By Imam M. Xierali, PhD, Sarah A. Sweeney, BS, Robert L. Phillips Jr., MD, MSPH, Andrew W. Bazemore, MD, MPH and Stephen M. Petterson, PhD
Journal of the American Board of Family Medicine, January-February 2012
Critical Access Hospitals (CAHs) are geographically isolated, small rural hospitals that are typically the sole source of care for their community, providing not only acute care but a broad spectrum of basic health services. There was a robust increase of CAH designations from 50 in 1998 to 1,310 in 2009.
Rural communities struggle to recruit and retain health care providers. In 2008, 81% of rural counties were or contained areas designated as Primary Care Health Professional Shortage Areas. Encouraging evidence shows that residents trained in a rural setting are much more likely to continue to serve in rural or underserved settings. Analysis of Medicare hospital cost report data suggests that very few CAHs ever have reported intern and resident training. As rural hospitals and as hospitals without prior graduate medical education (GME) programs, CAHs are eligible for starting or becoming funded members of GME training programs.
Increasing the capacity for CAHs to create and expand training programs could improve access to care in rural communities and strengthen existing rural training programs, many of which are threatened or closing. Recent policies promoting primary care training, such as the teaching health center program, also mean opportunity for CAHs to play an important role in GME expansion. Though this role for CAHs requires no legislative changes, CAHs will face additional hurdles related to accreditation and staffing.
http://www.jabfm.org/content/25/1/7.full
And…
Critical Access Hospital (CAH) Graduate Medical Education (GME): Too Little, and Maybe Too Late
By Frederick M. Chen, MD, MPH
Journal of the American Board of Family Medicine, January-February 2012
In the context of national scrutiny on graduate medical education (GME) from both the Medicare Payment Advisory Commission and the Joint Select Committee on Deficit Reduction, Xierali et al, bring our attention to the ongoing needs of rural underserved communities and the potential role of critical access hospitals (CAHs) in training the rural physician workforce. Their analysis demonstrates the minuscule number of CAHs that have reported resident training within their walls. The literature shows that physician training in rural settings is successful in producing rural physicians but also is endangered with the number of rural training tracks and rural residencies in free-fall over the past 10 years.
Although CAHs may be an untapped resource for GME, there are significant barriers to their success. Xierali et al point out the challenges of accreditation and staffing. CAHs, like RTTs, are by definition located in small communities that tend to be under-resourced for physician faculty and other medical education needs. Often the loss of a single physician in these settings results in the loss of the training site.
Financing is always an important consideration. Though CAHs may be eligible for Medicare GME payments because they are free of the resident cap, many CAHs have a low percentage of Medicare inpatients, resulting in payments that are insufficient to cover the costs of residency training. On the other hand, this has not precluded urban hospitals from claiming the time that residents spend in CAHs. Though this enables some residency training time in CAHs, the flow of funds, if any, from the urban hospital to the CAH is unknown, except to hospital financial officers.
Enabling and encouraging more residency training in rural settings is a priority if rural communities are to have adequate access to health care. New training models that encourage community-based training also encourage CAHs to participate in physician training. However, changes to GME financing are needed if CAHs are going to be able to play a larger role in rural physician training.
http://www.jabfm.org/content/25/1/6.full?etoc
Comment:
By Don McCanne, MD
Critical Access Hospitals serving rural communities provide an opportunity to train physicians who would more likely stay in these communities, many of which are designated as Primary Care Health Professional Shortage Areas.
If our current fragmented system of financing health care were replaced with a single payer national health program – an improved Medicare for all – the coordinated allocation of our health care funds could ensure that these training programs for rural physicians would be adequately funded, not to mention ensuring the perpetuation of Critical Access Hospitals wherever they are obviously needed.