Washington State Necessary Provider Definition
(not applicable for new applicants after December 31, 2005)

Necessary Provider of Health Care Services is the designation given by the State to rural hospitals that meet certain State criteria.  Necessary Providers are considered essential to the welfare of their communities.  Closure of a Necessary Provider would pose a threat to the health of the residents of an area.  A hospital must meet one or more of the following criteria to be considered for designation as a necessary provider of health care services:
1.  The hospital:

• Has Medicare/Medicaid inpatients comprising more than 50% of total patient days for the last available twelve months of CHARS data, or,

• Qualifies as a Medicare or Medicaid Disproportionate Share Hospital, or,

• The hospital is identified as an approved sole community hospital by the federal  Centers for Medicare and Medicaid Services (CMS). 

(This criterion recognizes hospitals serving large numbers of elderly and low income. These hospitals are critical to access for a needy population who may have difficulty traveling to another location for services.)

2.  The hospital is located on an interstate highway and is more than 20 miles or 30 minutes from the next designated emergency trauma facility.  (This criterion recognizes the "golden hour" during which emergency care must be initiated.)

3.  The hospital is:

• Considered at risk of imminent closure due to the loss of physician staff or “Financially Vulnerable” as calculated by Department of Health from the Hospital Financial Data Set, and,

• Closure of the hospital would result in Medicaid residents of the county or public hospital district losing access to 24 hour emergency room care within 20 miles or 30 minutes travel distance of their residence.

(This criterion recognizes the need for assuring emergency department access to the state’s most vulnerable population.  Medicaid residence data is readily available for analysis and is used as a proxy for all vulnerable populations including the uninsured and Medicare population in Washington.)

4.  The hospital is located in a county with a higher percentage of Medicaid residents than the state average.  (The rationale for this criterion is that medical need is highly associated with income level.)

   There will be no more than one hospital designated by the state as a Critical Access Hospital in the same city or town at the same time.  If there is more than one CAH eligible hospital in the same city or town, the applicant hospital must provide the following documentation with its application for designation as a Critical Access Hospital:

•  Evidence of joint planning between the hospitals in the same city or town

•  Support for designation of the applicant hospital by the other local hospital and by the community;  and

•  Network arrangements between the two hospitals in the same city or town.

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Process to Convert to Critical Access Hospital Status
We expected hospitals to take a thoughtful, considered approach to Critical Access Hospital conversion, one reason that conversion was slow but steady.  We required a financial feasibility study be completed. Once the financial impacts were known, hospitals were required to conduct community, medical staff and Board planning and education. Each community was unique, and their preparation tasks varied.  The state program manager worked with each site to determine the scope of activity needed for each set of stakeholders, identified grant support through the Flex program or other sources, and stayed in close contact while activities unfold. Hospitals began early discussions with the nurse surveyor, so education and planning efforts completely addressed all the changes and opportunities afforded by the change.  The implications of the network requirements (outside arrangements for quality improvement, credentialing and peer review; community representative reviewing policies and procedures) needed to be fully understood and creatively addressed. Workshops were held to bring together survey, fiscal and policy stakeholders together with hospital staff and community stakeholders. Once their “homework” had been done, the hospital board passed a resolution certifying that all the State requirements were met.  A designation application with required back-up was sent to the state program manager. Once approved, a survey date was finalized and a pre-survey phone conference held to assure all written agreements have been completed. Hospitals were advised to set their start date six to eight weeks after their survey date to assure a smooth billing transition.