Rural Community Health Act of 2013: The Critical Access Health Complex

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

The Critical Access Hospital (CAH) was conceptualized in the late 1980s in Jordan, Montana. Jordan, pop. 360, is the seat of Garfield county, about the size of Connecticut but with less than 1,300 people. Garfield is 90 miles northwest of Miles City. The road’s good but it closes during snowstorms. The idea was to get Medicare to help subsidize maintenance of an emergency room and a few hospital beds in Jordan. When there were no patients in the facility, no staff would be required to be there.

At this point, after a multi-state demonstration project and more than a decade of national experience, we have over 1,300 CAHs scattered across 45 states. Eligibility criteria have evolved over the years. Until January 2006, governors could override the objective criteria to declare that a particular hospital was critical to access to care regardless of what the map said. Some governors appear to me to have been more scrupulous than others. Experts estimate that half of the hospitals average six or fewer patients in their regular hospital beds at any particular time, though their clinics may be busy. CAHs collect an average of $7.5 million from Medicare per year. They’re reimbursed 101 percent of their reasonable costs for caring for their Medicare patients.

The Medicare Payment Advisory Commission (MedPAC), staff has recommended abolishing special “cost plus one percent” reimbursement for CAHs as a cost saving measure. I am skeptical that putting the same patients in larger hospitals where they would get more consultations from more referral specialists during and after their hospitalizations would save Medicare money, but I doubt that the proposal will go away.

A widely quoted article in the Journal of the American Medical Association in July of this year analyzing Medicare data reported that CAHs show poorer results on measures of quality of care and patient outcomes than larger hospitals. Researchers more familiar with CAHs responded, pointing out methodological problems documenting and attributing care when patients are transferred from smaller to larger hospitals, and the fact that CAHs are involved in intensive programs to improve care. The paper also pointed out that patients discharged from CAHs are more likely to die within 30 days than those discharged from larger hospitals. Sad but true, rural people are documentably sicker and, hence, poorer 30-day survival risks, than their urban and suburban counterparts. Obviously CAHs were developed to care for these rural people who don’t have access to larger hospitals.

At this point the CAH model has been stretched from a way to subsidize maintenance of an emergency capability in a remote place, to a way to subsidize 1,300 rural hospitals, many of which are probably too small to be operationally sound inpatient operations even if the financial issues can be managed. Belonging to a regional multi-hospital system certainly helps in some respects but doesn’t solve all the problems. It also may introduce new problems of distant control.

Our existing models aren’t working as well as we pretend. First, it’s awfully hard to run a hospital with an average of only six patients. Keeping the right things in stock and up-to-date and specialized people’s skills sharp are constant challenges even if one can make the finances work. Second, most of the potential patients are going elsewhere. But you have to look like and act like a real hospital even if it’s the clinics that people need and use. Third, hospitals and community health center sites and Veterans Affairs clinics in small towns belong to different hierarchies, none of which are local. They can’t even set up coordinated night call, let alone adapt to the complexities of parallel information systems and health care reform.

Financial pressures will get worse while technical demands related to information technology and coordination of care will grow. We can’t just “keep on keeping on.”

I propose that some rural people outline a menu of services from which most small, reasonably prudent communities could design a system that would meet most of their local needs. I’m thinking of the community with a CAH with less than half of its beds occupied most of the time. Would such a community be willing to trade its CAH papers, and its right to cost based reimbursement for hospital care of older folks, for help with some of the following? Add or subtract as your experience dictates:

  • Emergency care with tele-medical back-up, transport and, perhaps, boarding
  • Primary care clinics
  • Itinerant and telemediated medical specialty clinics
  • Public Health Nursing
  • Lay health worker / patient navigator / promotora services
  • Oral health services
  • Telemediated mental/ behavioral health services
  • Telemediated special educational evaluation

Some elements would be private, some public. All would share a common parking lot, a core record and a community coordinating board.

If a community has a robust CAH and wants to stay with it, bravo! But if the more flexible menu can provide a better fit for local needs, then let a community group go to work on it.

I have no idea what it might be worth to Medicare and the collaborating states’ Medicaid programs to buy back those CAH designations, or what legislative support might be built behind this proposal. Might other private and public entities buy in? Most important, would the locals use it and pay for selected parts, or would they drive to Miles City?

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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