Kensington, Minn. is barely a dot on the map. This small grid of concrete, where fewer than 300 people live, is a brief interruption amid the sprawling acres of green corn, soybean and wheat fields that cover Minnesota’s western plains.
Similar tiny villages exist every seven or so miles along the Soo Railroad route. These once busy agricultural hubs are now skeletons of commerce with rapidly aging populations.
About one-fifth of Americans live in rural areas, and providing health care to them is a challenge financially and logistically. Only 10 percent of the nation’s doctors practice in rural areas, and rural residents tend to be poorer and less likely to have employer-based insurance than urban dwellers. The list of challenges is long.
I grew up in rural
Minnesota. I went to elementary school in Kensington, and my mom works as a nurse at the town’s health clinic. On a recent trip home, I decided to learn more about rural health care.
I spoke with Dr. Robert Montenegro, the primary provider at the Kensington clinic, and interviewed Mark Schoenbaum, the director the state Office of Rural Health and Primary Care.
Kensington’s clinic has two small exam rooms and is located in the
Main Street Community Center. A nearby 16-bed hospital opened it two years ago as a satellite facility to expand access to care and its catchment area.
What I find is amazing is that in June the clinic went to a completely electronic medical records system. That’s more advanced than 80 percent of doctor’s offices nationwide.
Most of the clinic’s patients are elderly with multiple chronic
diseases. Many are also poor, thus Medicare and Medicaid are top payers. Transportation is a problem for many patients because the town with most shopping and services is 20 miles away.
J-1 doctors provide the medical backbone
Only about 5 percent of Minnesota doctors work in rural areas,
Schoenbaum said. Foreign medical
graduates or “J-1 doctors” like Dr. Montenegro increasingly provide the primary care backbone in rural areas.
Montenegro trained in the Philippines and
completed his residency at the University of Pittsburgh. Six years ago with a J-1 visa waiver,
he moved to rural Minnesota. I asked him what it was like to be the only Filipino in the
community. (Kensington’s population is 98 percent white.)
He had a surprisingly upbeat attitude. He is married with two children
and said his family makes him happy. The area is quiet, safe and has
nearly all the necessary amenities, especially compared to rural areas
in the Philippines. Many of his colleagues, however, he said left their
designated underserved areas after fulfilling their three-year
About 4,000 J-1 doctors are employed nationally, and about 144 currently practice in Minnesota. Congress created the J-1 visa waiver program in 1995. It is also known as the Conrad State 30 program because it allows 30 foreign doctors in each state, each year, to practice in urban blighted areas or rural underserved areas. The foreign docs agree to work in these areas for at least 40 hours a week for three years, and in return, they become permanent residents.
In an award-winning series, Las Vegas Sun reporter Marshall Allen found evidence of abuse in the J-1 program in Nevada. “(J-1 doctors) are frequently overworked, cheated financially, and diverted away from the underserved patients they are supposed to serve. … The abuses are possible because each employer sponsors the visas for his J-1 doctors. That means a J-1 doctor who loses his job might have to leave the country. The foreign doctors have worked their entire lives for the chance to become Americans, so they’re unlikely to complain, because it puts their immigration status at risk,” Allen wrote.
The Government Accountability Office looked into the program in 2006, and concluded that no single agency polices the program, making it easier for abuses to go unchecked.
Montenegro overall seems to enjoy working in a rural area. The limited resources forces him to keep up with new therapies and drugs and sometimes become creative in his treatment plans.
Working in a rural area, though, does pose great challenges, he said.
The hospital that employs Montenegro has no emergency department specialists so he shares call with the other primary care doctors and general surgeons. Patients who need a specialist can’t always get a timely appointment and may have to travel 60 miles or more. Psychiatric referrals, especially, can require days of dogged phone calls.
Also, dealing with a predominately elderly population with multiple chronic diseases and corresponding prescriptions sometimes requires the primary care docs to manage patients beyond their comfort level –- but there is no other choice, Montenegro said.
One point Montenegro talked about at length was the rural doctors’ reliance on drug samples. He acknowledged the controversy around accepting gifts and samples from pharmaceutical salespeople, but said his clinic and patients often need them.
When patients come in for a late afternoon appointment and need to start a prescription as soon as possible, samples are often, Montenegro said, his only option. There are no 24-hour Walgreens stores here, and the hospital pharmacy services only inpatients. Admitting someone for a prescription would not be cost-effective, he said. But when I pointed out that giving patients samples means they will take the most expensive drugs available, he agreed that this is a dilemma.
When I shared this scenario with Schoenbaum, he said it was an example of how telepharmacy could improve patient care. More widespread use of telepharmacy and telemedicine are ways Minnesota is working to improve access to care in rural areas, he said.
In many ways, Minnesota is at the forefront of improving rural health care, he said. The state has a strong tradition of sharing information and resources, and rural hospitals have learned to be financially limber and creative.
Rural hospitals provide more than acute care; they serve as community health care hubs. The Kensington clinic, for example, is one of three satellite clinics to the 16-bed hospital 20 miles away. The hospital also operates a home health agency, hospice and nursing home. As one of Minnesota’s 79 critical access hospitals, it receives higher Medicare reimbursements — a critical aspect to its survival because on average, Medicare comprises about 80 percent of rural hospital business, Schoenbaum said.
Technology advancements offer great opportunities to expand access and improve qualify of care, but they are not a panacea for the significant policy challenges facing rural health care providers. High rates of
uninsured people also pose access and financing issues.
The shortages of rural health care workers, ranging from nursing
assistants to radiology technicians, is a problem Minnesota cannot
train its way out of, Schoenbaum said. Future projections are bleak, he said, and there is no foreseeable solution.
Baby boomers dedicated to providing care in rural areas, such as my mom,
will retire in the next decade or so, and my generation has not stayed
around to replace them. I wonder who will care for my parents.