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Rural Hospital Flexibility Program Tracking Project Chapter 3H Curt D. Mueller, Ph.D. Introduction and Purpose The Flex Program allows a variety of approaches to be implemented for the purpose of improving the rural health delivery system. As noted elsewhere in this report, states are encouraged to use program funds to improve rural emergency medical service (EMS) and community development in addition to critical access hospital (CAH) designation. Ultimately, the success of the Flex Program depends, in part, on the rural health care workforce, including facility administrators and the community's providers of health care. Based on discussions with administrators and a survey of physicians of CAHs conducted by Project HOPE Walsh Center for Rural Health Analysis, our impressions are that conversion has either helped or has not affected facility-physician relations. In this chapter, we examine how physicians perceive the impacts of CAH conversion, both on their own practice of medicine and on their community's health care infrastructure.
Construction of the Sampling Frame We conducted a four-page mail survey of physicians who are currently affiliated with a CAH that has been functioning for at least one year. The sampling frame of affiliated physicians was constructed by identifying 158 CAHs of interest, and then identifying physicians who practice in each CAH's "market area." CAHs of interest were those facilities that acquired the CAH designation prior to April 2000, as we wanted to focus on facilities with the most experience as CAHs. These facilities were identified from the list maintained by the University of North Carolina. An initial list of physicians was constructed from electronic telephone listings of physicians' practices (1) with addresses having the same ZIP code as the CAH, and (2) with addresses having ZIP codes that were physically contiguous to the area defined by the CAH's ZIP code. A physician was deemed to be potentially eligible for the survey if his/her practice address was within the CAH's "market area," defined as within 15 (driving) miles of the CAH. The final step was determining the status of the physician's affiliation with the CAH. We telephoned each of the 158 eligible CAHs, and asked for a list of physicians who either treated patients at the facility or had some affiliation with the facility. Our final sampling frame contained physicians who appeared on the list provided by the CAHs and on our telephone list of market area physicians. Physicians who were identified by the facility as affiliated physicians, but were not on our list, were included in the final sampling frame after verification that the practice was located in the CAH's market area. Physicians who were on our list were not included in the sampling frame if they were not listed as an affiliated physician by the CAH. A total of 621 physicians were included in the final sampling frame. Data Collection The survey instrument was designed to obtain information on effects of conversion on the physician's practice, and physician perceptions of the effects on the facility and the community. A copy of the instrument is provided in Appendix D. A packet was mailed to each physician in the sample of affiliated physicians. The packet contained a personalized cover letter explaining the nature of the survey, the survey instrument, a business reply envelope, and an honorarium check for $20, in an attempt to maximize the response rate. A reminder postcard was mailed to surveyed physicians who had not responded after the first week. Follow-up reminder calls were placed to non-responding physicians beginning three weeks after the initial mailing. The data collection period continued for approximately eight weeks. Estimation Three sets of estimates based on the survey data are reported below. First, we provide background information on the population of physicians who are affiliated with a CAH. By definition, affiliation means that the physician sees patients at the facility (although not necessarily frequently). Second, we focus on the subset of affiliated physicians who were also affiliated with the facility prior to conversion. Estimates address whether conversion to CAH status has affected the numbers of inpatients and outpatients treated by the physician and inpatient and ER outcomes. We hypothesized that conversion would have little or no effect on inpatient volume, based on anecdotal evidence from discussions with administrators during our site visits. Several administrators indicated that any anticipated changes in service volume and service mix that might be related to conversion probably occurred prior to the actual conversion. We had no expectations concerning outpatient volume effects. We asked physicians about perceived changes in inpatient outcomes because both positive and negative opinions have been expressed about possible consequences of conversion. Although administrators indicated that conversion should not adversely affect outcomes, several expressed concerns raised in their communities that outcomes and quality of care would deteriorate as facilities "are no longer full-service hospitals." We asked physicians about changes in ER outcomes because the Flex Program permits the targeting of funds to EMS activities, and it was possible that CAH conversion could lead to changes in the CAH ER and/or the local EMS system. Finally, we report estimates that describe the affiliated physician's current experiences with the CAH. These estimates, based on the entire sample of currently affiliated physicians, concern the nature of communication with the CAH's administration, the physician's perceptions of how conversion has affected the community, and personal satisfaction with the facility's decision to convert. We focus on whether the physician has received communication from the CAH's administration on two issues that are important in utilization management - the types of treatment that the CAH will offer to inpatients and inpatient length of stay. We do not have any hypotheses about these factors, as the urgency of utilization management efforts may have been weakened when the 96-hour rule was changed from a per-stay limit to an average. Most facilities that were candidates for conversion had a length of stay less than 96 hours before conversion.1 We hypothesize that the Flex Program has strengthened the community's medical infrastructure, and expect to see this expressed by affiliated physicians. Estimates presented below are primarily of a descriptive nature. We report means of continuous variables and percents for categorical data. Standard errors and the number of respondents are also provided, should the reader desire to calculate selected confidence intervals and conduct tests of statistical significance. Findings Characteristics of Affiliated Physicians A total of 471 physicians completed the mail survey, resulting in a response rate of about 76 percent. A subset of 430 respondents, who currently see inpatients at the CAH in their market areai, is the group of interest in this analysis. Of these physicians, 179 (42%) characterize themselves as staff physicians employed by the CAH, and 251 (58%) are members of independent practices who see inpatients at the CAH (Table 1). Table 1. Characteristics of Physicians Affiliated with a Critical Access Hospital
Sixty-one percent of physicians with a CAH affiliation (also to be referred to as "CAH-affiliates" below) are general or family practitioners. About 88 percent of affiliates specify general or family practice or a medical specialty as their primary specialty.ii The remaining 12 percent of CAH-affiliated physicians are surgical specialists (8%) and other specialists (4%). Although the average CAH-affiliated physician has been practicing for about 19 years since completing medical school training, the amount of time the physician has practiced in the community served by the CAH is considerably less -- 10 years. The distribution of time in the community, however, is very skewed. About one-half of CAH-affiliates have practiced in their communities for five years or less; 17 percent have practicing in their current community for more than 20 years. The work week of the average CAH-affiliate is lengthy. The average CAH-affiliate worked 59 hours during the week prior to the survey, and 25 percent of respondents reported working in excess of 70 hours during that week. Much of the affiliate's work time is in the CAH community. The average CAH-affiliate spent 86 percent of his/her work time in the community during the week prior to the survey, and only 20 percent of respondents spent less than 80 percent of their work hours in the community. There is considerable variation in the number of patients admitted to the CAH by CAH-affiliates. The mean number of admissions during the previous month was 11. About 47 percent had fewer than 10 admissions, while 18 percent reported 20 or more. Impacts of Conversion Of the 430 physician respondents who are currently affiliated with a CAH, 375 (87%) also treated patients at the facility prior to conversion. The survey was designed to obtain several measures of the extent to which conversion has affected these physicians' practice of medicine. Patient Volume. Most physicians (80%) reported no change in the number of inpatients treated at the CAH, or in the number of outpatients treated at either the CAH and in their office (79%) as a result of the conversion (Table 2). About 16 percent reported a change in inpatient volume, with two-thirds of those reporting a change (11% overall) reporting a decrease in inpatient volume. The opposite effect, however, was observed among the 15 percent of physicians reporting a change in outpatient volume. Among these physicians, most (13% overall) reported that conversion increased outpatient volume. We cannot determine whether this increase resulted from changes in outpatient services provided at the CAH or at the physician's office. Table 2. Impacts of Conversion on Patient Volume
Patient Outcomes. A key issue is whether conversion has affected outcomes of patients using the CAH and ER, given the Flex Program's potential impacts on inpatient stays and the local EMS system. Most (76% overall, and 85% of those with an opinion) reported no impact on inpatient outcomes, and 72 percent reported no impact on outcomes among patients using the ER (Table 3). Among those reporting a change in outcomes, most reported improved outcomes in each setting. The number of physicians reporting improved inpatient outcomes exceeded the number reporting worsened outcomes by a factor of 3.8 for inpatients and 6.8 for ER patients.iii Table 3. Impacts of Conversion on Outcomes
Communication with the CAH Administration Most physicians had not recently received information from the CAH administration that was targeted at limiting treatment of patients with certain conditions or affecting change in inpatient length of stay. Only 19 percent of physicians received information concerning limits on treatments (see Figure 1 at the end of this chapter). Among recipients, this information was not well received. Sixty-four percent of those physicians who received this information viewed it as compromising their practice, whereas only 17 percent found the information beneficial. Forty percent of physicians received information targeted at changing inpatient length of stay (Figure 2), and as expected, the communication encouraged length of stay reduction for most of these physicians - 36 percent overall, or 90 percent of the 40 percent receiving length of stay information. As with communication concerning changes in treatment of patients with certain conditions, communication concerning changes in length of stay was viewed negatively: 78 percent of length of stay information recipients thought this information compromised their practices, and only 10 percent found it to be beneficial to their practices. Physician Perceptions of Community Views and Infrastructure Impacts Although conversion seems not to have had significant impacts on the volumes of inpatients and outpatients, nor on changes in conditions treated in the facility, physicians viewed conversion as having effects on the facility's image in the community and on the community's health care infrastructure. Although most physicians believed that conversion had not changed community views on quality of care at the facility (68%), 59 percent of those who thought community perceptions had changed (18% overall) believed that community members perceived that quality of care improved (Figure 3). Approximately six of 10 respondents indicated that conversion has had no effect on the attractiveness of the community as a desirable place for them to practice. Of the 40 percent who indicated that conversion affected the attractiveness of the community for their practice, more physicians indicated the effect was beneficial than negative, by a factor of over two to one - 27 percent versus 12 percent (Figure 4). A related issue is whether physicians believe that conversion has improved the community's ability to attract new physicians. Nineteen percent indicated that conversion improved the community's ability to attract physicians, whereas 8 percent indicated that community attractiveness to other physicians had worsened (Figure 5). Forty-two percent of physicians believed that conversion had no impact, and 31 percent were not aware of changes in the community's attractiveness from the perspective of other physicians. Support for the conversion's positive effect on the stability of the community's infrastructure was considerably stronger than physician views on whether the conversion affected the perception of the community as a place to practice for him/herself and for others. Forty-seven percent indicated that infrastructure stability was enhanced by conversion (Figure 6), while only seven percent indicated that conversion has weakened the community's health care infrastructure. Physician Support for Conversion Overall support by physicians for conversion was very positive (Figure 7). Nearly 70 percent were supportive of conversion, and only 8 percent opposed or strongly opposed conversion. Other physicians were neutral, neither expressing support nor opposition. Discussion Perhaps the most important conclusion from this analysis is that physicians are very supportive of the facility's decision to become a CAH. This conclusion is reassuring, as it is consistent with claims by the typical CAH administrator, during Tracking Team site visits, that the medical staff is supportive of conversion once the conversion process is explained. We are not able to fully account for the reasons for physician support. Survey results suggest that some support stems from perceived effects of the CAH on the stability of the community's health care infrastructure. However, support does not appear to stem directly from perceived conversion effects on the attractiveness of the community as a place to practice or in attracting other physicians. We suspect that some of the advantages of conversion are only a subset of the factors that determine whether the community is an attractive place to practice medicine. Project HOPE researchers are continuing to study the nature of physician support for conversion. A second conclusion from this analysis is that conversion per se does not appear to have dramatically affected the day-to-day practice of medicine by physicians who affiliate with a CAH. Most physicians reported no changes in the volumes of inpatients and outpatients, nor did most physicians report perceived changes in inpatient outcomes and outcomes of ER patients that could be attributed to conversion. Again, the lack of immediate effects of conversion on inpatient volume is consistent with our in-the-field discussions with CAH administrators. Why most physicians who reported outcome effects of conversion reported positive effects cannot be determined from the survey data. One hypothesis, however, is that physicians are aware of efforts by CAH administration, observed during the Tracking Team's site visits, to implement quality improvements. At the same time, conversion has not been painless for physicians. Some-albeit a small number-indicated that their practices were adversely affected by challenges from CAH administration to limit treatment of certain types of conditions at the CAH (12% of CAH-affiliates), and a larger number reported adverse effects of challenges by CAH administration to reduce inpatient length of stay (28%). Finally, it is important to emphasize that results from this survey describe physicians
who are affiliated with CAHs. Clearly, this is an important set of providers in rural communities that have received funds from the Flex Program. We believe that monitoring of affiliate physicians in the future is important, as some of the effects of conversion may become apparent only as time passes. But it is also important to recognize that other physician providers practice in communities served by CAHs. In fact, we estimate that there are about as many non-affiliates as affiliate physicians who serve CAH communities.iv We have not studied this important group of providers - a group that is not likely to be as supportive of the CAH concept and of the Flex Program. Hence, our results should be interpreted with caution and with the understanding that study of the reactions of non-affiliated providers to the Flex Program is warranted. Figure 7. Physician Strength of Support for Conversion
Chapter 3I: Administration in Critical Access Hospitals Footnotes i Forty-one survey respondents are excluded from the analysis below: 32 claimed to be familiar with the CAH but see no patients there, 7 respondents claimed not to be familiar with the CAH, and current relationship was not ascertained for the remaining 2 respondents. ii Definitions of the specialty categories in this analysis are those used by the American Medical Association in analyses of its survey data. The Medical Specialties category includes internists, cardiologists, gastroenterologists, pediatricians, and others; Surgical Specialists include general surgeons, obstetricians, ophthalmologists, and others. iii The difference in percents of physicians who believe outcomes improved versus worsened is statistically significant, p<0.01, for both inpatients and patients who use the ER. iv Our estimate is based on our sampling frame - we deleted about 50 percent of physicians with practice addresses in the CAH market areas because these physicians were not identified as affiliated physicians by CAH staff. 1 Mueller, CD, CM Cheng, JA Schoenman. Alternatives to the 96-Hour Rule for Critical Access Hospitals. Final Report, submitted to the Health Care Financing Administration, 2000. 2 Roback, G, L Randolph, B Seidman. Physician Characteristics and Distribution in the U.S. Chicago: American Medical Association, 1990. RHFP
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