RURAL MEDICINE: Doctors in Demand

In rural areas, the need for family physicians continues to put pressure on smaller communities, and health care networks are finding it increasingly difficult to find physicians to work in rural areas.

In Minnesota, there is a shortage of primary care professionals. There are also shortages of mental health care professionals, dental care specialists (especially for those who can’t afford dental services) and a lack of funding has created a risk of closure for some facilities in the state, says Judith Neppel, executive director of the Minnesota Rural Health Association.

In North Dakota, there are 2.13 physicians per 1,000 people, while nationally there are 2.57 physicians per 1,000. Also, in urban areas of North Dakota there are 3.25 physicians per 1,000, while in isolated rural areas there are 0.50 physicians per 1,000, says Brad Gibbens, deputy director of the Center for Rural Health and assistant professor at the University of North Dakota School of Medicine and Health Science in Grand Forks, adding that most isolated rural areas make up 27 percent of the state’s population but have only 6 percent of the state’s physicians.

“There is a greater need for physicians in rural areas, and certainly this is true for rural North Dakota,” he says.

The Center for Rural Health is just one organization that assists the rural communities in North Dakota.

In Pierre, the South Dakota Office of Rural Health focuses on the delivery of health services to rural communities, emphasizing access while working primarily at the local level.

In Minnesota, the Minnesota Rural Health Association, headquartered on the University of Minnesota campus in Crookston, focuses on advocacy around rural health issues at the state and national level, and education.

The Center for Rural Health also works on the state and national level. In North Dakota, the center works with rural communities and health organizations to help improve their performance and ability to meet local health needs. At the national level, the center focuses on health services research and information dissemination.

All three organizations provide help in finding physicians.

Making a difference

For example, The Center for Rural Health, through the Medicare Rural Hospital Flexibility Program (a federally supported program to assist critical access hospitals) provides almost $275,000 each year to critical hospitals for developing and expanding services, improving quality of care, and staffing and networking development. In addition, as much as $1 million is used from federal funding and private sources to assist rural communities in service development, health information technology, quality improvement and education and training.

“We definitely help and we do make a difference,” Gibbens says. “In working with rural communities, I’ve always been impressed with the commitment people have to their community and the quality of the ideas of those who live in rural North Dakota. The solutions to whatever rural health issues or problems, come from the communities. We try to provide additional resources and help build their capacity.”

A major program the South Dakota Office of Rural Health spearheads is the South Dakota Healthcare Workforce Center. The center works to assure a competent and qualified future health care workforce in the state. From 2008 to 2018, the Department of Labor predicts a 13.1 percent increase in the number of family and general practitioners and 16.7 percent increase in the number of internists needed in South Dakota.

“Workforce is one of the greatest needs in South Dakota because of an aging population,” says Sandra Durick, administrator for the South Dakota Office of Rural Health, adding that providing medical services to rural areas is important because it helps with rural health infrastructure. “Rural health infrastructure is key to having vibrant economies in rural areas. We do our best to help with rural health care needs.”

The MRHA provides monthly cyber conference programs discussing topics of interest throughout the region. As many as 65 rural health professionals are involved in the cyber conference events. There are discussions on electronic medical records, recruitment and retention of health professionals and cross training across multiple professions.

Brad Schipper, executive vice president of the Sanford Health Network in the Sioux Falls, S.D., area, adds that physicians are looking to have a family work life balance in covering emergency rooms. He adds that the increased complexion of regulatons is also adding challenges.

Gordon Larson, CEO of Sanford Aberdeen Medical Center in South Dakota, says that an important factor is allowing patients to continue health care close to home. In order to do that, health care networks are implementing telemedicine opportunities to assist a local physician with expertise from other specialists in different parts of the region.

“The Sanford One Chart allows a patient’s electronic medical chart to be available for any clinician to share and consult with others,” Larson says.

Neppel agrees that telehealth is a big help to rural areas. “It continues to expand and now has made it possible for specialized needs, including psychiatry, which is in short supply and large demand in rural areas,” Neppel says.

In addition, Neppel notes that the first dental therapist is going into practice in rural Minnesota. “A dental therapist is a substitute for the short supply of dentists in the state,” she says.

Grass roots approach

Many health care networks determine needs in rural communities by listening to patients and physicians in the community. “Obviously we look at trends and we look at geographics,” Schipper says. “We also look at the community and what the community desires and combine them to come up with a plan that is doable and makes sense.”

Gibbens, who has been involved in rural health for 28 years, is seeing changes. For example, rural health care providers are more willing to work with other providers and other types of networks. Rural hospitals collaborate with each other in networks and with the larger urban hospitals. The Critical Access Hospital Quality Network, for example, while focused on the needs of rural hospitals has participation from the urban hospitals. Rural hospitals and public health are working together to address local health needs. In addition, he is seeing an increase in willingness of rural North Dakota to support rural hospitals.

When the Center for Rural Health conducted surveys in 2005, 2008 and 2011 two specific issues showed a growing support for rural health care facilities. First, an increase in the use of local sales tax or property taxes for rural hospitals. In 2008, 25 percent of the critical access hospitals had local tax support, while now 40 percent have local support. In addition, rural citizens are willing to make donations to local health entities. In 2008, less than 50 percent of the critical access hospitals had a local hospital foundation. Today, that number is 75 percent.

Neppel notes that MRHA is also consistently addressing the state legislature to let them know that rural economic development is critical to the longevity of rural communities, as well as pushing for better long-term care funding.

“We help by increasing the awareness of critical and new health issues around reform so people have a better understanding of what others are doing so they might improve the service they are providing,” Neppel says. “Access to good health care is essential to a good way of life.” PB

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