Met­rics de­bated

Ru­ral hos­pi­tals de­fend mor­tal­ity rates

Modern Healthcare - - THE WEEK IN HEALTHCARE - Mau­reen Mckin­ney

Af­ter re­search re­leased last month called into ques­tion the qual­ity of some ser­vices pro­vided at crit­i­cal-ac­cess hos­pi­tals, th­ese small and mostly ru­ral fa­cil­i­ties are laud­ing a new study that sug­gests their in­pa­tient sur­gi­cal mor­tal­ity rates are on par with those of larger hos­pi­tals. “It’s great news and it demon­strates what we be­lieve to be true, that qual­ity met­rics are equiv­a­lent or bet­ter in ru­ral com­mu­ni­ties as they are in ur­ban ones,” said Brock Slabach, se­nior vice pres­i­dent for mem­ber ser­vices for the National Ru­ral Health As­so­ci­a­tion, who spent more than two decades as ad­min­is­tra­tor of a 25-bed hos­pi­tal in ru­ral Mis­sis­sippi.

Au­thored by re­searchers from the Univer­sity of Michi­gan Health Sys­tem, Ann Ar­bor, and pub­lished in JAMA Surgery, the study ex­am­ined the costs, length of stay and in­pa­tient mor­tal­ity rates as­so­ci­ated with eight com­mon, low-risk sur­gi­cal pro­ce­dures, in­clud­ing ap­pen­dec­tomy, knee re­place­ment and hip frac­ture re­pair.

Hos­pi­tals that have the crit­i­cal-ac­cess des­ig­na­tion, which cur­rently num­ber more than 1,300, are lo­cated pri­mar­ily in ru­ral ar­eas, have no more than 25 beds and re­ceive cost-based re­im­burse­ment from Medi­care at a rate of 101% for in­pa­tient and out­pa­tient ser­vices.

Ad­justed mor­tal­ity rates were vir­tu­ally the same for nearly all of the sur­gi­cal pro­ce­dures, whether care was pro­vided at crit­i­cal-ac­cess or non­crit­i­cal-ac­cess hos­pi­tals, al­though costs were 9.9% to 30% higher at the small, ru­ral fa­cil­i­ties, the study found.

But even as au­thors of that study cau­tioned that cut­ting pay­ments or ty­ing some por­tion of crit­i­cal-ac­cess hos­pi­tals’ re­im­burse­ment to per­for­mance could put ru­ral fa­cil­i­ties on thin ice fi­nan­cially, oth­ers are push­ing for more over­sight of ru­ral hos­pi­tal qual­ity as well as poli­cies that man­date their par­tic­i­pa­tion in fed­eral im­prove­ment ini­tia­tives.

Dr. Karen Joynt, an in­struc­tor in the depart­ment of health pol­icy and man­age­ment at the Har­vard School of Pub­lic Health, Bos­ton, pointed out some lim­i­ta­tions to the UMHS study, in­clud­ing its use of a small sub­set of crit­i­cal-ac­cess hos­pi­tals. But the re­sults, she said, do sug­gest that “if you choose pa­tients ap­pro­pri­ately, they can safely re­ceive low-risk surg­eries at crit­i­cal-ac­cess hos­pi­tals.”

Joynt was the lead author of an April 2 study in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion, which found that crit­i­cal-ac­cess hos­pi­tals’ 30-day mor­tal­ity rates for heart at­tack, heart fail­ure and pneu­mo­nia rose over the past decade, even as such rates fell at larger acute-care fa­cil­i­ties.

Joynt and her col­leagues ar­gued that the way those hos­pi­tals are paid could re­duce in­cen­tives to im­prove qual­ity, as could their ex­emp­tion from par­tic­i­pa­tion in fed­eral qual­ity ini­tia­tives such as the CMS’ value-based pur­chas­ing pro­gram. “Given the sub­stan­tial chal­lenges that (crit­i­cal-ac­cess hos­pi­tals) face, new pol­icy ini­tia­tives may be needed to help th­ese hos­pi­tals pro­vide care for U.S. res­i­dents liv­ing in ru­ral ar­eas,” they wrote.

That study drew sharp reaction from crit­i­cal-ac­cess hos­pi­tals and some ru­ral health ex­perts. In one re­sponse, Ira Moscov­ice, di­rec­tor of the Univer­sity of Min­nesota Ru­ral Health Re­search Cen­ter in Min­neapo­lis, crit­i­cized the study for mis­clas­si­fy­ing crit­i­cal-ac­cess fa­cil­i­ties and fail­ing to rec­og­nize ru­ral hos­pi­tals’ high-level par­tic­i­pa­tion in qual­ity im­prove­ment ini­tia­tives.

One such qual­ity col­lab­o­ra­tive is the Michi­gan Crit­i­cal Ac­cess Hos­pi­tal Qual­ity Net­work, a group of 36 small, ru­ral hos­pi­tals. Be­cause such hos­pi­tals typ­i­cally have low vol­umes of many of the types of cases com­monly used to mea­sure qual­ity, the Michi­gan net­work’s mem­bers ag­gre­gate their data in or­der to as­sess statewide per­for­mance.

“We also have quar­terly meet­ings, share best prac­tices and have a very ro­bust agenda of on­go­ing ac­tiv­i­ties,” said Ed Ga­mache, pres­i­dent of the net­work and CEO of 15-bed Har­bor Beach (Mich.) Com­mu­nity Hos­pi­tal. He balked at the no­tion that crit­i­cal-ac­cess hos­pi­tals weren’t as en­gaged in qual­ity im­prove­ment projects as their larger peers. “It’s

some­thing we’ve been work­ing hard at for years.”

But Joynt ar­gued that her study and the most re­cent one on in­pa­tient sur­gi­cal costs and out­comes should be looked at in the same light: as re­search that shows which ser­vices crit­i­cal-ac­cess hos­pi­tals ex­cel at pro­vid­ing and which ones should per­haps be de­liv­ered at larger fa­cil­i­ties. The goal, she said, is to move to­ward more “pa­tient­cen­tered sys­tems of care” that treat pa­tients close to home when it’s safe and ap­pro­pri­ate and at larger med­i­cal cen­ters when it’s nec­es­sary.

“There are lots of things that crit­i­cal-ac­cess hos­pi­tals do re­ally well, and pa­tients usu­ally pre­fer them,” Joynt said. “One thing that I think would be very help­ful would be more for­mal part­ner­ships be­tween crit­i­cal-ac­cess hos­pi­tals and re­fer­ral hos­pi­tals to fa­cil­i­tate trans­fer of pa­tients to larger cen­ters and back again.” Fu­ture stud­ies are needed to bet­ter un­der­stand the best roles for crit­i­cal-ac­cess hos­pi­tals and their larger coun­ter­parts, she added.

The in­creas­ing at­ten­tion paid to ru­ral health­care out­comes comes as many crit­i­cal-ac­cess hos­pi­tals are strug­gling fi­nan­cially. Even with cost­based re­im­burse­ment from the CMS, the se­ques­tra­tion’s 2% Medi­care cut has put a strain on th­ese fa­cil­i­ties, of­fi­cials say. Pres­i­dent Barack Obama’s bud­get for 2014 also in­cludes a pro­vi­sion that would de­crease pay­ments for crit­i­cal-ac­cess hos­pi­tals from 101% to 100% of costs.

“I’m not try­ing to cry wolf here, but there are con­se­quences to pol­icy de­ci­sions,” said Slabach, of the NRHA. “Th­ese providers serve an im­por­tant role in their com­mu­ni­ties and with­out them, what we’ll end up with in some cases are med­i­cal deserts.”

Dr. Adam Gadzin­ski, lead author of the newly re­leased study on in­pa­tient sur­gi­cal pro­ce­dures, warned that re­source-strapped crit­i­calac­cess hos­pi­tals are “likely to be far more sen­si­tive to re­duc­tions in re­im­burse­ment,” which he said could po­ten­tially lead to cuts in ser­vices and hin­dered ac­cess to care.

“It is fine line that must be walked be­tween sav­ing health­care dollars and still pro­vid­ing suf­fi­cient pay­ments to hos­pi­tals that pro­vide health­care to ru­ral and other un­der­served pop­u­la­tions,” Gadzin­ski said in an e-mail.

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