Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals

To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010.

We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey.

We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression.

We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey.

Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p < 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p < 0.001).

Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.