Rural Health Advisory Committee
Tuesday, January 21, 2014
9:00 a.m. - 11:30 a.m.
RHAC Members Present: John Baerg, Thomas Boe, Daron Gersch, Representative Clark Johnson, Margaret Kalina, Tom Vanderwal, Millicent Simenson, Ellen Delatorre, Representative Joe Schomacker, Thomas Crowley
RHAC Members Absent: Ray Christensen, Senator Tony Lourey, Jacqueline Osterhaus, Senator Julie Rosen, Nancy Stratman
ORHPC Staff: Judy Bergh, Darcy Dungan-Seaver, Tim Held, Cindy LaMere, Nitika Moibi, Katherine Schleiss, Mark Schoenbaum, Will Wilson
Guest: Ed Ehlinger (MDH Commissioner)
Introductions and Member Updates
Tom Boe (RHAC Chair and Licensed Health Care Professional, Moorhead) – Minnesota legislature memorandum increasing MA fee-for-service payment reimbursement for dental services by five percent went into effect on January 1, 2014.
Daron Gersh (physician member, Albany) – Mayor of town that will receive four million dollar road construction project this summer, which will be huge for the city.
John Bergh (Butterfield) – Local hospital that is part of the Mayo system is seeing positive things happening. Mayo realized that small rural hospitals are where people are getting first contact with the procedures they need. Some patients are sent to Mayo’s larger hospitals and then return to the community’s hospital for recovery, wonderful use with vision of cooperation.
Clark Johnson (Minnesota House of Representatives, District 19A) – Sponsoring a bill that supports STEMI through the Minnesota Department of Health, with creation of a system registry so we know more about it.
Margaret Kalina (Registered Nurse Member) – Recent struggle to ensure that inpatient state versus observation state is interpreted correctly, there have been insurance issues that affect the public when nursing home stays become expensive. Many people are impacted.
Tom Vanderwal (Ambulance Service Member) – EMS agencies helping with STEMI outreach and placing leading EKG units and updates with lights and sirens services, and promoting systemic approach to STEMI understanding. Criticality of time is a goal, making sure there’s access. We are the fiscal authority for the RTAC in that area and creating a more umbrella approach to maximize time and efforts. Local residents are receiving best care and American Heart Association collaboration with STEMI program.
Millicent Simenson (Consumer Member, Beltrami) – OB workgroup has put something on the calendar for cultural awareness event, has spoken to spiritual advisors who are interested in presenting to the RHAC group and hopes to set something up sometime this May.
Ellen Delatorre (Consumer Member, Blue Earth) – New ambassador position with MNSure, has been busy contacting 27 counties throughout Minnesota with her ambassador program.
Mental Health Transport Update
Tom Boe –Wrote letter to US Congress in support of Critical Access Hospital (CAH) system in Minnesota after last meeting. In October 2013, RHAC members wrote a letter to members of congress expressing concerns about recommendations from the Inspector General of the U.S. Department of Health and Human Services to modify state designations of certain hospitals as “necessary providers.” Letters were sent to Sen. Klobuchar, Sen. Franken, Sen. Reid, Sen. McConnell, Rep. Boehner and Rep. Pelosi.
Katherine Schleiss (ORHPC) –Issue brief recently completed on mental health transportation, which was an update on a report published in 2007 by the Emergency Medical Services Regulatory Board (EMSRB). This report is a continuation of an oral presentation given by Rachel Gunsalus at a previous RHAC meeting.
Clark Johnson – This is an important issue here, many people comment on this. Particularly with protected transfer, what is the timeline? When will we see more concrete progress?
Mark Schoenbaum – We expect there will be a legislative proposal.
John Baerg – Transportation and finding a bed are issues. There are 18-hour waits for acute care bed transports to Sioux Falls for suicidal patients. Community programs don’t take suicidal or acute patients with other medical problems, there are no places to put them.
Mark Schoenbaum – The issue is so stuck, and connects to so many other pieces. If the mental health crisis can be de-escalated on site, we can avoid admission or transport. There have been some attempts to improve locating a bed.
Tom Vanderwal – Volunteer responses can be challenging in the northwest region. We work with a crisis county team to springboard this discussion but struggle to get that moving.
Tom Boe – This has always been a priority.
MDH Commissioner Update
Ed Ehlinger – Commissioner Ehlinger recently read a book on physician’s experiences in a rural Montana practice that highlights many issues in rural communities for providers who are on call 24/7/365.
RHAC has the toughest job of all the advisory committees, includes work on aging populations and resources distribution (with focus on rural vs metro regions). Resource distribution takes ownership and direction away from rural communities, as does growth in medical specialization. Decreases in family medicine in rural settings and underinvestment in primary care are breaking the glue that holds a lot of rural health care together. What I see in the RHAC work plan has identified many of these challenges; the workforce has not invested enough in primary care or prevention. The work plan will address many of these issues in rural communities, long-term planning will help us deal with chronic diseases and dementia, reduce unhealthy years at the end of lifespan, address health disparities. We need to build a broader definition of primary care, including social workers and nurses, so they can be maximized in a rural community. MERC funding is shifting towards ways to invest more in primary care.
There needs to be an integrated team, with medical, social, dental, public health, and long-term care players all at the table. Finally, I would like to see more community ownership and community decision-making in rural or suburban or urban communities, integrate public ownership about how to invest in what a community needs, or these decisions are made by those in another community or health care system who won’t pay attention to the needs of the community. SIM grants give power to local communities’ decision-making. I’m interested in universal access single payer approaches to primary care, which is the only core health service that saves money and improves overall population health. Reforms and changes to the health care system utilize the use of technology (such as e-health initiatives at the MDH). Health promotion investment built on the SHIP model needs to be a priority; we can’t treat our way out of a chronic disease epidemic. Long-term aging care and dementia care are ways to get at this.
Questions/Comments for Commissioner Ehlinger:
Tom Vanderwal – EMS is gearing towards a public safety model. EMS has always been considered the redheaded stepchild. First responders are getting equipment and training for volunteer services; we need to make it strong enough and a gateway to the system. Need to build a strong foundation. Having worked with ORHPC in the past, it’s not all doom and gloom. We have made some good strides in community assets.
Ed Ehlinger – We need to build and invest more in local EMS, we need to figure out how to do that.
Tom Boe – Workforce problems continue to be a challenge. I work as an educator, director of a dental hygiene program, and we are graduating many young women from the program, asking the question, how can we get them into rural Minnesota? How do we get them into rural areas? Ed Ehlinger – The dental profession has been a leader in expanding workforce. How do we develop new professions so they can practice in communities? We’re not investing enough in people who have potential to go into rural communities. This has been a problem since I graduated from medical school in 1972. The University of Minnesota Duluth Medical School has a rural practice program that pre-selects students, there are very few students from big cities there, their students are more likely to go into a rural practice and start there.
Tom Boe – These are areas we could use help on. I was involved with Governor Pawlenty in the original SHIP program, and in building programs around those issues the problem we run into is money. With the Affordable Care Act, we hoped some prevention programs would be covered and there’d be different ways to pay rural communities. One strategy was bringing groups with similar problems together, like addressing sugar drinks, heart disease with treatment teachings; people learn well here. It’s harder to carry these programs and people are unwilling to pay more for them, but there’s a tremendous need. How do we put more emphasis on prevention, diet and exercise so they no longer need cholesterol, hypertension, or diabetes medication? Twin Cities is one of the fittest cities in the country; we have more parks, more farmers markets, and more community investments here. On the medical side we save more money here but it doesn’t go back into more prevention, more community ownership.
Clark Johnson – Seeing primary care as a public good would serve us all well. Accountable organizations need a broader definition of primary care.
Ed Ehlinger – Accountable care organizations have to take this step for a population-based approach, taking consideration of a broader health care frame and total cost of care. By doing better we will save money and improve health. ACOs should be embedded into the community with all other public health social services, and are combined in responsibility with these other components, how do we decide and govern these things? There was an experiment in Hennepin Health County, by getting housing and transportation engaged where the county board decided how to spend these dollars.
Ed Ehlinger – ACOs are a key step and provides a frame for understanding the total cost of care idea. But, the ACO needs to happen along with other things, like transportation, social service systems, public health, etc. The ACO need to be embedded in a broader community framework that has a decision-making capacity. The ACO shouldn’t be responsible in deciding for all that. If so, ACOs can be helpful not just for medical care, but for health overall.
Mark Schoenbaum – Sounds like an intersection between the department and RHAC agenda. Is there any other work or research that would be helpful to you, or the MDH?
Ed Ehlinger – I would like to see RHAC make some recommendations about ACOs/SIM, and would like to see it weigh in on how we do this in rural communities. Is anyone else doing stuff better? Are other states doing workforce development and distribution better? What can we learn? Are there best practices? Also, harebrained notions are welcome. There’s enough angst and knowledge about the power of prevention, now is the time to make bold moves.
Daron Gersh – We don’t see that infusion of cash into primary care that generally people have been talking about, it’s a critical junction for those who have invested and there’s hesitancy in going further until there’s a cash infusion. Broader primary care will continue to stagnate until investments start coming in. Minnesota has passed legislation ahead of other states but now other states are passing us because they are infusing more cash in.
Ed Ehlinger – What’s an appropriate investment in primary care? Now is the time to make bold moves. RHAC could weigh in on this.
Daron Gersh – Other counties have about 20 percent investment in total primary care with better outcomes, there’d be a paradigm shift for primary care physicians.
Ed Ehlinger – One example is the Rhode Island primary care trust fund.
RHAC Workplan: Workforce Update
Mark Schoenbaum – Refreshing where we are with the work plan, the next task is to figure out what work RHAC wants to do on these issues over the next 18 months. Workforce is a top priority, and since it’s such a huge topic, it would be good to have ORHPC staff share what we do as a base on that issue at MDH, and the resources and expertise available to RHAC. Asked staff to present an overview, in part as a jumping off point for developing work plan activities, and asks that as members listen to these presentations, think about what policy issues they raise and recommendations for action.
Daron Gersh – The Commissioner seemed interested in pre-selection techniques, asked if it would be possible to study whether or not this has been done in the past.
Mark Schoenbaum – Yes, we could do a literature review or search.
Tom Boe – There can be legal issues involved, so this should probably be included in the review.
Will Wilson – “Programs Assisting the Rural Healthcare Workforce” PowerPoint presentation:
- MERC funding
- Loan Forgiveness Program
- ORHPC Grants and Loan Programs
- Other Programs and Assistance
Nitika Moibi – “Minnesota’s Health Care Workforce” PowerPoint presentation:
- Diversity of Minnesota’s Workforce
- Primary Care Physician Mix
- Physician Mix by Gender, Age, Region, and Race
- Geographic Distribution and National Comparison
- Registered Nurses, Physician Assistants, and Marriage and Family Therapists
Comments and Questions:
Mark Schoenbaum – Thinking of RHAC’s roles and the various options in the tool box, such as issues briefs, full blown reports and workgroups, keep in mind that 2015 will be the budget year for the Legislature, so if spending recommendations are involved, we would need to work fast but it’s possible.
Tom Boe – One thought I had when the commissioner was here is how do savings get to the medical side, for example in Fargo Sanford and the YMCA have a partnership, a huge, beautiful facility. All Medicare recipients get free membership, perhaps RHAC could look at examples like this.
Margaret Kalina – Are nurse practitioners finding jobs? We could look at PA’s too, my sense is they’re having trouble.
Nitika Moibi – No hints yet of an oversupply.
Mark Schoenbaum – One interesting angle to look at might be how teams are developing these models.
Daron Gersh – Physician assistants and nurse practitioners are finding jobs, but I’m not sure how many of these are in primary care or rural professions. These are more urban professions, working alongside specialty physicians for follow-up support. I’d love it if someone could show that NPs, when they are practicing independently, are more likely to go to rural independent practices, but don’t think this is what happens.
We need to increase the pipeline to rural practice from the Twin Cities medical school. I’d love to see data on pre-selection, does it work and if so, let’s help push the message out here in Minnesota. If that model works, more institutions should know about it and implement it, such as the University of Minnesota Medical School Duluth. Also, nursing schools and other schools. We may need to make this a policy issue.
Clark Johnson – There’s a growing interest in developing rural Minnesota, for travel, recreation, tourism, making it a viable place for people to choose to live. The health voice is relevant here, especially research questions about how some towns are more appealing for young professionals to live, what makes successful rural communities successful, how to attract young people there, we need to promote that choice.
Mark Schoenbaum – There is a renewed interest in forming a rural caucus in Legislature, would likely have the broad scope.
Tom Boe – Interested in learning more about successful models of integration of health care with public health, social services. Not sure if public dollars have to drive this, or how this happens best. Social service funding is key in rural areas as well.
Mark Schoenbaum – The Accountable Communities for Health (ACHs) under SIM are meant to help move this.
John Baerg – It can be too stressful for physicians who are the only ones in their communities, too stressful with professional isolation. The issue of how to attract and keep young providers is tough.
Clark Johnson – Professional isolation and quality of life can heavily guide choices and discourage those who might otherwise be interested in rural practice. How to build interaction and a support system with other professionals that are in related areas, such as social services or public health. Soft social science, but seems to be future for rural Minnesota.
Will Wilson – With grant programs we are sending out a lot of money for technology improvements in rural hospitals. Technology can help physicians feel less isolated and more connected to other professionals and physicians.
Mark Schoenbaum – It may be useful to spend some attention and analysis on whether physician assistants and nurse practitioners in primary care are meeting their potential in rural areas. How might they do better? What are the pre-selection factors that predispose young people to both enter health professions and rural practice, what are the models of team care that reach beyond the physician and reach beyond health care and contribute to breaking down isolation, and what would advance that? ORHPC can rough out some project plans, and see how we can proceed in one or all of those ideas and bring them back after sending them out for comments through email.
Tim Held – RHAC may also want to take a fresh look at last year’s workforce recommendations from the health reform task force, and jumpstart some of those.
Joe Schomacker – A lot of those recommendations were funding-based, but if the workforce areas could be applied to a more rural base, there may be potential to adjust the formulas.
ORHPC published the Rural Health Advisory Committee Report on “Obstetric Services in Rural Minnesota” in January 2014 and is now available in the RHAC website.
The next Rural Health Advisory Committee meeting will be on March 18, 2014 in the MDH Orville Freeman Building. Videoconferencing services will be available.