"But what is important here is not the specific numbers but recognizing that the effort to carve these critical access hospitals into a separate program than the remainder of the hospitals in the country has not done them any favors and it hasn't done any favors for the people seeking care at these hospitals," says Joynt, an instructor at Harvard Medical School and the Harvard School of Public Health.
When the Critical Access Hospital Program was created by Congress in 1997, qualifying CAHs could have no more than 25 beds and had to be located at least 35 miles from the nearest hospital. Since then states have been given leeway to broaden eligibility and now only 20% of the CAHs current meet the distance requirement and nearly one in four U.S. hospitals is designated as a CAH.
CAHs are exempted from prospective payments but are reimbursed at 101% of costs. They are also exempted from national quality improvement programs.
Joynt says that while the higher reimbursements have allowed scores of CAHs to keep their doors open, it may be time to reconsider their exemptions from reporting and quality improvement programs.
"Part of the program worked terrifically. The closures have dropped tremendously. There really are areas in which there would be no medical care if it weren't for this program. But leaving them on their own and saying 'good luck' has not been a good solution," she says.
"I understand that (the Centers for Medicare & Medicaid Services) was trying to relieve these hospitals of an administrative burden by not including them. But the consequence seems to be that no one knew these outcomes were not improving at many of these CAHs in the way that we were seeing mortality from many inpatient conditions drop over the last decade. That to me in this era of transparency and trying to build better systems and being more patient-centered doesn't make much sense as a long-term strategy."