July 15, 2022

As poor financial health forces hospitals to close in rural areas across the country, remaining rural hospitals are seeing a decline in patient admissions. New research shows that this is not because fewer patients are seeking emergency services. Instead, these patients are more likely to be admitted to hospitals in urban areas, even if a closer hospital is nearby.

New findings from the UNC Gillings School of Global Public Health suggest that Medicare patients may be bypassing rural hospitals altogether and traveling longer distances to seek care at urban hospitals.

Hannah Friedman

Hannah Friedman

“There are a number of different factors that influence where someone goes for treatment, such as proximity, the referral from a primary care provider, and differences in cost and quality of care between hospitals,” said Hannah Friedman, doctoral student in health policy and management, who is lead author on a study published recently in Health Services Research. “Proximity may be outweighed by other considerations that drive people to seek care farther afield, which could be contributing to declines in rural hospital volume that may eventually lead to closures.”

In the study, Friedman and Mark Holmes, PhD, professor of health policy and management and director of the Cecil D. Sheps Center for Health Services Research, examined hospital admission and Medicare Fee for Service (FFS) data between 2010 and 2018 to determine what kind of impact rural hospital availability had on admissions.

They found that rural areas experienced a 2% yearly increase in Medicare patient admissions to urban hospitals per ZIP code. This equates to an estimated 16% increase over a period of eight years.

Although urban hospitals admitted more patients even if a rural hospital was close by, rural hospital closures also boosted the likelihood of admission to an urban hospital. In addition, admissions to urban hospitals increased even if the nearest rural hospital joined a larger health care system.

These results were consistent throughout the continental United States. While rural hospital closures are more prominent in the Southeast, the findings suggest that patient priorities and referral patterns are shifting or that rural hospitals across the country may be unable to meet all the needs of Medicare patients in their communities.

Declining admission rates will inevitably lead to more hospital closures – a concerning trend that signals the need for rural hospitals to adapt to changing patient care-seeking behaviors.

“This trend may not be sustainable for hospitals relying on fee-for-service models that depend on the volume of patients, especially hospitals that are already experiencing financial challenges. Some patients, such as those with complex conditions, should probably not be treated at critical access hospitals because of the lack of facilities or specialists available to treat them. More can be done to make it easier for people to access this type of care,” Friedman explained. “Larger hospitals often have more resources to dedicate to quality improvement initiatives and other programs that can influence health outcomes for patients.”

“Rural hospitals can provide high-quality health care,” she continued. “From an equity perspective, we want to ensure that people who go to rural hospitals have similar outcomes to those who go farther away. For those who must visit the nearest hospital because of cost or time-sensitive medical needs, hospital closures can lead to reduced access and worse health outcomes.”

Friedman suggested several ways to address issues in access. Free-standing emergency departments (EDs) can provide emergency care for time-sensitive conditions without having any affiliation with a hospital. Similarly, the Centers for Medicare & Medicaid Services (CMS) authorized the creation of rural emergency hospitals (REHs), which provide 24-hour emergency care but no inpatient care. Although CMS is still finalizing the rule for REH creation, she says that some hospitals may begin converting to REHs instead of closing, which could preserve some access to health care despite the loss of inpatient services.

The research team aims to continue studying ways to ensure broad access to high quality health care that meets the needs of communities. This will involve researching factors that make patients more or less likely to bypass their nearest hospital and evaluating alternatives to hospitals such as free-standing EDs or REHs.

Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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