Provision of Adequate Healthcare Resources to Rural Communities in Minnesota

Provision of Adequate Healthcare Resources to Rural Communities in Minnesota

Executive Summary:

          According to the National Rural Health Association, rural residents have less access to medical specialists and mental health workers. For rural residents to have sufficient healthcare access, necessary and appropriate services must be available and obtainable promptly. (Rural Health Information Hub, 2017) Minnesota has 87 counties across 22,454,358 square miles with a population of 5,489,594 which includes seven Anishinaabe (Chippewa, Ojibwe) and four Dakota (Sioux) tribal communities. There are multiple definitions of “rural” dependent on the data source that is being used. Not only do the definitions change, but the classification of geographic areas can change, which in turn can have a significant impact on specific variables like population. (Asche, 2018) For this brief, The National Center for Health Statistics’ definition of rural will be utilized which categorizes rurality based on county status, population size and location of the largest city populations.

          For clinicians to provide adequate and comprehensive care, they must function effectively within the context of cultural beliefs, behaviors, and needs of the consumers and their communities. The residents of the rural communities in Minnesota face different healthcare needs and challenges than their counterparts in the urban communities. Higher rates of chronic illness and poor overall health are often found in rural communities which leads to significant health disparities in these communities.  Rural risk factors for health disparities include geographic isolation, lower socioeconomic status, higher rates of risky health behaviors, and limited job opportunities. (Stratis Health, 2018)

     Barriers to health care result in unmet healthcare needs including lack of preventive and screening services, treatment of illnesses, and preventing patients from needing costly hospital care. (Rural Health Information Hub, 2017) Although access to medical care does not guarantee good health, it is necessary for the well-being of the community and rural communities rely on a healthy productive population. Shortages of health care providers to these communities appear to have the most critical impact to access. As of September 2018, 57.27% of Primary Care Health Professional Shortage Areas were located in rural areas, according to the Bureau of Health Workforce Health Resources and Services Administration. (Rural Health Information Hub, 2017)

     Innovative initiatives will be required to address these shortages in the health workforce. These initiatives include allowing physician extenders to work at the fullest of their abilities with fewer restrictions on their scope of practice. Another option is to leverage the technology that is available through the use of telemedicine to provide both primary and specialty care. Solutions should be cost-effective and make use of existing resources if possible.

Problem Statement:

     Adequate access to health care services is critical to ensuring good health. Residents of rural Minnesota face a variety of barriers to health care access. The rural communities of Minnesota should be able to conveniently and confidently obtain services such as primary care, emergency care, dental care as well as behavioral health and public health services. How can the Governor of Minnesota ensure that the rural population of Minnesota receives the appropriate access to health care services?

Background:

     According to the Minnesota Demographic Center, approximately 25% of Minnesotans currently live outside of an urban area with 44% of rural residents over the age of 50 (compared to only 32% in urban). (Office of Rural Health and Primary Care, 2017) Those living in rural communities have a higher incidence of significant health disparities. Health disparities are differences in health status when compared to the general population, often characterized by indicators such as higher incidence of disease and disability, increased mortality rates, lower life expectancies, and higher rates of pain and suffering. (Stratis Health, 2018) Multiple risk factors associated with people living in rural communities also contribute to the prevalence of health disparities.

     One way to determine the extent of the health disparities faced by those in rural communities is through the collection of data regarding perceived health status. Minnesotans living in rural communities rated their health as “fair” or “poor” more often than their counterparts living in urban communities. (Figure 1) Obesity rates are another way to gauge health status since it is a significant contributor to chronic disease and these rates are measured by a calculation of body mass index (BMI), which is a ratio of weight (kg), divided by height (m2). A BMI greater than 30 indicates obesity with the incidence of obesity in rural communities greater than those living in urban settings. (Figure 2)

     The most substantial barrier faced by rural Minnesotans is adequate access to health care services in a timely fashion. According to Healthy People 2020, access to health care is essential for:  overall physical, social, and mental health status; prevention of disease; detection and treatment of illnesses; quality of life; preventable death and life expectancy. (Office of Disease Prevention and Health Promotion, 2018) Providing an adequate health care workforce is critical for ensuring that rural Minnesotans have appropriate access to healthcare services. Overall, the ratio of all types of physicians per population is eight times higher in rural Minnesota than in urban areas. (Office of Rural Health and Primary Care, 2017) Current data shows that there are 2,715 people for every one primary care physician in isolated rural areas, 7,166 people per physician assistant in isolated rural areas and 8,433 people per physician assistant in mostly rural areas. (Figure 3)

Options:

     Recent federal efforts to improve access to care by improving insurance coverage did not get to the heart of the rural access issue—a shortage of providers. (Wells, et al., 2018) Current attempts by Minnesota’s legislature to improve the availability of physicians in rural areas through loan forgiveness have had some success at the beginning of the program, but it has not shown to improve the numbers as dramatically as is required. The number of physicians available to rural communities in Minnesota has been steadily declining with a significant loss estimated to occur within the next decade due to the aging of the workforce. Innovative solutions are needed to address the barriers and improve access to healthcare services.

     Utilization of Physician Assistants (PA) or Certified Nurse Practitioners (CRNP) as primary care providers is a valid option for increasing the number of available providers. Despite years of high-quality, cost-effective practice, there are still state and federal laws and regulations that prevent PAs from practicing to the fullest extent of their education and experience. (Wells, et al., 2018) Medicare laws require the PA to practice “under the supervision” of a physician as well as requires a physician co-signature for specific orders and services provided. At the state level, a written delegation agreement between the supervising physician and the PA is required and outlines what defines the supervisory relationship as well as outlining the duties and responsibilities of the PA as assigned by the physician. (Scope of Practice Policy.org, 2018) Conversely, in Minnesota, a CRNP may practice independently after a specified number of hours practicing within a collaborative agreement with a physician.

     PAs have a broad, generalist education which allows for them to take medical histories, perform physical examinations, order and interpret laboratory tests, diagnose illness, develop and manage treatment plans for their patients, prescribe medications, and assist in surgery. (American Academy of Physician Assistants, 2017) State laws allowing for a broad scope of practice that is decided at the practice level can improve outcomes for patients, providers, and communities. The decision should be made at the state level to allow PAs to practice independently, as the CRNP does, after a mandatory number of practice hours under a collaborative agreement with a physician. Critical areas of modernization of the PA scope of practice include laws governing efficient collaboration between PAs and physicians, patient access to PAs, and enrollment of PAs as providers in state Medicaid programs. (Wells, et al., 2018)

     Telemedicine has the potential to provide timely access to adequate health care services to those individuals living in rural Minnesota. The Health Resources & Services Administration defines telemedicine as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. (HealthIT.gov, 2017) The most common type of Telemedicine is the use of video conference that allows patients face to face access to a physician for consultation. Mobile health communication (mHealth) and remote patient monitoring (RPM) have become tools allowing for real-time monitoring and assessment of patients by both primary care physicians as well as specialty healthcare providers.

     Utilization of telemedicine to provide specialty services to rural communities is a viable option versus staffing facilities with challenging to recruit specialists. Telemedicine allows specialists to visit rural patients virtually to provide services such as neonatology, cardiology, neurology, pulmonology, dermatology, ophthalmology, audiology, infectious disease, and behavioral health. Telemedicine programs offer new methods for improving health care access and quality by extending the reach of health care services, improving the ability of rural providers to address a broader range of medical conditions, and facilitating collaboration between professionals with limited access to their colleagues. (Rural Health Information Hub, 2017) Leveraging technological advances and improved access to telemedicine allows for face to face assessments and services for patients located in the rural communities of Minnesota.

     Clinical trials, as well as studies, have focused on telemedicine as a cost-effective approach to the provision of health care services to those in rural areas. According to the American Hospital Association, in 2012, patients participating in their telemedicine program constituted a savings of $6500 per patient compared to patients who did not participate in telemedicine. (Sanders, Allen, & Maurer, 2017) The Veterans Administration showed that the cost of treating a patient via telemedicine was approximately $1600 per year vs. $13,000 a year for traditional home-based care and they reduced their hospital admissions by 19% and a 25% reduction in bed days. (American Hospital Association, 2016)

Recommendations:

     The healthcare most often available in rural communities is less likely to include specialty or high impact, sophisticated services. For some services, such as emergency medical services, the lower level of care available, when added to the increased time to services caused by distance, can be the difference in life or death. (Stratis Health, 2018) Taking into consideration the current state of health and access to quality health care in rural Minnesotans to do nothing to improve availability has far-reaching ramifications for potentially disproportionate impacts to these rural communities. The decision for a recommendation was made by comparing utilization of PAs with an expanded scope of practice against integration of telemedicine services to improve access of health services to rural communities with consideration to targeted impact, political feasibility and cost-effectiveness it appears that telemedicine is the most viable solution. (Table 1 & Table 2)

     In order to provide the appropriate level of care required to a population that is older and more likely to have poor health behaviors, chronic illness, and reduced overall health there is a need to focus on access to specialized high-quality care. Research shows that telemedicine is an effective tool for providing access to healthcare, particularly those specialty disciplines that are difficult to recruit. The National Quality Forum determined that telemedicine activities would be especially useful in rural and underserved areas where patients have more risk factors and tend to be older. (Sanders, Allen, & Maurer, 2017) Telemedicine would allow the primary care providers in rural areas to collaborate with a multidisciplinary team to provide specialized, high-quality healthcare.

     With rural Americans having less access to health care, less access to reliable transportation, greater distances to travel to receive the care and lower income than their urban counterparts the benefits of telemedicine should be able to provide them the care they require to live healthy lives. (Sanders, Allen, & Maurer, 2017) In summary, the Governor of Minnesota can ensure that the rural population of Minnesota receives the appropriate access to health care services through support for the utilization of telemedicine. Through the support of efforts by the National Rural Health Association which outlines recommendations for telemedicine use in rural areas, this can be achieved.

References

• American Academy of Physician Assistants. (2017). PA Scope of Practice. Alexandria: AAPA.
• American Hospital Association. (2016). Telehealth: Helping Hospitals Deliver Cost-Effective Care. https://www.aha.org/system/files/content/16/16telehealthissuebrief.pdf: American Hospital Association.
• Asche, K. (2018). The State of Rural Minnesota 2018. Mankato: Center for Rural Policy and Development.
• HealthIT.gov. (2017, September 28). Telemedicine and Telehealth. Retrieved from Official Website of The Office of the National Coordinator for Health Information Technology (ONC): https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth
• Office of Disease Prevention and Health Promotion. (2018, October 25). Access to Health Services. Retrieved from Healthy People 2020: https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Access-to-Health-Services
• Office of Rural Health and Primary Care. (2017). Snapshot of Health in Rural Minnesota. St. Paul: Minnesota Department of Health.
• Rural Health Information Hub. (2017, June 9). Healthcare Access in Rural Communities. Retrieved from https://www.ruralhealthinfo.org/topics/healthcare-access
• Rural Health Information Hub. (2017, August 2). Telehealth Use in Rural Healthcare. Retrieved from Rural Health Information Hub: https://www.ruralhealthinfo.org/topics/telehealth#improve-access
• Sanders, B., Allen, Z., & Maurer, G. (2017). 2017 Telehealth Policy for the National Rural Health Association. Washington: National Rural Health Association.
• The scope of Practice Policy.org. (2018). Minnesota Scope of Practice Policy: State Profile. Retrieved from Scope of Practice Policy: http://scopeofpracticepolicy.org/states/mn/
• Stratis Health. (2018). Understanding rural health in Minnesota. Retrieved from Culture Care Connection: http://www.culturecareconnection.org/matters/diversity/ruralhealth.html
• Wells, R., Cody, M., Alpino, R., Van Dyne, M., Abott, R., & King, N. (2018). Physician Assistants: Modernize Laws to Improve Rural Access. Leakwood: The National Rural Health Association.

Appendix

Figure 1 “In general, would you say that your health is…?” Percent of adults who responded, “Fair or Poor health.”

Figure 2 Percent of adults who are obese according to BMI

Figure 3 Population to Primary Care Provider Ratio

Table 1: Descriptive Side-by-Side Table

Table 2: Analytic Side-by-Side Table