Rural hospital and health system CEOs are entering 2026 with a clear focus: sustaining community access and financial viability by protecting essential services, redesigning care delivery and scaling what is working.
Leaders are making tough calls on service lines — investing in high-demand areas, right-sizing others and exiting those that no longer serve their mission or margin. Becker’s spoke with four rural CEOs about the service decisions that had the greatest effect in 2025 and how those lessons are shaping their plans for the year ahead.
In 2025, leaders at Troy (Ala.) Regional Medical Center made a deliberate shift toward right-sizing and redesigning key service lines rather than maintaining each one in its traditional form, according to CEO Rick Smith. One of the most impactful decisions its leadership made was prioritizing high-demand core services — including emergency care, inpatient medicine and outpatient diagnostics — while redesigning lower-volume or higher-cost services to be more sustainable.
“This included expanding outpatient and same-day service options and aligning staffing models more closely with actual patient demand as well as exiting a non-profitable, underperforming service line,” Mr. Smith said. “As a result, we saw improved operating margins, reduced length of stay and better throughput, while maintaining quality and access for our community. Most importantly, this shift helped stabilize the organization financially while positioning us to reinvest in services that matter most locally.”
A key project for Joplin, Mo.-based Freeman Health System in 2025 was the development of a five-year strategic plan, which was rolled out in November and has already led to improvements in operational efficiencies, financial performance, access and quality, President and CEO Matthew Fry said. Amid this, the four-hospital system also revitalized an orthopedic spine program — previously offered at the system two decades ago — to improve access to care, Mr. Fry said.
Leaders at Roosevelt General Hospital in Portales, N.M., expanded into new surgical subspecialities: orthopedics, urology and cardiology. The hospital is taking a measured approach as it establishes the services and uses a contracted partner, CEO Kaye Green said.
“We intend to start small, with only a few days per month, and scale up over time as volume increases and we gain knowledge and competence in the new workflow and meet the resource demands of these new specialties,” Ms. Green said. “We targeted specific surgical subspecialties as not only are these needed within our community, but they should also be significant new revenue sources to financially sustain our hospital in the future.”
Roosevelt General also purchased a new building in 2025 to expand primary care with a rural health clinic designation within one of its markets, both to enhance revenue and generate more referrals for the specialty services it is building, she said. Upon being accepted into CMS’ rural hospital demonstration program, the hospital also established a swing bed program.
“With the new designation, this will allow for what was previously a breakeven — albeit community-oriented service — to become a significant revenue source in the future,” Ms. Green said. “By increasing the census of swing bed patients, this will also stabilize nurse staffing and prevent sending nurses home due to low census on the acute care unit.”
At Pinckneyville (Ill.) Community Hospital, leaders in 2025 emphasized a careful evaluation of each insurance contract to ensure it is profitable, CEO Randall Dauby said.
“We are seeing more push to ‘take it or leave it’ responses to their proposals to keep their insured covered at our hospital,” Mr. Dauby said. “We have to ‘fight’ for a favorable contract.”
2026 strategies
Decision-making at Troy Regional Medical Center is being guided by three primary factors: community need and access, clinical quality and outcomes, and financial sustainability, Mr. Smith said.
“Services that are essential but financially challenged are not automatically eliminated; instead, we look at alternative delivery models, partnerships, telehealth integration or outpatient transitions,” he said. “Growth investments are focused on services where demand is increasing and where we can compete effectively as a rural/community provider. We continue to look at primary care as the foundation of everything we do in this community. With other private practices closed to new patients, we feel it is our obligation to provide that access.”
Mr. Dauby also said community need is a key priority when weighing service-line decisions.
The primary focus in 2026 at Roosevelt General is to grow and expand services that can be safely provided and serve as revenue generators in the future, Ms. Green said.
“We made the decision to purchase another building to expand primary care with a rural health clinic designation within our market, while also expanding our existing physical space,” she said. “With both initiatives, we should be able to add an additional four to five primary care providers under the rural health clinic designation. This will enhance revenue and generate more referrals into the specialty services we are currently building.”
Freeman Health System prioritizes data when determining service-related decisions, identified through community health needs assessments, known gaps or supply-and-demand analysis, Mr. Fry said.
“Ultimately, we want patients to be able to receive as much of their care as they can, as close to their home as possible,” he said.
Freeman Health System is also using data to make decisions about pulling back on certain services. For example, if data shows an overabundance of one specialty in a department or region, resources can be redirected toward areas with greater community need.
As for 2026, the system is aiming to expand comprehensive cardiovascular care, medical and radiation oncology, and ancillary services such as radiology and pharmacy.
“We’re in a growth mode at Freeman Health System, and it’s going to be a really exciting 2026,” Mr. Fry said. “We’re thrilled to continue to expand in many respects, and we’re also investing heavily in our human capital. At the end of the day, it’s the most important asset that we have as an organization, and we’re really keen on ensuring that we’re taking care of our people and that we’re recruiting and retaining in a very intentional manner.”
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