Rural Healthcare and the Critical Access Hospital

During my career as an Emergency Physician, I have experienced a variety of hospital settings, from the small 5 bed ER to the some of the largest tertiary centers in America, but no job has inspired me more than in the critical assess hospital (CAH).

Most people have never heard of a critical assess hospital, even though critical access hospitals represent a quarter of all U.S. and more than two-thirds of all rural community hospitals, according to the American Hospital Association.

The concept of the CAH is not an old one. During the 1980s and 1990s, there were many rural hospitals that had to close their doors due to economic hardship. In response to this, through the Balanced Budget Act of 1997, congress created the CAH designation with the idea of improving access to healthcare and reducing the financial strain placed on rural hospitals. By creating different reimbursement programs like flex programs and cost-based reimbursement, these small, rural hospitals were able to maintain themselves, providing lifesaving services to local residents.

To be eligible for this program, the CAH must comply with stringent guidelines. For example, they must maintain 24/7 emergency care, have 25 or fewer acute care beds and be located more than 35 miles from another hospital. The healthcare “squeeze” has affected all levels of hospitals and reimbursement rates have continued to drop for the CAH’s as well. According to Becker’s Hospital Review, 83 CAH’s have closed since 2010. These closures place enormous strain on one’s ability to access healthcare in the rural setting.

The rural population is declining and aging, as well. Based on 2017 USDA statistical information, poverty levels are high and job recovery has been much slower in rural areas, contributing to the growing economic strife. Staffing at rural facilities is also difficult. The population density is lower, so fewer medically trained staff live in the area and must be recruited, adding to cost. In addition, standard of care for a CAH is the same as its urban counterpart, so there is equal need for trained ancillary staff and high-tech equipment. Specialists are few, due to lower patient loads, and often only available on a limited basis. This creates a challenge for the CAH provider but make their roll critical in each patient’s life.

What does all this mean to the rural dweller? Imagine, for a moment, that you are 70 years old. You fall and break your hip. You call EMS, which takes 30 – 60 minutes to arrive. They drive you 90 miles to the nearest hospital with orthopedic services, where you are admitted for surgery. Your family and friends must find gas money or rides to visit you. There is no UBER or public transportation. In addition to this mental and financial strain on your limited budget, when you are ready for discharge, you have a 90 mile ride home, not to mention the follow up appointments, rehab or physical therapy. Now, repeat this process for every patient with pneumonia, cellulitis or other medical condition requiring admission, and the roll of the CAH becomes clear.

Critical access hospitals play a crucial role in the healthcare system by providing access to quality care and fulfilling the needs of rural America. They present unique challenges and create rewarding careers for those who choose to walk their halls.