HLM: Your study suggests that "new efforts" are needed to improve mortality rates at CAHs. What do you recommend?
KJ: Finances and the quality should be separate. Regardless of how the hospitals are financed if you are providing care to Medicare patients in this day and age… people deserve to understand data and to see what is happening at their local hospitals and exempting 1,000 hospitals from having to participate in quality monitoring is not a good long-term solution.
HLM: Do you believe that the reporting exemptions for CAHs should end?
KJ: I do. The burden of reporting can be lessened if that is the barrier. If the barrier is we need to have them electronically report because they don't have the infrastructure to be able to have a person doing the chart instruction, then let's find electronic records systems, which would help all small rural hospitals.
Saying they are too small to collect data is not realistic in this day and age. Something about the participation in these quality programs and reporting really does make a difference in what these hospitals are able to do. Small rural hospitals that aren't critical access hospitals still have to submit their quality data and have to function in the same roles as everybody else.
HLM: How do you address criticisms that your study relies on administrative data to measure clinical outcomes?
KJ: I agree there are limitations to administrative data, but it doesn't make it useless. Administrative data can show us a pattern and then we need clinical and qualitative data to understand why. The wrong response to this paper would be to say there is obviously no problem. This is all a trick of administrative data. That is a little biased.
The appropriate response is that it looks like there is a problem in that these hospitals appear to be falling further and further behind.
What we need to do now is to ask why and what can we do about it. If we determine that it's all because the patients are older and sicker then OK, let's figure out what we need to do to take care of older sicker rural people. And if we find out it's because patients are declining transfer to the big city hospital because they want to be close to home, OK then let's find telemedicine or tele-ICU or other consultations to bring the care to them so they can stay close to home.