This story originally appeared here and is published by Carolina Public Press through a content-sharing agreement with N.C. Health News.

By Taylor Sisk, N.C. Health News

A team of UNC-Chapel Hill researchers has found Medicare patients in rural areas are less likely to receive adequate follow-up care after leaving the hospital than patients in urban areas.

As a result, they may well be at greater risk of winding up back in the hospital or the emergency room soon after discharge.

Matthew Toth, now a research public health analyst at RTI International, was lead author of the study, conducted while he was earning a doctorate in health policy and management at UNC’s Gillings School of Global Public Health and serving as a research assistant with the Cecil G. Sheps Center for Health Services’ N.C. Rural Health Research Program.

The results, published in the September issue of Medical Care, found that Medicare patients living in rural areas were 19 percent less likely to receive follow-up care within 30 days of leaving the hospital than those living in urban areas.

Patients discharged from hospitals in relatively smaller rural areas faced a 42 percent higher risk of being readmitted to the hospital within 30 days than patients discharged from hospitals in urban areas. Patients discharged from hospitals in larger rural areas were 32 percent more likely to be readmitted than their counterparts in urban areas.

Patients living in small rural areas were also 44 percent more likely to be seen in the emergency department within 30 days, while those in large rural areas were 52 percent more likely.

The study comes shortly after the release of the fourth year of federal data showing the 30-day readmission rates for most hospitals in the nation. This year, a majority of hospitals will face Medicare fines for having patients frequently return within a month of discharge.

Barriers to care

The UNC study looked at some 12,000 Medicare-eligible patients with hospital admissions between 2000 and 2010, using data from the Medicare Current Beneficiary Survey.

Toth pointed to workday schedules as a barrier to primary care for people who cannot get to the doctor during regular business hours. He suggested extending weekend clinic hours as a potential solution.

Toth and his colleagues also outline some potential policy initiatives to address the problems they found, including investment in telehealth, care management and transitional care and policies to enhance primary care services.

“Policymakers and researchers ought to continue to monitor the utilizations and outcomes among rural beneficiaries to better understand some of the specific barriers to care that they’re experiencing,” Toth said in an interview.

This could “help shape some of the payment and delivery-system reforms that are taking place in our health care settings,” he said.

Hospital fines

CMS officials will penalize 2,592 hospitals across the country this year, all will receive lower payments for every Medicare patient admitted to that hospital for the coming year.

The penalties will be assessed starting in October. They’re mandated by the Hospital Readmissions Reduction Program, created as part of the Affordable Care Act to encourage hospitals to more closely monitor what happens to patients after discharge.

The hospitals penalized will lose a combined $420 million. The percentage of North Carolina hospitals that will be fined is higher than the national average: 68 percent compared with 54 percent.

Toth placed the results of his team’s study in the context of the Hospital Readmissions Reduction Program.

“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,” he said in a press release announcing the results. “If so, poor readmission outcomes among these hospitals may be exacerbated.”

A deeper understanding of the reasons for the discrepancies between rural and urban areas could help inform efforts to improve care, he said. “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?”

“Especially with new ‘pay-for-performance’ programs tying reimbursement to hospital performance on patient outcomes, [our] results highlight the need for policies to improve follow-up care for patients in rural areas,” he said.

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