Describing a "wicked problem" with a "fractured" health care marketplace in which "standard market principles don't apply," the Department of Health released a first wide-ranging compilation of data last week on the worsening state of rural health care in Minnesota.
In an interview, state health officials were largely neutral about the findings, which seem to highlight systemic problems and only theoretical solutions.
"People who live in rural Minnesota experience health care differently than people who live in the Twin Cities, Duluth or Rochester," said Alesha Simon, supervisor in the Office of Economic Policy. "It's important for us to keep that in mind.”
"This is the first time that we've pulled all this information on rural health together, and we wanted to release it on Rural Health Day," said Zora Radosevich, Director of the Office of Rural Health and Primary Care. "The intention is to update it annually."
The report, a synoptic look at multiple survey and census data findings filed in time for the November 21 occasion, depicts something of a perfect storm of competing incentives for the nearly one-third of Minnesotans who live in non-metro and isolated rural areas, on measures of health, cost, access to care and sustainability.
If the age-old city-country idea portrays urban hardship and the good life in the country, these data suggest it's the farm towns that have become burdened with excess illness and understaffed clinics, changes set in motion while rural Minnesota has increasingly become served by large health systems.
"We're noticing at the hospital level that more and more rural facilities are becoming affiliated with larger systems, about half the rural hospitals, all told," says Radosevich. "There are some advantages to that. They have access to more specialty care in larger systems. Financially these hospitals tend to do better when affiliated with a larger system as well. That said, there are concerns that once they are part of a larger system, some services can be consolidated, meaning people have to travel farther to get these services."
This development caused the southern Minnesota town of Albert Lea to lose its labor and delivery services last month. Nine Minnesota counties have lost birth services over the last 15 years, according to the MDH report, a retrenchment of services during boom years for health care in the US, and one that currently leaves the entire arrowhead and much of northwest and south central Minnesota without delivery rooms.
This same health-systemizing of rural healthcare has been accompanied by higher costs, less access to care and worsening health in rural communities, according to the report. "Research has generally shown that hospitals consolidating don't necessarily reduce costs," says Radosevich.
The report listed a host of other areas in which rural healthcare increasingly comes up short:
- Where urban hospitals tend to use their charity care reserves to give back to the community, rural hospitals tend to use their small discretionary funds to retain basic services and forgive bad debt.
- Rural patients more often than urban patients experience being told a clinic is taking no new clients.
- At 47 percent, a greater percentage of rural patients use lower-paying public health plans than in urban areas, where the ratio is 33 percent.
- Rural residents report more unhealthy days in the past month, more chronic conditions, higher opioid use, and equal levels of mental distress.
- At 80 percent volunteer staffed, the rural EMS system is almost entirely run by unpaid providers, and "unsustainable" as a business model going forward according to the MDH.
- The few increases in rural health services have been primarily in specialty services areas like imaging and psychiatry, while the losses have come in higher-need in-patient and outpatient surgery.
Moreover, any change in these factors will likely have economic repercussions outside of the health care system, the authors noted. "One person's health expenditure," as the report put it, "is another's income."
Among the proposed solutions are, expanding the categories of providers accessible in rural areas; using telehealth to connect rural residents by broadband to providers in metro areas and increasing quality measurement reporting.
"What we're really trying to get at is, there isn't one solution," says Simon. "We need a multifacted approach."