Rural hospital rescue program encounters skepticism from administrators

In West Texas, the small hospital in Crosbyton has only two beds, and they aren’t always full.

“We rarely admit patients,” said Steve Beck, chief executive of the hospital, which is 40 miles east of Lubbock and serves a town of about 1,500 people.

The hospital is struggling to keep staff, and “we lack technology and expertise,” he said. And money.

The city held bake sales and garage sales to keep its emergency and primary care departments open. On paper, Crosbyton Clinic Hospital shouldn’t exist, Beck said, but it does – out of “sheer determination, commitment and work ethic”.

In states with many rural hospitals — like Texas, Kansas and Iowa — hundreds of those facilities have fewer than three overnight patients on any given day. The financial strain of staffing and maintaining those beds is having an impact, and federal lawmakers last year responded to calls for help from hospital officials in places like Crosbyton.

The Rural Emergency Hospital scheme, due to launch in January, will offer to pay struggling small hospitals to abandon their inpatient beds and focus solely on emergency and outpatient care. It will be the first new federal payment program for rural hospitals in 25 years, and lawmakers hope it will stem the tide of rural hospital closings that has accelerated over the past decade.

A patient room is seen inside the Crosbyton Clinic hospital.(Annie Rice for KHN)

The law is “an unprecedented approach to maintaining access to emergency health care in these communities,” said Sen. Ron Wyden (D-Ore.), who chairs the Senate Finance Committee, which would oversee any changes of the law in the Senate. in a statement to KHN.

Still, state hospital leaders predict the program may find few immediate takers.

The plan would increase payments for a hospital’s Medicare patients and provide an additional lump sum “facility payment.” But the exact amount of those payments and whether they will be enough to support struggling hospitals are unclear, even after the release from the US Centers for Medicare & Medicaid Services. a first rule proposal just before the 4th of July bank holiday weekend. A final rule is expected this fall.

In Kansas, where about 40 hospitals reported an average inpatient count of one or two before the covid-19 pandemic, no hospital is ready to raise their hands to join the program, said Jennifer Findley, vice president. chair of education and special projects for the Kansas Hospital Association. Hospitals are “waiting and very eager” for CMS officials to release more funding details, Findley said.

CMS Chief Medical Officer Dr. Lee Fleisher responded to KHN’s questions about the new program with an emailed statement in June confirming the agency is “on track” to launch the program. by January 2023. Agency officials declined to answer any further questions. .

Sen. Chuck Grassley (R-Iowa) confirmed this month that CMS will roll out the new law in a “series of proposed regulations.” Grassley, who co-sponsored the legislation that led to the program’s creation, urged the agency to do so “in a timely manner.”

The rural emergency hospital model builds on Medicare’s “critical access hospital” designation, which hospitals joined only after a series of amendments. The existing program allows Medicare to give additional funds to small, rural hospitals that have no more than 25 inpatient beds and whose average patient length of stay is 96 hours or less.

Grassley said in an interview with KHN that it is impractical to require rural hospitals to keep inpatient units nearly empty. He wanted to offer “an alternative to the closure and the absence of health care”.

Grassley emphasized that the new program will be voluntary. The law was a compromise, he said. Wyden objected to the costs of the original proposal, estimated at around $30 billion over 10 years. In the final version of the bill, the Medicare boost was lowered and the cost estimate dropped by more than two-thirds.

In his statement to KHN, Wyden said the law was designed to “address specific gaps in existing federal safeguards.” Although Medicare reimbursement is lower than originally proposed, the law also includes a facility fee, which is paid regardless of the number of patients a hospital serves.

CMS officials have yet to reveal how much the payments will be, but Brock Slabach, director of operations for the National Rural Health Association, said hospitals need them for $2 million to $3 million a year. The settlement payment amount is “the keystone of the entire program,” he said.

A picture shows Crosbyton Water Tower in the distance framed by trees in the foreground.
Crosbyton, Texas, which is 40 miles east of Lubbock, held bake sales and garage sales to prevent its only hospital from closing its emergency and primary care departments.(Annie Rice for KHN)

But politicians in Washington are nervous about spending, and there’s “general suspicion about the value of this program,” Slabach said.

Comments from rural health advocates and hospital system administrators indicate that they are also wary of the still amorphous framework of the rural hospital bailout.

In regulatory comment letters filed last year, health systems and rural hospital organizations highlighted the importance of facility payment. They also asked about participation in a federal discount drug program and the potential for overnight swing beds, which are beds that could be used for patients requiring acute care after surgery or for an illness, such as pneumonia, and for those who need skilled nursing care while recovering. They also asked how funding for outpatient services such as behavioral health and telehealth could be included or paired with the new payment program.

CommonSpirit Health, an Illinois-based Catholic health system that operates in 21 states, said in its comment letter that while a rural hospital “isn’t delivering many babies,” the use of telehealth in case emergency could save the life of a baby or a mother. , “as one of our critical access hospitals has done twice this year.”

According to the proposed rule published on June 30, flexible swing beds will not be allowed. Julia Harris, senior policy analyst at the Bipartisan Policy Center, said CMS should consider allowing a “minimum number” of beds or improving hospitals’ ability to keep patients longer under observation.

“Fixing the loose ends” on the beds and making sure reimbursement is adequate are key to the program’s success, Harris said.

James Roetman, longtime CEO of Pocahontas Community Hospital in north-central Iowa, said that to overcome any skepticism among residents about eliminating inpatient beds, administrators will need to assure them that the new arrangement will pay enough to support and preserve the emergency of their hospitals. room and primary care services.

So far, Roetman said, it’s not clear the program would.

“Unless something changes, there’s very little discussion about it” among hospital administrators in Iowa, he said.

Chris Mitchell, CEO of the Iowa Hospital Association, said the covid pandemic may have made the public less receptive to eliminating inpatient beds in small hospitals.

During covid surges, many urban medical centers were overwhelmed with patients and they often asked outlying hospitals to treat as many non-critical cases as possible, Mitchell said. Inpatient units in small hospitals have regained their importance, if only for a few weeks.

Rural communities would need assurances that under the Rural Emergency Hospital program the system would maintain sufficient capacity to handle waves of critically ill patients, Mitchell said.

With CMS’s final rules not arriving until at least the fall, hospitals may struggle to prepare for the conversion in January, said George Pink, principal investigator at the Cecil G. Sheps Center for Health Services Research. University of North Carolina-Chapel Hill. Once federal regulators finalize the rules, many states will need to pass laws to certify or license the redesigned facilities.

A photo shows cars parked in the Crosybton Clinic hospital parking lot.
Crosbyton Clinic Hospital(Annie Rice for KHN)

Yet when some hospital administrators and rural health advocates talk about the law, they emphasize that the situation is urgent. More than 130 rural hospitals have closed since 2010, and closures hit a 10-year high in 2020, at 19.

Although coronavirus relief funds have supported struggling hospitals for the past two years, closures are set to “start again with a vengeance” as emergency aid dwindles, Slabach said.

The money from the pandemic has “slowed down and pretty much disappeared,” said Beck, the Texas hospital administrator. He hopes the new Medicare payment program will be the next to help Crosbyton stay open.

“We will survive until that happens,” Beck said. “We are doing everything we can.”

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