Research - Completed Projects
2024
Clinical-Community Linkages in Non-Metropolitan and Metropolitan Hospitals: COVID-19 Impacts and Trends
This study will examine trends in partnerships between hospitals and public health departments and other community linkages in both non-metropolitan and metropolitan hospitals with a particular focus on the impact of the COVID-19 pandemic.
Funder: Office of Rural Health Policy
Lead Researcher: Whitney E. Zahnd, PhD
Publications:
Partnerships to Address Social Needs across Metropolitan and Non-Metropolitan Prospective Payment System Hospitals and Critical Access Hospitals. Date: 3/2024
How Does Participation in Medicare Accountable Care Organizations Affect Rural Hospital Financial Outcomes?
This project will examine the impact of Medicare Accountable Care Organizations' (ACOs') participation on rural hospitals' financial outcomes. Findings from this project will provide policy-relevant information on how ACO participation affects rural hospitals' financial bottom lines, contributing to further program design.
Funder: Office of Rural Health Policy
Lead Researcher: Xi Zhu, PhD
Publications:
Financial Performance of Rural and Urban Hospitals in the Medicare Shared Savings Program. Date: 9/2024
The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis. Date: 10/2022
Medicare Advantage Plan Growth in Rural America: Opportunities for Beneficiaries?
County Medicare Advantage enrollment data and plan characteristic data will be used to create a model accounting for the availability of plans offering benefits addressing social determinants of health. Analyses will compare rural and urban counties, and examine county characteristics to explore potential equitable opportunities for rural beneficiaries because of geography and other factors.
Funder: Office of Rural Health Policy
Lead Researcher: Keith Mueller, PhD
Publications:
Evaluating Medicare Advantage Benchmark Setting Methodology on Rural Counties. Date: 1/2025
Medicare Advantage Plan Growth in Rural America: Availability of Supplemental Benefits. Date: 5/2024
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations. Date: 8/2024
Rural Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces: An Updated Analysis
The project will describe variations in Health Insurance Marketplace plan design and availability, total and net-of-subsidy premium trends, and enrollment over time between rural and urban areas and identify associations between these factors and several key policy differences and changes, controlling for economic and demographic variation.
Funder: Office of Rural Health Policy
Lead Researcher: Tim McBride, PhD
Publications:
Nonmetropolitan Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces in 2022. Date: 3/2024
2023
Changes in Hospital Services Offered After Mergers, Acquisition and Affiliations
Hospitals have affiliated with systems in increasing numbers since 2007, as of 2016 reaching 56.1 percent of nonmetropolitan prospective payment system hospitals and 42.8 percent of critical access hospitals. This project examined resulting changes in services offered by rural hospitals, hypothesizing shifts of some services to regional hospitals and growth in some service lines.
Funder: Office of Rural Health Policy
Lead Researcher: Keith Mueller, PhD
Publications:
Changes in Service Offerings Post-System Affiliation in Rural
Hospitals. Date: 1/2023
Financial Risk Assumption Among Rural Healthcare Providers
This project assessed rural/urban providers' participation in different payment models and assumption of financial risk in the Medicare Quality Payment Program. We conducted qualitative interviews to examine rural providers' motivations and preparedness for participating in different risk-bearing payment models.
Funder: Office of Rural Health Policy
Lead Researcher: Xi Zhu, PhD
Publications:
Financial Risk Acceptance among Rural Health Care Providers Participating
in the Quality Payment Program. Date: 3/2023
2022
An Insurance Profile of Rural America: A Chartbook
This chartbook describes current conditions and recent trends in rural health insurance by drawing from census data and other sources. Tables and maps, accompanied by bulleted policy takeaways, compare rural and urban coverage sources, the degree of competition among issuers, and the share of the population who are underinsured.
Funder: Office of Rural Health Policy
Lead Researcher: Tim McBride, PhD
Publications:
An Insurance Profile of Rural America: Chartbook. Date: 11/2022
Continuous Services in the Absence of Retail Pharmacies in Rural Communities
This project identified communities with and without pharmacies by rurality and described the differences in population and market characteristics of communities with and without any pharmacies. Research findings regarding "pharmacy deserts" informed alternative methods of securing services based on community characteristics.
Funder: Office of Rural Health Policy
Lead Researcher: Keith Mueller, PhD
Publications:
Rural and Urban Pharmacy Presence – Pharmacy Deserts. Date: 8/2022
Location and Characteristics of Nursing Homes in the Rural and Urban U.S.
This project examined rural and urban nursing home availability; assessed the nursing home bed supply relative to the elderly population in rural and urban counties; summarized resident and nursing home characteristics; and analyzed the relationship between the rural location of nursing homes and resident and nursing home characteristics.
Funder: Office of Rural Health Policy
Lead Researcher: Hari Sharma, PhD
Publications:
Nursing Homes in Rural America: A Chartbook. Date: 7/2022
Medicare Beneficiary Access to Prescription Drugs Under Part D
This study will build on RUPRI Center work describing patterns of enrollment into Medicare Part D plans (including access to zero deductible plans) by using transaction files to analyze how medications are actually acquired and implications for access to local pharmacy services.
Funder: Office of Rural Health Policy
Lead Researcher: Keith Mueller, PhD
Publications:
Access to Medicare Part D Plans: A Comparison of Metropolitan and Nonmetropolitan Areas. Date: 5/2020
Medicare Beneficiary Access to Prescription Drugs in Rural Areas. Date: 8/2022
2021
Rural and Urban Sources of Insurance Coverage: the Role of Public and Private Coverage over Time
We estimated the percent of rural residents obtaining insurance coverage under each of the major options available to them using multiple data sets and a methodology that accounts for multiple sources of coverage. We compared rural and urban coverage sources and changes in coverage over time.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
Sources of Insurance Coverage in Nonmetropolitan Areas: The Role of Public and Private Insurance Since 2009. Date: 3/2021
Rural Nursing Home Closures - Trends, Characteristics, and Impact on Access
This project built a database of nursing home closures across rural and urban areas in the U.S. and evaluated the changes in access to post-acute and/or long-term care providers. It also described the differences in organizational, financial, and market characteristics between open vs. closed nursing homes in rural vs. urban areas.
Funder: Office of Rural Health Policy
Lead researcher: Hari Sharma, PhD
Publications:
Trends in Nursing Home Closures in Metropolitan and Nonmetropolitan Counties in the United States, 2008-2018. Date: 2/2021
The Availability of Optional Benefits in Medicare Advantage (MA) Plans in Rural and Urban Areas and the Implications for MA Payment Policy
Enrollment and landscape files containing data regarding Medicare Advantage plan activities by county were used to describe the geographic differences in what is available to beneficiaries in benefit design and total out-of-pocket liability. Findings revealed potential for policy actions to address equity of benefits and cost to beneficiaries.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
Availability of Supplemental Benefits in Medicare Advantage Plans in Rural and Urban Areas. Date: 2/2021
The Geographic Expansion of Medicaid MCOs
This project characterized the counties into which Medicaid Managed Care Organizations (MCOs) expanded in 2012-18, focusing on population and provider density, sociodemographics, and health indicators. We assessed the extent to which MCO geographic expansion occurred in compliance with previous network adequacy standards and evaluated how well MCOs were performing in rural areas.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
Geographic Expansion of Medicaid Managed Care Organizations: Assessing Access to Primary Care in Nonmetropolitan Counties. Date: 3/2021
What Makes Successful Rural Accountable Care Organizations Successful?
The U.S. Department of Health and Human Services plans to shift at least 50% of traditional Medicare spending into alternative payment models by 2018. Accountable Care Organizations (ACOs) represent a popular model in both the Medicare and Medicaid programs. This study used multiple methods to find what makes a successful ACO.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
High-Functioning Rural Medicare ACOs – A Qualitative Review. Date: 2/2021
2020
Rural Community Response to Hospital Closure
The Rural Community Response to Hospital Closure project will study how rural communities adapt to local hospital closure. Within selected communities, the project will evaluate the impact of hospital closure on multiple community health-related services and characteristics.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
Health Care Professional Workforce Composition Before and After Rural Hospital Closure. Date: 4/2020
What Factors Influence Rural Hospitals' Participation in Accountable Care Organizations?
This project examined rural hospitals' participation in Accountable Care Organizations (ACOs), identified factors that influenced ACO participation, compared whether different factors influenced rural/urban hospital participation in ACOs, and analyzed factors influencing Critical Access Hospitals' participation in the Medicare Shared Savings Program.
Funder: Office of Rural Health Policy
Lead researcher: Xi Zhu, PhD
Publications:
Rural Hospital Participation in Medicare Accountable Care Organizations. Date: 4/2020
2019
An Empirical Study of Health Insurance Firm Participation over Time in Rural Counties
We examined changes in firm participation in multiple health insurance markets (FEHBP, MA, HIMs) over time in rural counties. We had hypothesized that participation would be related inversely to population density, because it becomes more difficult to spread risk, and network formation becomes more challenging when primary and specialty care becomes less available.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
Insurer Participation in Rural Health Insurance Marketplaces: Are Some Markets Intrinsically More Competitive Than Others? Date: 6/2019
Impact of Capping Medicare Disproportionate Share Hospital Payments on Rural Hospitals
Rural hospitals receiving Medicare prospective payment system payment and receiving disproportionate share hospital payments are subject to a 12% cap on those payments. This project provided information on the number and location of rural hospitals subject to this cap and the fiscal impact.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
Impact of the Medicare Disproportionate Share Hospital Payment Cap on Urban and Rural Hospitals. Date: 12/2019
The Rural/Urban Impact of Insurance Coverage Changes
We examined the impacts of changes in health insurance coverage during the last several years on use of health services and health outcomes separately for rural and urban areas. Due to differences in demand and supply level factors, we hypothesized that the effects of coverage changes differ by rural/urban status.
Funder: Office of Rural Health Policy
Lead researcher: Dan Shane, PhD, George Wehby, PhD
Publications:
Effects of the Patient Protection and Affordable Care Act on Coverage and Access to Care in Metropolitan vs. Nonmetropolitan Areas through 2016. Date: 8/2019
Analysis of Trends in Characteristics of Rural Beneficiaries Enrolling in Medicare Advantage Plans
This work compared characteristics of rural and urban beneficiaries enrolling in Medicare Advantage (MA) plans, including their age, health status, and income. Analyses included the consequences of increasing use, promoted by policy choices, of a market-based approach in the Medicare program.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
Comparing Rural and Urban Medicare Advantage Beneficiary Characteristics. Date: 3/2019
The Rural MACRA Experience
This project studied primary care clinician participation in the Medicare Quality Payment Program (QPP). Low participation rates could identify opportunities to extend the QPP to more clinicians serving non-metropolitan populations.
Funder: Office of Rural Health Policy
Lead researcher: A. Clinton MacKinney, MD, MS
Publications:
Primary Care Clinician Participation in the CMS Quality Payment Program. Date: 4/2019
Changes to the Merit-based Incentive Payment System Pertinent to Small and Rural Practices, 2018. Date: 11/2018
2018
Health Insurance Marketplaces, Medicaid, and Uncompensated Care: The Rural Impact
This project provided an in-depth analysis of Health Insurance Marketplace (HIM) plan design, specifically measuring the availability and prevalence of high-deductible plans in rural as compared to urban areas.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
The Market Mechanism & Health Insurance in Rural Places: Lessons Learned from an Economics & Policy Perspective. Date: 2/2019
Distance and Networks: A Regional Analysis of Health Insurance Marketplaces. Date: 1/2018
Rural/Urban Analysis on Individual Insurance Market Topics - A RUPRI Special Data Release. Date: 8/2017
What Does Healthcare Delivery System Reconfiguration Portend for Rural Health?
This project worked to understand the dynamic relationships between healthcare system changes and healthcare network configurations that involve rural providers.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
The Rural Hospital and Health System Affiliation Landscape – A Brief Review. Date: 11/2018
Trends in Hospital System Affiliation, 2007-2016. Date: 10/2018
2017
After Hospital Closure: Pursuing High Performance Rural Health Systems without Inpatient Care
Opportunities for rural communities to develop a high performance rural health system after hospital closure, including three case studies that describe real-world transitions from hospital-based locus of care to new models of care delivery in rural places.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
After Hospital Closure: Pursuing High Performance Rural Health Systems without Inpatient Care. Date: 6/2017
Assessing the Impact of Medicaid Policy Changes
This project was designed to: 1) clearly articulating the rural considerations in Medicare reform by synthesizing information on the impact of Medicare on rural people, places, and providers; 2) assessing the impact of specific proposals to reform Medicare; and 3) analyzing the effects of market-based reform on rural populations, focusing on specific provisions of Medicare reform proposals.
Funder: Office of Rural Health Policy
Lead researcher: Keith Mueller, PhD
Publications:
Distribution of Disproportionate Share Hospital Payments to Rural and Critical Access Hospitals. Date: 11/2017
Changing Rural and Urban Enrollment in State Medicaid Programs. Date: 5/2017
Assessing the Stability of Rural Pharmacy Services
This project's goals included deepening our understanding of economic forces beyond the immediate control of local pharmacies that are affecting their ability to remain in business, assessing the future of sole community retail pharmacies in rural places, and exploring alternative modalities for delivering pharmacy services in the absence of retail pharmacy businesses.
Funder: Office of Rural Health Policy
Lead researcher: Fred Ullrich, BA
Publications:
Telepharmacy Rules and Statutes: A 50-State Survey, 2018. Date: 5/2018
Financial Issues Challenging Sustainability of Rural Pharmacies. Date: 8/2017
Issues Confronting Rural Pharmacies after a Decade of Medicare Part D. Date: 4/2017
Telepharmacy Rules and Statutes: A 50-State Survey, 2017
- Supplemental Table. Date: 4/2017
Do Rural Health Clinics (RHCs) Provide Services that Lower Rates of Preventable Hospitalizations?
This project used 3 years of individual-level Medicare claims data to analyze the relationship between receiving care at a Rural Health Clinic (RHC) and the likelihood of potentially preventable hospitalization and/or potentially preventable emergency department (ED) visits. Further, it explored this relationship among both fee-for-service Medicare enrollees and Medicare-Medicaid dual eligibles.
Funder: Office of Rural Health Policy
Lead researcher: Brad Wright, PhD
Publications:
The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries. Date: 7/2017
State Policy Issues That May Impact HIMs’ Success in Rural Places: A Regional Analysis
Goals of this project included gathering detailed data and providing analysis and policy recommendations on issues relating to network adequacy and service areas for HIMs, with additional investigation of other state-level policy variables (such as the Medicaid expansion decision) which may have a confounding or moderating effect on the relationship between network adequacy and enrollees’ choices and premiums.
Funder: Office of Rural Health Policy
Lead researcher: Tim McBride, PhD
Publications:
Rural Enrollment in Health Insurance Marketplaces by State 2016.pdf">Rural Enrollment in Health Insurance Marketplaces, by State, 2017. Date: 1/2017
Health Insurance Marketplaces: Premium Trends in Rural Areas. Date: 1/2016
Rural Enrollment in Health Insurance Marketplaces, by State, 2015. Date: 10/2015