May 2008 | Back to Table of Contents

Clinical and Health Affairs

Primary Care in Minnesota

An Academic Health Center’s Perspective

By Kathleen D. Brooks, M.D., M.B.A., M.P.A., Jennifer E. Cieslak, Ed.M., Peter M. Radcliffe, Ph.D., and Kaia Sjogren, B.S.N., M.P.H. candidate

Abstract
Although Minnesota’s overall supply of primary care physicians is as good as or better than that of many other states, Minnesotans in some rural and urban communities do not have ready access to primary care. Simply training more doctors using the current model is not a viable solution to this problem. In order to increase the supply of primary care physicians, the state, its educational institutions, and its health care provider organizations will need to develop new educational opportunities, explore new models of care, and create viable systems for health care delivery for all Minnesotans. This article describes the current status of primary care in the state and ideas for addressing anticipated workforce shortages and enhancing the vitality of primary care.

 Since 1990, Minnesota has been ranked one of the top 2 healthiest states in America’s Health Rankings, and for 11 of those years has held the No. 1 spot. Minnesota’s strengths include having the lowest rate of cardiovascular deaths, a low premature death rate, and a small percentage of the population uninsured. It is also among the top 5 states for having a small percentage of children in poverty, a low infant mortality rate, a low rate of occupational fatalities, a low rate of motor vehicle deaths, and a high rate of high school graduation. The state’s biggest health challenges are obesity, limited access to adequate prenatal care, violent crime, and smoking.¹

Changing demographics will likely have an effect on the type of health challenges the state will face in the future. Between 2000 and 2030, the portion of the state’s population that is 65 and older is expected to increase from 12% to 24%. This is the fastest-growing age group in Minnesota, and the people in this group use far more physician services than their younger counterparts.² Although advances in treatment and early screening should bring improved outcomes for certain conditions, the prevalence of chronic diseases will increase over time. Patients are likely to live longer and will do so with multiple conditions that require ongoing medical care.³

Minnesota’s racial composition also has changed dramatically. Between 2000 and 2005, the nonwhite population grew by 21%, compared with 2% for the white (non-Latino) population. Refugees arriving in Minnesota in 2005 constituted 11.8% of all refugees entering the United States. In 2005, 40% of all immigrants to Minnesota came from Africa and 28% from Asia.⁴

Despite Minnesota’s consistent high ranking for health nationwide, not everyone has shared in this good fortune. A report published by the Commonwealth Fund in 2007 rated Minnesota 38th overall in equity rankings in health care. This poor ranking was a result of large disparities among minority groups, specifically Asian Americans and Native Americans living in both urban and rural areas.⁵ The documented health disparities in the state’s minority and tribal communities include shorter life spans, poorer general health, higher rates of infant mortality, and higher incidences of diabetes, heart disease, and cancer.

Rural Minnesota, in particular, is coping with the effects of rapidly changing demographics. Forty-one percent of those 65 and older live in rural Minnesota. In addition, rural Minnesota is experiencing significant growth in minority and immigrant populations, much of which has been attributed to the employment opportunities provided by manufacturing and food processing plants. Between 1990 and 2000, the rural Hispanic population increased by 176% and the rural African-American population by 178%,⁶ making it a challenge for rural hospitals and clinics to provide culturally appropriate care. Although rural Minnesotans face the same challenges to their health as residents of more urban areas, their struggles are often magnified because they lack access to core health care services.⁷

In 2007, 62% of Minnesota counties carried a full or partial Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA) designation in primary care, mental health, and dentistry (Table). The primary care category included doctors of medicine and doctors of osteopathy who practice general or family medicine, general internal medicine, pediatrics, and obstetrics and gynecology.⁸ Thirty-seven percent of Minnesota’s rural population lives in an area that has a shortage of health professionals or is considered medically underserved.⁹

Minnesota’s Physician Workforce
The Minnesota Department of Health’s Office of Rural Health and Primary Care surveys physicians regarding employment status and the nature of their practices each year when they renew their licenses. In 2002, there were 4,261 primary care physicians licensed and practicing in Minnesota. Of those, 1,286 (30%) were practicing in rural Minnesota.

Primary care physicians represent the largest proportion of physicians practicing in Minnesota. In 2007, 49% of Minnesota physicians claimed a primary care discipline as their principal specialty.¹⁰ The breakdown is as follows: 23% were in family medicine, 12% in internal medicine, 9% in pediatrics, 4% in obstetrics/gynecology.¹¹

The number of primary care physicians in Minnesota grew by 20 between 1999 and 2002, increasing the supply from 4,241 to 4,261. The number of other specialty care physicians rose by 129 (6%) during the same time period.¹² A similar trend has been demonstrated nationally, with the rate of growth of subspecialties far exceeding the rate of growth of family medicine and other primary care specialties in the last 25 years. Specialists accounted for more than three-fourths of the growth in the physician (per capita) workforce from 1980 to 1999, despite concerted, widely publicized policy and funding efforts to increase the number of primary care physicians. During that period, the number of family physicians grew 0.3%, general internists 8%, and general pediatricians 7.5%, while the number of other physician specialists grew 41%.¹³

Demand for family medicine physicians nationally has grown in recent years. Merritt Hawkins and Associates, a physician search and recruitment firm, reported an 84% growth in the number of family practice search assignments in the last 5 years. Family physicians were at the top of the recruitment list for the first time in 6 years, passing orthopedic surgeons, cardiologists, and radiologists.¹⁴ In 2007, 91 health care employers in greater Minnesota reported that they had 168 physician vacancies and were recruiting 284 physicians. Primary care accounted for 56% of the positions under recruitment.¹⁵

Challenges to Primary Care Practices
The introduction of managed care and health maintenance organizations brought new responsibilities for primary care physicians. In the 1980s, primary care practices found they needed to sign agreements accepting financial risk for patients’ health care costs, and their physicians became “gatekeepers.” This placed physicians in complex and fundamentally different roles than many had trained for, which led to significant consternation. Health insurance models changed again as a public backlash against capitation led to the development of new financing plans. The declining reimbursements to primary care physicians that went along with these new models drove expectations to see more patients in less time. Now, insurers and purchasers of health care are implementing pay-for-performance initiatives involving public data reporting on physician performance measures. Successful performance on these measures requires physicians to develop new models of care delivery. All of these factors contributed to significant angst and, in some cases, disillusionment among this group of physicians.

Financial factors are influencing future physicians’ choice of specialty. In 2007, the national median salary was $185,730 for family physicians and $193,162 for those practicing general internal medicine. Median salaries for non-primary care specialists were much higher. For example, the median salary of cardiology subspecialists ranged from $389,243 to $435,000, while the median salary for orthopedic surgeons was $436,481. The median salary for a family physician in the West North Central Census Division, which includes Minnesota, was $170,000.¹⁵

According to the Association of American Medical Colleges, the average educational debt of 2007 medical school graduates (including pre-medical school borrowing) was $137,437.¹⁶ The average indebtedness of 2007 graduates of the University of Minnesota Medical School was $141,691.

The declining interest in primary care has been associated with student perceptions that primary care is not sufficiently remunerative and that its demands are not compatible with their lifestyle expectations.¹⁷ Recent surveys of students also demonstrate a decline in valuing primary care’s “intellectual stimulation” (“Is my work interesting and challenging?”), meaning “Am I contributing to the greater good of individuals and society?”¹⁸

Preparing Physicians for Minnesota
The University of Minnesota Medical School is widely recognized for its success in training family physicians. In 2006, it ranked second out of 125 medical schools in the number of graduates choosing family medicine and eighth in the percentage of graduates choosing family medicine.¹⁹ Over the last 5 years, 511 (47%) University of Minnesota Medical School graduates chose and matched with a primary care residency, including 62% of students who spent their first 2 years on the Duluth campus (n=160) and 42% of those who began their studies in the Twin Cities (n=351).

In the recent past, total class size for the medical school has hovered around 220. In 2007, the school’s entering class increased significantly as a result of a higher-than-expected enrollment rate among accepted applicants; total class size expanded to 241, a 10% increase.

University of Minnesota medical students are exposed to primary care practice through a variety of experiences, including the following:

• The Primary Care Clerkship. This is required of all medical school students. It is an 8-week experience that exposes them to family medicine and primary care, more broadly, in ambulatory settings.
• The Rural Observation Experience. This program provides any first- and second-year medical student on the Twin Cities campus with an opportunity to shadow a rural family physician for several days.
• The Rural Physician Associate Program (RPAP). This is a 9-month, community-based educational experience for third-year medical students; during their time in the program, they live and train in rural communities.
• Urban Community Ambulatory Medicine. This is a 4-week optional experience available to students who have completed the primary care clerkship. Students spend time at clinics in underserved urban communities and are exposed to a diverse population of patients.
• Summer Interns in Medicine. Offered to Duluth and Twin Cities medical students between years 1 and 2, this is a 2- to 8-week internship in a rural community. In addition to spending time with a physician, students are exposed to an array of people, professions, and services involved in emergency medicine, hospice, home care, pharmacy, public health nursing, law enforcement, and dentistry in rural communities.

Minnesota has 11 family medicine residency programs, seven of which are affiliated with the University of Minnesota: University of Minnesota Medical Center, Fairview/Smiley’s Clinic, North Memorial, St. Cloud, St. Joseph, St. John’s, Methodist, and Mankato. The others are the Hennepin County Medical Center, Mayo Clinic, Duluth, and Allina/United programs.

From 2003 to 2007, the total number of family practice residency positions offered in Minnesota ranged from 71 to 94. In 2007, 72 of the 78 positions offered (92%) were filled in the National Resident Match Program; an additional 5 positions (6%) were filled by unmatched residents.

From 2001 to 2006, 76% of graduates of the University of Minnesota’s family medicine residency programs chose initial practice sites in Minnesota. Taking a broader look at University of Minnesota primary care residency graduates between 2003 and 2007, more than 75% of the graduates of internal medicine and medicine/pediatrics residencies who intended to pursue primary care chose an initial practice site in Minnesota.

Addressing Primary Care Needs in Minnesota
Traditional models of primary care delivery have limitations. They place the primary care physician in the role of a technical pieceworker, providing urgent acute care for illness. Reimbursement models pay for acute, episodic care. Patients with complex chronic diseases find that short, problem-oriented interactions with primary care physicians do not meet their needs. The movement toward measurement and transparency in health care data reporting on system and physician performance on these measures has highlighted the limited success current models have to improve the health of the community.

New models of primary care have developed to address these issues. These models, which recognize changing roles of health care practitioners as they coordinate their efforts as teams, are being tested across Minnesota. They are largely based on the concept of the medical home and the Wagner model for chronic care.

The American Academy of Pediatrics (AAP) introduced the term “medical home” in 1967. Initially, it referred to having a single source of medical information about a patient. Since then, the term has evolved to describe a model for providing primary care that is accessible, family-centered, coordinated, comprehensive, continuous, and culturally effective, and it has caught on with other organizations. In 1978, the World Health Organization also described the basic requirements of a medical home, including the role of primary care. Then in the 1990s, the Institute of Medicine began using the term.²⁰ In the meantime, Edward Wagner introduced the idea that effective chronic care required integration of 6 components: the health care organization, community resources, self-management support, delivery-system design, decision support, and clinical information systems.²¹

In 2002, the leaders of 7 national family medicine organizations conceived the Future of Family Medicine project. The result was a proposal for a new model of practice for family medicine that incorporates many of the concepts in the medical home and Wagner models. The model has 11 key characteristics: patient-centered care, whole-person orientation, team approach, elimination of access barriers, information systems, redesigned offices, focus on quality and safety, enhanced practice finance, and a commitment to provide a portfolio of services. This model articulates a multidisciplinary team approach to care that requires a shift in the culture to cooperation and an understanding that a practice is more than the sum of its parts.²²

Such models of primary care delivery are redefining the roles of all members of the health care team, including pharmacists, nurses, dentists, and public health providers. These models call for health care practitioners to practice their discipline at the “top of their license.” For primary care physicians, this means concentrating on differential diagnoses and complex medical decision-making. Other members of the team concomitantly would change their focus, and all the practitioners would form alliances to care for individuals and the overall population. The University of Minnesota’s Academic Health Center is piloting these new models in training programs and measuring their effectiveness.

For example, in 2006, the University of Minnesota Medical School was one of 10 medical schools selected for a 2-year chronic illness care education grant from the Josiah Macy, Jr. Foundation. The medical school partnered with Smiley’s Clinic, one of the university’s family medicine residency sites, to develop a curriculum in chronic illness care for medical students and family medicine residents. This is a longitudinal patient care and faculty mentoring experience focused on the care of chronically ill patients.

In another example, University of Minnesota Physicians and Fairview Health Services have worked collaboratively to develop an innovative clinic at Fairview Maple Grove Medical Center. This multispecialty ambulatory care center is patient-focused and comprehensive and integrates the best practices of primary care, chronic disease management, and specialty services.

No single model of care delivery will serve as a silver bullet for alleviating the state’s primary care needs. As one place to start, however, we suggest investing significant effort in developing and testing these and other new models of care.

Proposal for Minnesota
The University of Minnesota Academic Health Center is making the following recommendations for strengthening primary care medicine in the state. We recognize that success will require the support of and participation by government, health systems, communities, and practicing health professionals. Some of our suggestions are long-term solutions, others could make a more immediate difference.

Maintain 10% increase in medical school class size. The medical school experienced an unanticipated increase in the size of its incoming class this past year, from 220 to 241 students. We propose maintaining that 10% increase in class size. This is a long-term strategy, as it takes 7 years before a larger cohort of students will enter practice.

Develop and expand programs that expose students to primary care. The Rural Physician Associate Program has been very successful in educating third-year medical students in rural settings. Traditionally designed for students with a demonstrated interest in rural primary care and experience in rural communities, the program has expanded in recent years because of increased student interest. Of 892 RPAP participants who currently practice, 575 (64%) are practicing in Minnesota. Of those, 361 (63%) are in rural communities, and nearly all are in primary care (89%).

Other programs are being planned that expose medical students to ambulatory care experiences, chronic illness care, and integrative medicine and allow them to work with a given patient population over time. A Rural Health Scholars Program has been explored as another possible track that would train students to provide health care for rural and Native American populations. Another possible program would involve fast-tracking carefully selected students through medical school and into primary care residencies in 3 instead of 4 years.

Increase by 10 the number of family medicine residency slots offered each year in Minnesota. Seventy-six percent of graduates of University of Minnesota family medicine residency programs establish their practice in Minnesota upon graduation. To expand the number of new physicians entering family medicine, we should provide expanded graduate medical education training opportunities in the state. These residency training sites could serve as laboratories for testing new models of care delivery.

Increase economic incentives for primary care. In 2006, Minnesota was identified as the second most expensive of 74 American public medical colleges with resident tuition and fees of $32,147. In 2007, University of Minnesota Medical School graduates left with an average $141,691 in educational debt.

We propose more robust loan repayment programs in Minnesota for primary care physicians in underserved communities. At a minimum, the Minnesota Rural and Urban Physician Loan Forgiveness Program and the Minnesota State Loan Repayment Program, both of which require recipients to practice in areas of need, should be expanded to cover more primary care physicians who would like to pursue practice in underserved communities. The Minnesota Rural and Urban Physician Loan Forgiveness Program aims to improve the distribution of health care practitioners in high-need settings. The commissioner of health distributes funds annually among eligible health professions, including physicians practicing family medicine, pediatrics, internal medicine, obstetrics/gynecology, or psychiatry in a designated rural or urban area. Participants are eligible to receive up to $17,000 a year and must practice at the approved site for a minimum of 3 years. The Minnesota State Loan Repayment Program makes up to $20,000 per year available for a 2-year commitment, with an option for extension, to physicians practicing in a federally designated Health Professional Shortage Area.²³

In a survey of Minnesota physicians who received loan forgiveness, 61% continued medical practice at their placement site for 3 or more years following completion of their service obligation.¹⁵

Explore opportunities to engage foreign medical graduate (FMG) immigrant talent. Licensure in Minnesota for FMGs involves completing at least 2 years of a U.S. residency and fellowship program that is accredited by the Accreditation Council for Graduate Medical Education. In order to be eligible for application to a residency program, a foreign medical graduate must receive an Education Commission for Foreign Medical Graduates (ECFMG) certificate that indicates their readiness to enter U.S. residency and fellowship programs.

To obtain an ECFMG certificate, a FMG must have graduated from an approved medical school, and successfully complete the U.S. Medical Licensing Examination Step 1 and Step 2 medical science examinations, the clinical skills examination, and the test of English as a foreign language. The FMG also will need to complete a clinical observership under the supervision of a licensed physician who can write a recommendation.

The University of Minnesota Medical School could assist these graduates as they prepare for licensing examinations or provide a clearinghouse for appropriate resources. Further, the medical school could provide resources to create cohort model groups to mentor, counsel, and support residents in training.

Support retraining of previously licensed physicians. Another way to address the need for primary care physicians is to assist those who stepped away from practice for a few years and now want to be relicensed. Often, these are women who stopped practicing during child-rearing years and now wish to return. The medical school is exploring options to create a refresher course for these physicians.

Collaborate on new models of primary care delivery. The university proposes partnering with health systems, other educational institutions, policymakers, payers and insurers, and the community to develop interprofessional, community-based health delivery models that emphasize the use of evidence-based information, prevention, wellness, and health promotion. We will build a body of evidence and scholarship about the effectiveness of new models that includes evaluation of patient safety, outcomes, and quality of care. As a broader community, we must leverage the use of telemedicine, the Internet, and other technologies to improve access to and the quality of health care in underserved areas and to empower Minnesotans to participate more fully in caring for their own health.

Advocate for better reimbursement for primary care physicians. The university will join with others who are advocating for change in the primary care reimbursement system.

Partner with communities. The university will need to work with communities that are currently underserved in new and more creative ways to recruit and retain primary care physicians and other health professionals who are key to providing primary care.

Conclusion
Too many Minnesotans do not have ready access to primary care, especially those who live in certain rural and urban communities. Training more doctors using the old model is not a viable solution. The state will need to strengthen its pipeline of primary care physicians, develop and expand educational opportunities that expose students to primary care in rural and underserved areas, explore new models of care, and engage in substantive dialogue with all stakeholders to develop viable systems for health care delivery for all Minnesotans. MM

Kathleen Brooks is associate dean for primary care at the University of Minnesota Medical School, Jennifer Cieslak is special assistant to the senior vice president for health sciences, Peter Radcliffe is director of planning and analysis, and Kaia Sjogren is a research assistant with the university’s Academic Health Center.

This article is a shorter version of a paper written at the request of the senior vice president for health sciences at the University of Minnesota.

References
1. America’s Health Rankings, 2007 Edition. United Health Foundation.
2. Demographics of an Aging Population, Minnesota Department of Health, Fall 2005.
3. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med. 2006:81(9); 782-7.
4. 2007 Eliminating Health Disparities Legislative Report. Minnesota Department of Health. January 2007.
5. Aiming Higher. Results from a State Scorecard on Health System Performance. The Commonwealth Fund. June 2007.
6. Health Care Reform: Addressing the Needs of Rural Minnesotans. Minnesota Department of Health Office of Rural Health and Primary Care. October 2007.
7. Quality through Collaboration: The Future of Rural Health Care. Institute of Medicine. November 2004.
8. Primary Medical Care Designation Criteria. Health Professional Shortage Area Bureau of Health Professions. Available at: http://bhpr.hrsa.gov/shortage/hpsacritpcm.htm. Accessed April 10, 2008.
9. Health Care Reform: Addressing the Needs of Rural Minnesotans. Minnesota Department of Health Office of Rural Health and Primary Care. October 2007.
10. Fonkert J. Rural Minnesota’s health care workforce: demographics, geography, and strategies. Rural Minn J. Spring 2007.
11. Minnesota Physician Facts and Data 2005, Minnesota Department of Health Office of Rural Health and Primary Care.
12. Buck ST, Trauba V, Christensen RG. Minnesota physician workforce analysis: rural supply and demand. Minn Med. 2004:87(9); 40-3.
13. Biola H., Green LA, Phillips RL, Guirguis-Blake J, Fryer GE. The U.S. primary care physician workforce: undervalued service. Am Fam Phys. 2003:68(8);1486.
14. 2007 Review of Physicians and CRNA Recruiting Incentives. Merritt Hawkins and Associates.
15. Moscovice I, Casey M. Options for Increasing the Supply of Primary Care Physicians in Rural Minnesota. Rural Health Resource Center. January 2008. Available at: www.ahc.umn.edu/img/assets/29897/Increase_PC_Phy_Supply_in_Rural_Minnesota.pdf. Accessed: April 10, 2008.
16. Medical Student Debt. Association of American Medical Colleges. Available at: www.ama-assn.org/ama/pub/category/5349.html. Accessed April 10, 2008.
17. Whitcomb ME, Cohen JJ. The future of primary care medicine. N Engl J Med. 2004:351(7);710-2.
18. Rueben DB. Saving primary care. Am J Med. 2007:120 (1);99-102.
19. Pugno P, Schmittling G, McGaha A, Kahn NB Jr. Entry of U.S. medical school graduates into family medicine residencies: 2006-2007 and 3 year summary. Fam Med. 2007:39(8);550-61.
20. The Patient Centered Medical Home. Robert Graham Center, November 2007.
21. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: Translating evidence into action. Health Aff. 2001:20(6):64-78.
22. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004:2, suppl 1; S3-32.
23. Bringing Health Care to the Heartland: An Evaluation of Minnesota’s Loan Forgiveness Programs for Select Health Care Occupations. Minnesota Department of Health Office of Rural Health and Primary Care. April 2007.