States with Flex Programs receive annual grants from the Federal Office of Rural Health Policy to provide their Critical Access Hospitals (CAHs) with training or interventions in five areas: quality improvement, financial and operational improvement, population health and emergency medical services, CAH conversion, and integration of innovative care models. States select activities based on the needs of their hospitals, and not all states fund activities in all areas. This study aimed to assess whether participation in Flex-sponsored financial and operational interventions influences CAHs’ financial performance. Key Findings

• Prior to state Flex grantee finance and operations interventions (Flex interventions), participating CAHs were generally in poorer initial financial condition compared to CAHs that did not participate.
• Participation in Flex interventions was associated with reduced CAH reliance on Medicare.
• Participation in Flex interventions was associated with improved revenue cycle performance.
• Significant data quality and availability problems, lack of control for market and state factors, and unobserved institution-specific factors limited the analysis. Collection of fewer but more-precisely-defined data may increase data reporting by state Flex coordinators as well as improve the accuracy and reliability of data reporting.