Clinical and Health Affairs
Critical Access Hospitals: Hubs for Rural Health Care
By Mark Schoenbaum, M.S.W.
■ A 1997 federal law created a new type of rural hospital called the Critical Access Hospital (CAH). Having CAH designation allows a facility to receive cost-based reimbursement from Medicare in exchange for providing services such as emergency care and limiting the number of beds and the average length of stay. Minnesota has 79 CAHs. This article describes how having the designation has allowed these facilities to better meet the needs of the populations they serve. It also describes the challenges all CAHs face in light of federal budget constraints and health care reform.
Following Medicare’s adoption of a prospective payment system in the 1980s, a system by which Medicare reimburses hospitals for inpatient services based on a predetermined rate for treatment of a specific illness, 23 rural Minnesota hospitals closed, causing thousands of area residents to have to travel farther for emergency and basic care.1 It was not possible for these low-volume hospitals to cover their fixed costs under the prospective payment system. Responding to similar trends nationally, Congress created a new type of rural hospital designation, the Critical Access Hospital (CAH), as part of the 1997 Medicare law.
The provision allows small rural hospitals to receive cost-based reimbursement on their Medicare business in return for limiting their bed count to 25, maintaining an average annual inpatient length of stay of four days, and offering 24-hour emergency care services. Becoming a CAH brings a facility an average of $850,000 in additional Medicare revenue a year.2 Despite this incentive, it took 10 years for eligible Minnesota hospitals to apply for CAH status.
Today, with 79 CAHs, Minnesota has the third-highest number in the country (Figure). The CAH program has helped those facilities become financially stable and keep their doors open, thus preserving access to care for an estimated 950,000 people in the state. This article looks at how CAHs in Minnesota are serving their communities as well as some of the challenges they face.
A New Breed of Hospital
The financial viability brought by their CAH status has enabled many small rural hospitals to better meet the changing needs of the populations they serve and keep pace with the broader evolution taking place in health care. As a result, many now offer a mix of services that makes these institutions very different from what they once were. Where they mainly provided inpatient care, many now serve as hubs for primary care, specialty care, rehabilitation, hospice care, senior services, and other outpatient services. Half of Minnesota’s CAHs own an attached nursing home, and about 35 offer assisted living units.3 Some provide home health care, Meals On Wheels programs, and mental health care. In many cases, no other organization in the community offers these services.
The following are examples of some of the services Minnesota hospitals provide as a result of having a CAH designation and some of the benefits patients in those communities receive.
■ Round-the-Clock Radiology
Although telemedicine is still an emerging technology, use of digital imaging and teleradiology is now almost universal in CAHs in Minnesota. With digital radiology equipment on their campuses, they can send images to consulting radiologists at distant sites for immediate reading 24 hours a day. This is not only more efficient for the CAH staff, it allows patients to receive more timely care close to home.
■ High-Quality Emergency and Trauma Care
For the majority of heart attack, stroke, and traumatic injury patients, a CAH is the place where they are stabilized and given initial treatment before being transferred to a tertiary care center. Critical Access Hospitals have adopted protocols for treating patients with ST-segment elevation myocardial infarction (STEMI) or acute stroke, trained their staff on the most current care guidelines, and developed and adopted policies supportive of systems-based care. Many CAHs have also developed relationships with larger hospitals to which they transfer patients. As a result, the quality of care for STEMI and stroke patients in rural areas has improved. Many CAHs also house the ambulance service for their area and participate in the state’s EMS and emergency response system.
Since Minnesota passed legislation in 2005 creating a Statewide Trauma System, 120 hospitals have become designated trauma hospitals, with nearly all CAHs having either a Level 3 or 4 designation (Table). With training for their primary care providers and staff available through programs such as Advanced Trauma Life Support and Comprehensive Advanced Life Support (a program developed in Minnesota), staff at Level 3 and 4 trauma hospitals are able to quickly stabilize and transfer seriously injured patients. In addition, Level 3 trauma hospitals are able to provide definitive care for some patients.
■ Access to Physicians
The financial stability provided by a CAH designation has lent support to primary care providers in many communities. In some, the physician practice has become part of the hospital, which can offer more substantial infrastructure and support systems. This has helped communities retain physicians who might otherwise struggle with feelings of professional isolation and to keep up with the rapid pace of change in health care delivery. In addition to offering primary care services on their campuses, CAHs often operate clinics in neighboring communities that might otherwise be too small to support an independent clinic. Cuyuna Regional Medical Center in Crosby and Riverwood Health Center in Aitkin, for example, have collaborated to establish a specialty program that offers access to minimally invasive surgery, ophthalmic surgery, and cardiac and other services in satellite clinics throughout the area they serve.
■ Improved Quality
The 1997 legislation creating CAHs included requirements for quality improvement and coordination with other providers. It also provided states with funding to work with CAHs on these issues. In Minnesota, this has happened through a partnership among CAHs, Stratis Health (the state’s Medicare quality improvement organization), the Minnesota Hospital Association, and the Minnesota Department of Health’s Office of Rural Health and Primary Care.4 During the last 12 years, CAHs have worked with these organizations to achieve measurable improvements in outcomes for patients with heart failure, atrial fibrillation, and pneumonia, as well as in care coordination and other areas.5 A recent article published in the Journal of the American Medical Association reported relatively lower marks on certain quality indicators by CAHs. Although the article raises some timely issues, the research suffers from a number of conceptual and technical flaws.6
All CAHs capture and report quality data required by state law, and all are involved in quality-improvement efforts. Critical Access Hospitals, like larger facilities, have found improving quality is an ongoing process. For example, CAH scores on pneumonia measures increased between 9 and 22 percentage points between 2005 and 2009.7
■ Care Coordination
The fact that CAHs often share staff with primary care clinics, nursing homes, home care agencies, and other services gives them experience with care coordination. Thus, CAHs tend to do well with such critical aspects of care as discharge planning and collaboration across the continuum of care. And this leads to improved quality, outcomes, and patient satisfaction. Improvements in these areas and reductions in hospital readmission rates are explicitly required in a number of the models created by federal and state health care reform legislation.
Rural providers have significant experience in coordinating care on behalf of their patients. Lakewood Health System, a CAH in Staples, which has clinics in five neighboring communities, became one of the state’s first certified health care homes, for example. At each Lakewood clinic, patients with multiple chronic conditions receive coordinated care and have ready access to providers, who are supported by an electronic health record (EHR) system and patient registry, and a dedicated heath care home staff. The support of the CAH administration was central to Lakewood’s adoption of the model, according to John Halfen, M.D., the physician champion for the health care home initiative.
■ Health Promotion and Chronic Disease Management
Some CAHs have clinical pharmacists on staff who can be a resource to primary care physicians regarding medication management issues. In some communities, CAHs have opened their rehab departments as fitness centers. Saint Elizabeth’s Medical Center in Wabasha, for example, has developed a risk-reduction program for patients at risk for metabolic syndrome in which patients see a multidisciplinary team of clinicians and take part in a regular exercise program at the hospital.1
Challenges
Even though the 1997 law that created CAHs has helped a number of institutions survive and even grow and thrive, these hospitals face an array of challenges including maintaining financial stability, keeping up with changing technology, serving the needs of aging patients, and recruiting and retaining physicians and other providers. Changes required by reform legislation and payers and turbulent economic conditions will further test the agility of small hospitals with limited resources.
Demographic changes, especially the aging of the population, will continue to be felt more so in rural areas than in urban ones. The proportion of elderly patients CAHs serve is much greater than the state average. In addition, more CAH patients have chronic diseases and poorer health status than those treated in larger facilities.8 Poor health and the lack of public transportation also limit mobility for many patients served by Minnesota’s CAHs.
Another challenge CAHs will have to address is attracting surgeons, as there is currently a shortage of general surgeons, especially those trained for practice in rural areas. According to a recent Minnesota Rural Health Advisory Committee report, 21 percent of Minnesota’s general surgeons practice in rural areas, with only 7 percent working in the areas most likely to be served by CAHs.9 Surgeons are essential to rural health care, as they provide their communities with timely treatment for trauma, as well as procedures such as appendectomy, cholecystectomy, small and large bowel procedures, bariatric surgery, and hernia repair. General surgery is often a key to the financial viability of a CAH, as it is a major source of revenue. If a CAH is unable to offer surgical services, it may struggle to provide other services. The Rural Health Advisory Committee report includes recommendations to strengthen general surgery in Minnesota through additional rural-focused training, infrastructure investments, and changes in pre- and postsurgical care. (The Rural Health Advisory Committee also has begun to study obstetrical care in rural Minnesota.)
Health information technology presents another challenge for CAHs. Critical Access Hospitals’ adoption of EHR systems lags behind that of larger facilities. Sixty-three (80%) of Minnesota’s CAHs have some components of an EHR, but they have a lower rate of adoption than that of non-CAH hospitals, which is 96%. In addition, the EHRs used by CAHs tend to have less functionality and be less likely to achieve meaningful use core objectives.10 Health information technology will play a key supporting role in payment reform models such as accountable care organizations (ACOs), and the CAHs that are farthest along in adopting EHRs will be better equipped to participate in these ventures. Health care reform is presenting CAHs with other challenges as well.11
Critical Access Hospitals have never operated in isolation. Under federal law, they are required to have a network agreement with at least one other hospital for patient referral and transfer, electronic sharing of patient data, credentialing, and quality assurance. Many also participate in networks for shared information technology services, group contracting and training, and joint clinical ventures. Historically, a number of CAHs have also been managed, leased, or owned by larger health systems, and there has been a noticeable uptick in the pace of system affiliation in recent years. Mayo, Sanford Health, and Essentia have all recently acquired additional CAHs in Minnesota. In light of health care reform efforts, independent CAHs will not need to be acquired or disappear as long as they have mutually beneficial partnerships and connections to networks and care systems.
Conclusion
Whether they are independent or part of a larger system, CAHs will need to continue to reinvent themselves if they are to remain essential community institutions dedicated to improving health outcomes all along the care continuum—from primary care and prevention to trauma care. Although CAHs face the same uncertainties as other hospitals, they can serve as a model for other facilities and health care organizations as reforms and financial challenges force them to become more nimble and adapt to the changing needs of the populations they serve. MM
Mark Schoenbaum is director of the Office of Rural Health and Primary Care at the Minnesota Department of Health.
References
1. Rural Health Advisory Committee. The Need for Alternative Licensing for Rural Hospitals. Report to the Legislature. Minnesota Department of Health. St. Paul, 1996.
2. Medicare Payment Advisory Commission (MedPAC). Report to Congress: Issues in a Modernized Medicare Program. Washington, D.C., 2005.
3. Race M, Gale J, Coburn A. Provision of Long-Term Care services by Critical Access Hospitals. Available at www.flexmonitoring.org/documnets/PolicyBrief19-LTC.pdf. Accessed August 17, 2011.
4. Office of Rural Health and Primary Care. A Look at Quality Improvement Activities, Outcomes, and Needs. Minnesota Department of Health. St. Paul. 2009.
5. Rural Health Advisory Committee. Rural Health Care: New Delivery Model Recommendations. Minnesota Department of Health. St. Paul. 2009.
6. Joynt KE, Harris Y, Orav J, Jha AK. Quality of care and patient outcomes in critical access rural hospitals. JAMA. 2011;306(1):45-52.
7. Casey M, Burlew M, Moscovice I. Critical Access Hospital Year 6 Hospital Compare Participation and Quality Measure Results. Flex Monitoring Team Briefing Paper No. 28. April 2011. Available at: www. flexmonitoring.org. Accessed August 17, 2011.
8. Rural Health Advisory Committee. Rural Health Status Report. Minnesota Department of Health. St. Paul. 2011.
9. Rural Health Advisory Committee. General Surgery in Rural Minnesota. Minnesota Department of Health. St. Paul. 2011.
10. Minnesota Department of Health. MN E-Health Brief: Acute Care Hospitals Adoption and Use of EHRs and Exchange of Health Information. Minnesota Department of Health. St. Paul. 2011.
11. Rural Health Advisory Committee. Health Care Reform: Addressing the Needs of Rural Minnesotans. Minnesota Department of Health. St. Paul. 2007.