Abstract
BACKGROUND: Global climate change has increased the likelihood of natural disasters, including hurricanes, floods, wildfires, tornadoes, and earthquakes; this increased risk presents acute socioecological disturbances that generate cascading impacts across healthcare systems, social structures, and economic frameworks. Forty-three percent of Atlantic hurricanes that make U.S. landfall hit the southeastern United States, and their increasing intensity threatens the healthcare infrastructure. Hospital cost-to-charge ratios (CCRs) vary between rural and urban facilities, but hurricane risk impacts on hospital financial performance remain poorly understood. OBJECTIVE: To examine relationships among hurricane risk, geographic location, and hospital CCRs among southeastern hospitals. METHODS: A cross-sectional analysis was used to merge 2021 CMS Cost Report data with 2023 FEMA National Risk Index data for 1,030 hospitals across eight southeastern states. All hospitals within this region were included except for federally funded hospitals due to their unique funding model. Each hospital self-reports its categorization of urban or rural on the CMS Cost Report. Multivariate regression was used to examine associations among log-transformed CCR and hurricane risk percentile, rural/urban location, and hospital quick ratio. RESULTS: Among 1,030 hospitals analyzed, 52% were rural and 48% urban. The regression model explained 24.7% of CCR variation (adjusted R (2) = 0.2465, F = 85.18, p < .0001). All predictors were statistically significant (p < .0001). Counter to expectations, each 1-point increase in hurricane risk percentile was associated with a 0.1% decrease in CCR, indicating improved cost efficiency in higher-risk areas. LOGCCR = - .75714 - .00840 (NAPCT) - .26551 (RURAL) + .01491 (QUICK) - .00011 (QUICK(2)). Rural hospitals as indicated by the CMS Cost Report demonstrated 26.5% lower CCR compared to urban hospitals. Hospital quick ratio showed a curvilinear relationship with CCR; at the mean quick ratio (3.819), each 1-unit increase was associated with a 1.4% increase in CCR. No significant multicollinearity was detected among predictor variables. CONCLUSIONS: Hurricane risk is paradoxically associated with lower hospital CCR, suggesting complex financial adaptations in high-risk areas. Rural hospitals maintain more favorable cost structures than urban facilities, and policymakers should consider these geographic variations in disaster preparedness strategies.