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Rural hospitals outperformed urban in value, readmissions, hospital acquired condition programs

Brief examines 2015 data from Hospital Readmissions Reduction, Hospital Value-Based Purchasing, Hospital-Acquired Conditions Reduction programs.

Beth Jones Sanborn, Managing Editor

When it comes to thwarting hospital-acquired infections and scoring better in government value-based purchasing programs, rural hospitals outperformed their urban counterparts and saw fewer penalties in 2015, shows a report released Wednesday by the U.S. Department of Health and Human Services.

The Hospital-Acquired Conditions Reduction program is a program that provides an incentive for hospitals to reduce HACs like surgical site infections and catheter-associated urinary tract infections and requires the Secretary of the Department of Health and Human Services to adjust payments to the worst-performing facilities. 129 rural hospitals saw penalties in 2015 in this program, which amounts to 14 percent. However, 568 urban hospitals were penalized, amounting to 26 percent.

In examining data from the Hospital Value-Based Purchasing program, which rewards acute-care hospitals with incentive payments based on the quality of care they provide to Medicare beneficiaries, 288 rural hospitals were hit with penalties, amounting to 34 percent. The number of urban hospitals that saw penalties totaled 1,040, or 49 percent. That's 15 percent more urban hospitals than rural.

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In drilling down further into data from this program, rural hospitals did better overall than urban facilities, as well as in the specific categories of efficiency and patient experience, the report showed.

The lone area where urban hospitals delivered better results was under the Hospital Readmissions Reduction program, which requires the Centers for Medicare and Medicaid Services to reduce payments to IPPS hospitals with excess readmissions. But the gap between them was reasonably small in terms of percentages. 709 rural hospitals saw penalties under the program, or 79 percent of rural facilities. Three percent fewer urban hospitals in this program were saddled with penalties, according to results.

The report explained that while rural hospitals operate at a disadvantage on several levels, their size and related logistics also offer some advantages that may have played a role in their 2015 scores, as well as future success in healthcare delivery reforms.

First, rural hospitals often perform particularly well on patient experience metrics, often besting urban hospitals, and the reason may be the small-town feel that pervades their facility and staff.

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"High levels of trust in providers may facilitate better patient experiences or outcomes both in the inpatient and outpatient setting," authors wrote.

Also, it is not uncommon that in some rural areas, hospitals, outpatient facilities and nursing home facilities are located at a singular site and have one owner. Specifically, critical access hospitals are often the only care provider in a wide geographic area, and may likely offer the full range of services from primary and preventive care to post-acute and nursing home care. Though this type of setup could be regardd as a threat to market sufficiency, in payment models that reward such coordination and place increasing focus on efficiency and collaborative care, rural hospitals may be poised to perform well with this setup, the report said.

Rural markets can also be especially conducive to fostering care coordination and cooperation among entities, something that is crucial to success in putting in place delivery system reform initiatives, particularly those in which both hospitals and other providers are both involved.

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"In rural communities, primary care providers operating in Rural Health Clinics and Federally Qualified Health Centers generally refer to a small network of referral hospitals and post-acute care providers because there are fewer of these providers available, which can encourage collaboration across care types and settings."

It's also worth noting that the health of the populations that rural hospitals serve is often not ideal. The report highlighted several troubling health trends among adults living in nonmetropolitan areas, including poorer health status, more tobacco use, and higher rates of major chronic conditions, poorer indicators of both oral and mental health and a lower likelihood of patients having health insurance.

Authors also wrote that these areas have shown a recent spike in morbidity and deaths from opioid and alcohol abuse. Rural populations are also older on average, with less income and higher poverty rates.

These challenges are coupled with challenged access to care, thanks to lack of public transportation or longer distances patients must traverse and physician shortages.

"Only 9 percent of U.S. physicians practice in rural areas, and the majority of designated Health Professional Shortage Areas are rural, indicating that the supply of physicians, nurses, behavioral health specialists, public health specialists, and other providers is likely inadequate for the current needs of the population," authors wrote.

Twitter: @BethJSanborn