RUPRI Center for Rural Health Policy Analysis Rural Policy Brief Brief No. 2023-2 JANUARY 2023 http://www.public-health.uiowa.edu/rupri/ Changes in Service Offerings Post-System Affiliation in Rural Hospitals Onyinye Oyeka, MPH, PhD; Fred Ullrich, BA; Dan Shane, PhD; Keith J. Mueller, PhD Background and Purpose Affiliations between rural hospitals and regional and national health systems have increased[1] from 10 to 30 per year in the 2000s to approximately 30 to 70 per year in the 2010s.[2] Rural hospital leaders have indicated that hospital affiliation with a regional or national system can result in substantial benefits through access to capital investments. Benefits may include updating systems and equipment, reducing costs through clinical process standardization, improving access to specialists, and adding service lines.[3, 4] However, affiliation may negatively affect rural hospitals and patients if it leads to higher prices,[5, 6] rural hospital closure,[7, 8] or eliminating essential health care services and service lines.[3] Prior research evaluating the impact of system affiliation in rural hospitals often focused on the financial performance, cost, quality, and service utilization in these hospitals post-affiliation.[9-12] There is limited research on what happens to hospital services in communities after the local hospital enters into system affiliation. One recent study reported reduced service availability in rural hospitals following system affiliation. However, that study focused on a limited set of service offerings.[3] System affiliation may lead to an increase or decline in the number of services offered in the local hospital. This may have positive or negative effects for patients and may change both access to care and quality of care. Plausible mechanisms for these effects include hospital systems' decisions to align services and resources such that areas of clinical excellence and cost performance across member hospitals are optimized and decisions to maintain or augment local access to services based on the need for frequent patient contact or a need to move low-acuity cases out of tertiary and quaternary care facilities. In these instances, primary care and telemedicine service offerings may increase. This policy brief aims to understand the range of effects on service offerings after rural hospitals become part of, or leave, a regional or national health care system. This analysis does not evaluate patient-level access to care and does not assign a positive or negative value to services gained or lost. gL ell Rural Health Research & Policy Centers RURAL POLICY RESEARCH INSTITUTE Funded by the Federal Office of Rural Health Policy = RUPRI Center for Rural Health Policy Analysis, University of lowa www.ruralhealthresearch.org College of Public Health, Department of Health Management and Policy, 145 Riverside Dr., lowa City, I1A 52242-2007, (319) 384-3831 http://www.public-health.uiowa.edu/rupri E-mail: cph-rupri-inquiries@uiowa.edu This project was supported by the Health Resources and Services Administration {HRSA) of the U.S. Department of Health and Human Services (HHS}) under grant # U1C RH20419, RUPRI Center for Rural Health Policy Analysis. The information or content and conclusions in this brief are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. Government. Key Findings o Of the 62 service offerings examined in the study period (2008 through 2020), there was a 5-percentage point or more increase in hospitals offering 23 of these services and a 5-percentage point or more decline in hospitals offering 10 services. e Changes in service offerings (either gains or losses) occurred across all hospital types regardless of whether the hospitals joined or left systems or were never or always in a system. e Compared with other hospitals in the study, service additions occurred more frequently in hospitals that left systems (35.4 percent), while the majority of service losses occurred in hospitals that joined systems (46.2 percent). Methods Systems To identify and define system affiliation, we followed the American Hospital (AHA) definition, which defines a multihospital health care system "as an entity with two or more hospitals owned, leased, sponsored, or contract managed by a central organization."[13] System membership is attributed to hospitals based on data taken from the AHA Annual Survey. Hospitals AHA annual survey data from 2008 through 2020 was used to identify hospitals and services. The AHA data were restricted to include nonfederal, general medical, and surgical hospitals in the 50 states and the District of Columbia. Nonmetropolitan hospitals were identified by linking the hospital ZIP Code (in 2008) to the Rural-Urban Commuting Area (RUCA) data (note that the RUCA data used were based on 2010 decennial census data). Hospitals in a ZIP Code with a RUCA code greater than three (i.e., nonmetropolitan) were retained for the analysis. Hospitals were linked over the survey years based on their actual location. Hospitals in this report include both critical access hospitals (CAHs) and rural prospective payment system (PPS) hospitals (which include Medicare-Dependent Hospitals, Sole Community Hospitals, and Rural Referral Centers). Services AHA data provided information on the availability of 142 hospital services in 2008. Many of the services were offered by a small proportion of the hospitals in this analysis. Therefore, we adapted the approach from a similar study[14, 15] using a more inclusive approach by considering the following: (1) services offered by 30 percent or more of hospitals in 2008, (2) services identified from the AHA Task Force on Ensuring Access in Vulnerable Communities[16] report, and (3) additional services that we felt should be considered for inclusion based on previous literature.[12, 17-19] There were 62 hospital services analyzed for this study. To study the relationship between changes in system affiliation and services, we created four cohorts of hospitals based on their system activity during the study period: (1) joined a system, (2) left a system, (3) always in a system, and (4) never in a system. Hospitals that either joined or left a system between 2008 and 2017 comprised the treatment groups. It is important to note that the data reflects only a single (first) change in system status for each hospital. Therefore, if a hospital joined a system and then left the system, only the first joining event is considered (a second change in status was a rare event during this study period). Propensity matching (forcing exact matching on hospital state and CAH status, with total beds for close matching) was used to select control hospitals from among those that were never or always in a system. Control group hospitals do not have a date of status change, therefore the year of system status change from the matched case hospital was used as a surrogate date of change for control hospitals. The state of service offerings at each always-in- and never-in-system hospital were established three years post system status change in the matched joined-system and left-system hospital. The propensity matching approach ensured comparability in important characteristics between the hospital groups. A one-to-one match was sought but given the relatively sparse number of hospitals available for matching and the strict model chosen, matching pairs could not always be established. Unmatched case and control hospitals were discarded from further analysis. Results/Findings Table 1 shows hospital system status and changes in system status for all rural hospitals by CAH and PPS classification, respectively. Between 2008 through 2020, system affiliation increased in rural CAH and PPS hospitals, although system affiliation among rural PPS hospitals had always been higher. The number and proportion of hospitals newly joining or affiliating with a hospital system each year (i.e., they were not previously a member of any hospital system) was relatively low (less than 5 percent) and appears to have declined in recent years. Similarly, the number and proportion of hospitals leaving a system (i.e., they were a member of a system and then left the system without joining another) year-to-year was lower (less than 2 percent) and was nearly always smaller than the number of hospitals joining systems. The number and proportion of hospitals remaining in the same system year-to-year, however, continued to remain high (greater than 90 percent). Table 1: AHA Responding Rural Hospitals, Annual System Status,* 2008-2020 Percent in System Status Change Over Two-Year Period System? Joined? In Same* In Different® Lefté Never' Unknown? Yeart CAH PPS CAH PPS CAH PPS CAH PPS CAH PPS CAH PPS CAH PPS CAH PPS 2009 1,139 1,020 38.7% 46.8% 19% 1.4% 33.7% 43.4% 2.7% 0.9% 0.6% 1.1% 59.7% 51.0% 1.3% 2.3% 2010 1,169 982 39.1% 47.8% 2.0% 1.8% 36.3% 44.9% 0.6% 0.4% 1.8% 1.2% 59.0% 50.7% 0.3% 0.9% 2011 1,175 979 40.5% 493% 2.3% 2.2% 37.9% 453% 02% 14% 0.9% 0.6% 58.0% 49.6% 0.9% 0.8% 2012 1,167 971 41.9% 50.5% 2.0% 2.3% 38.4% 46.4% 13% 13% 0.8% 13% 57.0% 47.9% 0.6% 0.7% 2013 1,184 948 42.4% 51.6% 1.0% 1.8% 39.3% 455% 1.9% 4.2% 0.6% 0.6% 56.4% 47.6% 0.8% 0.3% 2014 1,181 936 43.3% 53.0% 15% 2.1% 40.8% 48.4% 0.8% 2.4% 0.5% 0.7% 55.9% 46.0% 0.5% 0.3% 2015 1,182 915 44.2% 55.0% 11% 2.6% 41.1% 47.9% 1.9% 43% 03% 0.5% 552% 443% 0.3% 0.4% 2016 1,192 904 443% 57.7% 11% 2.8% 41.9% 53.1% 1.1% 1.4% 0.8% 0.4% 54.6% 41.7% 0.5% 0.6% 2017 1,195 895 44.6% 59.1% 12% 2.1% 42.6% 53.5% 0.8% 3.4% 0.7% 0.9% 54.4% 39.7% 0.3% 0.4% 2018 1,197 871 46.7% 59.8% 2.4% 1.6% 40.9% 54.5% 3.3% 3.4% 03% 1.1% 53.0% 38.8% 0.1% 0.5% 2019 1,207 845 46.1% 59.8% 1.2% 0.7% 44.5% 57.4% 04% 15% 1.5% 1.3% 52.2% 38.9% 0.2% 0.1% 2020 1,208 835 459% 61.0% 09% 1.7% 44.3% 56.6% 0.6% 2.0% 1.2% 1.0% 52.9% 38.0% 0.2% 0.7% Source 2008-2020 AHA annual data survey. Notes: Superscript numbers in the table denote the following: 1, end of two-year period; 2, system membership status at the end of the two-year period; 3, hospitals that were not system members at the beginning of the period but were members at the end; 4, hospitals that were members of the same system in both years; 5, hospitals that were system members in both years but were in different systems in each year; 6, hospitals that were system members at the beginning of period but not at the end; 7, hospitals that were not system members in either year; 8, inability to determine system membership status over both years. Percentages represent the proportion of all CAH and PPS hospitals in each column. Total Count Table 2 presents the set of hospital service offerings and the proportion of rural hospitals offering the services included in the analysis. The hospitals offered 62 services in 2008 based on the following inclusion criteria: (1) services met the 30 percent threshold, (2) services were identified in the task force report, and (3) services were added by this project's investigators based on previous literature. Table 2: Rural Hospital Service Offerings in 2008 Services Meeting the 30 percent Threshold Emergency dept 98.8% Community outreach 63.6% Patient education 45.6% CT scanner 94.5% Birthing room 61.2% Optical colonoscopy 45.0% Outpatient surgery 90.0% Obstetrics 61.1% Linguistic/translation services 44.6% Ultrasound 88.6% Occupational health 60.7% Chemotherapy 42.5% Physical rehab 82.9% Patient controlled analgesia 59.1% Home health services 42.4% Breast screening 80.9% Orthopedic services 58.3% Oncology services 39.7% Health screening 79.0% Medical/surgical ICU 57.6% Skilled nursing 38.6% Social work 78.8% MRI 57.4% Primary care department 36.6% Health fair 78.7% Patient represent. services 57.0% Women's health center 36.4% Case management 73.5% Cardiac rehabilitation 56.1% Enrollment assistance program 34.6% Hospital-based outpatient 72.6% Support groups 53.7% Pain management program 34.3% Volunteer services 70.3% Multislice spiral CAT <64 53.5% Trauma center 34.1% Aucxiliary services 70.0% Chaplain/pastor. care services 52.8% Sports medicine 33.5% Nutrition program 68.1% Wound management services 48.1% Geriatric services 32.1% Swing bed services 68.0% Tobacco treatment services 46.5% Immunization program 30.3% Airborne infect isolation room 67.7% Diagnostic radiation facility 46.4% Health information center 66.0% Sleep center 46.1% Additional Task Force Report Services Hospice 24.8% Psychiatric geriatric 17.8% Assisted living 7.4% Rehabilitation care 21.2% Cardiac ICU 17.2% Neonatal ICU 4.0% Psychiatric emergency 17.9% Dental services 12.2% Acute long-term care 3.9% Services Added Based on Previous Literature Fitness center 28.3% Palliative care program 17.4% Ambulance services 21.8% Ambulatory surgery center 17.4% Source: 2008-2020 AHA annual data survey. Table 3 presents the services that changed substantively in the proportion of rural hospitals offering such services from 2008 through 2020. We define substantive change as an increase (or decrease) of at least 5 percentage points in the proportion of hospitals offering the service. On balance, we found more service line increases than decreases in rural hospitals across the 62 services evaluated (23 services with substantive increases, 10 services with substantive decreases). Table 3: Changes in Rural Hospital Service Offerings, 2008-2020 Services 2008 2020 Percentage point change Optical colonoscopy 45.0% 72.6% 27.6 Enrollment assistance program 34.6% 60.8% 26.2 Immunization program 30.3% 50.7% 20.4 Health information center 66.0% 85.8% 19.8 Primary care department 36.6% 55.9% 19.3 Wound Management services 48.1% 66.6% 18.5 Airborne infection isolation room 67.7% 85.7% 18.0 Trauma center 34.1% 48.3% 14.2 Case management 73.5% 87.3% 13.8 Pain management program 34.3% 47.3% 13.0 Women''s health center 36.4% 49.1% 12.7 Sports medicine 33.5% 45.5% 12.0 MRI 57.4% 67.5% 10.1 Patient representative services 57.0% 65.8% 8.8 Patient controlled analgesia 59.1% 67.8% 8.7 Community outreach 63.6% 71.8% 8.2 Cardiac rehabilitation 56.1% 64.0% 7.9 Health screening 79.0% 86.2% 7.2 Palliative care program 17.4% 24.5% 7.1 Linguistic/Translation services 44.6% 50.9% 6.3 Hospital-based outpatient 72.6% 78.7% 6.1 Psychiatric emergency 17.9% 23.4% 5.5 Occupational health 60.7% 66.0% 5.3 Psychiatric geriatric 17.8% 12.7% -5.1 Auxiliary services 70.0% 63.6% -6.4 Medical/surgical ICU 57.6% 51.2% -6.4 Hospice 24.8% 18.1% -6.7 Obstetrics 61.1% 54.0% -7.1 Birthing room 61.2% 53.9% -7.3 Cardiac 17.2% 9.8% -7.4 Skilled nursing 38.6% 30.4% -8.2 Multislice spiral CAT 53.5% 43.4% -10.1 Home health services 42.4% 24.7% -17.7 Source 2008-2020 AHA annual data survey. Table 4 presents the number of rural hospitals pre-match and the sample of rural hospitals in each cohort after the matching process (i.e., post-match). Figure 1 shows the proportion of hospitals that gained and lost services within a 3-year window of either joining or leaving a system for all 62 services in the sample. The figure shows that while services were gained and lost in hospitals that left and joined a system, more services were gained among hospitals that left a system. Appendix Table A presents the detailed table for the change in services among all cohorts. Across all hospital cohorts (left a system, always in a system, never in a system, and joined a system), there were seventy-four (74) service changes (either gain or loss) of 5 percentage points or more. Many of the changes were for new services, with 65 percent of hospitals adding new services across all hospital cohorts. The biggest change in services offered among the cohorts was service gains in hospitals that left systems: airborne infection isolation room (11 percent), health information center (10.3 percent), optical colonoscopy (11 percent), enrollment assistance program (11 percent), and immunization program (10.3 percent). The plurality of service additions occurred in hospitals that left systems (35.4 percent). However, the plurality of services lost occurred in hospitals that joined systems (46.2 percent). Table 4: Pre-/Post-matching Hospital Counts Cohort Pre-match Count Post-match Count Always in a system 654 393 Joined a system 357 314 Left a system 164 145 Never in a system 9209 66 Source 2008-2020 AHA annual data survey. Note: Forced exact propensity score matching was used to assign the never-in-system hospital cohorts and always-in-system hospital cohort to the joined- and left-system cohort based on the state where the hospital was located, CAH status, and bed size. Figure 1: Proportion of Hospitals that Gained or Lost Services Neonatal ICU n Acute Long-term Care e Assisted Living i Home Health Svcs s Birthing Room | Obstetrics . CT Scanner | Emergency Dept N Cardiac ICU . Hospice Il Ambulance Services el Dental Svcs | Outpatient Srg N Physical Rehab e Case Mngment 1. Swing Bed Srvs 'NN Psych Geriatric I mm Chemotherapy Il Social Work 'l Oncology Svcs . Cardiac Rehabilitation 1 Ultrasound ' Palliative Care Prg N Orthopedic Srvs I Med/Surg ICU I Linguistic/Translation Srvs s Rehab Care I Patient Educ Al Support Groups | MRI I Fitness Center I Geriatric Svcs | m Left system Skilled Nurs | ® Joined System Ambulatory Surgery Cent. | Sleep Center BT Breast Scrn . I Auxiliary Services - e Psych Emerg T Diag Rad Fac - I Pain Management Pgm . IS Health Scrng I Chaplain/Pastor Care Srvs i | Womens Hith Ctr N Trauma Center I Patient Rep Svcs | [ Occupat Health | Nutrition Pgm | Community Outr [ | Primary Care Dept - N Sports Medicine . Health Fair | Patient Controlled Analgesia . I Volunteer Svcs . Hosp-Based OP T Wound Management Srvs B | Tobacco Treatment Serv 1. Multislice Spiral Cat <64 | | I S Health Info Center I Immunization Program B |00 Enrollment Assistance Prg 00 Optical Colonoscopy . I Airborne Infect Isolation Room I -20% -15% -10% -5% 0% 5% 10% 15% 20% 25% Source: 2008-2020 AHA annual data survey. Note: The blue bars represent service changes in hospitals that left a hospital system, and the gray bars represents changes in hospitals that joined systems. Services gained in hospitals that left a system are displayed in ascending order. Negative sign denotes loss of services and positive denotes service gains. Discussion In this policy brief, we examined the changes in service offerings at rural hospitals following system affiliation change (joining or leaving a health care system). We found that the change in a hospital's system status was associated with changes in the availability of services provided at the local hospital three years after a system status change. The results show that while rural hospitals both affiliating with and disassociating from a system experienced gains and losses of services, the largest changes in service offerings were gains in services among hospitals that left a hospital system. Specifically, 35.4 percent of the services that increased in availability by 5 percentage points or more occurred in hospitals that left a system. In contrast, 46.2 percent of the services that decreased in availability by 5 percentage points or more occurred in hospitals that affiliated with a health care system. Note that this analysis does not seek to assign value to a service gain or harm to a service loss. Rural hospitals play a key role in the timely delivery of health care services, and they have a unique opportunity to identify the health care needs of the local community. However, many rural hospitals are faced with myriad demographic, social, economic, and policy challenges that threaten their financial viability and capacity to deliver essential health care services.[20-22] Between 2010 and 2022, 140 rural hospitals have closed*, and many more are at risk of closure.[23] Affiliation with hospital systems has been proposed as an alternative for struggling rural hospitals to remain open and continue to serve their communities.[4] While system affiliation may be protective for financially distressed hospitals, thus enabling them to remain operational,[10] it may not be protective of health care services that were previously available to the community. Similar to the current study, prior research examining access to health care services provides evidence for service volume decline and the closure of service lines post-system affiliation.[3, 12, 24] Specifically, these studies found a reduction in the volume of outpatient visits and mental/substance use disorder stays, and the elimination of surgical, primary care, skilled nursing facilities, and obstetric service lines.[3, 12, 19] The effect of service elimination is mixed. Service elimination may result in increased patient costs (travel and time) and delay in seeking care, particularly for health care services that are time-sensitive, chronic, and complex.[25, 26] In particular, research provides evidence for poor birth outcomes and increased suicide rates due to the reduction in obstetric and behavioral health services, respectively.[27, 28] However, service elimination may also result in improved care quality and health outcomes if patients needing eliminated services are transferred to higher volume hospitals in the system. Research has shown that greater hospital volume is associated with better surgical outcome, reduced surgery-related mortality, and non- surgical outcomes including but not limited to treatment of congestive heart failure and obstetric care.[29-31] Other examples include regionalization of care strategies such as the Rural Maternity and Obstetrics Management (RMOM) program which aims to improve maternal care by coordinating care between larger hospitals and smaller rural hospitals.[32] This study also suggests that hospitals leaving systems may be offering new service lines not previously available in the local hospital when it was part of the system. The factors * Rural hospital closures as of November 23, 2022. Hospitals are considered closed when the facility no longer provides health care services or ceases to provide inpatient services but continues to provide some health care services (i.e., primary care). Hospital closures can be complete closures or converted closures (i.e., converted to some other type of health care facility). associated with service line addition after system disassociation are not clear. Rural hospitals no longer affiliated with a system may be driven to expand service offerings because of their mission to maintain or improve access to care, the community's health needs,[33] regaining decision-making autonomy, and competition.[34] However, increases in services over time may also be attributed to technological advancement and improvements in the practice of medicine. This analysis has several limitations. This study uses a loose definition of system affiliation, including mergers, acquisitions, joint ventures, and other forms of agreement between hospitals. AHA annual survey data may be subject to measurement error and recall bias. Although the AHA tries to report data on every hospital every year, the actual survey response rate (during this period) ranged from 86 percent in 2008 to 75 percent in 2020. For non-responding hospitals, AHA uses an estimation process to impute some missing statistical values and uses other resources to fill out hospital records. For this analysis, only hospitals that actually responded to the annual survey are retained. Only the first change in system status was used to classify hospitals as joining a system, but this is unlikely to bias our findings because there was minimal "system churn" (i.e., hospitals repeatedly joining/leaving systems) during this period. Only two hospitals had more than one joining event, and nine hospitals had more than one leaving event. This explorative analysis is descriptive and does not intend to infer causality. Note that hospitals respond to the AHA survey based on their fiscal year and nearly all of this study's hospitals responded to the 2020 survey using information from a fiscal year that ended well after the advent of the Public Health Emergency (1/31/2020). Certainly COVID-19 had a significant impact on service delivery at hospitals across the country. But as our focus was on service status three years following change in system affiliation, a "PHE effect" would only be seen in hospitals (or their matched controls) that changed status in 2017 - less than five percent of all hospitals in our analysis. Further, examination of service changes at all hospitals between 2019 and 2020 shows only four notable service availability changes in that year. The percentage of hospitals offering: e Health fairs declined 3.9% e Support groups declined 4.0% e Airborne Infect Isolation Rooms increased 2.7% e Immunization programs increased 4.4% Service-offering decisions may be a means for rural hospitals to strategically position themselves to improve local access, improve efficiency, and remain financially viable; however, these decisions should prioritize the health care needs of the local community. Future research should consider the impact of these changes (gains and losses) in service offerings on patient and population health in the local community. Additionally, future research is needed to compare existing policy recommendations to actual service availability in rural communities, which will also be useful to highlight the effectiveness of these policy recommendations and any existing gaps at the community level. References 1. 10. 11. 12 13. 14. 15. 16. 17. 18. 19. Oyeka, O., Ullrich, F., Mueller, K. Trends in Hospital System Affiliation, 2007-2016. 2018; Available from: https://rupri.public- health.uiowa.edu/publications/policybriefs/2018/Hospital%20System%20Participation%202018.pdf. Williams Jr, D. and G. Pink, Rural hospital mergers and acquisitions: 2005-2016. 2018, University of North Carolina at Chapel Hill, North Carolina Rural Health. O'Hanlon, C.E., et al., Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation. Health Affairs, 2019. 38(12): p. 2095-2104. Noether, M., May, S. Hospital Merger Benefits: Views from Hospital Leaders and Econometric Analysis. 2017; Available from: https://www.aha.org/system/files/2018-04/Hospital-Merger-Full-Report-FINAL- 1.pdf. Lewis, M.S. and K.E. Pflum, Hospital systems and bargaining power: evidence from out-of-market acquisitions. The RAND Journal of Economics, 2017. 48(3): p. 579-610. Cooper, Z., Craig, S. V., Gaynor, M., Reene, J. V., The Price Ain't Right? Hospital Prices And Health Spending On The Privately Insured. The Quarterly Journal of Economics, 2019: p. 51-107. D'Mello, K., Hahnemann's Closure as a Lesson in Private Equity Healthcare. Journal of Hospital Medicine, 2020. 15(2020-05}): p. 318-319. Tribble, S.J. Buy and Bust: When Private Equity Comes for Rural Hospitals. 2022; Available from: https://khn.org/news/article/private-equity-rural-hospitals-closure-missouri-noble-health/. Bozovich, L., Knocke, K., Pink. G., Howard, A., Reiter, K. The Association Between System Affiliation and Financial Performance in Critical Access Hospitals. 2021; Available from: https://www.flexmonitoring.org/sites/flexmonitoring.umn.edu/files/media/fmt-pb60-system-affiliation- 2021.pdf. Jiang, H.),, et al., Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals. JAMA Network Open, 2021. 4(9): p. e2124662. Williams, D.J., et al., Capital Expenditures Increased at Rural Hospitals That Merged Between 2012 and 2015. Journal of Healthcare Management, 2020. 65(5): p. 346-364. Henke, R.M., et al., Access To Obstetric, Behavioral Health, And Surgical Inpatient Services After Hospital Mergers In Rural Areas. Health Affairs, 2021. 40(10): p. 1627-1636. American Hospital Association. AHA Annual Survey Database ™. 2022; Available from: https://www.ahadata.com/aha-annual-survey-database. Knocke, K., Pink, G., Thompson, K. W., Randolph, R. K., Holmes. M. Changes in Provision of Selected Services by Rural and Urban Hospitals between 2009 and 2017. 2021; Available from: https://www.shepscenter.unc.edu/product/changes-in-provision-of-selected-services-by-rural-and- urban-hospitals-between-2009-and-2017/. Malone, T.L., Knocke, K., Pink, G., Thompson, K. W., Randolph, R. K., Holmes, M. Association between Rural Hospital Service Changes and Community Demographics. 2022; Available from: https://www.ruralhealthresearch.org/alerts/478?utm_source=alert&utm medium=email&utm _campaig n=20220531northcarolina. American Hospital Association. Task Force on Ensuring Access in Vulnerable Communities. 2016; Available from: https://www.aha.org/system/files/content/16/ensuring-access-taskforce-report.pdf. Cerullo, M., et al., Private Equity Acquisition And Responsiveness To Service-Line Profitability At Short- Term Acute Care Hospitals. Health Affairs, 2021. 40(11): p. 1697-1705. David, G., et al., Do hospitals cross-subsidize? Journal of health economics, 2014. 37: p. 198-218. John, R., Knocke, K., Thomas, S., Thompson, K., Holmes, M., Pink, G. Changes in the Provision of Health Care Services by Rural Critical Access Hospitals and Prospective Payment System Hospitals in 2009 compared to 2017 2022; Available from: https://www.shepscenter.unc.edu/product/changes-in-the- provision-of-health-care-services-by-rural-cahs-and-pps-hospitals-from-2009-t0-2017/. 10 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. United States Government Accountability Office. Rural Hospital Closures - Number and Characterisitics of Affected Hospitals and Contributing Factors. 2018; Available from: https://www.gao.gov/assets/gao-18- 634.pdf. Smith, A.S., Trevelyan, E., The Older Population in Rural America: 2012-2016, in American Community Survey Reports. 2019, United States Census Bureau: Washington, DC. Joynt, K.E., Nguyen, N., Samson, L. W., Snyder, J. E., Lechner, A., Ogunwumiju, O. Rural Hospital Participation and Performance in Value-Based Purchasing and Other Delivery System Reform Initiatives. 2016; Available from: https://aspe.hhs.gov/sites/default/files/migrated legacy files//156066/RuralHospitalsDSR.pdf. The Cecil G. Sheps Center for Health Services Research. Rural Hospital Closures. 2021; Available from: https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/. Jiang, H.),, et al., Risk of Closure Among Independent and Multihospital-Affiliated Rural Hospitals. JAMA Health Forum, 2022. 3(7): p. e221835. Finks, J.F., N.H. Osborne, and J.D. Birkmeyer, Trends in Hospital Volume and Operative Mortality for High- Risk Surgery. New England Journal of Medicine, 2011. 364(22): p. 2128-2137. Khushalani, J.S., et al., Impact of rural hospital closures on hospitalizations and associated outcomes for ambulatory and emergency care sensitive conditions. The Journal of Rural Health, 2022, Hung, P., et al., Changes in community mental health services availability and suicide mortality in the US: a retrospective study. BMC Psychiatry, 2020. 20(1): p. 188. Kozhimannil, K.B., et al., Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. Jama, 2018. 319(12): p. 1239-1247. Carroll, C., Impeding access or promoting efficiency? Effects of rural hospital closure on the cost and quality of care. NBER Working Paper Series, 2019. Birkmeyer, J.D., et al., Hospital Volume and Surgical Mortality in the United States. New England Journal of Medicine, 2002. 346(15): p. 1128-1137. Urbach, D.R., Pledging to Eliminate Low-Volume Surgery. New England Journal of Medicine, 2015. 373(15): p. 1388-1390. Government Accountability Office. Availability of Hospital-Based Obstetric Care in Rural Areas. 2022; Available from: https://www.gao.gov/assets/gao-23-105515.pdf. Nataliansyah, M.M,, et al., Beyond patient care: a qualitative study of rural hospitals' role in improving community health. BMJ Open, 2022. 12(3): p. e057450. Trinh, H.Q., Strategic management in local hospital markets: service duplication or service differentiation. BMC Health Services Research, 2020. 20(1). Suggested Citation: Oyeka, O; Ulirich, F; Shane, D; Mueller, K. Changes in Service Offerings Post-System Affiliation in Rural Hospitals. RUPRI Center for Rural Health Policy Analysis, Brief 2023-2. 11 %T'EE %8 EE NBE'GL BE'T %S'C | %G8V %8 VE %BLIT %00 %00 (%C'SCT%BTE BCLE BE'E %S'C | %6'LE BY'EC KO'TE BTV %V'E Aujoey uoperpel onysouselq %T'EE %BO'6C %B VT %L %V'9 |%S'8V %8 8C %L 'IT %SV %S'T |%C ST %EEE BB0E %6'S %8BV |%6'LE %0°0C %V'CE %06 %L'0 | SIJIAISS JusWIL3I] 020B(O] %T'EE BE'VE BT'STWY'S %T'9 | %G8V %8 VE %I'0T %SV %S'T (%C'SC BT IE B LT %6'S %9'S [%6'LE %0'6C %0'0C %L %S'S $32IAJ3S "d8euBW PUNOM %TEE BT EEUS'STWL'S %S'T |%S '8V %8 STUTLTTL%S'T %0°€ |%T ST %0'SY %6 EC %ET %€ |%6'LE %Y EC %L 6T %T'V %8'¥ |SIOIAISS 24ed Jojsed/ulejdey) %T'EE %8'9C %B'IC %V'9 %0'L |%S'8V %ELL%TBT %SV %S'T (%C'ST%T'SE BLVC %L %6'8 |%6'LE %S'ST BT LT %L'6 %L'6 9> LvD |edids 321NN %T'EE NV'SEBS'STHE'T %LV |%S'8V %V'9E %I'0T %S'T %0'E |%C'ST%6'6E %BT'ST RIS %LV | %6'LE BT VT BT'EE RV'E %V'T sdnoJs Joddng %T'EE %O'CY %Y'0C %6'C %I'T |%S'8Y %V 6€ %I'0T %S'T %00 (%C ST %ESY K6 EC BT'E %S'C |%6'LE %8 VT %8 EE %B8'C %L'0 uonejljiqeyad seipJiej %T'EE BT VE BE'ECHT'I %6'C | %G8V %8 VE BT'CT %St %00 (%C'SCT %L Y %6V %9V %S'C |%6'LE %0'6C %8'CC %8V %S'S S32IAIBS "Juasaldal Juanied %T'EE %8 6E BL'OCHCL'T %LV | %G8V %8BT %L 6T %S'T %S'T (%C'ST%EBY %6'0C %E'E %E'T |%6'LE BB EE %8 CC %V'E %1'C 4N %T'EE %BO'SE BTVTL NS'E %LV |%S'8Y %V IE %BT'ST %00 %00 (%C'ST %L6E %S'6C %E'TC %E'E [%6'LE BT'TC BO'TE %8'C %C'9 N2I 8uns/pa %T'EE %BCHE BL'6T BTV %SV | %G8V %V'6E %BL'6 %S'T %S'T (%C'SC %L LY %6°0C %8'E %L'E |%6'LE %8V %0'6C %8C %S'S S90IAIBS dIpadoynQ %TEEBLTY %S'8T %6'C %8'E |%S '8V %6 LEUT'6 %SV %00 [%T'ST LTS %T'8T %T'E %0'T |%6'LE %0'TE %L 0T %9'L %8'C | elsdgeue pajjosjuod judized %T'EE %BC6E %6'ST BL'S %T'9 |%S'87 %607 %9°0T %00 %00 (%C'SCT %E VY BL VT %8 E %0'C [%6'LE BL'6C %L'OC%C'I %S'S yyeay [euonednadQ %T'EE BL'SERTSTHET %8V %G8V %V'Ch %SV %00 %SV |%C'ST %L 6E %BEOE %B8'T %I'E |%6'LE BTICT BL'TE %00 %IV S2143131590 %L1 EE %BEIE BB ST HE'D %SV | %G8V %SGV %SV %00 %S'T (%C'SC%COV %T'CE %00 %S'CT [%6'LE %S'ST %' EE %00 %B'C wooJ Sulyuig %T'EE %6'EY %OVT %V'S %S'E | %G8V %8 VE %BC'ST %00 %S'T |%C'SC %L TS %BEIT %BB8'E %S'T |%6'LE BLTE BL'TC %69 %V'1 yoeaino Ayunwwo) BTEERBC TSI NI L BTV %6'C %G8V %SGV %T'9 %00 %00 [%C'ST%CIS %Y'0T %T'9 %0°C |%6'LE %L OV %EOT %E 0T %L0 493UdJ ojul yijesH %T'EEBE0T %08 BL'S %6'C | %S'8Y %V'CV %T'9 %S T %S'T (%C'SCT%0'6S %BCTT %8E %80 |%6°LE KL OV %I L %0'TT %8¢ | WJUOLE|OSI 134Ul suloqlly %TEE WV TV %BETC HSCT %90 |%G'8V %EEE NI ET BO'E %S'T |%C'SC %L TS %I'8T %O'T %S'T |%6°LE %I'LY %O'TT %T'C %V'1 S3IAIDS PaQg SuIMS %L1 EE %897 %E'ST B6'C %6'T | %G8V %SGV %SV %S'T %00 (%C'SC%CES BO'ST %BT'E %I'E [%6'LE %O'TE %E'6T %C'I %S'S weJgoud uonlINN %T'EE %61V %BTIT 6'T %B'E |%S'8Y %60V %SV %S'T %SV (%C'SCT%T LY %6CC %8 T %L'E |%6'LE %6°'LE T LT %LV %8'C S90IAIBS Adeljixny %T'EEBL'BY %S0T %6'C %8V | %G8V %S SV %0'E %S'T %S'T [%C'SCT %0'SS %BSET %€ %BC | %6'LE %Y CE %I'8T %L %P'E S3JIAISS 193]UN|OA %L EE BT %66 %L'S %L'S %G8V %60V %L %0€E %00 [%CSC%LSS BLTT %E'S %0°C |%6'LE %6'LE BL'TT %I'L %8V juanedino paseq-|eydsoH %TEE WO LSBTV %SV %ET %G8V %6 EV %T'9 %S T %00 (%C'SC %E0I %Y'0T %T'E %0'T |%6'LE %SVS %8V %T'C %LO juswadeuew ase) BTEEWV'BY BL'I BL'S %T'9 | %G8V %S'SV %0'E %0'€E %00 [%C'ST%0'6S %68 %BT'E %B'E |%6'LE %I'BE NI L %69 %06 die} ylesH BT EEUBETN6'6 %6'T %ET | %G8V %0O'LY %0'E %00 %S'T (%C'ST %S LS BOCT %E'T %I'E | %6'LE % VY %V CT %T'C %8'C 310M |ed0S BT EERCETNLI %BE BUE | %8V %SGV %0'E %0'E %00 [%CSCTH%BTCIBT'I %EE %ST |%6'LE%6'IV %69 %IV %IV 8ujuaauds yieaH %T'EE BL'GT %08 %BO'T %CT |%S87 %S TS %00 %00 %00 (%CSC%ITI%6°L %80 %S0 [%6'LE BV EV %' CT %LV %1'C 8uiuaalos isealq %T'EEN6'TTHE'8 BS'E WBCE | %IV %BS'SV %SV %00 %S'T (%CSCT%EGS BLOT %S'T %E'E | %6'LE%BEBY %06 %V'T %V'E geya. |eaisAyd BT EEW6'6T BTV %BIT %ET | %G8 %0 LY %0'E %S'T %00 |%CSTHLBI%BTY %0O'T %0'T |%6°LE BT ES %Y %8C %Vl punosenn %T'EE %S 09 %Y'S %00 %0'T |%S'87 %S 8V %0'E %00 %00 (%C'SCT%069 BTV %0O'T %80 [%6'LEBTSS WY'E %V'T %I'C A1a8uns juannedinQ %T'EE NI VI NO'T %BO'T %EOD |%S'87 %005 %00 %S'T %00 [%CST%CLWBOT %S0 %S0 |%6°LE %009 %LO %L'0 %LO Jauueds | %T'EE %6'G9 %00 %ED %90 |%S'87 %005 %00 %00 %S'T [%CSCT%IVLB0O0 %00 %EOD [%6°LE %009 %LO %L'0 %LO 1dap Aouadiaw3 Nyun Amly JAN uilen 1s07 | jun Amjy JAaN uien 31soq | jun Amy JAN uilep 1507 [ yun Am|y JAN ulen 1soq IJIAIBS (T E=U) WaisAs paulor (99=u) waisAs tanaN (€6€=u) waisAs shem|y (spT=u) waisAs Yo 0202Z-800¢ 'SHoYyo) [endsoH Suowy sSulIayQ 3IIAIDS Ul SISSOT pue sulen iy djqel xipuaddy €T "HOY02 yIea u] sjendsoy 0 Junod |210) 3Y3 SI JOJRUIICUIP pue Bullayo 321AIRS Ul (umowyun/sAem|e/ianau/uled/sso|) a8ueyd e pajuaadxa Jeyl LoYod Yyoes ulylm sjendsoy JO Jagwinu 8y} S| JOI_JBWNU 'ULIN|OD Yoes 104 "asuodsaluou A3AINS 0} anp Suliao 321A19s umouyun sjuasaidal pue UMOUUN 10} SPUBLS Jun "Lioyod [eNdsoy ayl Ul palayo SABM|E SEM SIDIAIBS 9Y} SueaW pue SABM|y 1O} Spuels AM|y "Hoyod |eNdsoy 3y} Ul pIajJo JOASU SeM BDIAIDS DY} SUBBW PUE JOABN JO} SPUB)S JAN "sHoyod |endsoy Suliayo adiaias ay3 Suayo sjendsoy jo uoiuodoad pue Jaquinu 3y) u] s33ueyd 910USp UleD pue 1507 'SHOYOoI |eNdsoy Juasaudal wasAS-pauIor pue 'WalsAS-UI-19ASN 'WISAS-UI-SABM|Y 'WD1SAS-1S7 910N "ADAINS BlEp |eNUUE YHY 0Z0Z-800Z 924n0S %T'EE %O0'T %T'EE%0'T %T'€9 %6'T %979 %9°0 %L EENCT %HL'EI %ED BT EE BB'E %6'85 %9'T %TEE %COT %C'CS %S'C %L'EEBE'B %005 %C'E %L'EE NS TT %Y'6V %1V %L EE %08 %CET%O'T %L EE N6 %BL'6V %6'C %T'€E %V CT %06V %6°C %T'EE %' TT %0'TS %0'T %T'EE %S TT %E'TS %6'T %T'EE %6'ST %C IV %6°C %L EE %8 VT %C'CE %P9 %T'€E %8BT %1'0V %6°C %T EE %V'9C %B'EE %LV %T'EE BC'SC RV VE BC'E %L'EE BLTC %Y'SE %IV %T'EE %8 TE BC'VC %68 %T €E %S'TC %CCE BL'S %T'EE %8'9C %9'0€ %19 %T'EE BT'6T %Y1V %S'C BT EE BC'TC BB'EE NIV %T'EE %V'6T %IV %0'T %T EE %E'6C % TE %S'C BT EE B EC HCTE %8V %T EE %6'8E %C'IT %98 T EE WL LT %8 TE %BST %8B'E %T EE %S TE %B8'9C %S'C %19 %0'T %9°0 %9°0 %S'C %61 %S %6'T %8V %1°S %S'¢C %C'E %C'C %6'T %S'€ %8V %S'C %T'V %L'S %61 %S'€ %S'€ %8'€ %8'€ %S %6'C %L'9 %C'E %519 %0°0 %587 %0°0 %S'TS %0°0 %587 %19 %6'EV %S'T %98V %1CT %'6€ %00 %98V %SV %S'SY %00 %587 %1'6 %V'6E %00 %587 %L 9T %E'0E %0'€ %587 %1'6 %EEEKL'9 %587 %1'CT %V'6€ %0°0 %587 %SV %6'0V %S'V %587 %1'CT %6'LE %0°0 %587 %C'8T %E0E %0'E %58V %L 'CC %8'SC %S'T %5817 %8'8C %C'8T %S'V %587 %C'8T %8'8C %0'€ %S98V %8°8C %C'8T %SV %587 %C'8T %E'0E %O'E %00 %587 %E'0E BC'ST %SV %S'T %58V %'V %L 9T %9°0T %0°0 %58V %EEE %8BT %00 %00 %587 %8'8C %BL'6T %S'T %S'T %587 %L 9T %8'8C %0'€E %0°€ %98V %CVC %C'8T %00 %I1'6 %58V %L 6T %ELCKHOE %S'T %98V %8°SC %L9T %SV %SV %98V %L 6T %8'8C %0°E %00 %98V %V 9E %T'CT %S'T %S'T %S98V %ELC %CVC %00 %00 %58V %L'CC %L 6T %19 %0'E %0°0 %0°0 %0°0 %0°0 %S'T %0°€ %S'T %0°€ %00 %S'T %S'T %0°0 %S'T %0°0 %S'T %0°0 %587 %0°0 %C'SC %S'T %C''ST %0°C %C'STHL'E %CSCHLY %L[9 %EO %CSC%L'9 %V'V9 %S'T %C'ST %0°CT %95 %9'€ %CSC%LTT %C'SS %9°S %CSCTHT'L %V'E9 %81 %C'SC %L 0T %S'6S %8'1 %C'ST %L 0T %8°85 %9'€ %C'SCT%CTT %819 %0'T %C'SC%C6 %L1 %S'T %C'ST %T'8T %6°05 %9'€ %C'SC %CEC %OV %69 %C' ST %9°0C %8 LY %T'€ %C'SC %0°9C %0V %EV %C'ST %0°8C %V'3E %3V %CSCBL VT HL6E KBTS %C'SC %6'VE %ECE %99 %C'SC %0°9C %S TV %1V %C°'SC %0°8C %9'9€ %99 %C'ST %6°0C %967 %S'C %C'SC %V %E SV %1'E %C'SC %8 VT %0°95 %S0 %C'SC %CIC % TY %9°E %C'SC %L VE %E6C %99 %L'SC %EEY %1°0C %6'8 %C'SC %I EE %V VE %E'E %9'E %C'SC %9°9E %80E BI'E %E'V %C'0L %0'T %0°'TL %E'T %L0L %EO %0°C %S0 %80 %8'C %8'C %1€ %E"C %S°C %8°C %8'T %80 %T'€ %EC %8°C %E'€ %E'V %9°€ %E'S %0'T %E'€ %9°€ %8'T %E'C %9'€ %8'€ %8'V %0°C %6°LE %L'0 %6°LE %0°0 %6°LE %L0 %6°LE %V'E %6°LE %8'C %.£'09 %0°0 %1°C9 %0°0 %0°09 %0°0 %999 %V'1 %9795 %L'0 %6°LE %06 %E8Y BTV %6°LE %L'6 %LV %B'C %6°LE %EOT %LV %T'C %6°LE %06 %S'SY BTV %6°LE %T'ET %8 VY %€ %6°LE %06 %BL'TS %V'T %6'LE %L'6 %LE6Y KBLO %BL'C %6°LE %L %69V NBV'E %IV %6°LE %6°ST %T'EE %E'OT %B'C %6°LE %T'ET %V TV BV'E %IV %6°'LE %8ET %6'LE %69 %V'E %6°LE %S ST HE'BC W'Y %V'E %6°LE NC LT %I'9E BTV %LV %6°LE %Y TC %9 LT %O TT %L'C %6'LE BT LT %TLE%BY %8'C %6°LE %0'TE %V TC %6'9 %8'C %6°LE %S VT %6'LE BV'E %C9 %6°LE %EOT %SGV %1'C %LV %6°LE %S VT %8 VY %00 %8'¢C %6°LE %6°LT %007 %T'C %L'C %6°LE %Y EC %I LT %BC %E'8 %9°8€ %9°9€ %0'TT %0'TT %8'¢C %6°'LE %L 0T %I9E BV'E %V'T %6'LE %8 CCRT'EERTY %L'C %L0 %00 %1 %L0 %L'C %L0 %Tl'C %l'¢C %b'€ %L0 %00 9.4e2 WwJal-3uo| 3Ny NI [ejeuosN SUIAl| paasIssY S9IAISS [BIU3Q Nl deipJie) 3uad AJ1aduns Alolenquiy weJsdoud a1ed aAnel|ed ou1elas yoAsd Adusdiswa yoAsq 9.4ed geyay S9JJAJIDS ddUR|INqUIY 221dsoH J393UdD SSaull4 weJdoud uonleziunwuw| S9DIAIDS J14}R1IDD) auplpaw syods 191U ewned| weusdoud Juswadeuew ujed weJs8oud "3sisse Juswjjotul J31U32 Y3}jeay s,uswopn 1dap aJed Asewld 8uisinu paj»s $321AI9s ASo|0ouQ S9DIAISS Y3|eay SWoH Adesayjowsay) "SOAS uolje|sueul/ansindur] Adoasouo|0d |eondo anpa jualled 193udd das|s jun Amly JAN ulep 1soq (vT€=u) waisAs pauior qun Amly JAN ulep 1soq (99=u) woaisAs tanaN yjun Amly JAN ulen 3so] (g6€=u) waisAs skem|y yun Amiy JAN ulep 1so] (spT=u) waisAs Yo IINIBS