Windshield time and North Dakota nice

Despite having one of the country's lowest reimbursement rates, North Dakota offers above average scores on access, quality, utilization, equity and health outcomes in recent rankings.


Cathy Houle, MD, a family physician in Hettinger, N.D., occasionally has to send her patients off to the city for specialist care—not surprising in a town of 1,307 people. But when she makes a referral, it's not to some anonymous urban doc.

“I pick up the phone and call a surgeon in Bismarck,” Dr. Houle said. “We know each other on a first-name basis. We could pick each other out on the street. In North Dakota, everybody knows each other.”

The close-knit nature of the medical community is just one of the ways that health care in North Dakota differs from that offered in the rest of the country. In a recent report, “The North Dakota Experience: Achieving High-Performance Health Care through Rural Innovation and Cooperation,” the Commonwealth Fund highlighted the eccentricities and efficiencies of this geographically large but sparsely populated state. (The report is available online.

Health care providers and residents of Carrington ND population 2100
Health care providers and residents of Carrington, N.D., population 2,100.

North Dakota is one of the most rural states in the country, yet it has come out above average on access, quality, utilization, equity and health outcomes in recent rankings. “There are other parts of the country where rural innovation is underway but North Dakota was in the top quartile across the measure set,” said Mary Wakefield, PhD, director of the Center for Rural Health at the University of North Dakota and a member of the Commonwealth Fund's Commission on a High Performance Health System.

In the Fund's state-by-state scorecard, North Dakota was ninth in the country at avoiding hospital use and cost, seventeenth in the equity and healthy lives categories, eighteenth in access, twentieth in quality, and thirteenth on the overall ranking. According to the Dartmouth Atlas of Health Care, North Dakotan medicine is also very efficient, offering highly rated care for Medicare patients despite having the lowest reimbursement rates in the country. “The fact that those two factors—high quality and low cost—are married here attracted interest,” Dr. Wakefield said.

What's their secret?

Researchers and North Dakota medical experts attribute the state's success to a number of factors, some of which may be reproducible elsewhere and others which may not.

It's hard to envision Institute for Healthcare Improvement projects or CMS bonuses targeting neighborliness, but North Dakota health care providers say that their sense of friendly, shared responsibility for the community's health is key.

“It's hard to imagine if you've never lived in a small state. You end up feeling like you know everybody in the state—kind of a band of brothers and sisters,” said James D. Brosseau, FACP, ACP's Governor for North Dakota.

The state is actually famous for the niceness of its population. Rhonda L. Ketterling, FACP, chief medical officer for MeritCare Health Systems in Fargo, cited a recent study which rated the state the friendliest spot in the country. “You can't spell friendly without N.D.,” she joked.

At the West River Regional Medical Center in Hettinger ND UND medical student Rachel Aufforth and Robert Beattie MD check out the injured shoulder of Kenny Huber as his mother Toni looks on
At the West River Regional Medical Center in Hettinger, N.D., UND medical student Rachel Aufforth and Robert Beattie, MD, check out the injured shoulder of Kenny Huber as his mother, Toni, looks on.

On a practical level, the sense of community means that health care providers are unusually eager to cooperate with each other. Marlene Miller is a program director of the Center for Rural Health, which facilitates network-building among small rural hospitals. The facilities share resources from quality improvement staff to health information technology and use their collective size to negotiate reduced rates from varying consultants.

The cooperation is facilitated by the hospitals' sense of each other as allies rather than competitors, Ms. Miller explained. “There's less of a sense of competition because the competition could be 75 miles away.”

Necessity is also the mother of much of the cooperation. “In North Dakota, our health care facilities are not so rich that they can afford to pursue new initiatives without thinking first of knocking on the door of a neighbor and asking for help,” said Dr. Wakefield.

With a limited and small patient population and fixed overhead, the rural hospitals are very interested in ways to share costs and increase profitability. “We heard examples of directors of nursing or quality improvement coordinators spending half a day trying to figure out if a new regulation applies to them and then learning that it didn't and thinking, ‘Couldn't somebody have helped with that?’” said Ms. Miller.

Old-fashioned general internists

The state's outpatient care systems are typically also low on money and staff, which inspires more cooperation. “The small towns are dying, but the people living there don't want to see their towns disappear, so they're willing to work with the larger clinics to keep some presence,” said Dr. Brosseau.

These circumstances also make for challenging and unusual—if not high-paying—work for general internists. Dr. Houle and her 11 colleagues at the West River Health Center see patients over a 25,000-square-mile area. “On the downside, there's a lot of windshield time, and that's not time that generates income,” she said.

But once the physicians get out to the remote patients, they find enjoyable relationships and tasks. “There are places where general internal medicine isn't only necessary but thriving, and internists can do a lot of what they're trained to do during residency, instead of having to shuffle it off [to specialists],” she said. Even physicians who want to rely less on specialists don't relish being entirely on their own, however. The need for up-to-date, expensive technology drives primary care providers to network, too.

“A lot of the young physicians coming out really do not want to be in solo practice,” said Dr. Ketterling. “It is the group practice hub-and-spoke model that seems to work well in North Dakota.”

The centralization of North Dakota health care is not entirely organic, however. On the payer side, Blue Cross Blue Shield of North Dakota (BCBS) insures about 90% of the groups in the state. The state also has a few large multispecialty practices that provide a substantial portion of the care, and in some communities are the only provider.

Contrary to what one might expect, the consolidation of the market actually drives innovation, the North Dakotans said. The Commonwealth Fund report's authors were particularly impressed by a successful BCBS pilot of chronic disease management and medical homes.

Under the pilot, primary care physicians referred diabetes patients to an in-house disease management nurse for help managing their condition. The intervention resulted in greater use of recommended tests, decreased hospital visits and lower costs and, based on its success, was expanded to additional locations and conditions in 2007.

“If you want to get into a pilot program or doing something a little different, you have this huge payer who you are able to try to partner with, rather than trying to work with 10 or 15 of them,” said Dr. Ketterling, whose health system partnered with BCBS on the project.

Jon R. Rice, MD, BCBS's managed care director, agreed. “Because of the stability of our population, both patients and providers, and the substantial coverage by one paying entity, there's an opportunity to gather a lot of information and to provide some experimentation,” he said.

The experts did admit some disadvantages to the North Dakota way of medicine. “We've got multiple 800-pound gorillas [in the big providers and payers] and 800-pound gorillas have to be careful where they step,” said Dr. Rice.

Also, the lack of competition among providers can foster unconcern as well as cooperation, he noted. “Why should they go to the trouble of establishing after-hours clinics so that it would be more convenient for patients?” And whether the problem is a dispute over rates set by a single payer or the low status of rural reimbursement, the shortage of money in the North Dakota health care system is a big continuing issue.

But whatever the problem, North Dakotans seem to find a way to solve it together. “They have a really keen sense of their mission and their obligation to make sure their neighbors have the best possible care,” said Douglas McCarthy, senior research advisor to the Commonwealth Fund. “They're all in the boat together and they all have to pull together.”

Perhaps a lesson that urbanites could take home from this rural state.