Rural health care in Minnesota: a primer

How is the pressure on rural health care providers more intense than that on urban providers?

Rural areas long have had difficulty maintaining hospitals and attracting doctors, but political, economic and demographic changes are adding to the burden.

With the goal of making the health care system more efficient, new federal health care laws are pushing hospitals and clinics to adopt electronic record-keeping and cut down on repeat emergency room visits. Rural providers tend to survive on narrower margins than their urban counterparts — most rural hospitals in Minnesota operate in the red or with margins of less than 5 percent — so these standards are harder for them to meet.

Because the government will use Medicare and Medicaid reimbursement formulas to enforce change, the fact that rural systems rely more heavily on those programs than urban systems adds to the margin-squeezing. Rural populations tend to be older, poorer, less insured and more prone to chronic disease, which leads to a heavier than average reliance on public health insurance.

At the same time, the percentage of newly-minted doctors entering family practice — the specialty most in need in rural areas — is declining steadily. Fewer medical students are choosing to become general practitioners because the hours are longer and the pay is lower than in a specialty practice. Rising medical school costs contribute to the problem.

1) Doctor shortage

This graphic shows the number of primary care providers per 1000 people by county. In Minnesota, the ratio of primary health care providers to population tends to be lower in the west and northwest. Five Minnesota counties (shown in dark green) have no primary care providers. Source: Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

2) Hospital consolidation

Pressure on rural hospitals is leading them to join up with larger health systems. In the past 18 months, according to the Minnesota Hospital Association, eight small-town hospitals in Minnesota became affiliated with systems.

Are people in rural areas less healthy than people in urban centers? Why?

People in rural areas tend to be poorer, older, and less insured than people in urban areas. Often, this means they go to the doctor less often, receive less preventive care and wait longer to have chronic illnesses, like diabetes, treated.

When the University of Wisconsin and the Robert Wood Johnson Foundation ranked the overall health of Minnesotans by county, the worst health problems were found in rural parts of the state. Poor health outcomes were especially concentrated in central and northwestern Minnesota.

The county with the poorest health was Cass County, where smoking, obesity and teen pregnancy are issues and 15 percent of the population is uninsured, compared to the state average of 11 percent. According to recent census data, more than 14 percent of the county's population lives below the poverty line, compared to the state average of less than 10 percent.

At the same time, there are not enough doctors in rural areas to effectively treat these sparse populations. In Minnesota, there are five counties without a single primary care provider. That means rural people have to travel farther for treatment, especially when it comes to specialty treatment.

This throws up another barrier to care, since rural communities tend to have few transit options and people with limited resources may not have access to a car.

1) Chronic diseases in rural areas

Chronic diseases are more common in rural areas, according to data compiled by the American Hospital Association.

2) Diabetes

3) Obesity

4) Uninsured

How does national health care reform affect rural providers in particular?

When President Barack Obama signed federal health care reform in 2010, he and Congress set in motion a complex series of incentives, penalties and shifted priorities that will dramatically affect rural health care providers.

Federal reform aims to encourage cooperation among doctors, nurses, clinics and hospitals. In the future, it may be that an "accountable care organization" will be paid to treat a group of patients' needs and reap bonuses for keeping costs down. This is more difficult for rural providers because populations are sparse and there are fewer medical specialists in small towns.

The mandate for electronic health records is one of the biggest hurdles. Not only can these systems cost hundreds of thousands of dollars to implement, but the task is made more difficult by the lack of IT people in rural Minnesota. For now, the federal government is offering grants and incentives to help ease the way. But starting in 2015, providers who can't show they are using electronic records in a "meaningful" way will face penalties from Medicare, to the tune of 1 percent of reimbursements each year up to a potential maximum of 5 percent.

The penalties for some rural hospitals — those with 25 beds or fewer, designated as "critical access hospitals" — will face lesser fines. But since these small facilities often operate on the tightest margins and treat populations disproportionately reliant on Medicare, the penalties could have dire consequences.

1) Electronic records

Rural hospitals are more likely than larger counterparts to say they expect to face financial penalties by 2015 for failing to achieve meaningful use of electronic medical records. Source: American Hospital Association.

What changes in health care delivery are being tried to relieve the pressures on rural health care providers?

A number of creative solutions have arisen to address the particular challenges facing hospitals and clinics in rural Minnesota. Hospitals having trouble standing alone when it comes to purchasing or implementing electronic health records, for example, have formed networks. These coalitions result in discounts, technical expertise and other benefits often enjoyed by larger health systems.

When it comes to providing health care to patients, the landscape is changing in other ways. One strategy for bringing specialty care to remote locations is via camera and monitor. Today, telehealth is used to deliver services from dermatology to endocrinology. Doctors at the University of Minnesota-Duluth conduct remote psychology sessions with clients as far away as Paynesville.

Another approach, focused more on primary and dental care, involves training midlevel providers to perform some of the services usually reserved for doctors, nurses and dentists. Minnesota, at the fore of this trend, is the first state to license "dental therapists" and certify "community paramedics."

Dental therapists will be able to fill cavities and even pull baby teeth, under the supervision of a licensed dentist. Likewise, physician-supervised community paramedics will be able to treat minor injuries and address chronic illnesses like diabetes and asthma on the spot, rather than automatically driving patents to an ER. These midlevel providers will be deployed to underserved and rural areas.

Rural hospitals are more likely than urban hospitals to join cooperative networks and cite survival as a reason for doing so.

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