Rural Hospital Mergers Followed by Service Line Cutbacks, Study Finds

Researchers show that rural hospital mergers result in decreased services for maternal and neonatal care, surgical care, and behavioral health care.

Mergers of rural hospitals with health systems or other hospitals can achieve financial sustainability, but the deals can be followed by the reduction of services lines that are essential to the community, a new research article says.

Adults living in rural areas are more likely to be poor, have health conditions, and have greater unmet health needs than adults in living in urban areas, the new study says. Rural communities often depend on their hospitals to provide acute inpatient care, as well as outpatient services such as routine chronic, urgent, and emergency care instead of primary care, the new study says.

The research article, which was published today by Health Affairs, focuses on 172 rural hospitals that merged between 2009 and 2016 in 32 states as well as 549 comparison hospitals. The study features several key data points.

• Before the mergers, 74.5% of hospitals that merged provided maternal and neonatal services. This percentage decreased 13.4 percentage points after the mergers to 61.1%. The percentage of the comparison hospitals providing these services was stable during the merger time period (64.3% and 65.1%.)
   
• The surgical service line decreased by 5.0 percentage points at merged rural hospitals versus the comparison hospitals.
   
• As measured by hospital discharges, average mental health and substance use disorder volume fell by 10.4% at merged hospitals but the discharges increased 41.1% at comparison hospitals.
   
• In examination of catchment area data, there was no lasting decline in inpatient care at merged rural hospitals, which indicates that hospital mergers did not reduce inpatient care access. "However, whereas stays for mental/substance use disorders in the catchment areas of merged hospitals remained stable from the pre to the post period (1.0% decrease), they increased by 12.4% in areas of comparison hospitals," the study says.

Interpreting the data

After mergers, rural hospitals eliminated some service lines, the study says. "This study found that rural hospitals that merged were more likely than hospitals that remained unaffiliated to eliminate certain services lines in the first and second years postmerger, specifically for maternal/neonatal and surgical care. Merged hospitals in rural areas also showed reductions in the volume of mental/substance use disorder stays, whereas hospitals that remained unaffiliated showed increased volumes."

Mergers impacted utilization of behavioral health services, the study says. "The stable trend of mental/substance use disorder discharges within the catchment areas of merged hospitals, versus comparison catchment areas where mental/substance use disorder discharges increased, suggests that communities with merged hospitals may have experienced decreased access to behavioral health care."

Although mergers can boost rural hospitals financially, the deals come at a cost to the communities that the merged hospitals serve, the study says. "Although mergers might salvage hospitals' sustainability, they do not necessarily mean that all service lines are retained or that hospitals are as responsive to community needs as before the merger. Specifically, we found that merged hospitals had reduced maternal/neonatal, surgical, and mental/substance use disorder services."

Photo credit: Antonina Heeres