Overcoming the challenges facing rural health care

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.

Looming challenges

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.

18 replies »

    ” .. There is a distinction between rural areas one hour outside a city populated by people fleeing urban life (12%) and rural areas hundreds of miles from any city (5%).”
    Big difference in population, madam.
    That wasn’t made clear.
    Unclear data — PGA-level golf courses on Hilton Head Island. Visits from “60 Minutes.” Congressional hearings. Newspaper investigations.
    Facts is hard, as is authentic action. Talking about “change” is easy, theoretical, and often wasteful.

  2. Can we redirect the conversation back to health care challenges in rural areas? Being poor is tough wherever you live, whether it’s in the city or a rural area. It doesn’t serve any purpose to compare which is harder. Both populations struggle to afford health insurance and guarantee access to care. Transportation also can be difficult for both populations. Rural areas are distinct in that they have smaller populations from which to draw health care providers. Attracting physicians and nurses to work in inner city hospitals is no simple task, but often there are esteemed academic medical centers nearby and large intellectual communities.
    There is a distinction between rural areas one hour outside a city populated by people fleeing urban life and rural areas hundreds of miles from any city. And communities with PGA golf courses number far fewer than the communities with skeletal economies.

    ” .. Ah, Green Acres never had it so good.”
    Morley Safer from “60 Minutes” just skewered the “Ruppies” — PGA-level golf courses at HILTON HEAD ISLAND, taxpayer-subsidized by that bastion for the “rural poor,” the U.S. rural development agencies.
    Those poor, suffering “rural” residents, going with PGA-level golf courses for so long. I think I’m going to cry. BOO, HOO, HOO, BOO, HOO, HOO, BOO, HOO, HOO, BOO, HOO, HOO ..
    Yes — correct data matters. A lot.
    Unless, of course, you want “change.” Whatever the heck that means. Or whatever it costs.
    Which, of course, will be a lot. With no accountability.
    Congress’s current approval level: 9%. Any wonder why?

  4. Bart, states also subsidize rural yuppies. In NC the max generated $ for “farmland” to qualify for local tax exemption is $1000. Lots of lawyers, doctors and land investors gaming the system and free loading on non-farm tax payers. Ah, Green Acres never had it so good.

  5. ” .. Ever since the urban population has exploded while the rural population grew slowly then stabilized around 60 million about 30 years ago ..”
    Really? Actually, the Census indicated that rural/farm populations were doing down. But rural/yuppie populations were going up.
    “Rural” is a function of gaming for federal tax dollars. The “60 Minutes” gang had a field with “rural” yuppie communities, getting federal aid, for PGA-level golf courses. Some poor, pitiful “rural” lifestyle.

  6. “Do poor people have any easier access to adequate medical care because they live in the city?”
    Yes and no. In 2004 there were 185 non-metro counties with no primary care physicians practicing there. Probably there are only a few hundred thousand people living in those counties, but they really have limited access to care because if there are no primary care docs there I’d be willing to bet a lot that there are even fewer specialists.
    When you look at poverty, and poverty definitely affects access to care, rural poverty can look different than urban poverty in that you’re adding another variable, sheer distance, to all the other things that impact access.
    Also, in nonmetro areas poor people make up a larger part of the population and access is limited because providers do what others do: they go where the money is. Some nonmetro counties have poverty rates over 30% and being poor there is harder, in some senses, than being poor where there are more resources.
    It’s easier to go to an ER when the ER is only 2 miles away and the hospital has a base of patients who can pay their way then it is to go to an ER when the ER is 35 miles away and the hospital has a payor base that is mostly Medicaid and Medicare. The rural hospital hasn’t got much financial room left to take on patients who can’t pay anything at all.
    I can think of one way being poor in a rural area is easier than being poor in an urban area. You can (possibly) grow food, hunt or fish easier than in an urban area, and, if you’re lucky, you might already own some land even if you’re income is very low.

  7. So can the stats given;
    “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.”
    “Most of the clinic’s patients are elderly with multiple chronic diseases.”
    Apply to poor urban populations? I think so. Maybe we shouldn’t be dividing by city/country maybe by income. Do poor people have any easier access to adequate medical care because they live in the city?
    We live next door to farms along with other relocated urbanites and consider ourselves living in rural America. We are about 20 minutes drive from the state’s teaching hospital and about 30 minutes from another private hospital as well as small rural towns with lots of docs. How would we be classified?

  8. Bart, I meant no offense to you, sorry I used you as an example. I just meant that most people don’t realize how many Americans live in rural areas now. Before 1920 the rural population outnumbered the urban. Ever since the urban population has exploded while the rural population grew slowly then stabilized around 60 million about 30 years ago.

    ” .. Most people, like perhaps Bart, find that hard to believe since they think the rural population has shrunk over the years ..”
    What is hard to believe is that for all the taxpayer money spent on the Census, one still has get out their own PC to calculate rural/farm population v. “rural”/”micro-politan” population.
    As if facts actually matter. Which, it was recently show, there’s a high failure rate in public health citations —
    “This problem has been extensively studied in the health literature … 31 percent of the references in public health journals contained errors, and three percent of these were so severe that the referenced material could not be located.”
    Say what one will. Just don’t act all offended when data-validity questions arise.

  10. There is a big difference between nonmetro and rural, though the terms are frequently used interchangeably. Metro areas are based on whole counties and include lots of rural areas. My favorite example is that the Grand Canyon is in a Metro area.
    The Census Bureau’s definition of rural includes what most people would consider suburban areas. The figures from the 2000 Census were 59,061,367 rural residents out of 281,421,906 total, or 21% of the total population. You can get this out of the American Factfinder at the Census Bureau website, http://factfinder.census.gov/
    The nonmetro population is 17% based on 2002 population estimates. You can find more at
    I can go into considerably more detail about how to define rural, but it won’t make much difference to the discussion. It’s safe to say that somewhere between about 50 to 60 million people live in rural areas of the country. Most people, like perhaps Bart, find that hard to believe since they think the rural population has shrunk over the years. It actually hasn’t but the urban population has grown a lot so, while the number of people in rural areas has been pretty constant over the last 30 years, the percentage of the population that lives in rural areas has gone down.

  11. There is a significant difference between nonmetro and rural. The best figure I could find puts the rural population at about 10 percent.

  12. “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.”
    “Most of the clinic’s patients are elderly with multiple chronic diseases.”
    Larry, there’s either a lack of prayer in rural America or a lack of God.

  13. I’m wondering what role churches play in Kensington. When a chronic diagnosis is given, folks still have their church, neighbors and friends, with whom they heal . . . if healing doesn’t mean “fix” but “adapt.” So the link between the hospital/clinic would seem to be really importnat as the clinic receives parisioners, and the church receive patients and both the health care and religious communities are struggling for financiual survival.
    In Kensington, do churches have cancer support groups, or stroke groups, for example? Is there a faith-health dialogue on any organized basis?
    I know when I was in rural ministry groups like these were essential, meaningful, and full of hope. So, I’m wondering about the role of churches and their dialogue with the clinic/hospital in Kensington.

  14. “About one-fifth of Americans live in rural areas ..”
    That’s the correct number, depending on how you define rural. The Census puts the rural population of the US at about 60 million out of 300 million, or 1/5.

    “About one-fifth of Americans live in rural areas ..”
    Don’t you mean — 5%?

  16. Just look at what Geisinger has done in the realm of reaching and interacting with patients online, and their audience is mostly rural. A real model, I think.

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