Health care in rural Minnesota is increasingly under stress. As MPR News has been reporting this week with its Ground Level project, outstate hospitals and clinics face myriad obstacles, including a critical shortage of physicians and nurses. Some spend years trying unsuccessfully to lure a doctor.
In addition, they operate on ever-narrower margins. According to the Minnesota Hospital Association, one quarter of rural hospitals in the state operate in the red. This makes it difficult to keep up with a changing health care landscape, such as the push toward collaborative care and the mandate for electronic medical records.
And yet, there are people all over the state--doctors, paramedics, teachers, administrators, tech experts--trying to deal with those challenges. Here are just a handful of those people.
If you ask Terry Hill, connections — between people, organizations, and information — are key to the survival of rural hospitals and clinics.
"If there is a good model that might be working, we want to publicize that," says Hill, who was raised in tiny Tok Junction, Alaska, where healthcare options were severely limited. "We want to acquire those good models and examples and transfer them into something that can be shared."
These models might diagram methods for improving care quality, shoring up finances, or implementing electronic health records. Rural providers often operate by narrow margins and with limited staff, adding obstacles to modernization efforts. "We are the eyes and ears of rural hospitals and rural clinics," Hill says.
Hill started the organization in 1985 as a healthcare consortium, with a grant from the Grand Rapids-based Blandin Foundation. It morphed into the Minnesota Center for Rural Health and, in 1995, the National Rural Health Resource Center.
Having worked with hospitals in more than 40 states, Hill says the role of the Center gets more important with each new healthcare law that passes. "Every piece of legislation designed for larger hospitals," he says, "almost always has a consequence for rural providers that wasn't intended."
Working in the rural healthcare field, Hill adds, "appeals to my sense of the dramatic. We are the ultimate underdogs."
In rural Minnesota, doctors can be hard to come by. But Dr. Heidi Korstad, who has practiced in Bigfork for nearly 30 years, wouldn't live anywhere else.
Originally from Braham, a town of 1,800 people north of the Twin Cities, Korstad says, "When I came out of residency, I drew a line at Duluth and looked at everything north. That was a lifestyle choice." Korstad, who attended the University of Minnesota, completed some of her training in Minneapolis. "The longer I was in bigger cities, the more I found myself driving on the weekends north to camp and canoe because I felt really good when I was in the woods. I thought it was silly to be driving all the time."
She started at Bigfork Valley Hospital in 1983 and was the town's first female doctor. Since then, she's become embedded in the community of 450, having helped build a state-of-the-art community theater called the Edge, where she runs the lights during performances. She's part of why Bigfork Valley is one of the highest rated hospitals in the state.
"Small communities are misrepresented sometimes," says Korstad, a family practice doctor who talks a mile a minute. "Everybody thinks we're treating ear aches and sore throats because we're not the Mayo. Where do you think people around here go when they have a heart attack or major car accident or a stroke or cancer? They don't go to the Mayo. They go to us. And we may pass them on for specialty care, but we have to take care of everything that walks in the door."
Korstad calls this the rural health care story. "The quality has to be higher than in the city because there is nobody to bail me out," she says. "The quality has to be greater, but the volume is tiny."
Nationally, fewer than 10 percent of medical school graduates become family physicians and an even smaller sliver put out a shingle in a small town. The University of Minnesota medical school's Duluth campus bucks that trend, however, by turning out more family doctors than the average — 51 percent of graduates — and also more rural doctors than any other school in the country, 45 percent of graduates.
"That's not an accident," says Dr. Jim Boulger, who runs the school's preceptor program, which matches students with rural providers who show them the ropes. "We select [students] for that." The university recruits candidates who hail from small towns and thus are more likely to want to practice in one. "People don't go into rural family medicine for money," Boulger says. "If you don't get the people in who want to do this, you will never get them out to do it. We'll have 1,300 applications for 60 spots. We'll ask, 'Where did you grow up? What was that like for you? What is your experience taking care of others? What is your philosophy of life in terms of helping others?'"
"Everybody has the smarts," he adds. "There are 4.0s who can't tie their shoes. They are not going to get in here. We will take that kid who boot strapped himself off the farm, who took care of the crops and the animals."
"We take them from smaller communities, train them in smaller communities, and we've got them out there in the communities," says Boulger, who has been at the university for 37 years and working on rural health care issues since he started. "It's all conscious. It's all horribly time consuming to try to engineer this stuff."
He's driven by the belief that everyone deserves good health care, regardless of income or geography, and that the "front line generalist" is the core of the solution. "To me, these are moral issues before economic issues, human issues before systems issues, people issues before professional issues," Boulger says. "When we do not have the patient at the center of our care, we all lose. I do try to illustrate this to our students as they are trained."
One way rural communities fill the gaps left by a dearth of outstate psychologists is to utilize telemental health. With broadband spreading to Minnesota's smallest towns and farms, it's becoming possible for even the most remote patient to see, by camera and video monitor, a psychologist hundreds of miles away.
Often, when a patient sits before that camera for a session, the doctor they're talking to is Jane Hovland, a pioneer in telemental health. Rural people, says Hovland, who was raised in northern Minnesota, "are such a self-reliant bunch." When it comes to mental health, "We expect people to figure it out on their own."
But the fact is, some can't. The most common diagnosis Hovland makes is of major depression, followed by anxiety disorders.
Hovland notes that Minnesota has more psychologists than the national average. But they tend to practice in the city. "There are 13 counties without a single licensed psychologist," she says. "It's a matter of distribution." That's why doctors with the university's telemental health program have seen 2,300 patients over the past five years.
"I had a client who would ride a bicycle in from the woods for telemental health appointments," Hovland says, noting that because the university sees patients quickly, the no-show rate is very low. "We're trying to show that this is a sustainable model," she says.
In April, Minnesota became the first state in the nation to establish certification for a new class of health care practitioner called "community paramedics." These specially trained paramedics will be able to perform an expanded range of tasks typically reserved for doctors and public health nurses. By design, they'll perform them in underserved rural areas.
A community paramedic might suture a wound, adjust a medication, talk through a mental health issue, or address an asthma attack, all on the spot. In the future, they might make regular, preventative home visits to "frequent flyers," those patients who call 911 the most and cost the system dearly.
One of the forces behind this legislation was Gary Wingrove, program manager of St. Cloud's North Central EMS Institute, who helped establish the training curriculum and co-founded the International Roundtable on Community Paramedicine.
"What's kind of happened over time, as medicine has evolved, is we've identified gaps in a community that need to be filled," says Wingrove, who lives in Buffalo. "EMS workers already have a skill set that's common in primary care. When there is a hole in the community and the community searches out a way to fill that gap, the best thing they can do is look to existing providers."
What the curriculum does, he says, is train paramedics "to use their skills in a different way."
Driving this approach — besides the lack of doctors in rural Minnesota — are changes to federal healthcare laws which will penalize hospitals for some emergency room re-admissions on the theory that they should be coordinating better outpatient care. "Interest in this has exploded very quickly," says Wingrove.
New federal health regulations require hospitals and clinics to convert from paper to electronic medical records by 2015 or face fines from Medicare. The task is expensive and especially daunting for small, rural hospitals, since they operate on extremely narrow margins.
Help has come in the form of a Duluth consortium called SISU, which offers its members technical equipment and support and saves money through group purchasing and volume discounts.
"A lot of pricing is based on bed size or revenue," says Nelson. "These rural hospitals pay more. This was a means for us to pull together users for purchasing power and licensing agreements and to leverage the numbers."
Informally started in 1982, SISU became official in 1997. Its 22 full and associate members range from Regina Medical Center in Hastings to Cook County North Shore Hospital & Care Center in Grand Marais.
SISU's technical staff come in handy in rural areas, which are often short on IT professionals. Says Nelson: "Some of our members would say, even if I had the funds, I can't get the types of people, the breadth of knowledge I would need, [in my town]."
It's all but impossible for a hospital to go it alone on electronic medical records, Nelson explains. "It's about cost and resources. Partnering with other organizations allows them to pool together and make more headway. The savings are incredible."
Some of the people fighting hardest for the survival of rural hospitals are the people running them. Al Vogt is a stalwart advocate.
"The hospital itself seems to be doing okay, especially in Wild West of health care reform," says Vogt, who started at the hospital in 1976 as a lab supervisor and became CEO in 1989. "You never know which gun slinger is going to come to town. You walk down the street and hope you can avoid the gunfire."
Cook is stable and enjoys strong community support, he says, because "as a small primary care organization, we've found our niche and know our market. We don't try to be things we shouldn't be. You can't be all things to all people. So many folks try to do that and it gets them into trouble."
To fill service gaps, Vogt is a believer in telemedicine. "I feel an investment in this is an investment in the future," he says. Cook has utilized it for dermatology, endocrinology and psychology. "One area we're just exploring now, which has been tested in other places in the country, is teleorthopedics."
The hospital is working to get up to speed with electronic medical records, as required by federal health care reform. "It's a long haul," Vogt says. "I don't think there is enough time in my career to finish this project. I'll be rolling down the hallway in a wheelchair, hitting machines with my cane, saying 'Put in another module.'"
"There are a lot of threats out there, including physician recruitment," he adds, but it's important to remember that rural hospitals must continue to exist. "Say healthcare reform drives Cook Hospital under. People will have to drive up to 100 miles for health care. Is that the right thing to do? I don't believe it is."
In a rocky health care landscape fraught with increasingly complex regulations, requirements and reimbursement schemes, Dr. Susan Rutten Wasson's practice is revolutionary in an old-fashioned way. She sees patients the same day if she's not booked up, spends at least a half hour per visit — compared to the more typical 15 minutes — and usually charges only $50 for a consultation. She takes cash or check, but no insurance, and sometimes accepts gratuities of a dozen fresh eggs or a pie.
Rutten Wasson started out on a more conventional path, completing her post graduate training at the University of Minnesota and working for a couple of years at Allina Hospitals & Clinics in Richfield. But she quickly became disenchanted with the world of "relative value units," the fees charged for services that seemed to her disconnected from patient care.
What bothered Rutten Wasson most was that she couldn't give a break to patients without insurance. "It's hideously unfair that uninsured people are given a bill for $375 and are expected to pay the whole thing, while the insurance company pays between 60 and 75 percent," she says. "It's not right. People without insurance are subsidizing people who have it."
"I view medicine more as a ministry than an industry," she says.
Her clientele are people who can't or won't go elsewhere: people with no insurance or high deductibles, people looking for second opinions, Amish people and Latinos. Rutten Wasson, who speaks "medical Spanish," serves immigrants working in the area's dairies and meat packing plants. Other patients come from as far away as Bemidji and the Twin Cities, she says.
By Rutten Wasson's lights, they're drawn by a desire for privacy and because she listens and thinks independently. "Right now, the push with the third-party payers is, conformity equals quality," she says. "That works if you're building piston valves. But people are not all the same. You want every car to be the same. But with patients, one person is a Volvo and another is a Civic. You might have a Rolls Royce in there and maybe a Model T. I'm customized and personal. That's why people like to come here. I don't do the same thing for everybody."