Office of Rural Health and Primary Care

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Rural Health Care in Minnesota: Data Highlights Chartbook, 2019—Chart Summaries

Below are summaries of the charts, tables and graphs contained in Rural Health Care in Minnesota: Data Highlights Chartbook, 2019, by page number. This chartbook was last updated in November 2019 and contains 64 pages. Pages without charts or graphs are not listed below.

Data sources for this chartbook are available in the PDF: Data Sources Used in Rural Health Care in Minnesota: Data Highlights

Page 1—Rural Health Care in Minnesota: Data Highlights

This chartbook was created by the Minnesota Department of Health’s Division of Health Policy.
Publishing date: November 21, 2019.

Technical Notes

Page 4—Defining Rural: Rural-Urban Commuting Area (RUCA) Codes

This map depicts the state of Minnesota divided into Rural Urban Commuting Area Codes, rolled up to four different levels: Metropolitan, Large Town, Small Town Rural, and Isolated Rural.
Rural-Urban Commuting Areas are one of many ways to measure rurality.
RUCAs take into account population density, urbanization and daily commuting patterns to identify urban and rural regions of the state.
Current definitions are based on 2010 census data. More areas of the state became urban between the 2000 and 2010 census.
For slides with two categories, unless otherwise noted: “urban” means metropolitan; “rural” combines large town, small town rural, and isolated rural.

Source: Minnesota Department of Health. RUCAs were developed by the U.S. Department of Agriculture, Economic Research Service, and the University of Washington’s WWAMI Rural Health Research Center.

Page 5—Defining Rural: Three–Digit Zip Codes

This map depicts the state of Minnesota divided into three digit zip codes. There are 16 regions, with large cities and their suburbs (such as Minneapolis, St. Paul, and Duluth) comprising smaller geographic areas.
Divides the state into 16 areas based on the first three digits in zip codes
Crosses county boundaries
Nine are considered rural and seven are considered urban, based on if the majority of the population of ZIP code tabulation areas is in a rural or urban RUCA.

Page 6—Defining Rural: Regions

This slide contains two maps, showing the state of Minnesota divided into two regional groupings.
The State Community Health Service Advisory Committee (SCHSAC) Regions are 8 regions based on groups of counties. SCHSAC Regions are focused on developing, maintaining and financing community health services.
Economic Development Regions (EDR)s are 13 regions based on groups of counties. EDRs were created by the Minnesota Department of Employment and Economic Development (DEED), and are used for labor force and employment characteristics.

The State of Rural Health Care in Minnesota

Page 9—The population of Minnesota – and the country – is aging

This chart depicts the growth of the population aged 65 or older in Minnesota between 1950, projected out to 2070; both the percent of the population and the total count are shown.
1950: 269,130, 9.0%
1960: 354,351, 10.4%
1970: 408,919, 10.7%
1980: 479,564, 11.8%
1990: 546,934, 12.5%
2000: 594,266, 12.1%
2010: 683,121, 12.9%
2020: 965,266, 17.0%
2030: 1,262,142, 21.1%
2040: 1,320,170, 21.3%
2050: 1,358,031, 21.3%
2060: 1,422,908, 21.6%
2070: 1,504,067, 22.1%

Source: Minnesota Demographers Office

Page 10—People living in rural Minnesota are more likely to have household incomes below the statewide median income

This slide contains a chart showing the percent of people, by RUCA, with household incomes below the statewide median income of $65,699 in the 5-year period of 2013 to 2017. It also has a map which indicates, by census tract, if the median income is significantly higher, about the same, or significantly lower than the state median income of $65,699.
Chart:
Metropolitan: 20.7% of people have household incomes below the statewide median;
Large Town: 51.9% of people have household incomes below the statewide median;
Small Town Rural: 74.9% of people have household incomes below the statewide median;
Isolated Rural: 87.1% of people have household incomes below the statewide median;
Map:
36.8% of census tracts have median income below the statewide median – these are largely concentrated in outstate areas, or in major cities.
30.4% of census tracts have median income about the same as statewide median – these are distributed throughout the state, with no clear pattern
32.9% of census tracts have median income above the statewide median – these are concentrated in areas around the cities of Minneapolis, St. Paul, Rochester, Duluth, St. Cloud, Fargo, ND, Grand Forks, ND and La Crosse, WI.

Source: MDH Health Economics Program analysis of US Census Bureau data from the American Community Survey 5-year estimate 2013 to 2017.

Page 11—Areas of concentrated poverty occur in both rural and urban areas of the state

This slide contains a chart showing the percent of the population below poverty, by RUCA, and has a map showing census tracts in the state with concentrated poverty, and either white non-Hispanic majority population or Non-white or Hispanic majority population.
‘Concentrated poverty’ is defined here as having more than one in five residents living at or below federal poverty guidelines for income at the census tract level.
There are an estimated 122,000 people living in concentrated poverty areas in rural Minnesota.
Chart:
Metropolitan: 10.0% of people have incomes below poverty;
Large Town: 12.3% of people have incomes below poverty;
Small Town Rural: 12.2% of people have incomes below poverty;
Isolated Rural: 11.5% of people have incomes below poverty;
Map:
5.6% of census tracts are concentrated poverty, with a majority non-white or Hispanic population
7.6% of census tracts are concentrated poverty, with a majority white non-Hispanic population

Source: MDH Health Economics Program analysis of US Census Bureau data from the American Community Survey 5-year estimate 2013 to 2017.

Structure of Rural Health System: An Overview

Page 14—People in Rural Minnesota are more likely to have public health insurance coverage, such as Medicare, Medicaid or MinnesotaCare

This chart shows the percentage of Minnesotans who have different sources of health insurance coverage in 2017 by RUCA (Metropolitan, Large Town, Small Town Rural, Isolated Rural). The four different types of health insurance are Public (Medicare, Medical Assistance, MinnesotaCare, VA and TRICARe), Employer-sponsored (Group) Health Insurance, Individual Market, and Uninsured.
Public: Metropolitan=33.6%; Large Town=42.7%*; Small town rural=43.0%*; Isolated rural=47.4%*
Employer-sponsored (group) health insurance: Metropolitan=56.0%; Large Town=48.1%*; Small town rural=43.9%*; Isolated rural=40.5%*
Individual market: Metropolitan=4.3%; Large Town=3.9%; Small town rural=5.7%; Isolated rural=4.6%
Uninsured: Metropolitan=6.1%; Large Town=5.2%; Small town rural=7.4%; Isolated rural=7.6%
Reasons for higher rates of public health insurance:
Age: people over 65 are more likely to have Medicare;
Lower Incomes: more likely to be eligible for state public programs; and
Less access to employer coverage: fewer people are connected to an employer that offers coverage.

Source: Minnesota Health Access Survey, 2017; Geographies based on RUCA zip-code approximations.
*Indicates significant difference from Urban at the 95% level.

Page 15—Hospital and Nursing Home Services are available throughout the state

This map shows the state of Minnesota, divided in to the four RUCA groups, with the location of all hospitals indicated. There are 129 community hospitals, 77 of which are Critical Access Hospitals (CAHs), and 52 other hospitals.
Critical Access Hospitals (CAHs) are smaller hospitals (fewer than 25 beds), mostly in rural areas, which receive higher reimbursement from Medicare, as long as they maintain certain services.
Of the 129 community hospitals in Minnesota, 77 are designated Critical Access Hospitals.1,2
In total, 91 hospitals are located in rural areas.1
Around one-third of all hospital outpatient clinics in the state, 165 of 502 total clinics, are in rural areas.1,3
All but one county, Red Lake, has at least 1 nursing home as of 2018.4

Source and Notes:
1 Source: MDH Health Economics Program analysis of hospital annual reports, October 2019.
2 There are 78 Critical Access Hospitals in Minnesota; however one is an Indian Health Services Hospital. This is not included in the count of community hospitals, which are limited to non-federal short-term general and other special hospitals, and are accessible by the general public.
3 Outpatient clinics are designated by the hospital and may not be co-located with the hospital, but are billed to Medicare under the hospital’s provider identification number.
4 Source: Minnesota Department of Health, Health Economics Program analysis of 2018 Directory of Registered, Licensed and/or Certified Health Care Facilities and Services https://www.health.state.mn.us/facilities/regulation/directory/docs/2018mdhdirectory.pdf

Page 16—Primary and specialist clinics are available throughout Minnesota

This slide has two maps, one showing how primary care clinics are distributed across the state, and one showing how specialist care clinics are distributed across the state. Each clinic is represented as a dot, regardless of how many physicians practice there.
37% (266) of all primary care clinics (713) are located in rural areas1
19% (227) of all specialty care clinics (1,183) are located in rural areas. 1
Minnesota Community Health Centers served 190,690 residents in 2018.2
<data line>

Notes and Sources:
Primary Care includes general family medicine, general internal medicine, and general pediatrics; Specialty Care includes one or more non-primary care specialty.
1 Source: MDH Health Economics Program analysis of the Minnesota Statewide Quality Reporting and Measurement System Physician Clinic Registry.
2 Source: HCH: https://mnachc.org/community-health-centers/health-center-data/

Page 17—Person-centered, coordinated primary care available to most Minnesotans

This map shows the locations of certified Health Care Homes designated clinics in Minnesota by county as of 2019. There are 22 counties without a Health Care Home clinic and one county without any primary care clinics. In 2019, three new counties established certified Health Care Home clinics.
Minnesota Department of Health certifies primary care clinics and clinicians as health care homes, known nationally as patient centered medical homes.
The health care home clinic team coordinates care with the patient and their family to ensure whole person care and improve health and well-being.
74 percent of Minnesota counties have at least one health care home clinic.
196, or about one half, of the 398 certified health care home clinics are in rural areas (State Community Health Service Advisory Committee Regions)
Rural health care home clinics serve approximately 1.5 million patients.

Source: MDH https://www.health.state.mn.us/facilities/hchomes/index.html

Page 18—Rural Emergency Medical Services (EMS) reliance on volunteerism is unsustainable

This chart depicts the percentage of the volunteer and paid Emergency Medical Services (EMS) staff in rural Minnesota.
Chart:
5.4% of rural Emergency Medical Services staff are volunteer and do not receive compensation.
57% of rural Emergency Medical Services staff are volunteer and receive compensation while on call.
20.3% of rural Emergency Medical Services staff are paid an hourly wage or receive a salary.
17.2% of rural Emergency Medical Services staff are a combination between volunteered time and being paid for their services.
80% of rural Emergency Medical Service agencies rely on volunteers.
Rural Emergency Medical Service agencies rely on volunteers, but face decreasing volunteer roster sizes, and many shifts (weekdays, weekends, holidays) are difficult to fill.
About 60% of agencies have inadequate staff to cover their call schedule without undue burden.
59% of agencies do not have all of their shifts covered at least 24 hours in advance.
88% of agencies provide Basic Life Support (not paramedic level services) to their communities.

Source: https://www.health.state.mn.us/facilities/ruralhealth/flex/docs/pdf/2016ems.pdf

Page 19—Access to critical trauma care is available throughout the state

This map shows the drive time in 30 minute and 60 minute ranges to locations to trauma hospitals in Minnesota by their trauma level designation. The majority of the state can reach a trauma hospital within 60 minutes, with the exception of the Northwest, North Central, and Northeast corners of the state which have hospitals in their regions but they are undesignated as a trauma hospital.
121 of 130 hospitals have a trauma designation. 98% of Minnesotans live within 60 minutes of a designated trauma hospital.
Another map shows the parts of the state that have trauma level 1 and 2 hospitals and which areas of the state are able to access those hospitals within a 30 or 60 minute drive. The area of the state that has the most coverage is in the Eastern Central and Southeastern areas of the state.
74% of Minnesotans live within 60 minutes of a Level 1 or Level 2 trauma hospital.

Source: MDH Trauma System February 2019.

Rural Health Care Workforce

Page 22—Registered nurses and licensed practical nurses make up the majority of the health care workforce in Minnesota

This table shows the number of health care providers by profession in 2019 currently licensed to practice in Minnesota. This table excludes Respiratory Therapists and some other smaller licensed occupations, including: Chiropractic, Sports Medicine, and Occupational Therapy.
Table:
132,044 Registered Nurses and Licensed Practical Nurses
39,153 Pharmacists and Pharmacy Technicians
24,977 Physicians
23,431 Mental Health Providers
8,976 Advance Practice Registered Nurses
7,887 Physical Therapy Professionals
4,140 Dentists
3,521 Alcohol and Drug Counselors
3,251 Physician Assistants.

Source: MDH Office of Rural Health and Primary Care analysis. Data provided by Health Licensing Boards, October 2019.

Page 23—The majority of licensed health care providers work in metropolitan areas

This chart shows the percentage distribution of licensed health care providers by Rural-Urban Commuting Area in comparison to the percentage distribution of the population in each Rural-Urban Commuting Area. The data provided in this chart includes: physicians, physician assistants, respiratory therapists, oral health professions, pharmacy professions, physical therapy professions, and mental health professions.
Very few licensed health care providers work in rural areas.
Chart:
73.5% of the state’s population lives in Metropolitan areas and 80% of licensed health care providers are working Metropolitan areas.
10.1% of the state’s population lives in Large Town areas and 10% of licensed health care providers are working Large Town areas.
7.5% of the state’s population lives in Small Town Rural areas and 6% of licensed health care providers are working Small Town Rural areas.
9% of the state’s population lives in Isolated Rural areas and 3% of licensed health care providers are working Isolated Rural areas.

Source: MDH Office of Rural Health and Primary Care analysis. Data provided by Health Licensing Boards, October 2019.

Page 24—Rural areas face severe shortages of primary care physicians

This chart shows the number of physicians by specialty per 100,000 people by Rural-Urban Commuting Area. The health care profession specialties included are: Family Medicine, Internal Medicine, Obstetrics/Gynecologists, General Pediatrics, General Psychiatry, and General Surgery. The counts by Rural-Urban Commuting Area are based on the primary practice address that physicians report to the Board of Medical Practice.
Obstetrics/Gynecologists, Pediatricians, and Psychiatrists are in short supply in rural parts of the state.
Chart:
Family Medicine Physicians per 100,000 people in Minnesota: 41.8 in Metropolitan areas, 55.7 in Large Town areas, 75.6 in Small Rural Town areas, and 34.2 in Isolated Rural areas.
Internal Medicine Physicians per 100,000 people in Minnesota: 33.1 in Metropolitan areas, 19.2 in Large Town areas, 9.5 in Small Rural Town areas, and 2.5 in Isolated Rural areas.
Obstetric/Gynecology Physicians per 100,000 people in Minnesota: 10.7 in Metropolitan areas, 9.5 in Large Town areas, 5.9 in Small Rural Town areas, and 0.7 in Isolated Rural areas.
General Pediatric Physicians per 100,000 people in Minnesota: 17.2 in Metropolitan areas, 8.5 in Large Town areas, 1.8 in Small Rural Town areas, and 0.2 in Isolated Rural areas.
General Psychiatry Physicians per 100,000 people in Minnesota: 7.3 in Metropolitan areas, 5.8 in Large Town areas, 1.8 in Small Rural Town areas, and 0 in Isolated Rural areas.
General Surgery Physicians per 100,000 people in Minnesota: 4.8 in Metropolitan areas, 8.1 in Large Town areas, 9 in Small Rural Town areas, and 1.2 in Isolated Rural areas.

Source: MDH Office of Rural Health and Primary Care analysis. Data provided by Board of Medical Practice, June 2019.

Page 25—Rural providers are older than their urban counterparts

This chart shows the median age of health care providers across health care professions by urban and isolated rural Rural-Urban Commuting Area codes. The health care professions included in these data are: Advance Practice Registered Nurses, Dentists, Licensed Practical Nurses, Pharmacists, Physicians, Physician Assistants, Psychologists, and Registered Nurses. Licensed Practical Nurses, Pharmacists, Physicians, Physician Assistants, Psychologists, and Registered Nurses who practice in isolated rural areas all have a higher median age than their urban counterparts.
Chart:
Advance Practice Nurses in Minnesota have a median age of 44 in both urban and isolated rural areas.
Dentists in Minnesota have a median age of 48 in urban areas and a median age of 51 in isolated rural areas.
Licensed Practical Nurses in Minnesota have a median age of 47 in urban areas and a median age of 49 in isolated rural areas.
Pharmacists in Minnesota have a median age of 42 in urban areas and a median age of 43 in isolated rural areas.
Physicians in Minnesota have a median age of 48 in urban areas and a median age of 56 in isolated rural areas.
Physician Assistants in Minnesota have a median age of 36 in urban areas and a median age of 47 in isolated rural areas.
Psychologists in Minnesota have a median age of 57 in urban areas and a median age of 61 in isolated rural areas.
Registered Nurses in Minnesota have a median age of 43 in urban areas and a median age of 45 in isolated rural areas.

Source: MDH Office of Rural Health and Primary Care analysis. Data provided by Health Licensing Boards, October, 2019.

Page 26—Nearly one-third of rural physicians plan to leave the workforce within the next five years

This chart shows the percentage of health care providers who plan on retiring from their profession in the next 5 to 10 years. There is a comparison between the urban and isolated rural providers defined by the Rural-Urban Commuting Area codes. The survey categories used for to show these data are as follows: Plan to leave in 5 years or less, plan to leave within 6 to 10 years, and plan to leave in more than 10 years.
Chart:
18% of urban physicians and 32% of isolated rural physicians plan to leave their profession in 5 years or less.
19% of urban physicians and 23% of isolated rural physicians plan to leave their profession in 6 to 10 years.
63% of urban physicians and 45% of isolated rural physicians plan to leave their profession in more than 10 years.

Source: MDH Office of Rural Health and Primary Care, Physician Workforce Survey, 2018.

Page 27—54 of Minnesota’s 87 counties are designated as Health Care Professional Shortage Areas in Dental and Primary Care

This map shows the counties in the state of Minnesota that are designated as low-income and geographic Health Care Professional Shortage Areas for dental professions. Out of the 54 counties with the designation for dental Health Care Professional Shortage Area 44 of them include full counties, 10 counties have partial designation, and there are 33 counties without a designation.
An additional map shows the counties in the state of Minnesota that are designated as low-income and geographic Health Care Professional Shortage Areas for primary care physicians. Out of the 54 counties with the designation for primary care physician Health Care Professional Shortage Area 28 of them include full counties, 26 counties have partial designation, and there are 33 counties without a designation.

Source: https://www.health.state.mn.us/facilities/underserved/designation.html

Availability of Health Care Services in Rural Minnesota

Page 30—Rural hospitals saw service declines due to hospital closures, consolidation, or service loss over the past decade

This table shows the change in hospital service lines between 2009 and 2018 at rural hospitals. The table provides the number of rural hospitals with the service in 2009, the number of hospitals that closed/consolidated, lost service, or added services between 2009 and 2018, and then the number of hospitals with services available in 2018. Then it shows the percent change between 2009 and 2018.
Over this time period, rural hospitals lost inpatient and outpatient surgery, and renal dialysis services, as well as detoxification services. Much of this loss was due to closure or consolidations of hospitals, although 5 hospitals ended their inpatient surgery services.
Rural hospitals saw increases in outpatient psychiatric services and advanced diagnostic imaging services, due to hospitals adding these service line.

Source: MDH Health Economics Program analysis of hospital annual reports, October 2019; 2018 data is considered preliminary. Services are considered “available” when they are provided on site by hospital staff, on site through contracted services, or off site through shared services agreement. No rural hospitals had open heart surgery or organ transplant services available in 2009 or 2018.

Page 31—Nine Minnesota counties lost hospital birth services between 2003 and 2018

These two maps show the change in availability of obstetrics services within each Minnesota county for 2003 and 2018. The latter year also highlights nine counties that these services were no longer available in 2018 when there was availability within the county in 2003.
The nine counties included the following: Clearwater, Cook, Kittson, Lac Qui Parle, Lake of the Woods, Nicollet, Swift, Wabasha, and Watonwan.

Note: Due to a merger, the hospital in Mower County was no longer an independent licensed entity as of the end of 2014; however, birth services were offered at that site under the license of the remaining corporate entity.
Source: MDH Health Economics Program analysis of hospital annual reports, October 2019; 2018 data is considered preliminary. Community hospitals were categorized as not offering birth services if they did not have at least one routine birth, had no licensed bassinets, or stated that services were not available.

Page 32—Some counties lost inpatient cardiac, chemical dependency and mental health services over the past decade

This map depicts the five counties in Minnesota that lost inpatient service lines between 2009 and 2018.
Isanti county lost inpatient chemical dependency services
Pennington and Nobles counties lost inpatient mental health services
Wadena and Winona counties lost inpatient cardiac services

Note: The five counties listed are classified as “urban/town/rural mix” (Isanti and Winona) or “town/rural mix” (Pennington, Nobles, and Wadena) by the Minnesota State Demographic Center. See Greater Minnesota: Refined & Revisited at https://mn.gov/admin/assets/greater-mn-refined-and-revisited-msdc-jan2017_tcm36-273578.pdf.
Source: MDH Health Economics Program analysis of hospital annual reports, October 2019.

Page 33—The relative decline in nursing homes and nursing home beds was greater in rural Minnesota between 2003 and 2018

This map shows the percent change in the number of nursing home beds by county in Minnesota between 2003 and 2018. Many counties that lost nursing home beds were in rural areas.
The percent change in nursing home beds ranged from an increase of 29.9% (Wabasha County) to a decrease of 100% (Red Lake County)
The 18 counties (one-fifth of Minnesota counties) with the highest percent of nursing home beds lost were between 2003 and 2018 were: Big Stone (-43.5), Cass (-81.8%), Clearwater (-67.1%), Douglas (-38.6%), Faribault (-48.3%), Grant (-72.7%), Hubbard (-48.4%), Jackson (-52.1%), Koochiching (-43.7%), Le Sueur (-55.4%), Marshall (-47.1%), Pine (-46.8%), Pope (-51.4%), Red Lake (-100%), Rice (-37.9%), Steele (-52.5%), Watonwan (-39.3%), and Yellow Medicine (-57.0%).
The five counties which added nursing home beds between 2003 and 2018 were: Anoka (11.1%), Chippewa (1.5%), Traverse (5.9%), Wabasha (29.9%) and Washington (0.5%).
Rural counties1 have about 1/3 of all nursing homes, but accounted for over half of the closed nursing homes in the state between 2003 and 2018
In total, rural counties1 lost 21 nursing homes, and had a 33% decline in nursing home beds
The nursing home population has been declining since 1995, with more options for long-term care, including home care and assisted living becoming more common.

1 Rural counties are those that are either entirely rural, or a rural/town mix (49 counties), as defined by the Minnesota Population center in Greater Minnesota: Refined and Revisited (https://mn.gov/admin/demography/reports-resources/greater-mn-refined-and-revisited.jsp), page 33.
Source: Minnesota Department of Health, Health Economics Program analysis of 2018 Directory of Registered, Licensed and/or Certified Health Care Facilities and Services https://www.health.state.mn.us/facilities/regulation/directory/docs/2018mdhdirectory.pdf

Health Care Use in Rural Minnesota

Page 37—People in rural Minnesota report more chronic conditions, and more unhealthy days

The first chart shows the average number of unhealthy days in the past 30 days that residents experienced in urban and rural areas of Minnesota. Minnesotans in rural areas reported a significantly higher average number of physically unhealthy days in the past 30 days (3.4) as compared to Minnesotans in urban areas (2.4). There was no difference for mentally unhealthy days between rural (3.1) and urban (2.8).
The second chart shows the percent of Minnesotans who reported a chronic condition, by urban and rural areas. Minnesotans in rural areas were significantly more likely to report having a chronic condition (40.3%*) as compared to Minnesotans in urban areas (35.8%).
Minnesotans living in rural areas reported frequent mental distress at about the same rate (9.9%) as those living in urban areas (8.5%).1

Source: Minnesota Department of Health, Health Economics Program analysis of 2017 Minnesota Health Access Survey (Minnesota Department of Health and University of Minnesota School of Public Health, State Health Access Data Assistance Center)
Urban and Rural defined based on RUCA zip-code approximations.

Age-adjusted suicide rate in greater Minnesota (14.7) was higher than the 7-county metro area (12.0) for 2013-17.

Source: 1999-2017: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death on CDC WONDER Online Database, released 2018. https://www.health.state.mn.us/communities/suicide/documents/2017suicidedatabrief.pdf

Page 38—Minnesotans in Rural Areas have to travel longer to get inpatient services – especially mental health services

This chart shows the approximate travel time in minutes for inpatient hospital stays for patients seen in Critical Access Hospitals, urban ZIP codes, rural ZIP codes, and statewide. The major categories of hospital stays are mental health/chemical dependency, obstetrics services, and general medical surgical care. Non-metropolitan ZIP codes are classified as ‘rural’ using RUCA.
Mental health/chemical dependency: Critical Access Hospitals=81 minutes; urban=24 minutes; rural= 61 minutes; statewide=34 minutes
Obstetrics services: Critical Access Hospitals=27 minutes; urban=16 minutes; rural =20 minutes; statewide=20 minutes
Medical/surgical services: Critical Access Hospitals=26 minutes; urban=20 minutes; rural=61 minutes; statewide=32 minutes

Source: MDH Health Economics Program analysis of hospital administrative records (discharge data) from 2013 to 2017, October 2019. The analysis calculated the distance between the geographic centroid of each ZIP code to respective hospitals and excluded hospital stays that transferred to another hospital to avoid duplication.

Page 39—Rural Minnesotans have more problems accessing providers

This chart shows the percentage of Minnesotans who indicate having a problem accessing a provider for four different reasons. The four reasons are 1) not able to get an appointment as soon as needed, 2) told by a clinic or doctor’s office that they were not accepting new patients, 3) told by a clinic or doctor’s office that they did not accept their health care coverage, or 4) not able to get an appointment with desired provider, because provider was not in network.
Rural Minnesotans were more likely to be told that a clinic or doctor’s office was not accepting new patients (5.9% rural; 4.4% urban). They were less likely to have problems with providers not being in their network (3.6% rural; 4.85 urban).
Not able to get an appointment as soon as needed: Urban=12.8%; Rural=12.0%
Told by a clinic or doctor’s office that they were not accepting new patients: Urban=4.4%; Rural=5.9%*
Told by a clinic or doctor’s office that they did not accept their health care coverage: Urban=5.7%; Rural=5.5%
Not able to get an appointment with desired provider, because provider was not in network: Urban=4.8%; Rural=3.6%*

Source: Minnesota Department of Health, Health Economics Program analysis of 2017 Minnesota Health Access Survey (Minnesota Department of Health and University of Minnesota School of Public Health, State Health Access Data Assistance Center)
*Indicates significant difference from Urban at the 95% level.
Urban and Rural defined based on RUCA zip-code approximations.

Page 40—People in rural Minnesota had the most trouble getting primary care appoints as soon as they were needed

This chart shows the percentage of Minnesotans who had trouble accessing different types of providers, among those who indicated they had problems accessing providers. The types of providers include primary care, specialist, dentist, mental health or other.
Among those who weren’t able to get an appointment as soon as needed, rural Minnesotans were more likely to say they couldn’t get an appointment with a primary care provider as soon as they needed (64.6% rural; 48.3% urban).
Not able to get an appointment as soon as needed: Primary care provider – Urban=48.3%, Rural=64.6%*; Specialist – Urban=38.5%, Rural=24.8%*; Dentist – Urban=9.1%, Rural=6.6%; Mental Health – Urban=8.8%, Rural=8.7%; Other – Urban=0.6%, Rural=0.7%
Told by a clinic or doctor’s office that they were not accepting new patients: Primary care provider – Urban=35.0%, Rural=42.3%; Specialist – Urban=27.6%, Rural=21.1%; Dentist – Urban=24.9%, Rural=35.9%; Mental Health – Urban=14.3%, Rural=6.9%*; Other – Urban=0.2%, Rural=0.0%
Told by a clinic or doctor’s office that they did not accept their health care coverage: Primary care provider – Urban=33.0%, Rural=31.2%; Specialist – Urban=35.7%, Rural=39.6%; Dentist – Urban=22.6%, Rural=26.1%; Mental Health – Urban=7.8%, Rural=5.7%; Other – Urban=4.8%, Rural=0.9%*
Not able to get an appointment with desired provider, because provider was not in network: Primary care provider – Urban=35.9%, Rural=36.2%; Specialist – Urban=37.6%, Rural=44.6%; Dentist – Urban=16.8%, Rural=17.1%; Mental Health – Urban=12.1%, Rural=8.4%; Other – Urban=1.8%, Rural=1.3%

Source: Minnesota Health Access Survey, 2017
*Indicates significant difference from Urban at the 95% level.
Percentages for Type of Provider do not sum to 100 because respondents were able to select more than one type of provider. Urban and Rural defined based on RUCA zip-code approximations.

Page 41—Rural primary care physicians are more likely to fill gaps in care than their urban counterparts

Rural physicians often fill gaps in care when there is a lack or absence in specialty providers to serve rural populations.
In areas of Obstetrics/Gynecology, Oral Health, and Pediatrics, rural primary care physicians are 15% more likely to provide some level of care than urban primary care physicians.
This chart depicts the differences between urban and isolated rural, as defined by the Rural-Urban Commuting Area codes, in primary care physicians filling gaps in care in different specialty areas due to lack of specialists or availability for specialty services. Comparisons between primary care physicians filling in these gaps in care is categorized by those that say that they have never provided the specialty services and those that provide some level of care. The specialty areas included in these data are: mental health, obstetrics/gynecology, oral health, pediatrics, any type of specialty area outside of primary care, and a category of other. The most common responses provided for other specialties listed include: dermatology, emergency medicine, and orthopedics.
Chart:
75.1% of urban primary care physicians and 52.1% of isolated rural physicians said that they never provide care in a health care specialty area that is normally covered by a specialty physician. 24.8% of urban primary care physicians and 46.9% of isolated rural physicians said that they provide some level of care in a health care specialty area that is normally covered by a specialty physician.
17.2% of urban primary care physicians and 10.6% of isolated rural physicians said that they never provide care in mental health. 82.8% of urban primary care physicians and 89.4% of isolated rural physicians said that they provide some level of care in mental health.
49.2% of urban primary care physicians and 32.9% of isolated rural physicians said that they never provide care in obstetrics/gynecology. 50.8% of urban primary care physicians and 67.4% of isolated rural physicians said that they provide some level of care in obstetrics/gynecology.
49.2% of urban primary care physicians and 32.7% of isolated rural physicians said that they never provide care in oral health. 50.8% of urban primary care physicians and 67.1% of isolated rural physicians said that they provide some level of care in oral health.
40.0% of urban primary care physicians and 21.3% of isolated rural physicians said that they never provide care in pediatrics. 60% of urban primary care physicians and 78.7% of isolated rural physicians said that they provide some level of care in pediatrics.
67.9% of urban primary care physicians and 59.9% of isolated rural physicians said that they never provide care in other specialty areas. 32.1% of urban primary care physicians and 40.1% of isolated rural physicians said that they provide some level of care in other specialty areas.

Source: MDH – Office of Rural Health and Primary Care, Physician Workforce Survey, 2018.

Page 42—Fewer adolescent patients in rural areas are screened for mental health or depression problems

This map and table depict mental health and/or depression screening rates for adolescents in Minnesota in 2017. The US Preventive Services Task Force recommends that all adolescents are screening for mental health concerns or depression.
The map shows that higher screening rates were present in the Twin Cities area, Southeast Minnesota, East Central Minnesota, and around the Duluth and Brainerd Lakes areas. Northwest Minnesota, West Central, and parts of South central Minnesota have screening rates below 50%.
The table provides screening rates by geography:
Metropolitan and Large City=86%
Small Rural Town=66%
Isolated Rural=70%
Statewide=83%

Source: MDH Health Economics Program analysis of Adolescent Mental Health and/or Depression Screening data from the Minnesota Statewide Quality Reporting and Measurement System. Based on adolescent patients aged 12-17 who had at least one face-to-face well-child visit in a Minnesota clinic. White areas on the map had fewer than five patients for this measure.
US Preventive Services Task Force recommends screening for all adolescents (see: Final Recommendation Statement: Depression in Children and Adolescents: Screening (2016), U.S. Preventive Services Task Force.

Half of all mental health conditions begin by age 14.1

Source: Kessler, et al. “Lifetime Prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.” Arch Gen Psychiatry, 2005 Jun; 62(6): 593-602.

Early treatment may lead to better outcomes in the long term.

Page 43—Prescription opioid use is higher in rural areas

This map and chart depict prescription opioid use in Minnesota.
The map shows county-level prescribed morphine milligram equivalents (MME) per covered person. The MME ranges from 178 to 1670; most of northern Minnesota has rates of 568 or higher, while most of southern Minnesota is below that amount.
The four counties with the highest MME, of 1115 to 1670 are Aitkin, Cass, Koochiching, and Mahnomen. Kanabec, Mille Lacs and Pine counties have rates of 841 to 1114.
The chart shows opioid prescriptions per 100 covered persons by RUCA in 2012 and 2015.
Metropolitan: 2012=64.6; 2015=57.0
Large Town: 2012=74.0; 2015=64.5
Small Town Rural: 2012=77.8; 2015=71.2
Isolated Rural: 2012=77.8; 2015=70.4

Source: MDH Health Economics Program and Mathematica Policy Research “Patterns of Opioid Prescribing in Minnesota: 2012 and 2015” April, 2018. https://www.health.state.mn.us/data/economics/docs/opioidbrief20185.pdf

Financing

Page 46—Hospital markets in Minnesota are not competitive

This chart shows the difference between actual competitiveness of State Community Health Services Advisory Committee (SCHSAC) hospital markets in three annual periods (2009, 2013, and 2017). The values are a calculation of Herfindahl-Hirschman competition (HHI) index based on net patient revenue from hospital annual report data. Values in chart are subtracted from 2,500, or a highly concentrated market; positive values indicate a competitive market, negative values indicate a concentrated market.
Southwest: 2009=587; 2013=469; 2017=642
West Central: 2009=848; 2013=642; 2017=640
Metro: 2009=623; 2013=412; 2017=-42
Central: 2009=365; 2013=17; 2017=-360
South Central: 2009=-832; 2013=-1,093; 2017=-513
Northeast: 2009=-189; 2013=-1,073; 2017=-876
Northwest: 2009=694; 2013=-970; 2017=-1,825
Southeast: 2009=-3,845; 2013=-4,610; 2017=-5,142

Source: Source: MDH Health Economics Program analysis of hospital annual reports, (October 2019). For more information on this index, visit the US Department of Justice website at https://www.justice.gov/atr/herfindahl-hirschman-index. SCHSAC Regions are defined on slide 6.

Page 47—Half of Minnesota’s rural hospitals were affiliated with a larger provider group in 2017

This map and table depict rural hospitals and whether or not they are affiliated with a larger provider group. Of the 91 rural hospitals in 2017, 46 were affiliated with a larger provider group or hospital system. Critical Access Hospitals as well as non-Critical Access Hospitals are affiliated with larger hospital systems.
Most of the provider groups were geographically based. Sanford Health is in Western Minnesota, though mostly in the Southwest; Essentia health is in Northern Minnesota; Mayo Clinic is in Southeast and South central Minnesota; Catholic Health Initiatives in central and West Central Minnesota; CentraCare Health System is in central Minnesota; Avera Health is in Southwest Minnesota; and Allina Health System is in South Central and South East Minnesota.
Hospitals that are part of larger systems: 1) May offer increased access to specialty services only available in urban areas; 2) May increase financial viability; and 3) Lead to consolidation of services to fewer hospitals, meaning some services may be less available in rural areas.
Sanford Health: Total Hospitals=15; Available beds=419
Essentia Health: Total Hospitals=9; Available beds=334
Mayo Clinic Health System: Total Hospitals=8; Available beds=179
Catholic Health Initiatives: Total Hospitals=4; Available beds=90
CentraCare Health System: Total Hospitals=4; Available beds=95
Avera Health: Total Hospitals=3; Available beds=80
Allina Health System: Total Hospitals=3; Available beds=111
Unaffiliated or Single Rural Hospital in Hospital System: Total Hospitals=45; Available beds=1,307

Hospitals are classified based on RUCA census tracts. Health care systems are ordered by total number of hospitals in descending order.
Source: MDH Health Economics Program analysis of hospital annual reports, October 2019.

Page 48—Hospitals that are part of larger systems have higher net income

This chart shows hospital net income as a percent of revenue for the following four groups of Minnesota hospitals: Medicare Critical Access Hospital designation (CAH) that are part of multi-hospital systems, CAH hospitals that are independent, non-CAH hospitals that are part of multi-hospital systems, and non-CAH hospitals that are independent. All four groups were within the three to five percent range in 2002 and were very far apart in 2018 with multi-hospital system hospitals for both CAH and non-CAH having much higher percent of net income than independent hospitals.
Non-CAH Multi-Hospital Systems 2002=3.0%; 2003=3.8%; 2004=5.4%; 2005=5.3%; 2006=3.8%; 2007=5.6%; 2008=-0.2%; 2009=6.7%; 2010=7.1%; 2011=7.8%; 2012=7.3%; 2013=8.7%; 2014=9.5%; 2015=8.5%; 2016=6.6%; 2017=9.8%; 2018*=11.1%;
CAH Multi-Hospital Systems 2002=3.3%; 2003=6.1%; 2004=5.8%; 2005=6.7%; 2006=6.7%; 2007=8.6%; 2008=5.4%; 2009=4.1%; 2010=5.8%; 2011=9.0%; 2012=6.0%; 2013=7.1%; 2014=8.2%; 2015=7.0%; 2016=6.7%; 2017=8.6%; 2018*=7.7%;
Non-CAH Independent Hospitals 2002=3.1%; 2003=2.6%; 2004=4.0%; 2005=3.1%; 2006=3.1%; 2007=2.5%; 2008=1.0%; 2009=1.5%; 2010=4.0%; 2011=3.1%; 2012=1.9%; 2013=2.1%; 2014=3.2%; 2015=3.0%; 2016=0.4%; 2017=1.6%; 2018*=1.9%;
CAH Independent Hospitals 2002=4.8%; 2003=4.2%; 2004=2.9%; 2005=4.0%; 2006=5.0%; 2007=5.5%; 2008=3.7%; 2009=3.9%; 2010=2.2%; 2011=3.1%; 2012=2.9%; 2013=5.5%; 2014=3.0%; 2015=3.5%; 2016=2.9%; 2017=3.1%; 2018*=4.8%

Source: MDH Health Economics Program analysis of hospital annual report data from 2002 to 2018 (October 2019).

Page 49—Number of MN Hospitals with Nursing Homes, 2009 and 2018

This chart shows the number of nursing homes attached to hospitals in 2009 and 2018 by RUCA in Minnesota. The number of hospitals stayed the same in both large towns and isolated rural areas, but dropped by five in small town rural areas and by two in metropolitan areas.
Metropolitan 2009=12, 2018=10;
Large Town 2009=8, 2018=8;
Small Town Rural 2009=15, 2018=10;
Isolated Rural 2009=17, 2018=17;

Source: MDH Health Economics Program analysis of hospital annual report data from 2009 and 2018 (October 2019).

Page 50—We spend more per-person on medical care in rural areas

These two maps show per capita spending by quantile three-digit ZIP code areas in Minnesota for residents under the age of 65 (map 1) and over the age of 65 (map 2). The maps also shade three-digit ZIP codes where a majority of the population is in rural areas defined by RUCA.
Less than 65 per capita spending:
550 (not rural) =$3,912; 551 (not rural) =$4,339; 553 (not rural) =$3,634; 554 (not rural) =$4,226; 558 (not rural) =$4,776; 559 (not rural) =$4,709; 563 (not rural) =$3,839;
556 (rural) =$3,704; 557 (rural) =$4,389; 560 (rural) =$4,194; 561 (rural) =$3,876; 562 (rural) =$4,401; 564 (rural) =$4,760; 565 (rural) =$3,907; 566 (rural) =$4,560; 567 (rural) =$4,012;
65 or older per capita spending:
550 (not rural) =$10,307; 551 (not rural) =$11,416; 553 (not rural) =$10,483; 554 (not rural) =$11,877; 558 (not rural) =$11,219; 559 (not rural) =$10,069; 563 (not rural) =$11,338;
556 (not rural) =$11,012; 557 (not rural) =$10,728; 560 (not rural) =$11,343; 561 (not rural) =$12,627; 562 (not rural) =$13,092; 564 (not rural) =$11,592; 565 (not rural) =$11,166; 566 (not rural) =$12,157; 567 (not rural) =$11,815;

Source: MDH Health Economics Program analysis of All Payer Claims Database Public Use Files (2014) and population data from the American Community Survey Five-Year 2013-2017 Estimate, October 2019. Note: spending is not age-adjusted and is simply stratified by age group (over age 65 and under age 65). Spending does not include retail prescription drugs.

Page 51—Most spending is for hospital inpatient and outpatient services

These two charts show the distribution in spending by rural and urban residents (using RUCA categories) including hospital, clinic services, long-term care, and other types of health care. The first chart shows spending distribution for under age 65 and there is noticeably lower spending in long-term care and higher spending in clinical and other services. The second chart for age 65 and older shows very similar spending distribution for both rural and urban residents, but slightly higher hospital and long-term care spending.
Under Age 65
Hospital (Inpatient and Outpatient): Rural=54.7%, Urban=51.8%;
Clinic Services: Rural=29.0%, Urban=29.4%;
Long Term Care (Including Home Health): Rural=15.5%, Urban=13.9%;
Other: Rural=0.8%, Urban=4.9%
Age 65 and Older
Hospital (Inpatient and Outpatient): Rural=50.3%, Urban=51.5%;
Clinic Services: Rural=29.5%, Urban=25.9%;
Long Term Care (Including Home Health): Rural=14.7%, Urban=21.6%;
Other: Rural=5.5%, Urban=1.0%

Source: MDH Health Economics Program analysis of All Payer Claims Database Public Use Files (2014) and population data from the American Community Survey Five-Year 2013-2017 Estimate, October 2019. Note: spending is not age-adjusted and is simply stratified by age group (over age 65 and under age 65). Spending does not include retail prescription drugs.

Page 52—Rural hospitals rely more on Medicare than their urban counterparts

This table depicts the percent of patient revenue at from different payers in 2009 and 2018 for Critical Access Hospitals (CAHs), rural hospitals that are not CAHs, and all hospitals statewide. Payers include Medicare, state public programs (Medical Assistance or Medicaid and MinnesotaCare), private insurance, self-pay (which includes uninsured), and other payers (such as worker’s comp, auto insurance, VA or TRICARE, or Indian Health Services).
Across all types of hospitals, the primary payers are Medicare and private insurance.
Medicare has increased as a percent of revenues between 2009 and 2018, as the number of people with Medicare coverage has grown.
Critical access hospitals have a larger percentage of their revenue from Medicare than private insurance, while other rural hospitals and statewide have private insurance is the largest source of patient revenue.

2018 data is preliminary
Source: MDH Health Economics Program analysis of hospital annual reports, October 2019.

Page 53—Rural hospitals devote a larger percent of operating expenses to community benefit

This chart depicts what percent of hospital operating expenses are for community benefit in 2017, by RUCA category, as well as showing the overall statewide percent. Non-profit hospitals provide community benefit as part of their tax-exempt status, and are required to report community benefit spending to the Minnesota Department of Health.
Community benefit spending can be categorized into four broad categories: 1) Direct patient care or unreimbursed services; 2) Research and education; 3) Financial and in-kind contributions; and 4) Community activities.
Most community benefit is in the “direct patient care” category
Statewide, hospitals devoted 9.3% of their operating expenses to community benefit
Hospitals in isolated rural areas devoted 12.8% of their operating expenses to community benefit
Hospitals in small rural towns devoted 7.7% of their operating expenses to community benefit
Hospitals in large towns devoted 6.6% of their operating expenses to community benefit
Hospitals in metropolitan areas devoted 9.7% of their operating expenses to community benefit

Source: Source: MDH, Health Economics Program analysis of Hospital Annual Reports
Additional information on community benefit is available in MDH, Hospital Community Benefit Spending in Minnesota, 2013 to 2015

Page 54—Community benefit for direct patient care is different across the state

This chart depicts differences in how direct patient care community benefit is distributed between hospitals in different RUCAs in 2017.
The four direct patient care categories are: 1) charity care (care that is provided for free); 2) state health care program underpayments (the difference between the cost of providing services to state public program enrollees and the amount reimbursed – this amount can be $0); 3) operating subsidizes services (the cost of keeping services always staffed regardless of use – such as trauma and emergency services, burn units, and neonatal intensive care units); and 4) community health services costs (costs of community education, community clinic services and free screenings, and self-help programs).
Isolated rural areas focus on operating subsidized services – such as keeping emergency rooms open and staffed;
State health care programs underpayments – the difference between the cost of care provided to state program patients and the actual payment received – are greater in hospitals located in metropolitan areas, large towns, and small rural towns.
Isolated rural hospitals’ distribution of community benefit for direct patient care is: charity care=4%; state health care programs underpayment=20%; operating subsidized services=73%; community health services=2%
Small town rural hospitals’ distribution of community benefit for direct patient care is: charity care=10%; state health care programs underpayment=46%; operating subsidized services=41%; community health services=3%
Large town hospitals’ distribution of community benefit for direct patient care is: charity care=13%; state health care programs underpayment=70%; operating subsidized services=14%; community health services=4%
Metropolitan hospitals’ distribution of community benefit for direct patient care is: charity care=12%; state health care programs underpayment=48%; operating subsidized services=35%; community health services=5%

Source: MDH, Health Economics Program analysis of Hospital Annual Reports

Page 55—Most uncompensated care in rural hospitals is bad debt

This chart depicts the percent of uncompensated care between 2009 and 2018 that is charity care.
Hospitals provide uncompensated care (health care services that are received, but not fully paid for) in two ways. The first is bad debt, health care services are provided, and payment is expected but not received. The second is charity care, health care services are provided and payment is not expected. Charity care is part of hospital community benefit, bad debt is not.
The divide between rural and urban hospitals has been decreasing in the past 5 years, due to lower charity care at urban hospitals.
The percent of uncompensated care that is charity care between 2009 and 2018 was as follows:
2009: Urban hospitals=55.9%; critical access hospitals=24.3%; other rural hospitals=31.3%;
2010: Urban hospitals=57.9%; critical access hospitals=27.5%; other rural hospitals=29.6%;
2011: Urban hospitals=55.6%; critical access hospitals=26.9%; other rural hospitals=32.8%;
2012: Urban hospitals=52.5%; critical access hospitals=24.0%; other rural hospitals=28.1%;
2013: Urban hospitals=55.7%; critical access hospitals=26.0%; other rural hospitals=31.1%;
2014: Urban hospitals=44.8%; critical access hospitals=26.8%; other rural hospitals=33.5%;
2015: Urban hospitals=43.0%; critical access hospitals=26.5%; other rural hospitals=33.5%;
2016: Urban hospitals=47.1%; critical access hospitals=32.2%; other rural hospitals=30.3%;
2017: Urban hospitals=43.0%; critical access hospitals=30.1%; other rural hospitals=35.6%;
2018: Urban hospitals=40.3%; critical access hospitals=31.9%; other rural hospitals=37.3%;

2018 data is preliminary
Source: MDH, Health Economics Program analysis of Hospital Annual Reports.

Health Care Transformation

Page 60—Emerging providers extend provider reach and access

This table details the role and need for new health care professions along with how many are currently practicing in each profession in Minnesota and the type of credential needed.
Table:
International Immigrant Medical Graduate is not a new provider type. The International Immigrant Medical Graduate Assistance program began in 2015 to address barriers and explore pathways to integrate International Immigrant Medical Graduates into Minnesota’s health delivery system. International Immigrant Medical Graduates need a license to practice. There are currently 168 International Immigrant Medical Graduates in Minnesota.
Community Paramedics are a paramedic with additional training who deliver primary and preventative health care services, often in patient’s homes and community settings, and connect patients to local community and public health resources. Community Paramedics need a certificate to practice. There are currently 144 certified Community Paramedics in Minnesota.
Dental Therapists are a mid-level oral health provider trained to provide both clinical and therapeutic care as part of the dental team in clinic and non-clinic settings. Dental Therapists are required to serve the uninsured, underinsured and underserved. Dental Therapists need a license to practice. There are currently 100 licensed Dental Therapists in Minnesota.
Community Health Workers are frontline public health workers who are a trusted member of the community and serve as a liaison to community, health and social services to ensure culturally competent delivery of services and increase access. Community Health Workers need a certificate to practice. Currently there are over 700 certified Community Health Workers in Minnesota.
Peer Recovery Support Specialists provide support for recovery from substance use or co-occurring mental health disorders based on their own lived experience with substance use, recovery strategies and skills. Peer Recovery Support Specialists go through a certification process in order to practice. There are currently 227 certified Peer Recovery Support Specialists in Minnesota.
Collaborative Practice Dental Hygienists are dental hygienists authorized to provide preventative oral health care in non-clinic settings. Collaborative Practice Dental Hygienists need a Dental Hygienist license in order to practice. Currently less than 11% of Dental Hygienists in Minnesota are Collaborative Practice Dental Hygienists.

Source: MDH Office of Rural Health and Primary Care.

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