Hospitals on the frontier

The concept of a limited service rural hospital recently gained nationwide attention when Montana introduced the medical assistance facility (MAF) model, which allows a hospital to have a license under less stringent rules (rather than close completely). The MAF is a down-scaled, limited-service rural hospital that makes extensive use of midlevel practitioners and has flexible staffing requirements. MAFs restrict admission to patients with low-intensity, acute illnesses who typically require short-term hospitalization. Montana currently has four MAFs certified as Medicare and Medicaid providers under the terms of a waiver agreement with the Health Care Financing Administration (HCFA). MAFs are located in four "frontier" communities--counties or regions with fewer than six residents per square mile. A 96-hour cap on inpatient stay effectively guarantees that the MAF's scope of services will be circumscribed. However, the array of services that meet the definition of low intensity and short term is potentially broad. The flexibility--and thus the real strength--of the MAF model is in the licensure rules, which relax some of the requirements that the small rural hospital has difficulty meeting (such as those regarding staffing). The demonstration project is now entering its final two years. So far, it has gained widespread interest and support. The central question is whether HCFA will extend the waiver after 1993. Another possibility is the reclassification of MAFs to rural primary care hospitals, which do not require waiver coverage to receive Medicare and Medicaid reimbursement.