Rural Hospitals in Multihospital Systems: Does Knowledge From and About the Local Community Matter?

Abstract

Following the Affordable Care Act (ACA), the rural healthcare landscape in the United States has seen an accelerating trend toward consolidation through mergers with larger health networks. While mergers can prevent outright hospital closures, decisions driven by centralized systems risk not aligning with local community health needs. Grounded in a social constructionist paradigm sensitive to the rural-urban axis of power, this three-paper dissertation examines whose knowledge counts in post-merger rural hospital decision-making and evaluates the role of local community knowledge.

The first paper presents a scoping review and epistemic critique of post-ACA literature. Utilizing the literature on rural hospital closures and mergers, this paper develops a novel "Health System Ecologies Impact Matrix" which reveals that academic knowledge regarding rural mergers is heavily underdeveloped and overwhelmingly biased toward facility-centered institutional metrics rather than person-centered social impacts. This systemic lack of foundational data constitutes a form of hermeneutic injustice for rural communities.

The second paper employs an inductive qualitative case study to explore strategic decision-making among hospital and network executives and board members. It demonstrates that despite diverging values and goals, decision-makers construct shared understandings through an iterative frame alignment process. This information exchange culminates in collective decision frames that integrate diagnostic, prognostic, and motivational rationales.

The third paper investigates how a merged rural hospital maintains accountability to its community through community intelligence, community orientation, and community benefits frameworks. It reveals that, although the hospital performs community orientation activities that increase community benefits, the community perceives a diminished congruence with local norms, preferences, and values. Sociostructural exclusion, tokenized or illegitimate community representation, and testimonial injustice frequently discount lay knowledge and undermine meaningful public participation. As a result of these challenges, the legitimacy of community accountability is threatened.

Ultimately, this dissertation demonstrates that while local knowledge is integrated through proximal decision-makers, it must continuously share space and compete with dominant medical and managerial rationales. Despite structural and regulatory mechanisms that attempt to establish community accountability, who participates and what knowledge they contribute is shaped by managerial choices and sociostructural challenges. This dissertation exposes the rural community as an epistemically marginalized group, facing both testimonial and hermeneutical injustice.