There is a health care crisis erupting in rural America. Hospitals are closing across rural America, increasing time and distances travelled to receive care, exacerbating existing health disparities, and creating new ones. For example:

A set of papers the October issue of Health Services Research, researchers from academic and government agencies discuss the repercussions of these changes and forecast how rural America’s hospitals can transform for the better.

The first paper looks at the relationship between hospital closures and the local economy. Nearly 8% of the nation’s 1,800 rural hospitals have closed in the last two decades.  Chatterjee and colleagues found that in many cases, hospital closures were preceded by steady economic decline. This means the closure of a hospital didn’t lead to worse economic conditions but rather, worsening conditions may have forced hospitals to close. After a county experienced a hospital closure, the authors found only health sector jobs were impacted and saw no decline in other economic indicators such as total income, disability, and unemployment rates. People who previously worked at a rural hospital either found jobs in a new field or commuted to another location. The authors note there is a need to understand this issue in finer detail. Future research should take a granular look at local economic indicators to see how closures impact individual rural towns and small cities.

This issue of bed to patient ratio is known as hospital capacity. Hegland and colleagues published an innovative method to characterize hospital capacity while accounting for patient behavior. Most hospitals work on a hub and spoke model with one larger urban hospital and other (smaller) hospitals in suburban and rural areas. Researchers tend to look at hospital capacity without considering interstate transfers or hospitals that use a hub and spoke structure. “The authors found rural hospitals, despite having fewer resources, generally have higher capacity and, on balance, experience no care quality differences compared to urban areas. That is, although there may be differences in specific measures of quality care, when taken as a whole the areas where quality looks better wash out against those where it looks a bit worse.” This means that rural hospitals can accommodate patients more easily than urban hospitals though they may not offer as many specialized services. The authors also found rural residents typically travel five times further to access a hospital compared to urban dwellers (20.51 miles vs. 3.93 miles, respectively). This longer distance means those facing time-sensitive issues (such as a heart attack or stroke) are at higher risk for negative outcomes. Finally, the authors note that hospitals with a lower quality rating tend to be in areas with more racial diversity. Understanding if there are downstream consequences to hospital capacity and quality can be critical in understanding rural America’s health.

Hospital bypass refers to individuals bypassing local (rural) health care systems to use urban-area health care. While Friedman and Holmes did not specifically look for hospital bypass behaviors, they found rural Medicare beneficiaries are increasingly (at 2 percent increase per year) being admitted to urban over rural hospitals. Speculation on why bypass behaviors occur typically assumes residents choose urban areas for specialized or expanded services. Friedman and Holmes suggest choosing urban (over rural) hospitals may be a function of hospital consolidation into an affiliated network or seeing urban hospitals as higher quality. Additional research is needed on how these results translate to other insured populations such as Medicare Advantage, Medicaid, or commercial patients.

Reimagining rural hospitals may be one way to ensure that high-value services are maintained in rural areas. In a commentary in this issue, Carroll and colleagues point out the reasons to keep rural hospitals open (including those mentioned above: options and timeliness) and the potential downsides if closures continue (e.g., furthering health inequities). However, they also suggest that closures could potentially be beneficial if the care provided is subpar, and patients have access to another, higher-quality hospital. Keeping hospitals open is also expensive. Therefore, there is a need to critically evaluate the role that hospitals should play in rural health care delivery, and whether new delivery models can enhance rural health and health equity. The forthcoming Rural Emergency Hospital program, for example, uses a new infrastructure-based payment model to support limited-service hospitals (emergency and outpatient care only). Some communities may benefit from this type of delivery model – paired with regionalization of specialty care – while others would be better off maintaining a full-service hospital.

This collection of articles focused on rural hospitals shows several indicators of the fate of the rural hospital. Economic decline preceding rather following rural hospital closures shows the importance of investing broadly in rural communities. In addition, acknowledging how hospital capacity works and how rural bypass occurs can help health services researchers better assess rural hospital performance and quality. This could potentially lead to fewer closures and enhanced service opportunities. Finally, reimagining the significance of rural hospitals requires the recognition that each rural community has unique needs. Future federal policies intended to alleviate financial pressures should pay attention to the needs of local communities.

Committee Member, Member

Kaleigh Ligus, M.A.

Ph.D. Candidate - University of Connecticut

Kaleigh is a doctoral student in the Human Development and Family Sciences department at the University of Con... Read Bio

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