title: How Would Rural Hospitals Be Affected by Loss of the Affordable Care Act's Medicare Low-Volume Hospital Adjustment?
abstract: The low-volume hospital (LVH) payment adjustment established in the Patient Protection and Affordable Care Act (ACA) of 2010 is scheduled to sunset on October 1, 2017. The purpose of this analysis was: (1) to estimate the effect of the ACA LVH adjustment on qualifying hospitals' profitability margins; and (2) to examine hospital and market characteristics of the hospitals that would be most adversely affected by the loss of the ACA LVH adjustment.
  
  
  
  2004-2015 data from the Hospital Cost Report Information System, Hospital Market Service Area File and Nielsen-Claritas Pop-Facts file were used to estimate difference-in-difference regression models with hospital-level random effects in order to determine whether the ACA LVH adjustment improved qualifying rural hospitals' profitability margins. Recycled predictions estimated the effect of losing the ACA LVH adjustment on profitability margins. Bivariate analyses explored associations between the predicted profitability margins and hospital and market characteristics.
  
  
  
  The ACA LVH adjustment significantly improved Sole Community Hospitals' Medicare inpatient margins in the year they received the adjustment, and it had a large but statistically insignificant effect on the profitability margins of other rural hospitals. Hospitals that would be the most adversely affected by loss of the ACA LVH adjustment were more likely to be small, located in the South, and in high-poverty markets with higher proportions of black and uninsured individuals.
  
  
  
  Elimination of the ACA LVH adjustment would have differential effects on subgroups of hospitals, and those located in markets serving historically underserved populations would be the most adversely affected.
authors.affiliation: North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.|Department of Health Policy & Management, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: Rebecca Garr
authors.initials: RG
authors.lastname: Whitaker
authors.affiliation: North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.|Department of Health Policy & Management, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: G Mark
authors.initials: GM
authors.lastname: Holmes
authors.affiliation: North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.|Department of Health Policy & Management, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: George H
authors.initials: GH
authors.lastname: Pink
mesh_terms: D016009:Chi-Square Distribution; D005102:Health Expenditures / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000639:trends*; D006780:Hospitals, Rural / Q000639:trends*; D006801:Humans; D006278:Medicare / Q000639:trends*; D058991:Patient Protection and Affordable Care Act / Q000639:trends*; D011445:Prospective Payment System; D014481:United States
keywords: Medicare; health care financing; low-volume hospitals; policy; rural hospitals