An updated model of rural hospital financial distress.

Purpose: To create a model that predicts future financial distress among rural hospitals.

Methods: The sample included 14,116 yearly observations of 2311 rural hospitals recorded between 2013 and 2019. We randomly separated all sampled hospitals into a training set and test set at the start of our analysis. We used hospital financial performance, government reimbursement, organizational traits, and market characteristics to predict a given hospital's risk of experiencing one of three financial distress outcomes-negative cash flow margin, negative equity, or closure.

Findings: The model's area under the receiver operating characteristic curve (AUC) equaled 0.87 within the test set, indicating good predictive ability. We classified 30.55% of the observations in our sample as lowest risk of experiencing financial distress over the next 2 years. In comparison, we classified 32.52% of observations as mid-lowest risk of distress, 26.40% of observations as mid-highest risk, and 10.52% of observations as highest risk. Among test set observations classified as lowest-risk, 5.78% experienced negative cash flow margin within 2 years, 1.50% experienced negative equity within 2 years, and zero observations experienced closure within 2 years. Within the highest-risk group, 61.57% of observations experienced negative cash flow margin, 43.02% experienced negative equity, and 3.33% experienced closure.

Conclusions: Given the ongoing challenges and consequences of rural hospital unprofitability, there is a clear need for accurate assessments of financial distress risk. The financial distress model can be used by researchers, policymakers, and rural health advocates as a screening tool to identify at-risk rural hospitals for closer monitoring.