Saturday, June 20, 2015

Fact checking reveals misinformation about rural hospital closures

This is a draft of a letter to the editor, or maybe op-ed, I will send to the Star later today.

In a Letter to the Editor in Friday's Daily Star, Timothy Michael makes stunning claims about rural hospital closings. Here I report on a fact checking investigation. My results indicate that Michael's claims include a numerical falsehood and questionable attributions of cause and effect.

Michael makes this claim about the frequency of closings: "Consensus: ACA’s heightened costs caused hundreds of hospital closures, as numerous pundits predicted." That claim is false in two ways. First, there have not been "hundreds" of closures. Second, whatever "consensus" there is comes from various news sources relying on the same data showing the number of closures at well under 100 (one hundred) during the last 10 years.

Here are quotes (from what I assume to be) Michael's sources.

USA Today: "Since the beginning of 2010, 43 rural hospitals — with a total of more than 1,500 beds — have closed, according to data from the North Carolina Rural Health Research Program. The pace of closures has quickened: from 3 in 2010 to 13 in 2013, and 12 already this year. "

Reuters: "The majority of rural residents in the United States live in states which are not expanding Medicaid, reported the North Carolina Rural Health Research Program. A majority of the 24 hospitals closed since the start of 2013 are in those states."

Washington Post: "The Kansas-based National Rural Health Association, which represents about 2,000 small hospitals across the country and other rural care providers, says that 48 rural hospitals have closed since 2010 ..."

Nowhere is there information to support the claim that ACA "caused hundreds of hospital closures." The consensus numbers vary a little depending on the date of the report, but all converge on something less than 50.

Other sources agree. This infographic from FamiliesUSA shows 31 closures since 2010, 20 in states that did not expand Medicaid but only 11 in states that did expand Medicaid. Apparently, the decision to not expand Medicare might have something to do with the likelihood of a rural hospital closure. That conclusion would be strengthened by a comparison of closure rates before and after 2010.

The University of North Carolina (UNC) has studied such closures for years and provides an interactive map of closures during the 5-year period after the ACA (2010-2015) but also for the years before the Affordable Care Act (2005-2009). That comparison gives us a way of deciding whether ACA was accompanied by a big jump in closures. The UNC rural health research program now has 90 hospital closures in its database. Of those, 37 occurred before 2010 and 53 occurred after the beginning of 2010. However, the pattern is different for those states that expanded Medicaid (23 dropping to 14) and those that did not (14 increasing to 39). Thus states that expanded Medicaid experienced a 40% drop in closures but states that refused the Medicaid expansion saw their closure rates increase by nearly 180%.

Even a brief glance at the maps in suggests that there is another variable at play, namely the geographic location of those non-expansion states: mainly in the south. So, is ACA to blame - as Michael suggests - or not?

The possible causes of rural hospital closures have been studied for years. A very clear takeaway from such studies is described in the Washington Post article.

If there was one particular policy causing the trouble, it would be easy to understand," said Mark Holmes, a health economist at the University of North Carolina. "But there are a lot of things going on."

... rural hospitals ... suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.

These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.

The Kaiser Family Foundation has a good report on what it costs states to not expand medicaid.

Thus the possible causes of rural hospital closures are many and complex. Blaming a single agent, as Michael does, is an ideological bias and not a factual statement.

Let me end with a plea for a tighter editorial review of letters claiming to provide factual information. I will readily admit that I am a numbers guy by training and profession. But Michael's false numerical claims can be disproved easily by anyone doing a simple Google search as I did. The Star owes more to its readers than reprinting misinformation.

If that last paragraph prevents publication, believe me, I will get it printed elsewhere.

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