Primary Care in Rural Minnesota

Health Care Economics Presents an Ever-Fluid Reality Rural or urban, young or old, when you need care, you want it to be there for you—affordable, high-quality, and centered around your needs and goals. But the healthcare delivery and payment system is incredibly complex. Hospitals, clinics and individual healthcare providers throughout Minnesota are constantly adapting to market changes on all sides—new organizational affiliations, consolidation, value-based budgeting, population health pressures and declining inpatient care. In rural areas, the challenges can sometimes be more complex and require solutions that are tailored to rural needs. Relatively higher use of government healthcare programs, declining payment rates, changing insurance mandates, and intense workforce issues in rural Minnesota require that we continuously assess and analyze trends to help ensure our healthcare systems are positioned to provide necessary, affordable and appropriate care in communities all across the state. The Minnesota Department of Health’s (MDH) Office of Rural Health and Primary Care tracks Minnesota’s rural health systems and access to primary care for our rural residents, and uses that data to develop and implement programs to address rural healthcare needs.

Rural Health Care in Minnesota: Data Highlights On National Rural Health Day 2019, MDH published Rural Health Care in Minnesota: Data Highlights (https://www.health. state.mn.us/facilities/ruralhealth/docs/ruralhealthcb2019.pdf), a chartbook of data from across the department that “paints a picture” of rural health care in Minnesota.

The map of hospital affiliations shown below begins to reveal the complexities of current market trends. In 2017, half of Minnesota’s rural hospitals were affiliated with a larger provider group. This trend yields mixed results. Hospitals that are part of larger systems may offer increased access to specialty services and may increase their financial viability. But, affiliation can also lead to consolidation of services, meaning some services may be less available in rural areas, and patients may face transportation and other barriers in accessing them. The Data Highlights report also shows how noncompetitive hospital markets are in Minnesota. Analysis shows that highly

concentrated healthcare markets can lead to higher prices. We know that rural areas face a severe shortage of primary care physicians, including OB/GYNs, pediatricians and psychiatrists. Nine Minnesota counties lost hospital birth services between 2003 and 2018, with recent studies finding that increases in preterm births have been associated with the loss of these services in rural areas. Finally, we cannot underscore enough the impact closure of a healthcare facility has on its community. In many rural areas, the clinic or hospital is one of the largest employers in the area, as well as being an important part of a community’s identity. The loss of readily accessible health care causes great hardship to any local community, and then creates a domino effect that makes it harder for other parts of the community to grow. Young families may find it difficult to move to a community that does not offer healthcare services. We are still digging into how consolidation affects rural populations, particularly

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when it comes to primary care. We do know that there are fewer primary care physicians in independent practices across the state. We’re gathering economic data from a variety of sources to better visualize and understand the rural healthcare map to help rural communities anticipate changes in healthcare delivery.

Primary Care Improving access to health for rural and underserved Minnesotans is the core purpose of Minnesota’s Office of Rural Health and Primary Care (ORHPC). Ensuring access to primary care plays a large role in what we do. Studies show that focusing on primary care can lead to better health outcomes and lower costs. We also know that the presence of even a single primary care provider has a significant effect on the economic vitality of a rural community.

Workforce Shortage In addition to healthcare workforce shortages across rural Minnesota, we have a serious mal-distribution of primary care providers. The majority of providers work in urban areas. As a result, rural areas face a more severe shortage, especially when it comes to primary care and mental health. In fact, 80% of Minnesota counties qualify as mental health professional shortage areas and 62% of Minnesota counties qualify as primary care shortage areas. In addition, we know that rural physicians are older and closer to retirement than their urban counterparts, underscoring the need to increase efforts to recruit providers to rural Minnesota and build a more effective pipeline of rural providers.

Improving the Pipeline Currently, we are addressing this in a number of ways. Minnesota has a robust healthcare loan forgiveness program (https://www. health.state.mn.us/facilities/ruralhealth/ funding/loans/index.html) for healthcare professionals that has demonstrated a 72% retention rate for rural physicians over the last 25 years. Physicians and other health professionals who choose to practice in rural areas or among the urban underserved can have significant portions of their school loans

forgiven in exchange for practicing in these areas. Expanding this program to recruit additional physicians for the hardest hit areas of the state is a promising concept. We welcome input on identifying providers motivated by the opportunity afforded in rural practice to deliver the full scope of services. One of the surest ways to promote practice in rural areas is to provide more training in rural areas. It is well-known that people tend to practice where they train, and Minnesota could do a better job of providing these opportunities. To this end, we are working on several fronts to learn what it takes to build more rural tracks for physicians and other primary care providers. Minnesota has had great success with the Rural Physician Associate Program (https://med.umn. edu/md-students/individualized-pathways/ rural-physician-associate-program-rpap), a nine-month, community-based educational experience for University of Minnesota third-year medical students who live and train in rural communities across Minnesota and western Wisconsin. We are interested in exploring whether some of those sites could add residency programs. In addition, ORHPC administers several grant programs to encourage the development of more rural and primary care residency programs, including: • The PrimaryCare ResidencyExpansion Grant to help with planning and the initial funding; • The Rural Family Medicine Residency Grant to support new and existing residency programs in rural Minnesota; • The International Medical Graduates Primary Care Residency Grant for Minnesota IMGs who agree to practice in rural and underserved areas of the state; and • The Health Professional Clinical Training Expansion Grant to expand clinical training for other primary care providers. In order for these programs to have real impact in expanding the number of residencies in rural Minnesota, we are working to understand the longer-term needs in creating new residency slots.

Scope of Practice ORHPC is also interested in promoting practices that allow primary care professionals to work at the top of their license, especially in underserved areas where the alternative can mean no access to service. Physicians can’t do it all on their own, especially when the population-to-provider ratio for primary care physicians is so much higher in small towns and isolated rural areas compared to metropolitan areas of the state. In all areas of rural health care, it seems clear that more can be done when clinical education, training and on-site practices like care coordination, which MDH’s Health Care Homes program actively promotes, continue to encourage team approaches where everyone makes the highest and best use of their skills and abilities.

Conclusion Ensuring that Minnesota’s rural health and healthcare system remains strong, financially stable, and able to meet the needs of all rural residents through all stages of life is critical. While the needs of rural communities are unique, so are the opportunities, energy and partnerships that exist in rural areas. In Minnesota and across the nation, exciting new models are being developed and tested—e.g., primary care and community collaboration models, global budgets for rural hospitals, and population-based or value-based payment systems centered around rural needs and challenges. These all hold promise for ensuring that our rural health systems thrive. ORHPC continues to work with community members, healthcare providers, legislators, members of the Governor-appointed Blue Ribbon Commission on Health and Human Services, and experts from around the nation to learn more about these strategies and how they could be used successfully in Minnesota. The issues of rural health are complex, and we’ll continue to work with communities and providers to build multi-faceted responses that adapt to changing times while valuing the economic and social networks that drive rural life.

Zora Radosevich, MPA brings a passion for rural health and the viability of rural communities to her role as director of the Minnesota Office of Rural Health & Primary Care. Zora has an MPA from the Harvard Kennedy School, and has served as an adjunct faculty member at the University of Minnesota. She can be reached at Zora.Radosevich@state. mn.us, (651) 201-3859.