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CAH Study Author Defends Surprising Data

John Commins, for HealthLeaders Media, April 3, 2013

The doctors working at critical access hospitals are probably the hardest working doctors in medicine. [That means] being the only person in a hospital trying to take care of someone who with a hip fracture and someone who walks in with a heart attack and someone who walks in with heart failure or a stroke wherein today's era of medicine we are changing the guidelines for the treatments for these things on a few monthly basis.

This may be pointing out that with the advancements we have been able to make treating heart attacks and heart failure and to some degree pneumonia, these hospitals and rural patients are getting left behind. That seems like a fixable problem.

HLM: Do you believe the CAH Program has been a success or a failure?

KJ: There were two big components of the Critical Access Hospital Program. One was to give them cost-based reimbursements. The other was to exempt them from quality reporting. They are not included in value-based purchasing. They are not included in accountable care organizations. They are not included in public reporting.

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.

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 critical access hospitals 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.

Another issue is [that] there are plenty of critical access hospitals that are not rural or isolated. It is hard to understand the rationale if it is a medium-sized hospital in a suburb for why their under this different set of regulations.

At this point we should be thinking about systems and transparency and not leaving out rural communities. It feels wrong to me that we are OK with folks in rural areas having worse outcomes than folks in urban areas. We can do better than that.

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6 comments on "CAH Study Author Defends Surprising Data"


Dean Coddington (4/4/2013 at 3:43 PM)
Hi, Having worked with a number of critial access hospitals over the years, they have a different relationship with their communities. Older people, when sick, like to go to a place where they know the staff and where relatives can easily visit them. Therefore, they often resist transfer to nearby tertiary care centers in larger cities. I believe this is a key factor differentiating CAHs. DCC

JKuriyan (4/4/2013 at 10:56 AM)
The result is statistical and it is difficult to grasp the strengths and weaknesses without more details, like error bars and standard deviations. For example, how do the results vary amongst the rural CAHs? Are there urban CAHs that performed as poorly as rural CAHs? The author's recommendation of tele-health tools to bring urban experts to rural areas via the web sounds a little too simple. What's the point if the rural hospitals are not equipped to perform new and complex procedures? Transporitng them to urban hospitals may not be affordable or practical depending on the medical issue. Another example where capitalism struggles to meet medical needs of societies. There are solutions but they are unacceptable to US citizens. So let's move on! I am not sure if this was covered in the last page of the article - a full page Ad blocked it, an unnecessarily intrusive step that insults the readers and the belittles the contribution of the journalist.

Chris (4/4/2013 at 10:37 AM)
Answer to confusedreader, CAH is Critical Access Hospital