Volume 9 Number 3
Pumpkin patch in Belle Plaine.
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Fall 2007
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.
Health reform ideas that fit
Health care reform is once again a focus for public policymakers. It’s a central issue in the
2008 presidential campaign, and states around the country are enacting a variety of
reforms. In Minnesota, the issue emerged from the 2007 Legislature as a priority for
attention during the interim session. The strategies being considered vary, but all seek to
address rising costs, improve health outcomes and secure coverage for those without
insurance. These are daunting goals, and part of the challenge will be to devise approaches
that are responsive to the variety of populations and communities in the state. One size
won’t fit all.
Mark Schoenbaum is
director of the Office of
Rural Health and Primary
Care. He can be reached
at mark.schoenbaum@
health.state.mn.us
or (651) 201-3859.
DIRECTOR’S CORNER
Mark Schoenbaum
The Rural Health Advisory Committee, which advises the commissioner of health and
other state agencies on rural health issues, established a Rural Health Reform Work Group
this past summer to offer a rural voice to the health reform discussions. The work group
studied the rural characteristics that affect health services, and proposed health reform
options in response.
First, the work group reviewed the unique features of rural Minnesota, which has 80
percent of the state’s land area, 30 percent of the total population and 41 percent of those
65 and older. This older population has more chronic disease and disability, and there are
other health status differences between rural and metro areas. Rural Minnesota has also
experienced significant growth in minority and immigrant populations. Rural employment
is disproportionately characterized by low-wage, part-time and seasonal jobs, making
uninsurance more common. Rural Minnesotans who are insured are less likely to have
employer-sponsored policies and more commonly have individually-purchased policies,
often with high premiums, deductibles and copays.
The rural health care system also has key differences that affect the implementation of
health policy changes. The rural delivery system is heavily reliant on primary care
providers, an increasingly scarce commodity. Parts of the system are financially fragile, and
the technical staff and investment capital required to adopt health information technology
can be harder to come by. In addition to its challenges, the rural health system also has a
record of innovation, creativity and collaboration.
With these attributes of rural Minnesota in mind, the committee put forward options for
policymakers to consider, organized according to the themes for action of the Health Care
Transformation Task Force established by the 2007 Legislature. Among their ideas are:
• Redesign health care jobs and health care delivery for better coordinated prevention
and health care services delivery.
• Increase support for primary care and for educating primary care practitioners.
• Support utilization of proven cost-effective technology, such as telehome care,
telemental health services and teleradiology.
• Work toward universal coverage, making incremental changes along the way such as
improving insurance options for small employers and lower wage workers.
• Build on strengths of the rural system such as its Critical Access Hospitals, which often
serve as a hub around which to integrate and redesign community services.
These and other options have the potential to help fine-tune the health reform effort so it
can be most effective in producing positive change in all reaches of the state. At its
meeting this month, the Rural Health Advisory Committee reviewed and adopted the full
report, which provides a deeper look at these issues. You’ll find it soon on our Web site at
http://www.health.state.mn.us/divs/orhpc/pubs/index.cfm.
2
I hope the report gets you thinking and involved, whether you agree with its proposals or
not. The Rural Health Advisory Committee recognizes we’re at one of those rare moments
in history when issues we care the most about are at the center of the public stage.
They’ve taken leadership and set an example for the rest of us.
Minnesota Rural Health Advisory Committee
Member Profile: ORHPC talks with Tom Nixon
Tom, what is your professional position?
I am an EMT at Cuyuna Regional Medical Center. I am employed in respiratory
therapy but improvising is fundamental to rural EMS and at our facility we wear
many hats—from conducting diagnostics to changing a patient’s tire—we try to
do it all! I am also involved with coordinating drills to help us all—law
enforcement, fire, first responders, EMS, the DNR—be prepared for the next
page we receive.
Tom Nixon
PROFILE
I have a vested interest in rural. I grew up in Deerwood, Minnesota—just
down the road from Cuyuna where my grandfather was the hospital’s founding
physician. I had planned to follow in his physician footsteps and that is still the
dream but you know that cliché, “life got in the way.” I was working as a
nursing assistant when I was told I also needed to be certified as an EMT. I
passed the EMT training and then they didn’t have any hours for me as a
nursing assistant. I didn’t think I wanted to work as an EMT but I tried it and it
was such a positive experience—not the least of which was meeting the
wonderful woman who became my wife—that I stuck with it. I truly did not
foresee that I would enjoy it as much as I have. I also teach pre-hospital medical
care and rescue. Rural medicine is the cornerstone of my future—whether or
not I eventually become a physician.
Tell us about your life away from work.
I live in Deerwood, about 20 miles east of Brainerd, with my patient, understanding and beautiful wife Heather, who has given us three beautiful, healthy
daughters: Karli is 4, Korinna is 2 and Kallie is 4 months. Camping is what my
family does most often to relax. And I take every chance I can to see a new
place and spend some time with family and friends. I have a hobbies list that is
long and more of a wish list but it usually involves something outdoors.
I have involved myself in probably too many things such as the fire department,
city council, first responders, even the local festival but these are places I feel
I can help.
What do you think are the most important issues facing rural
health today?
When we refer to pre-hospital care in rural Minnesota, we mean volunteers! We
ask a lot of our volunteers and understand that our expectations can often make
it feel like being an indentured slave. Nevertheless when First Responders leave
their warm beds at 3 a.m. on a winter morning to drive to the scene in their
own car it is because they want to help.
Certainly there is a need to examine the delivery model of rural medicine; but
specifically how people use it. Saving emergency room visits for emergency
matters will save costs and make sure that those who really need emergency
See “ORHPC talks with Tom Nixon”
(back page)
3
HIT FOCUS
Online, searchable Minnesota
By Karen Welle, assistant director of the Office of Rural Health and Primary Care
Minnesota’s health care providers have been expanding their offerings of telehealth services over the
last 15-20 years—in areas such as home care, behavioral health, dermatology, orthopedics, cardiology
and more. While Minnesota has been a pioneer in developing and using telehealth and telemedicine
applications, until the summer of 2007, there was no directory of the services available, nor who was
providing them. In addition, information about staffing, equipment, financing, reimbursements or
training was understood only on an anecdotal basis.
Beginning in early 2007, the Office of Rural Health and Primary Care teamed up with the University
of Minnesota’s Institute for Health Informatics to find out more about telemedicine and telehealth
services in Minnesota. The 2007 Minnesota Telehealth Inventory started with a survey mailed to
1,500 health care facilities and organizations, representing hospitals, clinics, long term care, home
health care, mental health and rehabilitation. The two largest categories of providers—clinics and
home health care agencies—were randomly sampled.
Response to the survey was highest among community mental health clinics (60 percent) and
averaged about 43 percent among all providers surveyed. Those responses became the basis for a
more in-depth follow-up survey and provided a beginning database of information on telehealth
providers and services in Minnesota and the foundation for the Minnesota Telehealth Registry (see
below). Some of the highlights from the initial survey were:
•
Over 100 respondents indicated that they provide some kind of telehealth service. Those
providers consisted of 34 hospitals, 42 clinics, 24 elder care organizations and three other
providers. Based upon the sampling process used, it is estimated that as many as 600 facilities
may be offering telehealth services.
•
Radiology was the most common telehealth-enabled service, reported by one-third of all sites.
Videoconferencing applications, such as training, mental health and psychiatry, home care and
dermatology were also commonly noted.
The follow-up survey yielded a low response rate (18 sites), but provided some additional information
about the sites, including funding, connectivity, staffing, training, reimbursements and future plans.
Among the findings:
•
Facilities used a variety of funding mechanisms for startup costs. Nearly half reported using
internal funding for startup.
•
Connectivity was consistently reported as the highest direct cost.
•
Only two sites reported difficulties in obtaining reimbursement for clinical services, with common
sources being Medicare/Medicaid and private insurance.
•
Most sites were planning to expand service types and capacity.
•
Physician support, including referrals or consultants, was a critical factor in success.
The full 2007 Minnesota Telehealth Inventory Final Report is available at
http://www.health.state.mn.us/divs/pubs/telehealth.pdf or at the Registry Web site:
www.mti.umn.edu.
The Minnesota Telehealth Registry is a searchable online directory of telehealth services in
Minnesota currently hosted by the University of Minnesota at www.mti.umn.edu. Launched in July
4
Telehealth Registry launches
2007 with data from the Minnesota Telehealth Inventory, the Registry is intended to promote the use
of telehealth among providers, patients and the general public, aid in policy and budget planning by
state agencies, and facilitate further research into telemedicine services. The Registry allows users to
search the site by types of services, by counties, or by specific location (Figure 1).
Figure 1
A map of telehealth services can also be produced by using the “search the Registry with maps” tool
on the main page. Powered by Google, the map will show the location of identified services;
highlighting the “balloon” will bring up the contact information for that location. Figure 2 shows the
results of a search for child/adult psychiatry providers.
Figure 2
The Registry was designed to
allow providers to easily add
information about their
facilities and telehealth/
telemedicine services. It has
the potential to be a reliable
source of information on
current telehealth facilities
and services.
Those health care providers
not listed on the Registry are
encouraged to add information
about their facilities and
services by going to the Web
site and completing a
submission form.
For more information about the Registry or telehealth activities in Minnesota, contact Karen Welle,
Office of Rural Health and Primary Care, at (651) 201-3865 or [email protected].
5
SPECIAL FEATURE
Reflections on the Upper Midwest
By Judy Neppel, executive director of the Minnesota Rural
Health Association
Health care reform is again in the spotlight as more and more
policymakers come to agreement that the current situation is in
crisis, or close. To solve a problem of crisis proportion requires
informed people at all levels. That’s why the Minnesota Rural
Health Association joined forces with the Minnesota Area Health
Education Centers (AHEC), and with colleagues in Montana and North Dakota to organize the Upper
Midwest Rural Health Policy Summit.
More that 130 people attended the Summit held August 17 at the University of Minnesota
Crookston. Chancellor Charles Casey welcomed the audience and introduced key note speakers
Frank Cerra, M.D. from the University of Minnesota Academic Health Center; Kristin Juliar from the
Montana Office of Rural Health; and Brad Gibbens from the Center for Rural Health at the University
of North Dakota.
Dr. Cerra focused attention on the challenges associated with educating health professionals saying
“Minnesota cannot afford to educate more of the same health professionals to do the same work
within the same models.” He cited the 2002 Future of Family Medicine report and described new
models of practice that are more patient-centered.
Kristin Juliar encouraged collaboration, communication and continuity as ways the rural health care
system can manage health care in the community. Moreover, she proposed that rural can lead when
it comes to health care reform because rural hospitals and clinics are closely connected to the people
they serve. Brad Gibbens echoed the theme of community, while advocating for a more unified
national rural voice on issues of health care reform.
The Mayo Policy Center proposal for health care reform was also on the Summit agenda. Mayo
administrator Carleton T. Rider gave an overview of the recommendations being considered, and
again, the focus was on a health care industry centered on patients. Mr. Rider quoted Sen. Howard
Baker, a Mayo forum participant, to affirm the urgency of the situation: “Congress does not act wisely
and well all the time. But it usually recognizes when the time has come to solve an issue. It’s now
time to formulate a health care policy that can be supported by the American people and Congress.”
Staff from the offices of Sens. Norm Coleman and Amy Klobuchar and Rep. Collin Peterson agreed
that there is momentum for health care reform in Washington, D.C. Tim Fry, government affairs
director for the National Rural Health Association, moderated a panel of congressional staffers who
described what the senators and congressman are considering. Each of the Minnesota congressional
delegates’ Web sites detail proposals and offer links for feedback.
The Summit concluded with a panel of six thought leaders offering five minutes of reflection on “So
what?” about what they learned at the Summit. The panelists were Deb Boardman, chair of the
Minnesota Hospital Association Board; Edith Clark, a Montana legislator; Sharon Ericson, chief
executive officer of Valley Community Health Center in Northwood, North Dakota; Jan Hively,
6
Rural Health Policy Summit
founder of the Vital Aging Network; David Molmen, chief executive officer of Altru Health System in
Grand Forks, North Dakota; and Mark Schoenbaum, director of the Minnesota Office of Rural Health
and Primary Care.
Clark asserted that a state office of rural health is an essential piece of infrastructure to help
communities identify barriers and support local initiatives. Hively commented that she was happy to
hear speakers talk about person-centered health care that is responsive to individual needs. Boardman
outlined several opportunities for change including the opportunity for the health care provider
community to work more closely with higher education on a regional basis, which would mean
crossing state lines in places like rural western Minnesota. She also stressed the importance of
technology as a resource for rural health care delivery. Schoenbaum encouraged attendees to take
leadership to ensure rural perspectives are included in health reform discussions.
The Upper Midwest Rural Health Policy Summit provided participants the opportunity to be better
informed, which is an essential step toward a health care system that promotes the health and wellbeing of rural people and communities. Check out the Minnesota Rural Health Association Web site
for Power Point slides from many of the presenters at www.mnruralhealth.org.
For more information, contact Barbara Muesing, president, Minnesota Rural Health Association at
[email protected] or Judith Neppel, executive director, Minnesota Rural Health Association at
[email protected], University of Minnesota Crookston, 217 Selvig Hall, 2900 University Ave.,
Crookston MN 56716. The mission of the Minnesota Rural Health Association is to bring together
diverse interests to address rural health issues and to advocate for and with rural Minnesotans.
7
ORHPC talks with Tom Nixon (continued from page 3)
Mark Schoenbaum, director
Mary Ann Radigan, editor
Cirrie Byrnes, editorial assistant
services can access them. People also need to be their own advocates by
learning what help is available—such as Minnesota Care.
Of course we need to recruit and retain good rural health providers. We need
mental health facilities to fill the voids left behind the state program closures.
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
What one or two changes do you think would make the most
difference for rural health?
www.health.state.mn.us/divs/orhpc
Education. Education is key to curbing the most serious problems before they
develop, such as healthy lifestyles are not a choice but a priority and those
choices start at home. Education so John Q. Public knows when he requires an
emergency visit as opposed to a clinic visit and facilitating this with better nurse
lines. Education for those who want to be in rural health professions; and not
only drawing them in but retaining them.
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.
The ORHPC Quarterly is using
electronic distribution instead
of the mail. Subscribe at
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bscribe.html
or request other arrangements by
contacting Cirrie Byrnes at
[email protected]
or (651) 201-3844.
85 E. 7th Place, Suite 220
P.O. Box 64882
Saint Paul, Minnesota 55164-0882