Although hospitals can improve financially when they join larger health systems, the merger may also reduce access to services for patients in rural areas, according to a new study.
After an affiliation, rural hospitals are more likely to lose onsite imaging and obstetric and primary care services, researchers report in a special issue of the journal Health Affairs devoted to rural health issues in the United States.
“The major concern when you think about health and healthcare in rural America is access,” said lead study author Claire O’Hanlon of the RAND Corporation in Santa Monica, California.
More than 100 rural hospitals in the U.S. have closed since 2010, the study authors write.
“Hospitals in rural areas are struggling to stay open for a lot of different reasons, but many are looking to health-system affiliation as a way to keep the doors open,” she told Reuters Health by email. “But when you give up local control of your hospital to a health system, a lot of things can change that may or may not be good for the hospital or its patients.” Using annual surveys by the American Hospital Association, O’Hanlon and colleagues compared 306 rural hospitals that affiliated during 2008-2017 with 994 nonaffiliated rural hospitals on 12 measures, including quality, service utilization and financial performance. The study team also looked at emergency department and nonemergency visits, long-term debt, operating margins, patient experience scores and hospital readmissions.
They found that rural hospitals that affiliated had a significant reduction in outpatient non-emergency visits, onsite diagnostic imaging technologies such as MRI machines, and availability of obstetric and primary care services. For instance, obstetric services dropped by 7-14% annually in the five years following affiliation.
“Does this mean that patients are getting prenatal care in their community at a different location, traveling to receive prenatal care at another location of the same health system, or forgoing this care entirely?” O’Hanlon said. “Trying to figure out the extent to which the observed changes in the services available onsite at rural hospitals reflect real changes in patient access is an important next step.” At the same time, the affiliated hospitals also experienced an increase in operating margins, from an average baseline of -1.6%, typical increases were 1.6 to 3.6 percentage points, the authors note. The better financial performance appeared to be driven largely by decreased operating costs.
Overall, patient experience scores, long-term debt ratios, hospital readmissions and emergency department visits were similar for affiliating and non-affiliating hospitals.
“Research on these mergers has been mixed, with some suggestions they are beneficial for the community (access to capital, more specialty services, keep the hospital open) and other evidence that there are costs (employment reductions, loss of local control, increase in prices),” said Mark Holmes of the University of North Carolina at Chapel Hill, who wasn’t involved in the study.
“Mergers can have a large impact on a community, so understanding the effect on the resultant access, cost and quality of locally available services is important,” he told Reuters Health by email.
A limitation of the study is that the surveys capture affiliation broadly and don’t specifically describe the arrangements, the study authors note. Future studies should investigate the different types of affiliations, such as a full acquisition versus a clinically-integrated hospital network, which may show different outcomes, said Rachel Mosher Henke of IBM Watson Health in Cambridge, Massachusetts, who also wasn’t involved in the study.
For instance, certain types of rural hospital affiliations may be better for the community than a full hospital closure, she said.
“However, it’s important to evaluate the potential for negative consequences for the community in terms of reduced service offerings,” she told Reuters Health by email. “New payment models such as all-payer global payments that allow rural hospitals to continue to operate independently with consistent cash flow may be an alternative to affiliation to consider.”