Minnesota's legislature has put in place a model for medical training that has improved rural health outcomes AND boosted rural economies. Why aren't federal health administrators taking note -- and taking action?
Rural leaders have long recognized that health care delivery is important to the rural economy — more important than in urban areas — and essential to recruiting and retaining other jobs and businesses. Despite consensus on this, there have been decades of little progress in resolving problems in the rural workforce. Designs for medical education and for rural health delivery have generally failed, yet there are huge success stories that remain models and work for rural economic development.
About 43 years ago the Minnesota legislature decided to hold the University of Minnesota accountable for producing the physicians most needed within the state. To their credit, lawmakers also provided funding for that training – $1 million initially, later trimmed to $800,000 a year. (The funds were cut back because the director of the program was too frugal.) After no investment for decades, the state achieved tremendous benefit for very little cost.
The Rural Physician Associates Program (RPAP) was created with 60 medical students a year spending 9 months in Greater Minnesota as members of health care teams. This structure remains one of the best ways for a low-cost boost in health care delivery where it’s most needed.
RPAP sites deliver $40,000 to $70,000 more care when they have a medical student on the team as compared to years without, as Jack Verby long ago noted. Studies in Australia support this value of long-term continuity in rural rotations. RPAP has been a key part of medical school graduates’ remaining in family medicine, instate, and where they’re needed.
For the past 30 years, the RPAP’s successes have been ignored by health care leaders, including the current leaders of the Health Resources and Services Administration (HRSA). Though aware of RPAP, they have not chosen to expand such a plan or make it specific to the agency’s mission.
At a time when the current administration is desperate to rapidly increase primary care – and so to ensure that the new health care plan really works — the proposal to expand RPAP to involve students of medicine, osteopathy, registered nursing, nurse practitioners, and physicians assistants has been turned down.
If the health-care workforce is missing in local or adjacent zip codes for over half of Americans, no health care plan can work. And there has, in fact, been no plan specific to this workforce or to its recovery since the end of the 1970 to 1980 restoration. Actually, national designs for health care have been cost cutting from Diagnosis-Related Groups to “shared savings” for areas with the least health spending already. The Institutes of Medicine have recommended lower reimbursement for smaller and rural practices, a continuation of flawed indices, biased reports, and lack of awareness of most Americans’ health care needs.
The Health Resources and Services Administration fails to comprehend that RPAP-type year-long experiences could deliver care to millions more people, involving thousands of health care students trained where care delivery is needed most. This design would do far more to train health care professionals to work with other health professionals, as the experience involves many months of continuous team work.
RPAP also has been effective in identifying problem future-physicians and problem current-physicians; current methods of health care training fail to do so.
RPAP provides an experience far beyond the usual few weeks or months of rural or of primary care exposure (which is about enough time to drive graduates away from choosing primary care as a specialty or opting to work in a rural area). Complex health care delivery and rural relationships -– as well as the literature on rural primary care — take time to understand and appreciate.
Instead of expanding the Rural Physician Associates Program, we have invested over $600 million over the past three decades to create too few health care professionals, placing them in the wrong careers and wrong locations. RPAP, especially combined with the Duluth Medical School, was specifically designed to turn out permanent family practitioners and yield more professionals in rural general surgery, rural obstetrics, and rural primary care.
Our nation supports generic primary care training, but in 70% of cases, these graduates do not continue working in primary care. The often promoted physicians assistant, nurse practitioners or advanced nurse interventions are low yield, with less than 25% of those so trained ultimately employed in family practice.
RPAP physicians assistants or RPAP nurse practitioners or RPAP registered nurses would be trained specifically for rural employment, to meet rural needs and enter the rural workforce. The beauty of RPAP is that spending is targeted to students who are serving in rural areas. They take their spouses and families to rural communities. RPAP has been a major boost to the in-state health care workforce in Greater Minnesota as students train. After such training, the economic impact has been over $4 billion in zip codes that have had multiple-times lower health spending per person.
Imagine that: a program for rural economic development that works for restoring rural jobs, providing a rural health workforce, health access, and awareness of rural America. RPAP is SMART – Specific, Measurable, Achievable, Realistic, Timely.
Dr. Robert C. Bowman, M.D., founder of the Rural Medical Educators Group of the National Rural Health Association, is a physician and long time health education policy advocate. He is professor in Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona, a school that partners with the National Association of Community Health Centers.