Factors associated with Iowa rural hospitals' decision to convert to critical access hospital status

J Rural Health. Winter 2009;25(1):70-6. doi: 10.1111/j.1748-0361.2009.00201.x.


Context: The Balanced Budget Act (BBA) of 1997 allowed some rural hospitals meeting certain requirements to convert to Critical Access Hospitals (CAHs) and changed their Medicare reimbursement from prospective to cost-based. Some subsequent CAH-related laws reduced restrictions and increased payments, and the number of CAHs grew rapidly.

Purpose: To examine factors related to hospitals' decisions to convert and time to CAH conversion.

Methods: Eighty-nine rural hospitals in Iowa were characterized and observed from 1998 to 2005. Cox proportional hazards models were used to identify the determinants of time to CAH conversion.

Findings: T-test and one-covariate Cox regression indicated that, in 1998, Iowa rural hospitals with more staffed beds, discharges, and acute inpatient days, higher operating margin, lower skilled swing bed days relative to acute days, and located in relatively high density counties were more likely to convert later or not convert before 2006. Multiple Cox regression with baseline covariates indicated that lower number of discharges and average length of stay (ALOS) were significant after controlling all other covariates.

Conclusion: Iowa rural hospitals' decisions regarding CAH conversion were influenced by hospital size, financial condition, skilled swing bed days relative to acute days, length of stay, proportion of Medicare acute days, and geographic factors. Although financial concerns are often cited in surveys as the main reason for conversion, lower number of discharges and ALOS are the most prominent factors affecting rural hospitals' decision on when to convert.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Bed Conversion
  • Budgets / legislation & jurisprudence
  • Decision Making, Organizational*
  • Financial Management, Hospital*
  • Health Services Accessibility / economics*
  • Hospital Bed Capacity
  • Hospital Costs
  • Hospitals, Rural / classification
  • Hospitals, Rural / economics
  • Hospitals, Rural / organization & administration*
  • Humans
  • Iowa
  • Length of Stay
  • Medicare Part A / legislation & jurisprudence*
  • Outliers, DRG
  • Proportional Hazards Models
  • Reimbursement Mechanisms*
  • Time Factors
  • United States