Date of Award

2026

Degree Name

Business Administration

College

College of Business

Type of Degree

D.B.A.

Document Type

Dissertation

First Advisor

Dr. Alberto Coustasse-Hencke

Second Advisor

Dr. Dennis Emmett

Third Advisor

Mr. Jesse Parker

Abstract

Critical Access Hospitals (CAHs) play a vital role in sustaining healthcare access in rural communities, yet many face persistent financial and operational constraints. A change in hospital ownership is frequently seen as a strategy to sustain these hospitals, improve access to capital, supplement administrative infrastructure, and leverage system-level expertise. However, empirical evidence regarding the effectiveness of acquisition for CAHs remains limited and mixed. Guided by Resource Dependence Theory (RDT) and the Balanced Scorecard framework, this study examines whether ownership change is associated with differences in financial performance, utilization, staffing, and quality outcomes among CAHs.

Using Medicare Cost Reports, the American Hospital Association Annual Survey, and publicly reported quality measures, this study employs a difference-in-differences design to compare CAHs that changed ownership with those that remained independent. Performance outcomes are evaluated using a pre-acquisition baseline (2018) and a post-acquisition period (2024), excluding years affected by the COVID-19 public health emergency. The analysis included fixed-effects models that control for time-invariant hospital characteristics, with standard errors clustered at the hospital level. County-level poverty is examined as a moderating factor.

The results indicate that a change of ownership is not associated with statistically significant improvements in financial margins, staffing levels, or most quality indicators. Utilization outcomes show modest declines over time, and higher community poverty intensifies reductions in outpatient visits among acquired CAHs. These findings suggest that an ownership change may reconfigure resource dependence without materially expanding managerial discretion or operational flexibility in highly regulated, low-munificence rural environments. By identifying regulatory reimbursement structures and socioeconomic conditions as boundary constraints, this study refines the application of RDT to rural healthcare ownership changes and provides CAH-specific evidence to inform policy and strategic decision-making.

Subject(s)

Industrial management.

Hospitals -- Administration.

Hospitals -- Ownership.

Rural health services.

Rural health services -- Effect of managed care on.

Critical care medicine.

Health services accessibility.

Rural hospitals.

Poverty.

COVID-19 (Disease)

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