Hospitals that have the critical-access designation, which currently number more than 1,300, are located primarily in rural areas, have no more than 25 beds and receive cost-based reimbursement from Medicare at a rate of 101% for inpatient and outpatient services.
Adjusted mortality rates were virtually the same for nearly all of the surgical procedures, whether care was provided at critical-access or non-critical-access hospitals, although costs were 9.9% to 30% higher at the small, rural facilities, the study found.
But even as authors of that study cautioned that cutting payments or tying some portion of critical-access hospitals' reimbursement to performance could put rural facilities on thin ice financially, others are pushing for more oversight of rural hospital quality as well as policies that mandate their participation in federal improvement initiatives.
Dr. Karen Joynt, an instructor in the department of health policy and management at the Harvard School of Public Health, Boston, pointed out some limitations to the UMHS study, including its use of a small subset of critical-access hospitals. But the results, she said, do suggest that “if you choose patients appropriately, they can safely receive low-risk surgeries at critical-access hospitals.”
Joynt was the lead author of an April 2 study in the Journal of the American Medical Association, which found that critical-access hospitals' 30-day mortality rates for heart attack, heart failure and pneumonia rose over the past decade, even as such rates fell at larger acute-care facilities.
Joynt and her colleagues argued that the way those hospitals are paid could reduce incentives to improve quality, as could their exemption from participation in federal quality initiatives such as the CMS' value-based purchasing program. “Given the substantial challenges that (critical-access hospitals) face, new policy initiatives may be needed to help these hospitals provide care for U.S. residents living in rural areas,” they wrote.
That study drew sharp reaction from critical-access hospitals and some rural health experts. In one response, Ira Moscovice, director of the University of Minnesota Rural Health Research Center in Minneapolis, criticized the study for misclassifying critical-access facilities and failing to recognize rural hospitals' high-level participation in quality improvement initiatives.
One such quality collaborative is the Michigan Critical Access Hospital Quality Network, a group of 36 small, rural hospitals. Because such hospitals typically have low volumes of many of the types of cases commonly used to measure quality, the Michigan network's members aggregate their data in order to assess statewide performance.
“We also have quarterly meetings, share best practices and have a very robust agenda of ongoing activities,” said Ed Gamache, president of the network and CEO of 15-bed Harbor Beach (Mich.) Community Hospital. He balked at the notion that critical-access hospitals weren't as engaged in quality improvement projects as their larger peers. “It's something we've been working hard at for years.”
But Joynt argued that her study and the most recent one on inpatient surgical costs and outcomes should be looked at in the same light: as research that shows which services critical-access hospitals excel at providing and which ones should perhaps be delivered at larger facilities. The goal, she said, is to move toward more “patient-centered systems of care” that treat patients close to home when it's safe and appropriate and at larger medical centers when it's necessary.
“There are lots of things that critical-access hospitals do really well, and patients usually prefer them,” Joynt said. “One thing that I think would be very helpful would be more formal partnerships between critical-access hospitals and referral hospitals to facilitate transfer of patients to larger centers and back again.” Future studies are needed to better understand the best roles for critical-access hospitals and their larger counterparts, she added.
The increasing attention paid to rural healthcare outcomes comes as many critical-access hospitals are struggling financially. Even with cost-based reimbursement from the CMS, the sequestration's 2% Medicare cut has put a strain on these facilities, officials say. President Barack Obama's budget for 2014 also includes a provision that would decrease payments for critical-access hospitals from 101% to 100% of costs.
“I'm not trying to cry wolf here, but there are consequences to policy decisions,” said Slabach, of the NRHA. “These providers serve an important role in their communities and without them, what we'll end up with in some cases are medical deserts.”
Dr. Adam Gadzinski, lead author of the newly released study on inpatient surgical procedures, warned that resource-strapped critical-access hospitals are “likely to be far more sensitive to reductions in reimbursement,” which he said could potentially lead to cuts in services and hindered access to care.
“It is fine line that must be walked between saving healthcare dollars and still providing sufficient payments to hospitals that provide healthcare to rural and other underserved populations,” Gadzinski said in an e-mail.
Follow Maureen McKinney on Twitter: @MHMMcKinney
