Rescue program for the rural hospital is met with skepticism from administrators

In West Texas, the small hospital in Crosbyton has only two beds, and they are not always occupied.

“We rarely allow patients,” said Steve Beck, general manager of the hospital, which is 40 miles east of Lubbock and serves a town of about 1,500 residents.

The hospital has problems with staffing, and “we lack technology and expertise,” he said. And money.

The city has held bakery and garage sales to keep its emergency services and primary care services open. On paper, Crosbyton Clinic Hospital should not exist, Beck said, but it does – through “pure determination and commitment and work ethic.”

In states with many rural hospitals – such as Texas, Kansas and Iowa – hundreds of these facilities have fewer than three patients staying overnight each day. The financial pressure of staff and maintenance of those beds is taking a toll, and federal lawmakers responded last year to pleas for help from hospital officials in places like Crosbyton.

The Rural Emergency Hospital program, scheduled to launch in January, will offer to pay small, struggling hospitals to drop their outpatient 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 fuel the stream of rural hospital closures over the past decades.

A patient room is seen at Crosbyton Clinic Hospital.(Annie Rice for KHN)

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

However, state hospital leaders predict that the program may find some direct contractors.

The plan would encourage payments for Medicare patients from a hospital and provide an additional flat “provision payment.” But the exact size of those payments and whether they will be enough to support struggling hospitals is unclear, even after the US Centers for Medicare & Medicaid Services released a first proposed rule just before the fourth of July holiday weekend. A final rule is expected this fall.

In Kansas, where an estimated 40 hospitals reported an average number of hospitals from one or two to the covid-19 pandemic, no hospitals are ready to raise their hands to participate in the program, said Jennifer Findley, vice president. -president of education and special projects for the program. Kansas Hospital Association. The hospitals are “waiting and very worried” for CMS officials to release more details about the funding, Findley said.

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

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 legislation leading up to the program’s inception, urged the agency to do so in a timely manner.

The rural hospital model builds on Medicare’s designation “critical access hospital”, for which hospitals only sign up after a series of amendments. The existing program allows Medicare to provide additional funding to small, rural hospitals that have no more than 25 hospitals and whose average length of stay of patients is 96 hours or less.

Grassley said in an interview with KHN that requiring rural hospitals to maintain hospitals that are nearly empty is impractical. He wanted to “offer an alternative to closure and not have a supply of health care.”

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

In his statement to KHN, Wyden said the law is designed to “fill in specific gaps in existing federal security measures.” Although the Medicare fee is smaller than originally proposed, the law also includes a provision fee, which is paid regardless of how many patients a hospital serves.

CMS officials have not yet disclosed the size of those payments, but Brock Slabach, chief operating officer for the National Rural Health Association, said hospitals need them to be $ 2 million to $ 3 million a year. The amount of payment for the facility is “the pivot point for the entire program,” he said.

A photo shows Crosbyton's water tower in the distance surrounded by trees in the foreground.
Crosbyton, Texas, located 40 miles east of Lubbock, has held bakery and garage sales to keep its only hospital from closing its emergency room and primary care services.(Annie Rice for KHN)

But politicians in Washington are nervous about spending, and there is a “general suspicion that this program is valuable,” Slabach said.

Comments from rural health advocates and hospital system administrators indicate that they also warn against the still amorphous framework of the rescue of the rural hospital.

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

CommonSpirit Health, a Catholic health system based in Illinois that operates in 21 states, said in its note that although a rural hospital “does not provide many babies,” using telehealth in an emergency could save a baby’s life as a mother, ” as one of our critical access hospitals has done twice this year. “

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

“Spreading out the details” on the beds and making sure the compensation is adequate are the key to the program’s success, Harris said.

James Roetman, the longtime CEO of Pocahontas Community Hospital in north-central Iowa, said that in order to overcome any skepticism among residents about eliminating hospital beds, administrators need to reassure them that the new regulation will pay enough to meet the needs of their hospitals. support and maintain. room and primary care services.

So far, Roetman said, it is not clear what the program would do.

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

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

During Covid congestion, many urban medical centers were overwhelmed with patients, and they often asked outside hospitals to treat as many non-critical cases as possible, Mitchell said. The clinical units of the small hospitals regained their interest, even if only for a few weeks.

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

With the final rules of CMS not coming until at least fall, hospitals could have trouble preparing for conversion in January, said George Pink, senior researcher at the Cecil G. Sheps Center for Research on Health Services at the University of North Carolina-Chapel Hill. Once federal regulators finalize the rules, many states will need to pass laws to certify or permit the redefined facilities.

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

However, 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 their doors since 2010, and closures reached a 10-year high in 2020, with 19.

Although funding for coronavirus relief funds has skyrocketed over the past two years, hospitals are expected to close “back with revenge” as emergency aid declines, Slabach said.

The pandemic money has been “wounded and basically disappeared,” said Beck, the Texas hospital administrator. He hopes the new Medicare payment program will be next to help Crosbyton stay open.

“We’ll survive until that happens,” Beck said. “We do everything we can.”

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Rescue program for the rural hospital is met with skepticism from administrators

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