A hospital closure can send tremors through a city or town, leaving residents fearful about how they will be cared for in emergencies and serious illnesses. A study released Monday offers some comfort, finding that when hospitals shut down, death rates and other markers of quality generally do not worsen.

Researchers at the Harvard School of Public Health examined 195 hospital closures between 2003 and 2011, looking at health experiences in the year before and the year after the hospital went out of business. Their paper, published in the journal Health Affairs, found that changes in death rates of people on Medicare — both those who had been in the hospital and among the broader populace — were no different than those for people in similar places where no hospital had closed.

While the researchers noted that some people might be inconvenienced by having to travel further for care, they found no significant changes in how often Medicare beneficiaries were admitted to hospitals, how long they stayed or how much their care cost.

The closed hospitals tended to be financially troubled, with revenues averaging 13 percent less than the cost of running the institutions. “It’s possible that we didn’t see any change in outcomes because patients instead went to nearby hospitals that had better finances and may have had more resources to provide care,” said Dr. Karen Joynt, the lead researcher on the study.

She cautioned that the study looked at the average experience of a hospital closure and should not be interpreted to mean that every hospital loss is harmless. “I would be shocked if you couldn’t find an example where access is really threatened,” she said.

One of the study’s surprises was that 70 percent of the hospital closures were in urban areas rather than in rural regions, where hospitals have had trouble staying afloat for decades. Rural closures can be devastating when the hospital is the only one in the region. Medicare pays isolated hospitals more generously to help them keep going. Since 2010, 50 rural hospitals have closed, 16 of them last year, according to the N.C. Rural Health Research Program.

A less surprising finding from the study was that a third of the closed institutions were safety net hospitals that treated large numbers of the poor and uninsured. Joynt said the researchers had no way of examining whether the health of low-income and uninsured people suffered from the closures, so it was possible those closures did have deleterious effects. The paper looked at Medicare patients because their records are easiest to analyze and compare.

Nancy Foster, a quality expert at the American Hospital Association, called the paper “an important first indication that nothing untoward has befallen patients thus far, but we’ve got to continue to monitor this.”

She said that with hospital admissions declining overall, many are building outpatient clinics and stand-alone emergency rooms, to ensure patients aren’t abandoned.

The Harvard study did find a few changes when hospitals closed. Readmission rates dropped by more than 6 percent, and patients were more likely to go out of their health care market when they needed to be admitted to hospital. On average in places where hospitals closed, the percentage of Medicare patients leaving the area for inpatient hospital care increased from 43 percent before the hospital closed to 54 percent afterward.

“On average, people are going a little further, but it clearly has no negative effect on their outcomes and on their health,” said Dr. Ashish Jha, another author of the study.

He said that while hospitals are often coveted because they are large employers, from a health perspective, fewer admissions can be a good sign. “If we do our job well and keep people healthy, many hospitals will become unnecessary,” Jha said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

When Bruce Hodgins went to the doctor for a checkup in Sioux City, Iowa, he was asked to complete a lengthy survey to gauge his health risks. In return for filling it out, he saved a $10 monthly premium for his Medicaid coverage.

In Las Cruces, N.M., Isabel Juarez had her eyes tested, her teeth cleaned and recorded how many steps she walked with a pedometer. In exchange, she received a $100 gift card from Medicaid to help her buy health care products including mouthwash, vitamins, soap and toothpaste.

Taking a cue from workplace wellness programs, Iowa and New Mexico are among more than a dozen states offering incentives to Medicaid beneficiaries to get them to make healthier decisions — and potentially save money for the state-federal health insurance program for the poor. The stakes are huge because Medicaid enrollees are more likely to engage in unhealthy practices, such as smoking, and are less likely to get preventive care, studies show.

For years, private employers and insurers have used incentives to spur employees and members to quit smoking, lose weight and get prenatal care, although the record of those programs for changing long-term behavior is mixed, studies show. “Financial incentives are effective at improving healthy behaviors, though the effect of incentives may decrease over time,” said a report last year by the Center for Health Care Strategies, a research group based in Hamilton, N.J.

Another analysis published this month in the journal Preventive Medicine, which looked at 34 studies, found that workplace and other incentives can change health behaviors in the short term, but the effects dissipated once the incentives were taken away.

The Affordable Care Act is behind the latest push of wellness incentives in Medicaid.  Besides Iowa and New Mexico, several other states that have expanded Medicaid under the health law have incorporated such incentives, including Indiana, Pennsylvania, New Hampshire and Michigan. Montana, which is about to become the 29th state to extend Medicaid, also plans to include such incentives.

“People are looking for some creative ways to pass Medicaid expansion and incentivizing healthy behaviors is pretty palatable to both conservatives and liberals,” said Maia Crawford, program officer of the Center for Health Care Strategies. “It’s a potential win-win because of the potential for cost savings and health improvement.”

But getting them to participate in incentive programs can be challenging. For example, an Idaho program that offered a $100 voucher to entice Medicaid recipients to lose weight or quit smoking attracted less than 2 percent of eligible adults after two years.

Among the biggest obstacles is simply getting the word out to enrollees, Crawford said.  But there are other issues, too: Poor people are less likely to understand how the incentives work and to face transportation and other barriers to get to doctor appointments or educational classes that are part of the program.

‘Long Way To Go’ To Learn What Works

Little is actually known about what types of incentives get people’s attention or help change their behavior, said Jean Abraham, associate professor of health policy and management at the University of Minnesota. It’s not clear, for instance, whether rewards are more effective in prodding people to take a concrete step, such as getting a colonoscopy or a mammogram, rather than in changing long-term behaviors, such as smoking. “We have a long way to go to understand what’s most effective,” she said.

The health law sought to get answers to some of those questions by including $85 million to test incentives in 10 state Medicaid programs.

States started the studies in 2012 and 2013 and some are struggling to get participants. Connecticut, for instance, has enrolled only half of the 6,000 people it sought for a smoking cessation program. The program pays Medicaid recipients as much as $350 in gift cards over a year for participating in smoking cessation counseling, using a counseling phone line and having a breathalyzer test showing they haven’t recently smoked. The $10 million, three-year study will compare that group’s health costs against those of a control group of Medicaid recipients who smoke but received no help.

Other states that received funding are California, Hawaii, Minnesota, New York, Nevada, New Hampshire, Montana, Texas and Wisconsin.

Separate from the health law, one of the largest incentives program is New Mexico Medicaid’s Centennial Rewards, which gives most of the state’s 600,000 recipients the chance to earn points to buy health care items.

They gain points each time they engage in a healthy behavior, such as getting a checkup or seeing a dentist. So far, only about 45,000 have registered and only half of those have redeemed points for gift cards.

New Mexico officials say they are not disappointed. “It is not only a new program for us, but a new concept for most Medicaid programs,” said Medicaid spokesman Matt Kennicott.

‘I’ve Never Felt This Good’

 Juarez, 57, of Las Cruces, said the program has motivated her to walk every day at the mall where she works as a hair stylist and helped bring down her blood sugar levels.

“I’ve never felt this good,” she said. “This program motivates me to do more — it’s not so much the money as it’s the improvement in my body.”

Charles Milligan, who until last month was senior vice president of Presbyterian Health Plan in New Mexico, another Medicaid plan, said he’s seen an increase in members seeking preventive care, such as diabetes screenings and prenatal care. “The rewards program helps us engage with our members,” he said. Still, only about 30,000 of their 200,000 members have registered for it.

Iowa has also faced challenges getting Medicaid enrollees to complete the wellness exam and health risk assessment survey — even though some will have to pay a $5 or $10 monthly Medicaid premium if they don’t.  About 19,500 of the state’s 125,000 enrollees have faced the potential penalty. Of those, about a third completed the wellness exam and assessment.

“The goal is to get people involved and to take a more active role in their own health and we are impressed with what we have achieved,” said Andria Seip, Iowa Medicaid’s Affordable Care Act policy manager.

Hodgins, who enrolled in Iowa Medicaid in January, said he’s glad his community health center advised him about the wellness exam and health survey —not because it saved him money but because he found out that he had high cholesterol and blood sugar, which he’s now working to bring under control.

“I’ve been blessed with decent health for 57 years,” said Hodgins, who recently started a delivery company and doesn’t mind the state prodding him to get examined. “I have to be responsible for my own health. That’s my obligation.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Affordable Care Act payment model saves more than $384 million in two years, meets criteria for first-ever expansion.