Can critical access hospitals properly treat seriously ill patients?

Emmet Pierce

Using Medicare data for more than 10 million patients, researchers from the Harvard School of Public Health recently found that beneficiaries with certain acute conditions at rural critical access hospitals -- facilities with limited medical services -- experienced higher death rates than patients in urban hospitals.

The study used data from Medicare fee-for-service patients admitted for heart attacks, congestive heart failure and pneumonia between 2002 and 2010. It concluded that those patients may not be getting the level of care they need in order to recover.

critical access hospitalResearchers say health care workers at small, critical access hospitals (CAHs) should work more closely with specialists in urban centers and establish better plans for collaborating and coordinating care.

Dr. Karen Joynt, a researcher and lead author of the Harvard report, says the way to reduce death rates at smaller facilities is to forge tighter bonds between with urban hospitals that are better equipped to deal with complications from the three illnesses that were studied.

"If you show up to a rural hospital and are having a stroke, the doctor [needs] someone he can call from a major care center who is a neurologist," she says.

Until recently, Medicare paid critical access hospitals for most inpatient and outpatient services at a rate of 101 percent of allowable costs. This means the hospitals receive 1 percent more than the normal allowable cost of treatment. This additional compensation is provided because actual costs for small hospitals can exceed what Medicare normally allows for reimbursements.

Following the recent federal spending reduction that began on in March 2013 because of budget constraints, the reimbursement figure dropped to about 99 percent of allowable costs, says Brock Slabach, the National Rural Health Association's senior vice president for member services.

He says it remains uncertain when the higher level of funding will be restored.

What is a critical access hospital?

Critical access hospitals are located primarily in rural communities. Under federal government requirements, they must be at least a 35-mile drive from any other hospital. They also must have 25 or less inpatient beds. The average length of stay for CAH patients must be 96 hours or less in order for the hospital to keep its CAH status.

The most common conditions treated by CAHs, according to a 2008 study funded by the Federal Office of Rural Health Policy and the Walsh Center for Rural Health Analysis, are pneumonia, heart failure, chronic obstructive pulmonary disease (COPD) and strokes.

Harvard researchers found differences in 30-day death rates between CAHs and non-CAHs for the three illnesses studied: heart attacks, congestive heart failure and pneumonia. During the study period, death rates increased at CAHs at a rate of 0.1 percent per year. In comparison, at hospitals in urban areas, death rates decreased 0.2 percent per year.

The study also found that by 2010 CAHs had higher overall death rates, 13.3 percent versus 11.4 percent for larger hospitals.

"New policy initiatives may be needed to help these hospitals provide care for U.S. residents living in rural areas," the authors of the study concluded.

How does Medicare help?

Medicare is a federal health insurance program for people age 65 and older and people with certain disabilities.

Joynt says the study wasn't attempting to compare the quality of care offered to Medicare patients versus private insurance patients. Researchers chose to focus on Medicare patients because of the broad availability of data, she explains.

Dr. Vincent Bufalino, cardiologist and spokesman for the American Heart Association, says the higher death rates in rural areas may be explained, in part, by lower levels of education among patients in those communities. People with less education tend to dismiss the symptoms of serious illness and delay visiting an emergency room, he explains.

"The window (for cardiac care) is just a couple of hours," Bufalino says. "The risk of dying goes up considerably when the hours go by."

Defending small hospitals

In a prepared statement, the American Hospital Association (AHA) said the Harvard study didn't reflect the true quality of small hospitals. CAHs already are working to rapidly transfer patients who can benefit from more aggressive treatment at larger hospitals, the association says.

The AHA says one reason for the higher death rate among smaller hospitals could be that many seriously ill patients simply are too sick to be transferred to larger hospitals after they are admitted. Because of that, they remain at the smaller facilities until they die, increasing their death rates.

Slabach says the Harvard study doesn't give a full picture of care in rural settings.

"Rural hospitals as a whole perform equal to or sometimes better than urban hospitals," he says.

He adds that patients in small hospitals generally report higher levels of satisfaction with the care they receive than patients in larger facilities.

Harvard researchers found that more than 60 million Americans in rural areas are facing challenges in accessing high-quality inpatient care. Joynt says she fully appreciates the hard work that goes on at rural hospitals.

"(Rural hospital staff) have to be a jack of all trades. You have to deal with everything that comes in your door," Joynt says.