Volume 8 Number 2
Fishing on the St. Louis River near Duluth
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Summer 2006
The mission of the Office of Rural Health & Primary Care is to promote access to
quality health care for rural and underserved urban Minnesotans. From our unique position
within state government, we work as partners with communities, providers, policymakers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
A means to an end
Technology has always been central to health care delivery. Using technology to attain our health
care goals in rural and underserved areas includes telemedicine and telemental health,
teleradiology, telehomecare and telepharmacy, as well as the electronic health records, health
information exchange and related applications on which the entire health care industry is focusing.
In its 2001 report Crossing the Quality Chasm, the Institute of Medicine proposes a vision that
health care must be safe, effective, patient-centered, timely, efficient and equitable. Let’s explore
some technology examples from Minnesota’s health care safety net through this lens.
Safe. Telepharmacy (directing medication dispensing and providing pharmacist services from a
remote site) and automated medication dispensing have reduced medication errors in several
rural Minnesota projects.
DIRECTOR’S CORNER
Mark Schoenbaum
Effective. In northern Minnesota, the HomeHealth Partnership of Crosby and Aitkin’s
use of telehomecare equipment to monitor patients with heart failure has significantly
reduced hospitalizations.
Patient-centered. Specialists at a tertiary hospital monitor intensive care patients in rural
southwestern Minnesota by using an “e-ICU” service. This responded to the interests of
patient, family and community for high quality local care and improved outcomes.
Timely. With major support from the U.S. Department of Agriculture, the Minnesota Association
of Community Mental Health Programs is building a telemental health network to connect 80
rural mental health centers, reducing wait time for appointments and emergency consults.
Efficient. Teleradiology, now widespread in rural Minnesota, delivers immediate after-hours
image interpretations to even the most remote emergency room.
Equitable. The Neighborhood Health Care Network, which serves Twin Cities community
clinics, will soon provide a centralized Patient Electronic Care System to coordinate disease
management for uninsured and underinsured patients with conditions such as diabetes,
cardiovascular disease and depression.1
These examples illustrate that technology is a means to achieving quality, maintaining access to
care for patients and mediating workforce shortages. Yet the health care safety net does face
barriers: uneven access to broadband services, limited financial capacity, shortages of health care
and information technology workers, conflicting referral and affiliation issues, and insufficient
scale to secure meaningful discounts on technology purchases.
There has also been increasing activity toward accelerating and coordinating the development of
HIT and telemedicine in rural and underserved areas of Minnesota. Among those who have
begun regular communications and planning are the University of Minnesota Telemedicine
Center, Blue Cross Blue Shield, the Minnesota Department of Human Services, USDA Rural
Development’s Minnesota office, Onvoy, the Blandin Foundation’s Get Broadband! Program and
the Office of Rural Health and Primary Care.
In May, Minnesota’s eHealth Advisory Committee adopted its 2006 recommendations, which
include several that support acceleration of HIT in rural and underserved settings. And in
response to the Governor’s proposal, the 2006 legislature has provided an initial $1.5 million in
grant funds for interconnecting electronic health records among providers in rural communities,
community clinics and others.
This year’s rural health conference, Smart Health 2006: Focus on Technology, Creating
Connections and Strengthening Minnesota’s Rural Communities, will delve into many of these
topics. The program looks great, and I hope to see you in Duluth July 17 and 18.
Minnesota’s health care safety net is focused on delivering quality health care—by achieving
technology’s potential we will further our progress toward that goal.
1
A good compendium of recent HIT activity, compiled by the eHealth staff at MDH, is available
at http://www.health.state.mn.us/e-health/profiles.pdf.
2
by Warren Wolfe, Star Tribune Staff Writer
Reprinted from the Star Tribune, Minneapolis-St. Paul
The new Medicare drug benefit that started Jan. 1 is just
the latest bit of bad news for Leah Seehusen and thousands
of other rural pharmacists in America.
“I’ve thought of all sorts of things,” she said. “I could
close the rest of the store and just fill prescriptions, or get
a smaller space attached to the medical clinic.”
“Medicare Part D is great for my customers. It’s cutting
their drug costs. But it’s also cutting our profits,” she said.
“We actually lose money on some prescriptions, and we
don’t make much on any of them.”
A common problem for rural pharmacists is finding help so
they can take vacations or a day off.
Business is so bad that more than 100 Minnesota drugstores
have closed in the past decade or so. Others will follow,
experts say, because there are few buyers for stores that are
turning unprofitable.
“We’re open six days a week, and I can’t afford to get
sick. But I’m lucky. The pharmacist from Hector 25 miles
away closed his store three years ago and retired. He
comes over so I can take Wednesdays off. And I did get a
week of vacation last year—at a professional conference.
But at least it was in Florida.”
Researchers at the University of Minnesota say Leah’s
Pharmacy in Renville (pop. 1,275) is one of 37 in
southwestern Minnesota at risk of closing in coming years.
One solution could be telepharmacy, a pharmacy in one
town linked by a computer and webcam to a satellite
office staffed by a technician in another town.
“These are one-pharmacy communities, and the
combination of financial pressures and pharmacists nearing
retirement is creating a difficult future,” said Todd Sorensen,
an assistant professor at the university’s College of Pharmacy.
That’s one of the tools Jill Reinhardt, 36, is trying at First
Choice Pharmacy in Gaylord.
Sorensen and his colleagues are working with pharmacists
and local officials seeking ways to keep them afloat—
perhaps through networks or purchasing groups.
Armed with an $84,000 federal grant, Sorensen held four
town hall meetings this spring to begin the work.
“This is not an easy time to be a pharmacist, especially in a
rural community,” said Julie Johnson, executive vice
president of the Minnesota Pharmacists Association. “The
hours are long, the work is demanding and the financial
rewards are leaching away.”
After the pharmacies closed a few years ago in Gaylord
and nearby Henderson, both communities tried to woo
her from her pharmacist job at the Minnesota Security
Hospital at St. Peter.
A year ago she chose Gaylord (pop. 2,200), where a new
medical clinic wanted to lease space for her to run a small
pharmacy. And a few months ago she also opened a
telepharmacy office in Henderson, 16 miles away. From
Gaylord, she looks at the prescription the technician fills
in Henderson, and counsels patients there via the camera.
Changing times
With both stores, she fills about 80 prescriptions a week
and is aiming for 100, which is about what she needs to
turn a profit.
When Seehusen, 41, bought the pharmacy in Renville 13
years ago, about 30 percent of her customers were covered
by insurance or government programs such as Medicaid for
the poor. Now it’s 90 percent.
“The combination of leasing a small space and
telepharmacy is giving us a chance to make this work,”
she said. “I wouldn’t have even tried buying a traditional
drugstore here.”
“And for the past four years, insurers and the government
have been trying to outdo each other in ratcheting down
what they pay us,” she said.
This week she received a $48,000 grant from the state
Office of Rural Health and Primary Care to start a
residency program for pharmacy students from the
University of Minnesota—“a help to train pharmacists in a
small town, and a help to me.”
In January it got worse.
Under the new Medicare drug program, which is handled
for the government by private firms, the fees she receives
dropped some more.
“I spent a lot of time on the computer helping my
customers figure out which Medicare drug plan was best for
them,” Seehusen said. “A lot chose Humana or Blue Cross
and Blue Shield, neither of which is doing us any favors.
“Blue Cross, for instance, had a drug plan for seniors that
paid us $2.50 per prescription. But their new Medicare
plans pay $1.75 as a fee for filling a prescription,” she said,
adding that sometimes reimbursement for the drug itself
won’t allow her to break even on a transaction. “When my
cost is about $8 to fill a prescription, that’s discouraging.”
As at most pharmacies, about 90 percent of the store’s sales
comes from drugs. The greeting cards, beauty aids, gifts and
other merchandise help get customers in the door.
SPECIAL FEATURE
Endangered species: The Main Street drugstore
Main Street loses, too
A survey of pharmacy students at the university found that
most of them would consider working in a rural pharmacy.
“They like the idea of small-town life,” Sorensen said.
“But they don’t like the idea of the long hours and
financial risk. We need to figure out how to make those
pieces fit. One way may be community ownership, like
the pharmacy in the clinic at Gaylord.”
Fellow researcher Tom Larson is sure there are ways to
help rural pharmacists survive. He heads the university’s
Pharmacy Rural Education, Practice, and Policy Institute
and is working with Sorensen to find solutions.
“The stakes are really high. This is about preserving health
care, and really about the economic health of the
See “Endangered species” (back page)
3
PROGRAM FOCUS
Minnesota’s Rural Hospital Flexibility Program enters a new era
80 Critical Access Hospitals — A Rural Health Milestone
“Being a Critical Access Hospital has made a significant
difference in our ability to expand and enhance the level
of health care services we offer. Many positive outcomes
have occurred across the state through the assistance
provided by the Flex Program, and without it, the quality
of health care would be diminished in each of our
communities.” Michael Hagen, Riverwood Health Care
Center, Aitkin
Since the inception of the federal program, ORHPC has
applied for and received ongoing federal Flex funding,
which it passed on to rural hospitals and community
agencies to ensure they have the infrastructure, tools and
resources to provide health care access and quality across
the life span, across the state. ORHPC also supports rural
systems of care through technical assistance, research
and collaboration.
Minnesota’s Medicare Rural Hospital Flexibility Program
passed a milestone. As of January 1, 2006, all rural
hospitals qualifying for Critical Access Hospital (CAH)
certification in Minnesota have been designated, bringing
the total to 80. CAHs are a unique category of rural
hospitals that receive cost-based reimbursement for their
Medicare services and are allowed greater flexibility in
staffing. In return, they agree to make emergency services
available 24 hours per day, maintain an annual average
length of stay of 96 hours or less and participate in
networking relationships with other health care providers.
Partnerships are fundamental to this work. The Flex
Program’s partners include the Minnesota Hospital
Association, Stratis Health, Minnesota’s Medicare Quality
Improvement Organization, the Emergency Medical
Services Regulatory Board (EMSRB) and its eight regional
affiliates, the Rural Health Resource Center (RHRC), the
Health Education-Industry Partnership and the Minnesota
Rural Health Association.
Minnesota Department of Health licensing and certification
survey teams, the Office of Rural Health and Primary Care
(ORHPC) and the Minnesota Hospital Association worked
together with hospitals to ensure that all those qualified
and interested could complete the process before the
December 31, 2005 designation deadline, which Congress
imposed in the 2003 Medicare bill.
Imagine a community breathing a big sigh of relief
because they can keep their hospital—that’s the effect of
Critical Access Hospital status and Flex Program
funding.” Dawn Wells, Administrator, St. James Health
Services, St. James
The Medicare Rural Hospital Flexibility Program had a
positive impact on health care and hospital viability in
rural communities. A report in April of 2005 from the
federal Flex Monitoring team indicated most hospitals
became more profitable, increased bed utilization and had
Bridges Medical Center in Ada
Benefits of the Flex Program in Minnesota
Congress created the Rural Hospital Flexibility (Flex)
Program in 1997 to help with economic and demographic
changes threatening the availability of health care for many
rural Americans. The Flex Program provides interested
states with grants to implement the CAH program,
encourage the development of rural health networks, help
with quality improvement efforts, and enhance rural
emergency medical services.
4
Cook Hospital construction
less debt because of CAH status. Mike Hedrix of the
Benedictine Health System says, “The difference for a
small hospital having Critical Access status is like night
and day, life and death, being there or closing. CAH status
is at the heart of the mission-critical turnaround we were
able to make at Pine Medical Center. We feel more secure
because of better reimbursement and are able to more
sure-footedly address our community’s health needs.”
CAH status goes beyond improving hospital finances in
rural communities. Sue Klabo of Mahnomen Health
Center in Mahnomen explains it this way, “The CAH
model has been a financial relief for Minnesota’s poorest
county and it came with collateral effect. The community
of Mahnomen has benefited through improved services,
and quality health care is now seen as a partner to
economic development in our rural area. With the grants
and assistance we have been able to receive, lives have
literally been saved in our county through emergency
services and trauma training, information technology
improvements, and improved radiology services to name
just a few.”
Sioux Valley Luverne Medical Center
networks and share resources to provide high quality care
well into the future. Flex grants have allowed a foundation
to be built in rural America; now we need to construct an
expanded system from that base.”
Minnesota’s Flex Program will continue to support rural
systems of care, with the Critical Access Hospital as the
hub, through continuation and expansion of:
• Grant programs (Information is online at
http://www.health.state.mn.us/divs/chs/grants.htm)
• Performance and quality improvement initiatives
• EMS-related research, workforce development,
partnering activities, grants and assistance
• Technical assistance, information and training in areas
such as reimbursement, licensing survey assistance
and grant writing
• Assistance and leadership in community health
development efforts.
St. Elizabeth’s Medical Center “field of dreams.”
Tom Crowley of St. Elizabeth’s Medical Center in Wabasha
concurs, “Without CAH status and Flex Program funding,
we couldn’t serve the health care needs of our community
to the fullest extent. We are better able to retain
physicians. We’ve had support for cardiac rehabilitation,
ultrasound, radiology renovations, a distance learning
program to train LPNs and RNs, and purchasing an
emergency generator.” Rick Failing, former chief executive
officer of Kittson Memorial Health Care Center in Hallock,
sees the Flex Program as, “a shining example of how
federal funds can be used very cost effectively!”
The Future Needs and Plans of the Flex Program
There are still many challenges affecting health care access
in rural Minnesota. ORHPC and the Flex Program will
work to ensure that the CAHs can sustain their efforts to
build a stable infrastructure, long-term access and quality.
As Mark Paulson of Chippewa County-Montevideo
Hospital elaborates, “The Flex Program has had a
significant impact on our rural hospital’s ability to deliver
health care. The grant dollars enabled our conversion to
Critical Access, but now the greater need is to allow us to
address ways in which our hospitals can continue to build
A summit is planned in 2007 for all 80 CAHs to showcase
health information technology, telemedicine, electronic
health records, quality and performance improvement,
leadership culture and patient safety, access to capital,
revenue management and other business and patient
services improvements. Pam Hayes, Minnesota’s Critical
Access Hospital and Flex Program coordinator, says the
Minnesota Flex Program, “will continue a leadership role
in developing collaborative delivery systems and
supporting innovation in service delivery. Our priorities
include improving and expanding E-health and other
information technology, community continuums of care,
healthy aging planning and mental health services.”
More information about the Minnesota Rural Hospital
Flexibility Program and Critical Access Hospitals is online
at http://www.health.state.mn.us/divs/chs/rhpc/cah/
index.html or contact Pam Hayes at
[email protected] or (651) 282-6304 or
(800) 366-5424.
5
by Jay Fonkert
Health care industries employ more than 300,000
Minnesotans, or about 13 percent of the state’s total nonfarm private sector employment.
That’s both good news and bad news for Minnesota. On
the plus side, health care is a leading economic engine for
many communities. This is obviously true for the Twin
Cities or Rochester—communities with large medical
centers; but it is also true for many smaller cities. Even in
non-metropolitan counties like Wilkin, Grant and Chisago,
health care and social services employment accounts for
more than 20 percent of all jobs.
100
80
60
40
20
0
25
30
35
40
45
50
55
60
65
70
Age
The challenge of finding enough health care workers is the
not-so-good news. Despite advances in medical technology,
health care remains a relatively labor intensive industry
that must compete with other businesses for workers.
If, as expected, demand for health care rises as the baby
boomers age, Minnesota will need even more health
care workers. Minnesota faces two major health care
workforce challenges:
• Many of the state’s most highly trained health care
professionals, including physicians, nurses and
dentists, are nearing retirement.
• Retirements may hit rural areas hardest, exacerbating
the inequitable distribution of health care providers
that already exists between urban and rural areas.
Workforce Renewal
The workforce is ever-changing. It must be constantly
renewed with younger workers as older workers retire,
and new kinds of workers must be trained as professions
evolve and entirely new occupations spring up to meet
new needs.
Two principal professions face heavy retirements in the
near future:
The median age of active registered nurses (RN) increased
from 42 in 1996 to 47 in 2006. Forty-three percent of
RNs are 50 or over. The RN workforce is predominately
45- to 55-year-old nurses. In 2004, there were only twothirds as many RNs 35-44 and 45-54 years old. Unless
large numbers of new RNs are developed over the next 10
years, Minnesota health care employers will have an even
smaller pool of RNs to draw on than they do today.
The median age of dentists climbed to 50 in 2005. More
than half of active dentists were 50 or older. Dental
retirements are even more imminent in rural Minnesota,
where the median age was 53, and 68 percent of dentists
were over 50. There has been an upturn in the number of
dental graduates in recent years, but there are still only 57
percent as many dentists aged 35-44 as aged 45-54. Thus,
the overall number of active Minnesota dentists may start
to decline in the next 10 years.
6
Active Minnesota Dentists by Age
120
Dentists
POLICY FOCUS
Minnesota’s Health Care Workforce: a look over the horizon
Until recently, most studies warned of an oversupply of
physicians. These studies generally estimated the number
of physicians needed to serve a given number of people,
and assumed gains in efficiency from managed care and
greater reliance on non-physicians such as physician
assistants and advanced practice nurses. More recent
studies have projected a physician need based on demand
for health care backed by economic growth. In 2004, the
Council on Graduate Medical Education reversed its
position and warned of large shortages by 2020.
The entire economy faces a labor challenge as the baby
boom generation approaches retirement. After growing
about 16 percent between 2000 and 2010, the labor force
is expected to grow only 6 percent between 2010 and
2020, and even more slowly after that.
Any tightening in the labor supply is especially challenging
for health care because health care needs are expected to
rise with a rapid increase in the senior population. The
number of Minnesotans 75 and older will grow modestly
until 2015, and then explode from about 345,000 in 2015
to more than 600,000 by 2030.
Now is the time to start recruiting the health care workers
to meet the needs of this older population. It takes more
than 10 years to train a physician. Dentists typically don’t
start practicing until their late 20s. Even nursing, a field
which hasn’t always required a four-year degree, is moving
toward more jobs requiring a master’s degree. The health
care providers of 2010 to 2015 are already in the pipeline.
Efforts to recruit more health care workers today will not
show results until 2015.
It is difficult to predict health care workforce needs with
precision for two reasons.
First, new technologies and treatments will create
demands for new kinds of workers. Second, shortages of
health care workers will likely push wage levels up,
creating incentives for hospitals, clinics, nursing homes
and other health care employers to seek new ways of
delivering care that may use different mixes of occupations.
Workforce Geography
Other challenges
Like many other specialized services, medical care tends to
be concentrated in regional centers and metropolitan
areas. And, just as specialty retail stores and “high-end”
services are most often located in more urban areas, so are
more specialized medical services. However, we rightfully
consider the distance someone must travel for dental or
medical care a more serious matter than distance to a
shopping mall.
Three other areas deserve attention:
• Minorities remain underrepresented in Minnesota’s
health care professions. Less than 5 percent of dentists
are minorities. Minorities account for only 6 percent
of physician assistants and 2 percent of physical
therapists. Minnesota’s population was 12 percent
minority in 2000. Because the minority population is
younger than the white population, the minority share
of the population is expected to continue to grow.
• Nationally, the number of primary care resident
positions offered to medical school graduates dropped
2 percent from 2000 to 2006, while positions in other
specialties increased 9 percent. This has raised some
concern about the future supply of primary care
physicians. However, if Rochester is excluded, 51
percent of Minnesota physicians said their principal
practice was in a primary care specialty in 2005.
Nationally, less than half of family practice residencies
were filled by U.S. medical school graduates,
suggesting that foreign-trained physicians will continue
to be an important source of family practice physicians.
• An expanding health care industry needs more than
physicians, nurses, dentists and pharmacists. These
highly visible professionals account for only 38
percent of the health care workforce. Their work
depends on dozens of technical professions. In
addition, hospitals, clinics and care facilities need
thousands of supporting occupations to function. Not
all health care occupations are high paying. Wage
levels may need to rise to attract enough workers
from a slower-growing labor force.
The state’s 46 most rural counties have 13 percent of the
state’s population, but only 8 percent of the state’s dentists
and registered nurses, and only 5 percent of the state’s
physicians. The state’s 21 metropolitan area counties have
73 percent of the population, but 78 percent of the state’s
dentists, 80 percent of the registered nurses and 85
percent of the physicians.
Conclusion
Specialists are even more concentrated in urban areas than
primary care providers. Eighty-four percent of surgical
specialists and 91 percent of other specialists practice in
metropolitan counties. Only 4 percent of surgical
specialists and 2 percent of other specialists practice in the
46 most rural counties.
Looked at another way, 74 percent of rural physicians are
primary care providers, compared to 57 percent of
micropolitan physicians and only 44 percent of
metropolitan physicians.
None of this is surprising. Larger populations are necessary
to support many specializations. Many smaller
communities simply cannot support full-time specialists.
The future of Minnesota’s health workforce is serious
business. Health care is a big part of the state’s economy
and, more importantly, timely and cost-effective health
care services depend on an adequate supply of health care
professionals. Most attention is paid to highly trained
professionals like physicians, nurses and dentists, but
hospitals, clinics, nursing homes and other health care
providers require a broad range of workers, including
clinical laboratory workers, imaging specialists, physical
therapists and others with specialized training. Many fields
require graduate-level training, so the time to take steps to
increase supply is before shortages become more severe.
A definition of metropolitan, micropolitan and rural,
along with additional information is online at
http://www.health.state.mn.us/divs/chs/data.htm or
contact the author at [email protected] or
(651) 282-5642.
7
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
www.health.state.mn.us/divs/chs/
orh_home.htm.
Endangered species (continued from page 3)
community,” he said during a break at a town hall meeting on the topic last week in
Montevideo.
“Most people don’t realize when their pharmacy is in trouble,” Larson said. “But if a
pharmacy closes, Main Street loses because people drive elsewhere to buy drugs—and a
bunch of other things.”
When she came to Renville, Seehusen thought she’d be there until she retired.
“Now I’m sure I won’t last that long,” she said. “I love the work. But we lost money in
January and February, although March was better. My technician says I have to figure out
when to cut my losses.
“I haven’t actively put the store on the market, but I’ve told our salesmen that the place is
for sale.”
Mark Schoenbaum, Director
Mary Ann Radigan, Editor
Cirrie Byrnes, Editorial Assistant
University of Minnesota researchers have identified 37 cities in southwestern Minnesota
where the local pharmacy is at risk of closing. In each case, the community has only one
pharmacy and the population is less than 3,000. Source: University of Minnesota College
of Pharmacy
Information on the drug benefit is at http://www.medicare.gov/.
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
Printed on recycled paper with a
minimum of 20% post-consumer waste.
Star Tribune staff writer Warren Wolfe (612) 673-7253
Copyright 2006 Star Tribune. Republished with permission of Star Tribune, Minneapolis-St.
Paul. No further republication or redistribution is permitted without the written consent of
Star Tribune.
The ORHPC Quarterly is going to electronic distribution beginning with the Fall
2006 issue. If you did not respond to our postcard announcing this change, you may
still subscribe via email at http://www.health.state.mn.us/subscribe.html or request
other arrangements by contacting Cirrie Byrnes at [email protected]
or (651) 282-6303.
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