Rural health: Health professional shortages force changes

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BRAINERD, Minn. — Howard Cronquist baled hay the other day, and also fit in some time to work on one of his farm buildings.

That may not be big news for many farmers, but it is for him. Fifteen months ago, the rural Brainerd man suffered what was described as a major stroke. He and his wife, Sharon, credit his recovery to a combination of his hometown hospital and a Twin Cities neurologist stroke expert being in the emergency room via video to help local health care professionals.

"We were happy that he was here," Mrs. Cronquist said about her husband being taken to the Essentia Health-St. Joseph's Medical Center in Brainerd.

Conquist, 75, himself said he is almost back to normal, but "I will space my words a little bit" and admits to a few physical limitations and "my patience is a little bit shorter."

His success story illustrates good news in a rural health situation that is full of bad news.

Terry Hill, Duluth-based leader of national and Minnesota rural health organizations, said rural health is in "turmoil."

The system of paying for health care is changing nationwide, causing some of the turmoil, but patients are more likely to be affected by a rural doctor shortage that can make it hard to get a quick doctor's appointment or force long drives.

Doctors working via video from far away will become more common, Hill said. "Telehealth is just an incredibly helpful asset."

Hill summarized the rural problem: "Rural people are older, sicker and poorer." Plus, doctors and other health care professionals not not as attracted to rural Minnesota as in the past.

The Minnesota Hospital Association recently released a report that said a majority of hospitals experienced a positive operating margin in 2015, but 38 hospitals (29 percent) lost money. The vast majority of those hospitals are in rural areas.

Interviews of health care professionals across the state showed some good signs, such as telehealth use in the Brainerd hospital that helped Cronquist recover. But they also showed difficulties likely will increase as doctors are aging and there are few signs that rural Minnesota will get younger, healthier or richer.

A 2015 survey showed nearly half of the state's doctors plan to retire within 10 years, meaning doctor recruitment will become a bigger issue. The same statistic holds for dentists and psychiatrists, although other health care providers tend to be younger.

Many reaching retirement age are in rural areas. A 2014 study, for instance, showed 51 percent of doctors in isolated rural areas were at least 55 years old, with 39 percent of those in small rural towns that age and 42 percent of those in larger greater Minnesota towns. In urban Minnesota, by comparison, 34 percent were 55 and older.

The latest data compiled by the state Health Department's Office of Rural Health and Primary Care shows that in the most rural parts of the state there are 1,922 residents for each primary care physician. That number drops dramatically even in small rural towns, with 642 Minnesotans for every primary care doctor and down to 480 in large greater Minnesota cities. Urban areas have 256 residents for every primary care doctor.

Urban Minnesota is home to 87 percent of all doctors, primary care and specialists. Large greater Minnesota communities have 8 percent while smaller towns host 4 percent. Very few live in isolated rural areas.

Many rural Minnesota hospitals use a similar model to overcome shortages of health care professionals they face: Recruit as many primary care professionals (doctors, dentists, psychiatrists, nurse practitioners, physician assistants, nurses and others) as possible and also get help from telehealth video-audio connections to specialists, who usually are in urban areas.
Telehealth has been around for years, but its use is spreading quickly. So is the use of nurse practitioners and physician assistants to do tasks formerly only handled by doctors.
Health care leaders want to continue to keep local professionals as the center of rural patient care, but they are struggling to find enough to set up shop in rural areas.
Even as doctors are in short supply nearly everywhere, some rural health care officials are learning to better target doctors and medical students who may want to work in rural areas, including recruiting them while still in medical school or even earlier.

"It often takes a community effort for recruiting," the Health Department's Mark Schoenbaum said.

Schoenbaum's office has determined that every county other than seven in the Twin Cities area has a primary care provider shortage. It is not quite as bad for dentists, with more than two dozen counties having a sufficient number of dentists, lthough the more rural a county the more likely it lacks dentists.

All of Minnesota other than the Twin Cities and southeast is short of mental health professionals.

Rural docs take on more

A new state Health Department survey shows rural primary care doctors do much of the work their urban counterparts turn over to specialists.

About 56 percent of the time the most rural doctors deliver treatment that would be sent to specialists if the specialists were available, the survey showed. Doctors in small rural communities did that 43 percent of the time, while those in larger greater Minnesota cities did what otherwise would be specialists' work 26 percent of the time.

Urban primary care doctors, meanwhile, kept just 22 percent of their cases instead of sending them to specialists.

The Health Department's Office of Rural Health and Primary Care reports that specialists are scarce in much of rural Minnesota, so primary care physicians and other medical professionals tend to do more of the work rather than send their patients long distances to urban areas where most specialists practice.

While rural doctors take on more, data show rural areas also rely more on nurse practitioners and physician assistants than other parts of the state. There also are new types of jobs, such as community paramedic that allows ambulance paramedics to visit people at home to deal with some medical issues that do not need transportation.