The Importance of Health Reform for Rural Health
in North Dakota

Testimony to Senator Kent Conrad, U.S. Senate Finance Committee
July 2, 2009 — Altru Health System, Grand Forks, ND

Senator Conrad, thank you for this opportunity to appear today to discuss a framework for health reform that is inclusive of rural health issues in North Dakota. Thank you too, for your leadership over the years in championing rural health issues and your leadership for national health reform. My name is Brad Gibbens and I am the Co-Interim Director of the Center for Rural Health, UND School of Medicine and Health Sciences. I have been actively involved in working on behalf of rural health and rural community issues in North Dakota for 24 years.

The subject of health reform – the need for it, the structure reform should take, and how to finance it – has come to dominate national, state, and community discussions. Much, if not most, of the national discourse revolves around coverage, a financing vehicle, and a rigorous debate on the “public plan.” These are all vital policy issues and they impact rural North Dakota. We know that our rural areas have lower insurance coverage, a higher poverty rate, and lower personal incomes. Financial and economic factors weigh heavily in many homes across rural North Dakota. However, many in rural health worry that other issues that are fundamental to building an equitable, stable, and sustainable health system will be lost in the overall debate on coverage and who pays for it. My remarks focus on three fundamental themes critically important to all North Dakotans, including those in rural and frontier areas. The themes are as follows: 1) a health workforce that is under serious distress, 2) health facility viability and sustainability is questionable, and 3) continuing our national focus on understanding care quality and making quality improvements.  All three contributes to improved population health. And, at the heart of health reform, be it coverage or access to care, the reason we are taking on this huge struggle is a desire to see improved health conditions for all Americans.

The three themes wrap around a systemic companion to financial access which is access to care or availability of care. Having some form of health insurance coverage is critical; however, if we do not have health professionals providing care, sustainable health institutions offering a physical location for that care, assurances of care quality, and efforts to improve the population’s health status, then improving the ability to pay for services which cannot be obtained in rural North Dakota does not actually create health reform. We address only half the problem.

Earlier this year, the Center for Rural Health completed an environmental scan of health and health care in North Dakota. With financial support from the Dakota Medical Foundation of Fargo, the Center published a two volume document that extensively reviewed and analyzed the dimensions of health and health care in the state, identified scores of programs and efforts already underway in our state, and reviewed a number of national health and health care measures to better understand how North Dakota compares with national metrics and statistics. I am using that environmental scan as the basis for my remarks. In general, North Dakota does well in terms of having a cooperative and collaborative environment making it easier to form networks and develop common solutions.  North Dakota tends to rank high in care quality and low in costs, which is likely connected to our relatively high proportion of primary care providers. North Dakota has seen improvement in a number of health behaviors such as youth smoking, seat belt use, and other factors. Our challenges are associated with health workforce, facility and system viability.

Health Workforce:

In interviews with statewide stakeholders in the development of our Flex program state rural health plan in 2008 and the environmental scan in 2009 along with a special survey of rural hospital administrators we found health professional workforce to be an overwhelming concern. Supporting these perceptions we note that 81 percent of the state is a federally designated primary care health professional shortage area and over 90 percent is a mental health shortage area. Work by the Center for Rural Health shows a need for 44 Family Medicine physicians in the state and 271 vacancies for physicians, nurses, clinical lab, mental health, and radiology technicians. Additional tracking of nursing in North Dakota completed by the Center for Rural Health indicates that while future statewide supply for RNs appears adequate, there are distribution issues as 17 rural counties have less RNs than the national average. North Dakota Job Service projects a demand exceeding 10 percent for pharmacy, occupational therapy, physical therapy, medical/clinical lab, nursing, and physician assistants. Health workforce is a chronic structural concern. Health reform must improve options for training and education, must create new incentives to inform and attract youth into the professions, create opportunity for mid-career changes, and empower rural communities to be more responsible in creating their own unique solutions.

Health Facility Viability and Sustainability:

Maintaining the organizational and physical infrastructure to seek care (e.g., hospitals, clinics, nursing homes, ambulance services, pharmacies, home health care, and others) was also detailed in the environmental scan. In rural North Dakota, these access points are under significant pressure. We have seen some closures and consolidations involving clinics, home care, and ambulance. One Critical Access Hospital (CAH) closed earlier this year. Rural CAHs margins in North Dakota, in the latest report, were -1.65 percent in comparison to a national rate of about +3.5.  Our urban hospitals - which are integral to rural hospitals due to the extensive networking in North Dakota – are experiencing payment threats as well. We also have challenges, yet opportunities in adjusting to new technologies such as HIT and expansion of telemedicine. We do have a strong and growing tele-pharmacy system but we need to expand access for tele-mental health and tele-home care. From a health policy perspective, we need to see health reform that fosters more flexibility in organizational arrangements and structures. We need to be less concerned with what a facility is called or how it is classified and more concerned with flexible models that meet local access and quality needs. We need to stretch our imaginations and in some cases mix-and-match our options. For example, in some communities if the structural and regulatory requirements are too constraining for a CAH to be sustainable, but a clinic structure is not comprehensive enough in service offerings, we need the flexibility to have expanded clinics with emergency care, observation beds, sliding fee payment scales, and access to mental and dental services. Something along the lines of the Frontier Extended Stay Clinic (FESC) Centers for Medicare and Medicaid Services’ demonstration model in Alaska is an option to review. In addition, the Frontier Community Health Integration model demonstration in Montana needs to be explored. We cannot afford to be wedded to strict definitions associated with a specific type of mortar and brick. Flexibility and creativity for service arrangements and levels of care coupled with improving care quality and patient outcomes are overarching rural health goals - they need to be health reform elements.

Care Quality:

Quality of care has been on the forefront of discussions since at least the seminal work of the Institute of Medicine in the early 2000’s. Topical health themes such as workforce development, viable and sustainable health systems, advances in health information technology, and other key elements intersect within the health system and contribute conditions that can both facilitate or hinder improved care quality. The environmental scan discussed quality of care in detail and identified some key findings. The federal Agency for Healthcare Research and Quality rates North Dakota as strong on hospital care, preventive, acute, and nursing home care and average on chronic, ambulatory, and home care. The Commonwealth Fund ranks North Dakota 13th out of 50 for “overall health system performance”, 20th on “quality”, 9th on “avoidable hospital use and costs”, and 2nd on “adult diabetics who receive recommended preventive care.” However, the Commonwealth Fund also rated the state 37th for “children with a medical home” and 46th for “children with both a medical and dental preventative care visit in the past year.” Finally, the Dartmouth Atlas finds that North Dakota is one of the most high quality and efficient states on a number of measures.

In looking at hospitals, data indicates that there are more challenges facing CAHs when compared to the state’s urban hospitals. According to the North Dakota Health Care Review, our state Quality Improvement Organization, there is about a 20 percentage point difference in quality performance between CAHs and urban hospitals. The QIO is working extensively with CAHs.  The Center for Rural Health, in partnership with the QIO and NDHA, has formed a statewide Quality Network involving all 36 CAHs.

As we move forward with health reform, continued efforts need to be made to provide technical assistance to CAHs working with them to better measure quality indicators, develop appropriate steps, and to improve overall quality. We need to continue to integrate quality and performance with payment methodologies in an effort to pay for the outcome – the quality, accuracy, effectiveness, and efficiency of the outcome – instead of simply paying for the patient encounter. As part of this pursuit of improved quality I hope we can take the opportunity presented by health reform and seriously explore concepts like the medical home which can fuse together so many necessary and wonderful options. This includes being patient centered, employing evidenced-based medicine and health care, emphasizing quality and performance, focusing on prevention and wellness, and relating to the patient through interprofessional medical and health teams as opposed to a hodge-podge of seemingly competing providers.

My concluding thoughts are these. Yes, finding options to help Americans pay for health services and health care is a fundamental element of health reform, but so too is strengthening the health system by addressing long term systemic problems like health workforce, facility viability, and improved care quality. We need more flexibility in testing new models of delivery and we need to trust rural Americans in developing systems and approaches that best meet their needs.

Thank You
Brad Gibbens, Co-Interim Director
Center for Rural Health
STOP 9037
UND School of Medicine and Health Sciences
Grand Forks, ND 58202-9037
bgibbens@medicine.nodak.edu
701-777-2569