Doctor shortage raises rural C-section rate

DULUTH--The lack of doctors in outstate Minnesota is affecting how rural women have babies. Because there are so few physicians in some rural counties, women there are more likely than urban women to give birth via Cesarean section, data compiled by a work group advising the Minnesota Department of Health show.

The information, included in a report from the state Office of Rural Health and Primary Care, was presented by a panel Monday that was part of a two-day Minnesota Rural Health Conference.

Health providers can't count on being able to mobilize a team of doctors and nurses quickly enough for a more spontaneous natural birth, according to the work group. For example, in urban Hennepin County in 2009, between 25 and 28 percent of births were by C-section. In the same year in Roseau County in northern Minnesota, between 36 and 41 percent of births were by C-section. Cesarean sections have been linked to increased infection rates and other difficulties.

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Minnesota Office of Rural Health and Primary Care.

The problem is that with an aging rural Minnesota population, there aren't enough births in some parts of the state to support full time obstetricians. "When you look at the average number of deliveries per provider, in the northwest there are only six in a year," said Scott Johnson, a doctor with Essentia Health. "That doesn't even cover the cost of malpractice insurance."

Medical workforce issues rose as a major theme during Monday's conference panels and discussions. Much time was spent talking about how to plug the physician gap, including better using foreign-born doctors, increasing the use of mid-level providers like nurse practitioners and ramping up incentives like loan forgiveness programs. Telemedicine could be a solution in some locations and when it comes to obstetrics, a few hospitals are testing its use for fetal heart monitoring.

Workforce topics bled into discussions of health care reform, especially relevant this week as the U.S. Supreme Court prepares to rule on the federal Affordable Care Act, including the individual mandate that requires everyone to buy insurance or face penalties. Rural hospitals are experiencing big changes right now, whether because of electronic medical records adoption, aging populations or a new push toward collaborative and outcome-based care.

A panel of chief executive officers of three small hospitals centered on matters of change and survival. "It's a new environment, a new day," said Mike Hagen, who runs Riverwood Healthcare Center in Aitkin. "Payers are already asking us to do things differently. Patients, too." He cited the hospital's new formula for paying physicians. Rather than basing pay on the number of patients seen, compensation is based on the quality of care. He said 20 percent of pay is "at risk," meaning doctors earn it based on how they stack up against quality indicators. Asking more of doctors can be a tricky proposition in a climate where they are hard to recruit and retain.

The day closed with a panel focused largely on health care reform, moderated by Julie Zenner, the host of Almanac North. She asked which part of the Affordable Care Act, if it stands, would have the greatest impact on rural health care.

Lucinda Jesson, Commissioner of the Minnesota Department of Human Services, said there are parts of reform that will help rural providers, like state insurance exchanges, which could lead to greater coverage rates, and the expansion of Medicaid. People in rural areas tend to rely more heavily on public programs, she noted. "It will be a challenge if they strike down the mandate," Jesson said. "But we [still] will have more people insured than before."

That comment brought Bill Finerfrock, executive director of the National Association of Rural Health Clinics, back to the workforce issue. He said that if you increase the demand for service but don't provide more doctors, you wind up with frustrating delays. "Demand is going to occur much sooner than the system's ability to provide the providers we need," he said. Urban areas will be looking for doctors, too. "We will see an effort to recruit, to take providers from rural communities to work in cities," he said. "They'll say, 'We'll put you on salary and you'll have regular hours.' We're running the risk of seeing a migration of providers from rural to urban areas."

Given all that's happening, Zenner asked whether it's possible for rural hospitals and clinics to remain independent. Lawrence Massa, president of the Minnesota Hospital Association, noted that by far the majority of hospitals in the state are affiliated with larger systems. "That trend has accelerated," he said. "I think communities can stay independent when it comes to the ownership model, but they have to integrate the delivery model."

In other words, no matter who owns a hospital or clinic, rural providers will have to rely on each other and larger systems in order to survive and keep patients served in the future. As Finerfrock said earlier in the day, "The notion that individual hospitals [and other providers] will exist as islands is probably not realistic."

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