or multihospital health system.

Main Outcomes and Measures

Closure was the main outcome. The models included hospital, market, and utilization characteristics and were stratified by financial distress in 2007.

Results

Among 2237 rural hospitals operating in 2007, 140 (6.3%) had closed by 2019. The proportion of rural hospitals that were independent decreased from 68.9% in 2007 to 47.0% in 2019; the proportion that were affiliated increased from 31.1% to 46.7%. Among financially distressed hospitals in 2007, affiliation was associated with lower risk of closure compared with being independent (adjusted hazard ratio [aHR], 0.49; 95% CI, 0.26-0.92). Conversely, among hospitals that were financially stable in 2007, affiliation was associated with higher risk of closure compared with being independent (aHR, 2.36; 95% CI, 1.20-4.62). For-profit ownership was also strongly associated with closure for hospitals that were financially stable in 2007 (aHR, 4.08; 95% CI, 1.86-8.97).

Conclusions and Relevance

The results of this cohort study suggest that affiliations may be associated with lower risk of closure for some rural hospitals in financial distress. However, among initially financially stable hospitals, an increased risk of closure for hospitals associated with affiliation and proprietary ownership raises concerns about the association of affiliation with closures in some circumstances. Policy interventions to stabilize inpatient care in rural areas should account for these findings.

Association Between Medicaid Expansion And Closure Of Hospital-Based Obstetric Services

Access to obstetric services has declined steadily during the past decade, driven by the closure of hospital-based obstetric units and of entire hospitals. A fundamental challenge to maintaining obstetric services is that they are frequently unprofitable for hospitals to operate, threatening hospital viability. Medicaid expansion has emerged as a possible remedy for obstetric service closure because it reduces uncompensated care and improves hospital finances. Using national hospital data from the period 2010-18, we assessed the relationship between Medicaid expansion and obstetric service closure in rural and urban communities. We found that expansion led to a large reduction in hospital closures; however, this effect was concentrated among hospitals that did not have obstetric units. Considering closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded within two years. Overall, our findings suggest that Medicaid expansion had little effect on the closure of obstetric services. Policies supporting access to obstetric care may need to directly address the financial challenges specific to this service line.