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Thursday, August 27, 2015

Family Farm Managers Earn Less, but Gain ‘Emotional’ Wealth

Newswise, August 27, 2015 — ITHACA, N.Y. – After hours harvesting forage, managing livestock and milking cows, new Cornell University agricultural economic research shows family members who work on the family dairy farm make $22,000 less annually than comparable hired managers, but are handsomely compensated with “socioemotional” wealth.

“While $22,000 seems like a large penalty, there are nonfinancial rewards they experience working for the family business,” said Loren Tauer, professor at Cornell’s Charles H. Dyson School of Applied Economics and Management, who with lead author Jonathan Dressler of MetLife’s Food and Agribusiness Finance, published “Socioemotional Wealth in the Family Farm,” in a forthcoming Agricultural Finance Review.

There are roughly 5,400 dairy farms in New York, large and small. “Family members like to work for the family farm, as it brings prestige and satisfaction by working with siblings, cousins and parents,” explains Tauer. “The socioemotional part is that these family members feel an attachment to the dairy farm. It’s a warm and fuzzy feeling.”

Further, Dressler explained that socioemotional aspects of running a dairy farm “create a sense of pride and belonging, as collectively each family member is contributing an effort toward a common family goal.”

Dressler and Tauer examined dairy farm income in 1999 through 2008 and showed that New York farm manager median salaries varied widely from $41,884 in 1999, to $64,466 in 2004 to $74,986 in 2005, all adjusted for inflation to 2008 dollars. 

While the family farm managers were paid on average about $22,000 less, family members were compensated in other ways, such as with equity in the family business, which includes land values and the value of the operation – all of which have risen over time.

For family farms, Dressler and Tauer estimated a 5 percent current return to equity and asset appreciation of 10 percent, for a total return to equity of 15 percent. 

With “sweat equity,” Tauer explains, children eventually inherit farms or are given an opportunity to purchase farms at a low estimate of the farms’ value. That future ownership opportunity and the chance to work with family members offset reduced annual compensation.

Friday, August 21, 2015

Rural Mainstreet Index Sinks in August

 Cash Rents Expand as Farmland Prices Slump

August Survey Results at a Glance:
• The Rural Mainstreet Index sinks to growth neutral for August.
• Farmland prices decline for the 21st straight month, but cash rents remain strong at $263 per acre.
• On average, bankers expect farmland prices to decline by another 5.8 percent over the next 12 months.
• Housing sales expand at a healthy pace.

Newswise, August 21, 2015 – The Creighton University Rural Mainstreet Index fell for August from July’s tepid reading, according to the monthly survey of bank CEOs in rural areas of a 10-state region dependent on agriculture and/or energy.

Overall: The Rural Mainstreet Index (RMI), which ranges between 0 and 100, sank to growth neutral 50.0 from 53.4 in July.

“This is the first decline in the overall index since March of this year. Weaker conditions among businesses tied directly to agriculture and energy accounted for the downturn in the reading," said Ernie Goss, Jack A. MacAllister Chair in Regional Economics at Creighton University's Heider College of Business.
Farming and ranching: The farmland and ranchland price index for August increased slightly to 32.7 from July’s 31.4. 

“This is the 21st straight month the index has remained below growth neutral. But, as in previous months, there is a great deal of variation across the region in the direction and magnitude of farmland prices,” said Goss.

This month the survey asked bankers to project the expected change in farmland prices over the next year. On average, bankers reported an estimated decline of 5.8 percent over the next year. Last August when the same question was asked, bankers reported an expected 4.8 percent decrease.

“Bank CEOs were also asked to estimate current cash rents for nonpasture cropland. On average, bankers reported $263 per acre, which is up from $258 reported last year at this time. Additionally, bankers reported an increase in the share of farmland financed from 74 percent last August to 77 percent this month,” said Goss.

The August farm equipment-sales index sank to a very weak 14.2 from July’s 17.9, but was up from June’s record low 12.5. “With farm income expected to decline for a second straight year, farmers remain very cautious regarding the purchase of agricultural equipment,” said Goss.

Banking: The August loan-volume index climbed to 73.0 from 72.1 in July. The checking-deposit index rose to 55.0 from July’s 53.4, while the index for certificates of deposit and other savings instruments dropped to 34.0 from July’s 38.6.

Hiring: Despite weaker crop prices and pullbacks from businesses with close ties to agriculture and energy, Rural Mainstreet businesses continue to add workers to their payrolls. The August hiring index increased to a strong 63.3 from 60.3 in July.

 “Rural Mainstreet businesses continue to hire additional workers, while rural Mainstreet communities are growing jobs at a solid annual pace of approximately 1 percent, primarily in businesses not linked to agriculture or energy,” said Goss.

Confidence: The confidence index, which reflects expectations for the economy six months out, slumped to 42.0 from 46.6 in July. “Declines for agricultural commodity and energy prices pushed bankers’ economic outlook lower for the month,” said Goss.

Home and retail sales: The August home-sales index declined to a strong 70.4 from July’s 73.3. The August retail-sales index decreased to 50.0 from 53.4 in July. “Home sales on Rural Mainstreet have been very healthy over the last several months,” said Goss.

Each month, community bank presidents and CEOs in nonurban agriculturally and energy-dependent portions of a 10-state area are surveyed regarding current economic conditions in their communities and their projected economic outlooks six months down the road. 

Bankers from Colorado, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota and Wyoming are included. The survey is supported by a grant from Security State Bank in Ansley, Neb.

This survey represents an early snapshot of the economy of rural agriculturally and energy-dependent portions of the nation. 

The Rural Mainstreet Index (RMI) is a unique index covering 10 regional states, focusing on approximately 200 rural communities with an average population of 1,300. It gives the most current real-time analysis of the rural economy. 

Goss and Bill McQuillan, former chairman of the Independent Community Banks of America, created the monthly economic survey in 2005.

Colorado: Colorado’s August Rural Mainstreet Index (RMI) dipped to 51.5 from July’s somewhat stronger 53.2. The farmland and ranchland price index expanded to 38.4 from 12.7 in July. Colorado’s hiring index for August advanced to a healthy 65.5 from July’s 52.9.

Illinois: The August RMI for Illinois declined to 50.0 from 53.6 in July. The farmland-price index dropped to 29.5 from July’s 31.6. The state’s new-hiring index increased to 62.0 from July’s 60.5.

Iowa: The August RMI for Iowa dropped to 53.4 from July’s 56.6. Iowa’s farmland-price index for August rose to 44.0 from July’s 43.9. Iowa’s new-hiring index for August jumped to 67.8 from 65.4 in July.

Kansas: The Kansas RMI for August slid to 49.8 from July’s 52.3. The state’s farmland-price index for August increased to 27.8 from July’s 24.6. The new-hiring index for the state expanded to 61.3 from 57.7 in July.

Minnesota: The August RMI for Minnesota fell to 48.4 from July’s 53.9. Minnesota’s farmland-price index declined to 33.7 from 37.4 in July. The new-hiring index for the state declined to a healthy 58.2.

Missouri: The August RMI for Missouri declined to 43.2 from 47.1 in July. The farmland-price index grew to 29.5 from July’s 13.9. Missouri’s new-hiring index decreased to 51.3 from July’s 53.4.

Nebraska: The Nebraska RMI for August slumped to 48.4 from 50.1 in July. The state’s farmland-price index fell to 19.6 from July’s 21.4. Nebraska’s new-hiring index advanced to 58.0 from 56.4 in July. According to Jon Schmaderer, CEO of Tricounty Bank in Stuart, “The high level of moisture in July-August has substantially reduced the cost of irrigation this season.”

North Dakota: The North Dakota RMI for August decreased to 47.1 from 50.6 in July. The farmland-price index fell to 24.8 from 36.5 in July. North Dakota’s new-hiring index declined to 60.1 from July’s 62.4.

South Dakota: The August RMI for South Dakota slipped to 55.1 from July’s 56.7. The farmland-price index rose to 47.2 from 43.0 in July. South Dakota's new-hiring index climbed to 69.1 from 65.0 in July.

Wyoming: The August RMI for Wyoming sank to 49.2 from last month’s 52.5. The August farmland and ranchland-price index expanded to 47.2 from July’s 27.9. Wyoming’s new-hiring index climbed to 60.9 from July’s 59.0.

Rural American population losses continue

  • by Tim Henderson
August 21, 2015 (Pew Charitable Trusts)--Bill Longnecker grew up in rural Nebraska and, after trying life in Kansas City, Missouri, and other urban areas, returned to his home state to start a jewelry store in Red Willow County, population 10,867.

He loves it there.

“All we need is more people,” he said. Every year when high school graduates head off to college, locals present them with a mailbox imprinted with a map of the area. 

“We’re hoping they’ll find their way back,” Longnecker said. Few do.

Population loss is a long-term trend in much of rural America, and it’s gotten more acute since 2010, according to a Stateline analysis. Although 759 rural counties in 42 states lost population between 1994 and 2010, more than 1,300 rural counties in 46 states have lost population since 2010.

As a result, some states with dwindling rural populations, such as Nebraska and Kansas, are trying to lure people with tax incentives, and small, shrinking localities are looking for ways to share services or cut back as the pool of taxpayers shrinks.

They’ve tried shifting schools online in Colorado, and reverting to gravel roads in North Dakota and Michigan. The 251 residents of the village of Brokaw, Wisconsin, have launched an online campaign to raise $2.5 million toward a $3.8 million budget shortfall.

“[Population losses] are immediately a slap to the local funding base for rural counties, because of the loss of property taxes,” said Arthur Scott, who works on rural issues for the National Association of Counties.

“Counties are regionalizing and sharing resources in the face of this rural flight, which is the long-term impact when the younger generation just leaves after college, because there’s no job opportunities that make it fiscally viable for you to return back home,” Scott said.

Enticing College Grads 
Faced with declining rural populations, Kansas decided in 2011 to offer incentives to people who move to a rural county with population losses. Kansas is offering state income tax breaks to people from out of state and will repay a portion of the student loans of Kansans.

Dr. Rachael Cavenee took advantage of the program. She moved to Greeley County in 2013 after attending college in Colorado and graduate school in eastern Kansas. She started an audiology clinic, which allows her time at home with her husband and two children.

Greeley County lost about a quarter of its population between 1994 and 2010, but has gained slightly since 2010, to about 1,300 people. Cavenee said she quickly came to love the area’s friendliness.

“My fear of moving here has evolved into a fear of ever having to move away,” Cavenee said. “This is where you can find genuine, supportive people. This is where we chose to raise our family.”

In a report earlier this year, Kansas estimated that the 330 people who got income-tax breaks in 2014 brought in more than $44 million in economic benefits. That year, 993 people got student-loan subsidies. 
Some analysts are skeptical about the plan’s strategy of paying people to move to rural areas.

The program “may help a few families here and there, which is of course very important for those people and can give positive examples to some communities,” said László Kulcsár, a demographer at Kansas State University.

 “But we have to remember that it was designed to counter long-term depopulation, in which it is terribly ineffective.”

Nebraska started accepting applications this year for enterprise zones that would encourage new businesses in areas with declining population and high rates of poverty and unemployment.

In another effort aimed at rural Kansas, where aging business owners may have trouble cashing out when they retire, the University of Kansas School of Business has a program called RedTire that helps match college graduates to opportunities to buy rural businesses.  

Michelle Reed, who moved to rural McPherson from Orange County, California, this month, said she was struck by the number of help wanted signs, businesses that closed several days a week for lack of employees, and business owners unable to cash out and retire. McPherson is a city of 13,322.

“There are older business owners who would like to sell, but there are no buyers in town,” Reed said. “We need to somehow make it hip to have chickens and farm to table in the heartland, and get the young adults to move east.”

Root Causes
Historically, despite losses in agricultural and mining areas, rural population has grown as suburbia has expanded or retirees sought scenic, low-cost destinations, according to a June report from the U.S. Department of Agriculture (USDA). The department excludes from its definition of rural and small-town areas all commuter areas clustered around cities of 50,000 or more.

Overall, the country’s rural population dipped for the first time between 2010 and 2014, the USDA report said, as the number of people moving to economically hard-hit areas dropped. There were sharp contrasts within individual states. 

An oil boom gave North Dakota the largest rural population gain in the nation at 10 percent, but 16 agricultural counties on the east side of the state lost population.

Coal- and timber-dependent counties have also been hard-hit as those industries founder in the face of less expensive natural gas and as electronic, digital information reduces the need for paper.

High school students in rural Coos County, New Hampshire, a major pulp and paper producer, were asked by researchers if it was easy for somebody their age to get a job in the county (population 31,653). In 2008, two-thirds said it was easy. Three years later, only one in five said so. 

Some of the biggest rural losses are in coal country. The largest population decline from 1994 to 2010 was in West Virginia’s McDowell County, historically the state’s coal capital, which lost 38 percent. It fell another 8 percent since 2010 and the county now has about 20,000 people.

About half the rural counties in Nebraska, North Dakota and Kansas have lost more than 1 in 10 people since 1994.

Some analysts argue that simple math keeps rural college students from going home: Is there a job for me that will pay my student loans, or enough income from a small-town business or farm to support a family? Often the answer is no.

Population decline has been a fact of life in parts of Kansas for 50 years, Kulcsár, the demographer, said. What’s made it worse recently is that there aren’t enough babies to replace people who are moving out and retiring baby boomers are depriving rural areas of a large part of their workforce.

If there’s a chance to lure people back, it may be later in life, after they’ve had children, according to a USDA report released last month. This is especially true for those whose parents still live in their hometowns.

“Conversations about returning home centered on the value of family connections for child raising in a small-town environment,” the report concluded.

About 350,000 people moved out of rural counties between 2010 and 2014. In that time, only 250,000 people were born there. Counties that are more urban had more than 4 million people move in and almost 6 million births.

Effect on Government
Diminished revenue is an ongoing strain on local governments, one that the National Association of Counties thinks should be addressed by counties consolidating services and applying for grants together.

“With regional partnerships, you realize the assets of your neighbors and count on them together,” Scott said. Last year, the group put out a guide to creating regional partnerships, citing examples such as five Minnesota counties that worked to restore a railroad to get crops to market.

School has largely shifted online in Branson, Colorado, where a regional school system has just 52 students remaining in a brick-and-mortar school building, said Lori Green, the school district’s assistant business manager. The system has helped to preserve jobs in a district with shrinking enrollment, Green said. Branson is in Las Animas County, which had one of the biggest rural population losses between 2010 and 2014, with almost one in 10 of its 14,000 residents leaving.

As early as 2010, towns and counties in North Dakota and Michigan were converting paved roads to gravel—and some counties in Ohio were simply letting them erode—to save on maintenance costs, according to a Wall Street Journal report.

Meanwhile, the residents of Brokaw, Wisconsin, which saw its population drop and tax revenue plunge since a paper plant closed in 2012, have raised $756 in their online crowdfunding effort to close the $3.8 million budget gap.

“Without money coming in, you don’t pave the roads, you don’t pick up the trash, you don’t upgrade the sewer system,” said Doug Farquhar, a program director at the National Conference of State Legislatures.

Monday, August 17, 2015

To Survive, Rural Hospitals Join Forces

WILLCOX, Arizona, August 17, 2015—Ask Sam Lindsey about the importance of Northern Cochise Community Hospital and he’ll give you a wry grin. You might as well be asking the 77-year-old city councilman to choose between playing pickup basketball—as he still does most Fridays—and being planted six feet under the Arizona dust.

Lindsey believes he’s above ground, and still playing point guard down at the Mormon church, because of Northern Cochise. Last Christmas, he suffered a severe stroke in his home. He survived, he said, because his wife, Zenita, got him to the hospital within minutes. If it hadn’t been there, she would have had to drive him 85 miles to Tucson Medical Center.

There are approximately 2,300 rural hospitals in the U.S., most of them concentrated in the Midwest and the South. For a variety of reasons, many of them are struggling to survive. 
In the last five years, Congress has sharply reduced spending on Medicare, the federal health insurance program for the elderly, and the patients at rural hospitals tend to be older than those at urban or suburban ones. Rural hospitals in sparsely populated areas see fewer patients but still have to maintain emergency rooms and beds for acute care. They serve many people who are uninsured and can’t afford to pay for the services they receive.
Several months ago, Northern Cochise sought to strengthen its chances for survival by joining an alliance with Tucson Medical Center and three other rural hospitals in southwestern Arizona. Together, the Southern Arizona Hospital Alliance is negotiating better prices on supplies and services. And the Tucson hospital has promised to help its rural partners with medical training, information technology and doctor recruitment.
“We are committed to remaining autonomous for as long as we can,” said Jared Wilhelm, director of community relations at Northern Cochise. “We think this gives us the best leverage to do so.”

Northern Cochise and the other rural hospitals in the alliance, which is similar to ones in Kansas, Mississippi, Washington state and Wisconsin, hope that by joining they will avoid the fate of 56 rural hospitals that have closed since 2010. Another 283 rural hospitals are in danger of closing, according to the National Rural Health Association (NRHA).

Right now, some Arizonans in the region are learning what it’s like to lose a hospital. Cochise Regional Hospital, in Douglas, near the Mexican border, closed earlier this month, following Medicare’s decision to terminate payments because of repeated violations of federal health and safety rules. 

The hospital was part of a Chicago-based chain and its closing leaves Arizona residents in the far southeastern portion of the state up to 75 miles away from the closest hospital emergency room.

Sam Lindsey shudders to think what a long drive to Tucson would have meant for him last Christmas.

“If I’d have had to go 85 miles,” he said, “I don’t think I’d be here today.”

Multiple Advantages
The alliance offers the rural members multiple advantages. One of the most important is in purchasing. Their combined size will enable them to get discounts that are beyond them now. 

For example, instead of being a lone, 49-bed hospital with limited bargaining leverage, alliance member Mount Graham Regional Medical Center, in Safford, is suddenly part of a purchasing entity with more than 700 beds.

“If I’m just Mount Graham and I’m going to buy one MRI every seven years, the sales people will say, ‘Oh, that’s very nice,’ ” said Keith Bryce, Mount Graham’s chief financial officer. “But as part of this alliance that they want to do regular business with, they are going to give us a much better price.”

Bryce said that he expects the added purchasing power alone will save Mount Graham “in the six figures” every year.

Similarly, the hospitals expect the combined size of the alliance to result in lower costs for employee benefits, workers’ compensation and medical malpractice insurance.

The alliance also helps the rural hospitals recruit doctors and other medical providers, many of whom are reluctant to work, let alone live, in isolated areas. 

Rural hospitals rarely have the contacts and relationships that help urban hospitals find doctors. “We’ve been trying to recruit another primary care doctor to this community for the last year with no success,” said Rich Polheber, CEO of Benson Hospital, another alliance member.

Tucson Medical Center has pledged to use its own recruiting muscle to help its rural partners find providers who are willing to live in rural areas, or at least regularly see patients there. As an incentive, Tucson will offer interested doctors help in managing the business aspects of their practices.

The rural alliance members also want Tucson’s help with medical training and IT. Some have dipped into telemedicine, which is particularly valuable for rural hospitals underserved by specialists, and are looking to expand those efforts. 

Copper Queen Community Hospital, in Bisbee, the fourth rural member of the alliance and probably the rural hospital in the best financial shape, is the most advanced user of telemedicine. Its networks in cardiology, neurology, pulmonology and radiology can connect doctors and their patients to specialists at major institutions such as the Mayo Clinic and St. Luke’s Medical Center, in Phoenix.

The alliance also will make it easier for patients who have surgery in Tucson to be transferred back to their home hospitals for recovery and rehabilitation, saving them and their families from traveling long distances.

A Defensive Strategy 

Despite the numerous advantages for the rural partners, the idea for the alliance began with the Tucson hospital, which approached the others with the proposal last spring. At the outset, some of the rural hospitals were skeptical.

“At first, we were like, ‘OK, so why are they doing this? What’s in it for them? Do they want to absorb us?’ ” said Bryce, the Mount Graham CFO.
But after a series of meetings, the suspicions disappeared and the rural hospitals eagerly signed on.

The Tucson hospital was frank about its motivation: to remain independent in an industry moving toward consolidation. As a result of acquisitions in the last few years, it is the last locally owned, independent hospital in Tucson.

“All of a sudden, we were in a situation where [Tucson Medical Center] found itself isolated and facing its own competitive market pressures because the environment had so dramatically changed,” said Susan Willis, executive director of market development at the hospital and president of the new alliance.

Nearly a quarter of Tucson’s patients come from outside the city, many from the areas served by the rural hospitals in the new alliance. Cementing the relationship with those hospitals, Willis said, will help Tucson maintain a flow of patients who need medical services that are beyond the capabilities of the rural hospitals. 

The rural members have laboratories, diagnostic equipment and therapeutic services, but some have little or no surgical or obstetrical services. Not one is equipped to perform complicated surgeries.
“Certainly you could describe it as a defensive strategy,” Willis said.

Decades of Pressure
Many of the problems plaguing rural hospitals date to 1983, when Medicare began paying hospitals a set fee for medical services and procedures rather than reimbursing them for the actual costs of providing that care. 

From 1983 to 1998, 440 rural hospitals closed in the U.S., according to the NRHA. That prompted Medicare to begin reimbursing certain rural hospitals for their actual costs, which helped stabilize them.
But the recession hit rural hospitals especially hard, as did 2011 budget cuts that reduced Medicare payments by 2 percent. 

Because the rural population tends to be older, rural hospitals rely heavily on Medicare payments. The pressure increased in 2012, when the federal government reduced by 30 to 35 percent its reimbursements to hospitals for Medicare patients who don’t cover their share of the bill.

“That’s an example of how a little policy change that seems insignificant in Washington can have profound effects in the rural areas,” said Brock Slabach, NHRA’s senior vice president for member services.

Finally, more insurance plans are increasing copayments and other out-of-pocket costs. Many of the patients at rural hospitals have low incomes. And when they can’t cover their costs, the hospitals have to pick up the tab. 

“We don’t have cash reserves,” said Polheber, the Benson Hospital CEO. “We live on the edge, day to day, week to week. [The alliance] seemed like the best way to keep us going.”

Given the threats to the nation’s rural hospitals, many are eager to learn from any models that work, which is why the Arizona alliance has attracted notice.

Slabach, for one, calls it a promising model, although one that may not be replicable everywhere. 

“You have to have willing partners willing to collaborate and provide assistance to each other,” he said. “You need partners that share a cultural fit with you.”

The rural members of the alliance are major employers in their communities and assets in attracting other employers and residents, including the snowbirds, who flock to the area every winter. 

But hospital leaders, workers and patients say saving lives is the main reason the hospitals must remain open.
“In medicine, distance lessens the chances of survival,” said Pam Noland, director of nursing at Northern Cochise. “Even if a patient has to be transferred to [Tucson Medical Center] or somewhere else, stabilizing them here is the difference between life and death.”

Rural Medicare Beneficiaries Receive Less Follow-Up Care

August 14, 2015- Medicare patients in rural areas have lower rates of follow-up care after leaving the hospital—which may place them at higher risk of emergency department (ED) visits and repeat hospitalizations, according to a study in the September issue of Medical Care.

The journal is published by Wolters Kluwer.

"This study provides evidence of lower rates of post-discharge follow-up care, and higher ED use for Medicare beneficiaries in rural settings," comments lead author Matthew Toth, PhD, MSW. The research was conducted while Dr. Toth was at University of North Carolina at Chapel Hill; he is now at RTI International. 

Especially with new "pay-for-performance" programs tying reimbursement to hospital performance on patient outcomes, the results highlight the need for policies to improve follow-up care for patients in rural areas.

Differences in 30-Day Outcomes for Patients at Rural versus Urban Hospitals

Using data from the nationally representative Medicare Current Beneficiary Survey, the study included approximately 12,000 Medicare-eligible patients with hospital admissions between 2000 and 2010. About 4,000 patients lived in rural areas; this group was further divided into patients living in large, small, and isolated rural areas (based on a standard coding system).

The rural and urban groups were compared on three key outcomes during the first 30 days after hospital discharge: follow-up healthcare visits, ED visits, and unplanned hospital readmissions. The comparisons were adjusted for a wide range of demographic, health-related, and hospital characteristics.

The results suggested that patients living in isolated areas were less likely to receive a follow-up visit within 30 days after leaving the hospital. Compared to those in urban areas, patients in isolated rural settings were 19 percent less likely to receive follow-up care.

The study also found a higher risk of ED visits within 30 days for patients living in large or small rural areas, compared to urban patients. This risk was 44 percent higher for patients who lived in small rural settings and 52 percent higher for those in large rural settings.

The overall risk of unplanned hospital readmissions was not significantly different for rural versus urban residents. However, this difference became significant when patients were classified by the location of the hospital where they were treated, rather than where they lived. 

Thirty-day readmission risk was 32 percent higher for patients discharged from hospitals in large rural settings and 42 percent higher for hospitals in small rural settings, compared to urban settings.

In addition to their impact on patient care, the findings may have important implications for rural healthcare providers at a time of changes in healthcare delivery and payment. 

These include a recently introduced Medicare program seeking to improve post-discharge outcomes by penalizing hospitals with higher-than-expected 30-day readmission rates.

"Consistent with previous [research] on safety-net and low-volume hospitals, our study finds that rural hospitals serving elderly Medicare beneficiaries may be disproportionately penalized under this program," Dr. Toth and coauthors write. "If so, poor readmission outcomes among these hospitals may be exacerbated."

The researchers believe their findings highlight the need for measures to improve access to care and reduce unplanned acute events for rural patients. That may include investment in programs such as telehealth, care management, transitional care, and policies to enhance primary care services.

 "A greater understanding of the reasons for these differences would help inform efforts to improve care," Dr. Toth adds. "For example, are patients of rural hospitals more likely discharged to under-resourced settings, or are there more likely gaps in post-discharge instructions in the inpatient setting?"

Article: "Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge" (doi: 10.1097/MLR.0000000000000401)
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Rated as one of the top ten journals in health care administration, Medical Care is devoted to all aspects of the administration and delivery of health care. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of health care. Medical Care provides timely reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services. In addition, numerous special supplementary issues that focus on specialized topics are produced with each volume. Medical Care is the official journal of the Medical Care Section of the American Public Health Association

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