Less follow-up care, more hospital readmissions for rural Medicare beneficiaries

Medicare beneficiaries in rural areas are less likely to seek follow-up care after hospital visits, which may put them at an increased risk for visits to the emergency departments (EDs) and hospital readmissions. The results of a study published in Medical Care suggest that policies need to be implemented that focus on improving follow-up care for rural Medicare beneficiaries, not only to provide better care, but also in consideration of the recent shift toward “pay for performance” programs that link hospital reimbursement to performance on patient outcomes.

30-day outcomes

The study, which was performed by researchers at RTI International and the University of North Carolina at Chapel Hill, examined 12,000 Medicare-eligible patients who had been admitted to a hospital between 2000 and 2010. Approximately 4,000 of those patients lived in rural areas. The patients were divided into rural (large, small, and isolated) and urban groups. The study examined the number of follow-up health care visits, ED visits, and unplanned hospital readmissions for each group. The data suggested that Medicare beneficiaries in isolated areas were 19 percent less likely to have a follow-up health care visit within 30 days of leaving the hospital. The results also showed that patients living in large or small rural areas had a higher risk of ED visits than patients in urban areas.

Hospital location

While the study found no major difference in the overall risk of unplanned hospital readmissions between rural versus urban residents, it did find that the location of the hospital had a significant effect on readmissions. The study found that patients discharged from hospitals in large rural settings had 32 percent higher risk of unplanned readmissions as compared to those discharged from urban hospitals. Additionally, Patients who were discharged from small rural settings had a 42 percent higher risk of unplanned readmissions.


The findings implicate not only patient care but payments to rural providers who may be subject to the CMS readmission penalty for higher-than-expected 30-day readmission rates. The Hospital Readmissions Reduction Program (HRRP) was implemented by Section 3025 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) required CMS to reduce payments to acute inpatient hospitals (IPPS) with high readmission rates.

Lead author of the study, Matthew Toth, PhD, MSW, and his coauthors stated, “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.” They added, “If so, poor readmission outcomes among these hospitals may be exacerbated.”


The study’s authors concluded that their findings show that health care policies need to focus on improving access to care and reducing unplanned acute events for rural patients, which could include support for programs that focus on primary care services, telehealth, care management, and transitional care.