An Introduction to Critical Access Hospital Doctoring – Part 1

Critical Access Hospitals (CAH)

I thought I would take some time to introduce the concept of the Critical Access Hospital and the kind of doctoring that is done in these facilities.  Likely, relatively few of you are familiar with them.

how do you define rural?

The relative obscurity of the CAH is natural, only about 19% of US population lives in rural areas.  Even fewer, about 3%, live in counties designated as “frontier.”  WTF does “frontier” mean, you ask?  I am glad you did, because it is one of my favorite little arcane facts about rural life.

In 1890, the US Census Bureau determined that the American Frontier had reached a population of about 6 people/square mile.  This, they decided, was a dense enough population to declare the frontier closed.  As noted above, 3% of the US population still lives in counties with a population density <6 people/square mile.  Thus is born the designation of frontier county, which is used in rural policy circles to denote a qualitative difference in the kind of rural life that exists in these places.

okay, but what is a cah?

CAH is a designation that can be earned from the Centers for Medicare and Medicaid Services(CMS). It is primarily based on distance from other services(generally 35 miles from the next closest hospital) and a few other a criteria, such as 25 or fewer beds, 24/7 emergency services, <96 hour average length of stay for acute care inpatients.

These facilities can range from having general and orthopedic surgery, internal medicine hospital, dedicated ED doctors and obstetricians to facilities that effectively have a clinic, and small 2 bed emergency department, and a few inpatient beds.  I tend to practice in the latter group.

Why would a facility want this designation?

Medicare cost-based reimbursement.  What does that mean?  For any inpatient treatments provided to medicare patients, medicare will reimburse critical access hospital 101% of the cost of providing those services.  This often includes costs associated with maintaining a hospital that often has empty beds.  It helps keep these low volume facilities, which are often located in poor areas, afloat so that they can maintain “critical access” to healthcare in rural areas.

why pay to keep these facilities open?

There is a moral argument that access to healthcare is important.  I tend to agree with that argument, but that isn’t really the reason why we continue support these facilities.  The real reason is that rural areas have a disproportionate say in national politics.

Let’s take the Senate for example.  There are currently 270,202 registered voters in Wyoming, that’s right, in the entire state.  In California, that number is 18,980,481, but California still only gets TWO senators. So, if I were a registered voter who voted in the last election and lived in WY, every time a senator voted in the Senate, 0.0000037 of that vote could be attributed to me.  A Californian on the other hand, can only be attributed 0.00000005 of his senator’s vote.  That is 74 times more representative power in the Senate for an active voter in Wyoming compared to California. The difference is less in the House, but still significant.

Let me be clear, I am not saying that I am opposed to these programs or that I oppose money being directed to rural areas for healthcare, education, or other social programs – my income currently depends on it, as a matter of fact.  I think these are interesting facts and realities about the macroeconomic forces at play in rural healthcare that are worth knowing.

But what about the doctoring?

In Part 2 of this series, I will discuss the actual doctoring that goes on in these facilities and what it is like to practice in these facilities.


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