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Faced with rural hospital closings, the Balanced Budget Act of 1997 set up criteria to establish critical access hospitals (CAHs) and alternative payment mechanisms for these facilities. The designation was intended for hospitals in areas where there was not another hospital within 35 miles. Until 2006, states had the ability to designate hospitals as necessary provider CAHs even if the 35-mile standard were not fulfilled. CAHs receive cost-based payments rather than prospective payments provided that they have no more than 25 beds and their annual average length of stay does not exceed 4 days. Currently there are more than 1300 CAHs.
In this issue, Ederhof and Chen1 raise important issues related to the cost-based reimbursement system for CAHs. The study concludes that in CAHs that are part of hospital systems that include non-CAH hospitals, the relative portion of a system’s costs of shared services attributed to CAHs increased by 40% after conversion to CAH status, thereby allowing systems to maximize cost-based payments at an annual cost of $150 million. These findings must be considered in the context of the goals of the CAH designation as well as the potential advantages of integration of CAH within a larger hospital system.
Although the CAH program has been unquestionably successful in preventing closures of rural hospitals, there are legitimate questions about the value of the program. A recent report of the Office of the Inspector General2 determined that 64% of CAHs are located less than 35 miles from another facility, and if the Centers for Medicare & Medicaid Services (CMS) decertified all CAHs located 15 or fewer miles from their nearest hospitals, Medicare could have saved $268 million in 2011. The CMS has recently proposed decreasing the cost-based payments from 101% to 100%.
Cost-based payments lead to less efficient providers. Rosko and Mutter3 showed that CAHs are 5% less efficient than other rural hospitals and their inefficiency increases over time. In addition to being inefficient, CAHs may provide lower quality care. Joynt et al4 found that, compared with non-CAHs, CAHs scored worse on process quality measures related to acute myocardial infarction, congestive heart failure, and pneumonia and that patients admitted to a CAH have significantly higher 30-day mortality rates for these conditions.
Ederhof and Chen1 raise the possibility of changing Medicare guidelines on administrative cost allocation to address what they describe as cost shifting. It is important to examine this suggestion in the context of the changing delivery system, specifically addressing the role of hospital systems with CAH members: (1) Do hospital systems shift costs to CAHs because of their more generous payments? (2) Did changes in the percentage of administrative costs attributed to CAH beds occur because care appropriately shifted from a prospective payment system acute hospital to the CAH? (3) Are CAHs more financially viable when they legally become part of or affiliate with a network of health care organizations in which the entire system receives 1 form of payment? (4) Does the quality of care at CAHs improve when the CAH is part of a larger system?
Consolidation has led to a growing number of integrated systems as more emphasis is placed on team-based care, coordination across different health care provider settings, and value-based payment methodologies. We learned from system integration in the 1990s that multihospital system integration did not show evidence of economies of scale or improvements in costs per admission, profitability, service provision to the community, charity care, or patient outcomes. Multihospital systems do not necessarily improve efficiency and may actually incur higher administrative costs.5,6 Structural integration does not lead to process of care integration, but consolidation has led to changes in the balance of market power between hospitals and health plans with an increase in hospitals’ market power and higher prices.7,8
We should consider these lessons but acknowledge the potential of integrated systems to address one of the major impediments to CAHs’ financial survival: their small size results in insufficient revenue to support their operational and infrastructure needs. Systems that include CAHs should be held accountable for the efficiency of those hospitals and the care they provide. Being part of a system should benefit the individual components of the system, the people using the system, and the larger society.
As members of integrated systems, CAHs may be capable of caring for appropriate patients who do not require higher level care in non-CAH settings. Avoiding transfers may save costs as well as being more patient and family centered. CAHs in larger systems should assess the needs of their communities and their role in meeting those needs. While maintaining their hospital service obligation as is necessary, they should consider undertaking responsibility for preventive care, chronic care and disease management, expanding behavioral health services, or community health improvement with support from the system. Payments and performance measures should reflect these efforts to improve health.
Given the evidence that paying hospitals on a cost basis leads to inefficiency, it is appropriate for the CMS to revise the policy that both designates a rural hospital as a CAH and pays on a cost basis. But the move toward more consolidated systems is an opportunity to reform the payment system to ensure that entire systems are efficient, ensure access, meet the needs of communities, and deliver high-quality care, including care to rural populations. Developing clear policies about how funds flow within a system with a CAH is as important as how CAHs are paid. Leaders of health system and payment reform efforts have the opportunity to explore innovative solutions to meet the health care needs of rural Americans.
Corresponding Author: JudyAnn Bigby, MD, 60 Burroughs St, Boston, MA 02130 (firstname.lastname@example.org).
Published Online: November 4, 2013. doi:10.1001/jamainternmed.2013.11469.
Conflict of Interest Disclosures: None reported.
Bigby J. Examine Critical Access Hospital Payment Policies Within the Context of Integrated Systems. JAMA Intern Med. 2014;174(1):144–145. doi:10.1001/jamainternmed.2013.11469
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