Critical Access Hospitals: The Canary in the Mine for Specialist Shortages?

An article in the April 3rd issue of JAMA describes the higher mortality from acute MI, congestive health failure and pneumonia in critical access hospitals (CAHs) (small hospitals in sparsely populated areas). The authors reasoned that the difference was due to the fact that most hospitals have quality reporting programs but CAHs do not. But CAHs lack another important ingredient: specialists. While the counties with and without CAHs had similar numbers of generalist physicians (about 50 per 100,000), counties with CAHs averaged only 14 specialists per 100,000 while other counties averaged 100 specialists per 100,000, a seven-fold difference.

Over the period of observation (2002-2010), mortality improved in some CAHs but not in others. There was no difference in the average numbers of generalists in the counties where improvement occurred vs. where it did not, but the number of specialists was 30% greater in the counties where mortality in CAHs improved.

There was a lot of variability in the data, so the statistics are not strong. But we know that the evolving specialist shortage hits remote areas first. Are CAHs showing us what happens when there aren’t enough specialists? Could CAHs be the canary in mine?


  1. Gabor Kaye

    This is just the beginning of what to expect in the not too distant future.The next several years will show an even a larger number of retiring physicians.Many will retire early due to” burnout” as a result of frustrations dealing with ever increasing administrative burdens created by the health care industry – government cartel.Morale among doctors is at an all time low.
    The situation will become very serious with the never discussed, looming shortage of general surgeons .Talk to your trusted general surgeon in any hospital doctor’s lounge across the country.They will confirm the likelihood of this impending major public health problem.
    Perhaps mid level practitioners will be able to fill the void created by a lack of primary care and even internal medicine physicians.But they will be totally inadequate in replacing general surgeons.Our general surgeons who are dedicated “specialists”, are
    so essential .More so in smaller outlying centers, where they perform a full gamut of surgical services from hip pinning to doing C-sections.

  2. Rich Martin

    There are multiple unintended consequences of changes in US health policy. Hillary Clintons fix, greatly increased funding for NP and PA training at thee expense of speciality fellowships. This resulted in a great reduction the production of cognitive specialists I.e. rheumatologists. The Kennedy/Obama health bill eliminated payment for consultations. This means a new patient evaluation for a new patient gyne exam with a NP and a complex new patient evaluation of a patient who is seriously ill and defied diagnosis by 5 other physician are potentially payed the same amount. In 2009 this 28% reduction in payment to cognitive specialists was implemented. The added overhead/cost and reduced productivity from electronic health records brings the overhead of providing care to about 70%. Thus a 28% reduction leaves a net $6.00 to the cognitive specialist for 1 hour of work. In our region 6 rheumatologists retired early around this time. We now receive 250 consult request per month and turn away 130. After 20 years of participation to survive, we closed to new medicaid patients. 100,000 new Medicaid patients will be added in our region in the next year due to the ACA but there is no rheumatology participating provider in 70 miles. Our metro area has 1,000,000 people. Rationing is occurring in our area.
    The increased provision of care by NP and PA has too often resulted in “moving people through then system” given their average 6.8 minute office visit time in our area. Many labs, MRI performed, but often the midlevel does not know how to interprete the results. This leads to increased # of consult requests to specialists. Then we must spend 60-80 minutes to unravel the mess, but essentially take nothing home for it. This is an unsustainable system, which will lead to a 2 tier health care system.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s