Turn funded rural-health initiatives into measurable operating results.

In the 139-hospital Kansas/Tennessee external validation cohort, labor cost relative to net patient revenue was the strongest externally tested operating discriminator of improving hospitals versus non-improving hospitals. It is not a proven predictor of which stable hospital will worsen. Revenue growth differed sharply by trajectory, but that relationship is associative rather than proven causal. No universal service-line cost benchmark survived cross-cohort testing, so we publish none.

The methodology was built to be falsifiable, and it falsified our own earlier work. The original RHRA v1 capability model — the assumption that technology, network participation, revenue-cycle capability, governance maturity, or service breadth indicates resilience — was not supported. Much of the later v2 work did not transport. The v2 proposition of timing × effectiveness × economic return × durability was a hypothesis, and it was not supported as a transportable causal model in external validation.

An apparent revenue-cycle signal was exposed as a critical access hospital reimbursement artifact. Service-line conclusions changed once the economically correct denominators were used. The strongest candidate service-specific finding (food service) failed prespecified Mississippi replication and was dropped. We report these outcomes because they are the reason the current diagnostic is narrower and more defensible.