Understanding Rural Hospital Bypass Behavior

CONTEXT: Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure. PURPOSE: This study provides a descriptive analysis of rural hospital bypass behavior in 7 states. METHODS: We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility. FINDINGS: We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self-pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty surgery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities. CONCLUSIONS: Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment.