UC Merced

Recent events have highlighted the intricate relationship between rural and urban communities. The pandemic made it abundantly clear how vital it is to maintain accessible quality healthcare services for all community members. However, it is evident that rural communities face additional challenges in maintaining their hospitals. There are various models that have been proposed for rural communities, but it is unclear to what extent the preferences of rural inhabitants have been considered in developing such models. This dissertation aims to examine the disparities in healthcare utilization between rural and urban areas, with a specific focus on pregnancy-related care. Furthermore, it integrates the findings of discrete choice experiments to generate models tailored to rural communities' needs and preferences.The first chapter corresponds to the revealed preference analysis, for which California’s patient discharge data from 2016 to 2019 was used to identify differences in access, patterns of care, and complications for patients in rural and urban regions, as well as individual factors associated with the outcomes of interest. During that period, there were 12,641,940 discharges. 15% (1,936,321) of those discharges were related to pregnancy, childbirth, and delivery. Within this group, rural patients were found to have ten times greater odds of having to travel outside their locality for care. While no statistically significant association was identified between patient’s rurality and complications related to pregnancy or puerperium, there was a significant association with shorter and more expensive hospital stays. Hospital’s rurality was associated with increased odds of induction, complications during labor, and during the puerperium, compared to non-rural hospitals. The cost of care was, on average, $2,650 higher in rural hospitals. The stratified analysis showed pronounced racial-ethnic disparities. Rural African Americans were found to have four times the odds of traveling outside their region to receive care compared to rural White patients, and their costs of care were 36% higher. The impact of higher poverty rates or limited access to maternal care was also higher within the rural group. The second chapter presents the discrete choice methodology to identify and analyze the preferences expressed by rural populations in relation to hospital care. A total of 204 individuals were recruited, encompassing 102 California zip codes classified as rural or small towns based on RUCA scores. Preferences related to the type of facility, travel and waiting times, quality of care, familiarity with the provider, and cost were assessed, as well as the variations in relation to health scenarios and socio-demographic aspects. The findings were then utilized to estimate the willingness to pay for each attribute in the general population and the identified strata. The third chapter of this dissertation employed the information gathered from the first two chapters to calculate marginal probabilities based on the utilization parameters observed in chapter one and the preferences identified in chapter two. The integration of both models revealed that enhancing modifiable aspects of care in rural facilities can increase demand. Providing financial support to reduce the cost of care and improving organizational aspects that shorten waiting times and enhance the quality of care in these facilities can significantly impact demand. In order to ensure their operation, it is critical to identify the needs and preferences of the population, especially of those subgroups that are most disadvantaged, to comprehend the reasons why, despite those disadvantages, they are inclined to travel greater distances and incur in greater out of pocket expenses to receive care.