Despite the fact that nearly 20% of Americans live in rural areas, rural hospitals have historically faced momentous challenges that limited the centers’ ability to provide quality basic care in an efficient and affordable manner. Plagued by a lack of staff, minimal clinical and technological resources, and the unique ailments of typically poor and underserved communities, smaller rural hospitals were unable to provide the same standard of care as larger urban healthcare centers and many were forced to close due to the lack of resources or public support. For while these hospitals gave services to roughly 51 million people, governmental organizations largely ignored the financial and demographic problems that these centers faced—perhaps due to the fact that the majority of the patients were on Medicare or had no health insurance—and patients were thus required to travel great distances to receive care at an urban acute care center.
After decades of mass hospital closings in rural regions, the federal government finally realized that financial support would be required to sustain these hospitals that filled such a crucial gap in our healthcare system. The Balanced Budget Act (BBA) of 1997 authorized certain rural hospitals that presently accepted Medicare, or had recently closed, to become Critical Access Hospitals (CAHs), or small acute care centers that received cost-based reimbursement from government funds, with the hope that this financial and public support would allow the hospitals to remain open and become effective resources in local communities. However, the BBA additionally set forth some very strict eligibility requirements that would ensure that only the centers that could benefit communities and that could receive the most benefit from the reimbursements would become CAHs. For example, to become a Critical Access Hospital, the center had to be in a state that had a State Rural Health Plan, be in a rural area, and be 35 miles from the nearest hospital. The hospital had to offer 24/7 emergency care, have no more than 25 beds, and ensure that the average length of stay of a patient for acute care was less than 96 hours. These requirements were crucial for CAHs to remain cost-effective and they emphasized that a CAH would primarily offer treatment for common conditions and short overnight stays, while referring more complex cases elsewhere. The establishment of Critical Access Hospitals and the 101% Medicare reimbursement of reasonable costs incurred immensely improved the financial performance of failing rural hospitals, and the 10% bonus payment awarded to doctors practicing at a CAH in a Health Professional Shortage Area ensured that there were sufficient incentives available to staff.
In the roughly twenty years since the passage of the BBA, Critical Access Hospitals have spread across the United States, now accounting for 25% of acute care centers nationwide, becoming an absolutely essential tool in meeting the unique needs of rural communities. As of December 2015 there were 1,332 certified CAHs, with the majority being located in the Midwest and the Great Plains region, all offering a great level of flexibility in staffing and in their services, usually catering the services they offer to the specific needs of the community.
However, reliable and effective anesthesia services must be available at CAHs in order for them to be deemed operational. Anesthesia is essential to all surgical procedures and many aspects of outpatient care, making it necessary to always have an anesthesiologist available at CAHs. Certified Registered Nurse Anesthetists (CRNAs) are the primary providers of anesthesia in CAHs, with CRNAs in fact providing nearly 100% of the anesthesia in rural areas. With CRNAs being much more cost-effective than anesthesiologists and many reports concluding that the quality of care is the same between CRNAs and physicians, CRNAs are excellent providers for these rural health care centers that need to maximize cost-efficiency while supporting a lower income populace. Additionally, studies have found that there is a large shortage of anesthesiologists in rural areas and CRNAs have subsequently risen to fill this void, for now 60% of CAHs are located in the 17 states in the US that allow a CRNA to work without the observation of a physician. In order to ensure the continued cost-efficiency of anesthesia services at CAHs, several financial incentive programs have been created, namely the Anesthesia Rural Pass-Through Program. This initiative offers Medicare reimbursement payments to CRNAs and anesthesiologist assistants (AAs) who work in Critical Access Hospitals, but not to anesthesiologists, who are significantly more expensive than CRNAs or AAs.
Critical Access Hospitals comprise a vital section of our healthcare infrastructure and offer lifesaving care to frequently overlooked and underserved populations. However, it will be interesting to see how CAHs are affected by a continuing desire to decrease federal healthcare costs at every turn, while simultaneously expanding coverage to the millions uninsured.