With rural doctors in short supply, Minnesota lawmakers consider more financial incentives

There's a bit of wanderlust in Dr. Michele Thieman, who worked in Washington, D.C., out of college, then spent a year outfitting canoists in the Boundary Waters, then pursued an advanced degree — not in medicine — before finally applying to medical school.

So even though she liked the notion of practicing medicine in a rural area, locking Thieman in one place with a financial incentive probably wasn't a bad idea. She received state loan forgiveness on her student debt for two years in exchange for a commitment to practice in Park Rapids and Walker, near the Mississippi River headwaters.

"Knowing I had that money and that commitment made it a given," she said. "I wasn't leaving."

A shortage of rural health care providers, combined with the success of Minnesota's current loan forgiveness program, is creating momentum at the Legislature for a plan to nearly triple the funding for these incentives — and perhaps extend them to other medical professionals.

Rural Minnesota is expected to face a shortage of at least 800 doctors in the next decade — a result of looming retirements and a lack of interest among medical students to do primary care — when at the same time the aging of its population will increase the need.

"We have a critical need for these providers," said Steve Gottwalt of the Minnesota Rural Health Association.

The deal is that doctors, dentists, nurses and others agree to practice for three to four years in sections of Minnesota designated as health care shortage areas, and in exchange receive $5,000 to $30,000 per year to cut down their student loan debt.

Considering that doctors enter practice owing $170,000 or so for their medical education, and dentists have loan debts exceeding $200,000, the incentives have allure.

Rep. Deb Kiel, R-Crookston, wants to increase state funding from $740,000 per year to $3 million. That would fund an additional 50 loan forgiveness awards per year, and more than replace state budget cuts from 2011.

The incentives seem to work. Of the 192 doctors who received loan forgiveness in Minnesota since 1991, 75 percent are still in rural areas; among dentists and nurses, more than half stayed in rural practices after their commitments ended.

"The intent is not just to have them plant themselves for five years," Kiel said, "but to actually build a career … in an area that needs medical help."

The loan forgiveness concept was immortalized by the TV show "Northern Exposure," in which a true New Yorker took the money to practice in remote Alaska. But just how much it changes doctors' decisions isn't entirely clear. Thieman, for instance, already wanted to practice in rural Minnesota; her residency had been in Park Rapids.

Dr. Andrea Westby has received awards for three years to practice in Perham and in her hometown of Pelican Rapids. She is thrilled, even though her friends and relatives had varied reactions.

"Some absolutely can't wait to have me as their doctor, just because they know I know them," said Westby, 33. "Then there are some who go, 'You know, I just know a little bit too much about you, and you know a little bit too much about me to have that relationship.' "

Even if loan forgiveness attracts doctors to locations in which they already intend to practice, that doesn't bother Mark Schoenbaum, director of the Minnesota Department of Health's Office of Rural Health and Primary Care. As they near the end of training, doctors are intensely recruited by clinics nationwide, and could be tempted to change plans, he said.

"Loan forgiveness can be the tiebreaker," he said.

Thieman, 40, is settled in Park Rapids, where she raises a child with her husband, also a doctor. But there were times when she might have bolted if it wasn't for the loan support. A takeover of her clinic group resulted in changes and stresses, and colleagues departed — some for urban practices — and left the group shorthanded.

"There were days when I was like, 'Ugh, God, really?!' " she said.

Westby said the allure of rural primary care is the variety. She recalled a recent day when she treated a woman going through a divorce for stress-induced heart problems, then a 90-year-old woman with dizziness, then delivered a baby. She once thought she'd never practice in a rural area, but now she can have lunch with her grandma each week and treat "my farmers and my bankers" and others she knows well.

"It's fun to take care of people when you know them as people," she said.

Minnesota's physician shortages are primarily in northern and southwestern counties, where there is less than one primary care doctor per 3,500 people. Physicians can also obtain loan forgiveness if they practice in north Minneapolis, where there are too few doctors accepting Medical Assistance to serve the disproportionate number of patients in poverty.

Many rural areas also lack dentists, nursing home nurses and pharmacists, who are already eligible for loan forgiveness. Some lawmakers want to add chiropractors, physical therapists, mental health providers, dental hygienists and public health nurses to the list. Doctors and dentists would be eligible for larger individual awards, because their student loan debts are higher, but the money would be tailored each year to the professions with the greatest needs.

The changes seem likely to pass, but disagreements have emerged.

Rep. Brian Johnson, R-Cambridge, said expanding eligibility for the program might "spread it too thin."

Kiel said communities need doctors but others as well: "We don't think of chiropractors as important as a doctor, but [they] are really doing things that relieve pain, especially for our senior citizens."

Jeremy Olson • 612-673-7744