Budget Committee on Health Care Testimony
North Dakota Legislative Council
Budget Committee on Health Care
Mary Wakefield, Ph.D., R.N.
Associate Dean for Rural Health and Director
January 4, 2006
This testimony is also available in pdf for printing.
The supporting PowerPoint presentation is also available in pdf.
Budget Committee on Health Care Testimony
Mary Wakefield
Center for Rural Health, School of Medicine and Health Sciences, UND
Chairman Krauter and members of the Committee, thank you for the opportunity to provide comments on three health care topics:
INTRODUCTION
Each of the topics reflects complex features of an industry that is a very significant part of the North Dakota economy. As you likely know, the Gross State Product (GSP) for North Dakota in 2003 (the last full year of statistics) was approximately $22 billion. If you take health care out of the service industry to stand on its own as a sector, it accounts for nine percent (9%) of GSP. This compares to agriculture at 7.5 percent. According to a 2005 report from North Dakota Job Service, eight of the ten largest private employers in North Dakota are health oriented businesses. In addition to its economic impact, the status of health care services is of course important because of its significance to the health of individuals and communities across North Dakota. Given the impact of this industry, the ability to thoroughly and accurately address the questions you’ve raised is important. However, before I address the topics, I want to tell you about the information I’m presenting this morning.
The information I’ll share draws on many different sources. In some cases, I’ll cite very current and full information because it is routinely collected or because the Center for Rural Health for example has a short term grant that happens to focus in that particular area at this time. In other cases, I’ll be sharing information that is not as current as it could be or that is incomplete. For example, in terms of incomplete information regarding hospital care, 46 states in the nation have a statewide hospital database. North Dakota is not one of them. There are about 37 states, including ND, that actually have legislative language to collect hospital data. Of those 37 states with that language, ND is the only state that doesn’t actually do it. The last year these data were collected by the ND Department of Health was in 1997. Because we don’t, we can’t participate in some important national data sets that track access, cost and quality issues or conduct certain statewide hospital analyses. For example, at the national level North Dakota is one of 13 states that does not participate in the Healthcare Cost and Utilization Project, a federal health care database that is one of the most important available to help policymakers and others understand trends in cost, access and quality. The HCUP database is a national resource for patient level health care data and produces information on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, and access to health care programs.
At the Center for Rural Health, some of our researchers use the HCUP national data set to get a picture of key rural health trends across other states. When we use this data, we know our research findings don’t reflect our own home state. Of course, data collection has costs associated with it. Participating in this data set requires data from third party payers such as Medicare, Medicaid and Blue Cross Blue Shield, among others. This would require for example, purchasing Medicare data and the state no longer does. If we did purchase the Medicare data set, we would be able to better plan for health care infrastructure designed to meet the health needs, financing and access to care for North Dakota’s elderly. This is of course an important population when projecting supply and demand of health care services in North Dakota given the elderly’s more intense use of health care services than younger age cohorts and given their rapidly growing numbers.
Using a different example to illustrate this challenge of lack of statewide hospital data, national data tell us that North Dakotans use emergency rooms at a higher average rate than the U.S. as a whole. Emergency rooms are an expensive place to get care and it would be useful to know categorically, who uses emergency rooms and for what services. About a year ago, the Center collected data from a sample of urban and rural hospital emergency departments to examine what types of ER care North Dakotans seek and how that care is paid for. Let me share just a few of the findings that have direct implications for cost, access and care quality. We found that a number of patients who sought care and were treated in the ER do not actually require emergency care. For example, just over 68% of workers compensation claim visits to the ER that we looked at, were non-emergency related. Just over 39% of individuals with commercial insurance presented in the ER with non emergency care conditions and over 38% of the Medicaid patients seen presented with non emergency level conditions. To learn this, we had to go to individual hospitals and ask them if they would be willing to collect this data for us and we only collected information from a relatively small number of hospitals. These data suggest strongly that there is room for cost savings given the significant amount of non-emergent care use. With a hospital data set, we could do a more thorough evaluation to help payers determine how consumers are accessing care, whether there is a need to do targeted consumer education, or revisit policies to drive cost effective choices that could decrease inappropriate ER utilization and save money, all while keeping the ERs available for true emergencies.
With resources to collect and synthesize this and other information, it would be possible to create for North Dakota a fairly comprehensive and current chartbook – tailored to the needs and interests of the state and detailing the issues you’ve asked me to speak to. This is being done in a number of other states like Minnesota and Nebraska, and I’ve included examples at the end of my testimony. But, it doesn’t exist here.
With the data limitations in mind then, I’ll turn to the three topics you’ve asked me to address. The first is the broadest and most complex so I’ll spend most of my time on this topic.
1. ACCESS TO CARE:
We generally think of access along four themes: 1) geographic access to health services, 3) virtual access to information and services through technology that can help to make the characteristics of geographic access such as time and distance, less relevant, 3) access to affordable health insurance, and 4th) access to health care providers. I’ll hold the 4th access issue for your second topic-- shortages of health care professionals.
In terms of geographic access, we generally think of it as miles or minutes to some set of health care services, and in the context of population density. So, geographic access is generally more of a concern for rural than for urban areas. We also have to think about access to what-what kinds of services and, for what volume of people. Or, put another way, what is the population density served by a particular health care facility or service? Let me give you a few examples of geographic access beginning with one measure of population density and one type of health care service. This map shows you- in light green- the part of ND that can be defined as frontier, which is six or fewer people per square mile. So, this gives us population density. Now let’s look at one type of health care service on the map. You can see the location of hospital care- ranging from small Critical Access Hospitals to tertiary care hospitals. However, even though these are all hospitals, the service mix available within them varies.
A hospital with 15 inpatient beds for example typically provides a core set of important services such as emergency room care and general medical inpatient care. These are services that are a subset of what you would generally find available at a 75 bed hospital. In contrast, 75 bed hospitals tend to support a greater array of major services, not all sub-specialty services, but a broader range of services available to the population such as more types of surgical procedures and an intensive care unit. So, when we think about access we need to think of it in terms of time and/or distance to a particular service and the population served. Some core services should be more immediately available, and other services may be acceptable at greater distances.
Here’s another example. We can map access to that greater array of services, say a 75 bed hospital and map what might be a reasonable distance to travel to access those services. This map uses what has been termed as the golden hour in health care - 60 minutes. So you can see what part of the state currently falls outside of and within that definition of access to care. Within 60 minutes and/or 60 miles is in dark green.
We can also map other services like levels of emergency medical services - services that many of us think should be more immediately available, regardless of population density. In terms of the most basic frontline services, when time really matters, access to emergency medical services during the “golden hour” can be severely impacted by weather conditions and distance. In terms of type of EMS services, we can talk about access to advanced life support or basic life support services. And, we should be able to plot time and distance and population volume served in order to really understand access to this most basic frontline service.
This map shows you only the location of EMS - not time and distance and not the population density served. Yet this resource, EMS, and the information about it is extremely important. For example, national data indicate that rural patients with severe injuries are 7 times more likely to die en route if the emergency response time is greater than 30 minutes. Illustrating the need for EMS that blankets North Dakota, over the past 5 years, 88.9% of fatal motor vehicle crashes in North Dakota have occurred on rural roadways. This statistic is significantly higher than the national average for MVA-related deaths in rural areas which is about 64%. However, as important as EMS services are to rural North Dakota, I can’t tell you, because of data limitations, how long the response time is for any ambulance runs and link that to how well patients do who are transported from accidents. If we had a statewide hospital discharge database, we could look at the state’s EMS ambulance data and the hospital data and determine emergency response times, whether patients survived or died and whether we need to improve response times, improve types of pre-hospital services provided and so forth.
Many states do collect this information. They link Department of Transportation crash data to ambulance runs and to hospital data, specifically to determine motor vehicle crash outcomes. The federal DoT has an open invitation to ND to participate in a program directly related to these issues-- just as soon as the state sets up a functional hospital discharge database. That offer has been on the table for the entire 4 years I’ve been back in the state and probably well before that.
Similarly, other services could be mapped such as public health, home health, nursing home care and so on to determine those parts of the state that lack certain services according to set criteria and those parts that have them. That information would have to be created, and acceptable distances defined. It doesn’t currently exist. Bottom line, it’s difficult to know how effectively we’re meeting access to health care for any particular service when we aren’t measuring it.
Having information about geographic access is important. Studies show that when certain categories of people have great distances to travel to get health care they often won’t get that care, resulting in an underutilization of health care services. For example, some data show that rural elderly in the United States use clinic care less and hospital care more than their urban elderly counterparts. The belief is that this happens in part because rural elderly often aren’t able to avail themselves easily of primary care services. So, they delay seeking care. By the time they are seen, they are sicker and more often require hospitalization. Utilization patterns like this are indicative of the degree of access to care.
We know from research conducted at the Center that while the majority of ND citizens can access health care services within a short travel distance, many cannot. In 2004, we analyzed consumer reported distance in miles to care. Over half of North Dakotans (58%) surveyed travel five miles or less to receive health care. Over 9% travel 21-50 miles, and just under 20% travel 51 to 100 or more miles—that equates to thousands of North Dakotans traveling 51 miles or more to access health care services. Whether it’s 30 miles or 60 miles, having to travel a distance to services is a significant access barrier. We have held 16 community forums across the state of ND in the last 2 years and in the majority of those forums, lack of transportation to health services was cited as a major barrier to accessing health care in rural areas.
There isn’t a universally accepted definition of adequate access within a certain radius for example. However, as North Dakota’s rural population continues to age, if more rural clinics close, if emergency medical services become more difficult to provide, geographic access to care in parts of the state will increase as a concern. The confluence of these and other trends speaks to the need to align certain locally available services to meet priority health care needs and consider building new and different linkages to services at a distance. For example, through a federal program managed by the CRH, nine rural hospitals have expanded services by creating cardiac rehabilitation programs locally to better meet the access needs of rural elderly patients by bringing this set of services closer to home. In contrast, again, to align services with need, some hospitals have limited their services, for example, by no longer providing obstetrical services and instead referring patients to larger hospitals for deliveries.
The second way to think about access is a relatively new focus and that’s virtual access to health information and services via information and communications technology. This area is commanding increased attention for a variety of reasons. Electronic records provide ready access to information-thereby improving both quality and efficiency. Many states and regions are planning for or beginning to adopt regional health information networks that connect all or most health facilities in a geographic area. In Nebraska and Tennessee for example, electronic health information systems are being built to connect facilities within those states. In his state of the union address a year ago, President Bush called for all Americans to have access to their personal medical and health information electronically within the next ten years. Since then, disasters like Hurricane Katrina have underscored the importance of having electronic access for consumers and health care providers and there is a steady push for electronic rather than paper medical records.
Access to electronic medical records for clinicians is currently available within some health care systems in North Dakota but by no means all of them and there is no interoperability between different health systems if a patient is transferred from one system to another. Of course this requires an investment of time and resources. Just as many of us barely remember when banks and their customers relied on handwritten ledgers to enter our savings and checking transactions, so too there will come a time when few people will remember paper charts being carted in and out of exam rooms and patient rooms. At some cost, health care is moving toward electronic information and services exchange to increase accuracy, efficiency and better access to information.
Beyond ready access to electronic health and medical information for consumers and clinicians, access to some health care services is also facilitated by technology. Anecdotally, we know of N.D. hospitals and clinics providing access to certain health care services through teleradiology, telemental health and telepharmacy for example. However, there is no inventory of these services that would tell us where in ND they are connecting and providing services electronically or how that might be diminishing barriers such as travel time to obtain services or where service gaps, that potentially could be filled, remain.
The last aspect of access I’ll comment on has to do with access to care based on insurance coverage or ability to pay out of pocket for health care. A Center study that I cited earlier indicates that overall, 8.2 percent of North Dakotans are uninsured (51,920) –a number comparable to the population of the city of Bismarck. Individuals residing in small rural areas (9.1%) are more likely to be uninsured than those residing in urban (7.7%) and large rural (7.4%) areas. Study findings indicate that:
- Children: There are over 11,000 uninsured children in North Dakota, representing 22 percent of the uninsured.
- Adults: There are over 40,000 uninsured adults in the state and males (9.6%) are more likely to be uninsured than females (6.8%). Native Americans (31.7%) are far more likely to be uninsured than White (6.9%). Nearly three-quarters of uninsured North Dakotans reside in a household with an income below 200 percent of the federal poverty level, which is less than $37,700 for a family of four.
On the insured side of the ledger, the largest health insurer in the state BCBS, insures about 400,000 North Dakotans. In spite of the fact that the vast majority of North Dakotans have health care coverage, anecdotally, some hospital and other health care administrators across North Dakota are concerned about the combination of low income health care consumers, lack of health care coverage, and the burden to health care facilities of uncompensated care. From the provider’s perspective, providing access to health services is influenced by adequate reimbursement.
Concerns about ensuring access to hospital services for Medicare beneficiaries was the driving force at the federal level for the creation of the Critical Access Hospital (CAH) designation which provides cost based reimbursement for treating Medicare-eligible patients. In North Dakota, 86 percent of eligible hospitals (31 of 37 hospitals) have converted to CAH status. Even with this additional reimbursement, as of 2003, the total payer margins of North Dakota’s CAHs, including Medicare, Medicaid and private pay, averaged a minus 2.07 margin. Financial fragility of health care providers has in the past and may in the future compromise access to services.
Quality of Health Care
Shifting our attention to quality of health care, here are the three major categories of quality problems.
Paying attention to care quality is important regardless of where and what care is being delivered, whether it’s public health or hospital based care, nursing home or ambulance care. Historically, government has been primarily interested in quality assurance –that is ensuring that health care providers have the capacity to furnish safe care of adequate quality. This is monitored through inspections and complaint investigations. The inspection process carried out by the ND DoH for licensure and under contract with CMS uses a quality assurance approach which is a point in time survey to determine compliance with requirements.
With regard to quality surveillance, the 2006 directives from CMS to the ND DoH identified that state survey agencies should plan to increase their onsite presence at hospitals. This means onsite surveys will occur more frequently and that no more than six years should elapse between surveys for any one hospital.
Moving well beyond quality assurance, there is an expanding interest in knowing not just how well a facility or clinician is doing but also whether care quality is improving. Quality improvement efforts, increasingly encouraged by public and private payors across the nation, aim to improve the average quality of care furnished by helping providers assess their performance, and work toward continuous improvement. This is all about increasing the value of the health care provided. To engage consumers, CMS is now posting public information on their websites about how well specific ND hospitals, nursing homes and home health agencies do on a set of quality indicators. This is being done to help consumers make informed choices about where to seek care based on quality.
On the CMS Hospital Compare website (http://www.hospitalcompare.hhs.gov/), information is provided on how well hospitals care for all their adult patients with certain medical conditions. Quality measures for 22 North Dakota hospitals are included in Hospital Compare. Eight of the state's 31 Critical Access Hospitals have submitted data, although they are not required to do so (the small number of patients treated at these hospitals makes comparison of services less meaningful. Comparisons to national and state averages for each quality measure are also provided).
Nursing Home Compare (http://www.medicare.gov/Nhcompare/Home.asp) offers access to state inspection information as well as how well nursing homes are caring for their residents' physical and clinical needs. Eight-three North Dakota nursing homes are included in Nursing Home Compare.
Home Health Compare (http://www.medicare.gov/HHCompare/Home.asp) provides information about Medicare-certified home health agencies, with quality measures addressing patients’ physical and mental health. Forty-three North Dakota home health agencies are included in CMS’s Home Health Compare website.
In the future, we’ll see information posted by CMS about the quality of physician care as well.
In terms of quality of care by type of service for specific diseases, we have important pieces of information but we’re far from having a comprehensive picture. Based on what we do know, compared to other states, in some areas, ND does extremely well in terms of how we measure up. In other areas, we don’t do as well as we should. I’ll tell you a little about what we do know.
Based on national published studies, on certain indicators of quality care for Medicare beneficiaries –on care for AMI, CHF, stroke, pneumonia, immunizations, breast cancer, and diabetes, ND does quite well. In fact, North Dakota ranked 4th in 2001/2002 across a set of 22 quality indicators for care of those diseases.
Another source, HHS’s annual report to the Congress on the state of health care quality, the most recently reported information assesses performance on 14 indicators by state. The data for North Dakota are limited for the reasons I mentioned at the beginning. Nevertheless, some state level data are included. For example, North Dakota had the best rating in the appropriate use of a very important blood test for diabetics (measuring in adults 18 and over with diabetes, a hemoglobin A1c measurement at least once in the past year). In terms of eye exams for diabetes, North Dakota again ranked first.
However, as I indicated, there is room for improvement in some of the care provided to North Dakotans. For example, on cholesterol checks (performed in the last five years on adults 18 and older) we’re below the national average. The national rate is 72 percent in contrast to North Dakota at 69 percent. On another survey that includes illness prevention and health promotion measures, (United Health Foundation), North Dakota is in the low half of the states –that is, 31st for its prevalence of obesity-not a good place to be. In terms of the quality of health, for North Dakota, this high rate of obesity is a potential harbinger of chronic diseases that, unabated, comes with a significant price tag in the form of higher spending on health care in the future. So, the picture is mixed.
Increasingly, to drive improvements in the quality of health care delivered, large payors across the country are linking payment to quality of care. Historically, in terms of encouraging better quality, payment for health care services has been neutral or negative. That is, regardless of the quality of care provided, the service is reimbursed. And, excellent care quality is reimbursed at the same level as marginal care. Now however, we’re getting much better at quantifying quality of care and using payment to incentivize high quality care. Interestingly, recent national research on Medicare beneficiaries clearly shows that there are parts of the country with significantly higher spending on their care and significantly poorer health care outcomes. ND is not one of those states. Instead, we have high quality across a number of indicators in spite of the fact that Medicare spends considerably less on care for ND beneficiaries. With regard to Medicare program payments per beneficiary (FY 2001) North Dakotans account for, per person served, about $4,700 vs. U.S. per person served at $6,400. So, on many indicators, North Dakota’s elderly receive high quality care but the providers of the service are being paid less than their counterparts in other parts of the nation where spending is higher and care is poorer. We can look forward to new models of linking payment to quality, referred to as paying for performance. Medicare is doing it already with certain hospitals and finding substantial improvement and some other major private payors nationally are beginning to as well.
Cost of Health Care
We can look at cost of health care in a couple of different ways by type of service and by payer. The most recent year for which data are available, 2000, indicate that total personal health care expenditures in ND per capita put the state at 48 - at $2,898 per person compared to say Nebraska ranked 35th at $6,973 per person.
As you can see from this slide, in terms of type of service, North Dakotans spend more on hospital care (43.7%), nursing home care (11.8%) and other personal health (3.3%) than the U.S as a whole (hospital – 36.4%; nursing home – 8.4%; and other personal health – 3.2%). However, North Dakotans spend less in a number of other categories, including physician and other professional services (ND – 23.6%; US – 29.0%); drugs and other medical non-durables (ND – 11.1%; US – 13.4%); dental services (ND – 4.2%; US – 5.3%); and home care (ND – 0.8%; US – 2.8%).
In terms of who is paying for these services, according to the Kaiser Family Foundation, when analyzing payment for health care premiums, (2003) North Dakota employees make a slightly larger contribution than found throughout the country. North Dakota employee contributions account for 19 percent of the cost of insurance for a single coverage plan compared to 17 percent nationally. Conversely, North Dakota employers contribute slightly less (81% vs. 83%, nationally). For family coverage a similar pattern emerges as a North Dakota employee pays 27 percent for a family plan compared to US, 25% and North Dakota employers pay 73 percent compared to US, 75%.
We can also look at the major public payors, Medicaid and Medicare. For the State, total Medicaid spending in ND stands at $490.5 million with the state share of expenditures at $141 million (FY 2004). The federal matching rate (i.e., the percentage of a Medicaid dollar provided by federal sources) is approximately 70 percent and is scheduled to decline to 65.85 percent in FY 2006, in North Dakota. The average annual growth in Medicaid spending from 1991-2001 was 7 percent (North Dakota) and 11 percent nationally. North Dakota’s Medicaid payments per enrollee (FY 2001) are higher ($5,766) than the U.S. ($4,011). The distribution of Medicaid payments by enrollment group indicates that North Dakota pays less in comparison to the U.S. as a whole for children (ND – 11.5%; US – 16.3%) and adults (ND – 6.6%; US – 10.6%); however, it pays more for the elderly (ND – 39.9%; US – 28.9%) and the blind and disabled (ND – 40.3%; US – 39.5%).
You can see from the series of 3 tables a break down of comparisons for long term care and acute care spending in Medicaid. In terms of the distribution of Medicaid spending by service, North Dakota in one of only four states that spends more Medicaid dollars on long term care than acute care services. North Dakota spends about 40 percent of Medicaid dollars on acute care and about 60 percent on long term care. Conversely, for the US as a whole, 59 percent is spent on acute care and 35 percent on long term care (Kaiser Family Foundation, State Health Facts, FY 2004 data).
Regarding Medicare, the total Medicare estimated benefit payments to North Dakota (FY 2001) was $563 million (out of a total U.S. estimated benefit payment of over $236 billion). I discussed per beneficiary spending in my earlier remarks about payment linked to quality.
2. SHORTAGES OF HEALTH PROFESSIONALS IN NORTH DAKOTA:
With some workforce categories, such as nursing, we have current, fairly comprehensive information. In other areas such as radiology and clinical lab technologists, we have very little data about supply and demand, other than anecdotal information that suggests that we may have an emerging short supply or at least a maldistribution of these providers.
Recently, the Center established a Health Professions Tracking Program infrastructure which can capture statewide data and has the ability to create and maintain a comprehensive inventory of our healthcare workforce. This program is based on a similar database that other states have. It can track and project supply and demand of multiple provider groups. In other states this program has been a valuable resource in terms of both healthcare workforce and bioterrorism planning efforts. In our tracking program, physicians and dentists have been included in the database. However, funding will be needed to sustain the tracking program and to incorporate other important types of providers such as pharmacists, mental health providers, clinical lab techs and others. With that, I’ll comment on a few specific workforce categories.
Status of Physician Workforce
North Dakota had 1,461 licensed physicians in 2004. Of the state’s 328 practicing
family medicine physicians, 68 percent (222/328) graduated from the University of North Dakota, with a medical degree, or residency training, or both. Nationally, 11 percent of U.S. physicians practice in rural areas as compared to 32 percent in North Dakota (Rural Health Facts: Primary Care Providers, Center for Rural Health, UNDSMHS, Summer, 2005). Family medicine physicians provide the majority of patient care in rural areas. Similar to the rest of the United States, North Dakota is experiencing a decline in the number of medical graduates choosing a residency in Family Medicine.
One measure related to the demand for health care professionals is the number of unfilled positions or vacancies. In 2004, 92 physician vacancies were reported. Of those, 34 were reported in rural communities and 58 reported in three of the four state’s urban cities. Vacancies in rural areas remain fairly stable with an average of 18 openings reported for Family Medicine each quarter from 1992-2005. Family Medicine constitutes the highest number of rural vacancies while subspecialty vacancies dominate in urban areas (North Dakota Physician Survey, Center for Rural Health, UNDSMHS, 2004). Vacancies across rural areas of North Dakota increased slightly between 2004 and 2005 (rural defined as communities other than Minot, Bismarck, Grand Forks, Bismarck/Mandan, Fargo, and Jamestown).
Another measure of type of physician availability are Health Professional Shortage Areas (HPSA), a federal measure that tracks physician shortages. HPSAs measure physician to population ratios (e.g., the physician to population ratio of 1:3500 or greater). As can be seen on this map of North Dakota, 81 percent of the state is designated (43/53 counties) as partial or full county HPSAs. Many federal programs use HPSA designations as a means to target federal resources.
Status of Mental Health Workforce
With regard to mental health, as can be seen in this map, fully 94 percent of the state’s counties have a Mental Health Shortage Designation calculated as one psychiatrist to 30,000 people. There are eight regional mental health centers and one state inpatient mental health facility. Vacancy rates for other mental health providers (for example psychologists, counselors, social workers) are unknown although in community dialogues the Center has conducted across the state, limited availability of mental health services is frequently identified as a very high priority concern for many rural communities.
Perhaps due in part to the lack of access to mental health services is the high incidence of suicide in North Dakota. The most recent data rank North Dakota 13th nationally in suicides for all ages, 2nd in the nation in suicides for 10-14 year olds, and 6th in the nation for 15-19 year olds. For the Native American population of the state, the Aberdeen Area of Indian Health Service is 2nd only to Alaska in the rate of suicide. Between 1994 and 2003, there were 797 reported suicides in the state, 700 whites, 89 Native Americans and 8 other ethnic minorities. Another indicator of the pervasiveness of mental health problems is the fact that the most frequently prescribed medications in the state are antidepressants, prescribed primarily by primary care physicians.
As we look forward, increased demand for mental health and other services may emerge associated with returning National Guard and other military personnel who have served in active duty. Given the number of returning Guard and the very thin mental health service infrastructure across the state, we could see unmet need for important services and further stress over an already fragile health care infrastructure.
Status of Dental Workforce
(The demand for dentists is calculated by looking at the number of dentists to population, the number of dental hygienists, hours worked, and procedures performed). Currently, about thirty percent of the state’s 53 counties are federally designated as Dental Health Professional Shortage Areas. As a result of growing concerns about a nation-wide shortage of dentists, and the number of designated dental HPSAs in North Dakota, the Center conducted a state-wide dental workforce survey to examine the demographics, practice profiles, and patient profile information of the state’s 316 licensed dentists. North Dakota does not have a dental school, and over half of our dentists were trained at the University of Minnesota.
Results from our 2004 survey indicate: just over half were born in ND, 73% practice general dentistry, the average age of North Dakota dentists is 52 years and 60% of dentists plan to retire in the next 15 years. In 2002 a state dental loan repayment program was established to attract dentists to areas of need across the state. There have been eight recipients of the loan program who located in 6 different communities (Minot, Fargo, New Rockford, Grand Forks, Bismarck, and West Fargo).
Status of Nursing Workforce
North Dakota has approximately 530 Advanced Practice Nurses (APNs), 7,900 Registered Nurses (RNs), and 3,260 Licensed Practical Nurses (LPNs), (North Dakota Board of Nursing Nurse Licensure Database, July 2004).
Research conducted by the CRH, found an 11 percent statewide vacancy rate for RNs in 2005 as compared to 9 percent in 2004 and 5 percent in 2003. (Vacancy rate-a measurement of the number of vacant positions relative to the total number of positions). Sustained vacancy rates above 5-6 percent are considered a shortage. (Three-Year Comparison of Nurses in North Dakota Health Care Facilities: Results and Implications, 2005). As this map indicates, two counties have RN vacancy rates above 15 percent in 2005.
For LPNs, the statewide vacancy rate in 2005 was five percent, which was the same as 2004 and 2003. Three counties had vacancy rates above 15 percent (Three-Year Comparison of Nurses in North Dakota Health Care Facilities: Results and Implications, 2005).
In addition to vacancy rates, turnover rate is indicative of fluctuation in staff in a particular work setting. In 2005 the LPN turnover rate was 21 percent and 20 percent for RNs. This means that about one out of five nurses in the state changed their employer in 2005 (Three-Year Comparison of Nurses in North Dakota Health Care Facilities: Results and Implications, 2005).
Status of Emergency Medical Service Workforce
Based on a North Dakota EMS workforce study in 1999 conducted here at the Center, among the state’s prehospital EMS personnel, approximately 90 percent are volunteer workers and their age ranges from 15 to 79 years. Compared to urban respondents, rural EMS personnel had a substantially higher percent of females (48 percent vs. 19 percent) and rural EMS personnel were typically 8 years older (average ages of 41 years and 33 years, respectively) than their urban counterparts.
In 2004, the state Division of EMS indicated there were approximately 347 EMS squads in North Dakota with varying capacities such as basic or advanced life support. (144 ambulance services, 124 Basic Life Support and 20 Advanced Life Support; 81 quick response units; and 122 rescue units). While most EMS providers in urban based squads are paid employees, their rural counterparts are not. In rural areas there is a high reliance on volunteer personnel, decreasing numbers of residents to share EMS duties, lower tax base for funding services, outdated equipment, expansive geographic service areas, and difficulty accessing training.
In the Center study, approximately two-thirds (62.3 percent) of respondents said recruiting EMS workers for their squad was a serious problem; and, about one-third (32.2 percent) indicated that retention of squad members was a serious problem. Anecdotally, we continue to hear in our Center sponsored community forums about the thin line of EMS service providers, the inability to recruit, and burnout among those who currently provide services.
Access to appropriate level of services matters. To take just one example, in a 2005 study, SMHS researchers focused on ambulance transport of children with serious head injury to non-designated trauma centers in rural North Dakota. The researchers found that a number of factors increased the likelihood of ‘inappropriate’ transport (that is, taking a patient to a non-designated trauma center) including greater distance to the nearest trauma center, distance traveled by the ambulance squad to the receiving facility, if the patient was Native American, and winter months (Native American ambulance patients had lower access to appropriate in-hospital trauma care than white patients). Ensuring an adequate Health Care Workforce for the state while not unique to North Dakota, is a serious enough challenge for us that we’re considering launching a health workforce summit to bring together representatives from both the supply and demand side – both academics and employers to work together to identify and implement new strategies to more effectively address this challenge. One side of the equation alone won’t solve this problem.
3. INNOVATION
The last topic area relates to innovations affecting rural health care delivery in North Dakota. I’ll comment on two categories of innovation-one, the organization of health care services and the other the use of technology. Increasingly across North Dakota we are seeing more providers developing collaborative arrangements and networks that focus on sharing organizational infrastructure and/or service delivery. This reorganization may be local,-- such as consolidating previously free standing health services in the same town like the hospital, clinic, nursing home and home health agency, all brought into one organizational entity; to regional-- such as 2 small hospitals sharing the same hospital administrator;-- to organizational networks that share services such as MeritCare working with 11 CAHs in eastern North Dakota and western Minnesota on a shared quality improvement initiative. We also see networks that partner across a number of different types of functions such as the Valley Rural Health Cooperative in eastern North Dakota and the Northland Healthcare Alliance in central and western North Dakota. This trend toward reorganization that involves networking and partnership development across facilities and services is an important innovation. It can enhance efficiency through greater economies of scale in terms of joint purchasing, sharing administrative and education functions and so on and, in the process, improve access to services and quality.
The second innovation has to do with health information technology applications. On this front, emerging innovation includes moving toward electronic patient information and telemedicine delivered services. While these developments are spotty and they vary in scope and focus, they are increasing in parts of the state. For example, as you are aware, some rural based home health programs have ceased operations. The question then becomes how to maintain access to a vital service for a low density population. One way is tele-home care. Prairieland Home Care of Fargo is working with the communities of Bottineau, Harvey, Rugby, Carrington, and Rolla using telephone lines to connect technology to monitor a variety of patient conditions such as diabetes and heart disease without having a nurse drive miles and hours to and from patient homes.
Another example of ensuring access to health services using technology can be found at Williston Mercy Medical Center. Mercy is connecting with a number of smaller rural communities to provide access to radiology services. Mercy has also acquired technology to conduct electronic fetal monitoring capable of being read at computers in different locations, within the facility, the clinic and at the physician’s home. The beauty of this system is easy access to information. If there is any problem a physician sees on the tracing for example, if a
c-section is needed, the physician can call in and get the wheels moving so that by the time the doctor arrives, the team is there and ready to go-losing very little time in the process. This same facility is developing a 24 hour tele-pharmacy program and uses a teleradiology system to transmit images for after hour’s coverage.
Also, through federal funding, and requisite state regulatory changes, the NDSU Tele-pharmacy Project has catalyzed new pharmacy relationships through licensed pharmacists at central pharmacy sites supervising pharmacy technicians at remote tele-pharmacy sites through the use of video conferencing technology. This effort includes connections between retail locations as well as with hospitals. The technician prepares the prescription drug for dispensing by the pharmacist. The pharmacist communicates face-to-face in real time with the technician and the patient through audio and video computer links. North Dakota is one of the first states to pass administrative rules allowing this reorganization of services. As of September 2005, fifty pharmacy sites are involved in the North Dakota Tele-pharmacy Project.
Another example of innovation through technology applications can be found at the Valley Community Health Center Tele-mental health network which involves a rural community health center in Northwood, a human service center in Grand Forks, and the UNDSMHS. The purpose of the project is to provide clinical counseling services and addiction services to patients in Northwood through video conferencing with the Northeast Human Service Center (NEHSC) in Grand Forks thereby increasing access to these services and eliminating travel.
Another example is the Mid-Valley Health Alliance comprised of the hospitals in Mayville, Cooperstown, Hillsboro, and Northwood that are working together on an adolescent focused health program. I’ve provided you with additional examples of innovations like these in the appendix to my remarks.
In North Dakota, both of these types of innovation – reorganization and increasing technology that links and delivers services will continue to evolve. Nationally in health care you often hear the concept Centers of Excellence discussed. But I think that for North Dakota we should also be envisioning Networks of Excellence that capitalize on these important linking innovations.
Clearly, the lesson of these innovations is that in trying to sustain health care services to North Dakotans by doing things the way we always have—but just asking providers or administrators to work harder at it—isn’t the answer. Reengineering the way we deliver health care, as illustrated in these and other examples, is. And of course our focus should always reflect consideration of all three issues of quality, access and cost as redesign of health care continues to evolve. Thank you for the opportunity to share information on the issues you asked me to address and I would be pleased to respond to questions.
APPENDIX
ADDITIONAL EXAMPLES OF INNOVATION
The Bottineau/Rolla Network involves the two CAHs found in these north central communities. The CAHs are currently developing an information technology network. They are piecing together varying funding sources and plan to have EHR and associated software components accessible within five years as recommended by the Institute of Medicine (IOM). The EHR will contain current and historical patient information that includes physician orders, medication history, lab results, clinical documentation, diagnostic imaging documents, and transcribed documents. All components will be accessible by both hospitals which will allow for shared information and possibly shared clinical software in the future. Administrations from both hospitals believe they could not attempt to build this capacity independently. This network hopes to expand and include public health units and home health agencies in the future. In addition, the two hospitals have created a shared surgical network. This network has received support from both the Flex program and the Blue Cross Blue Shield of North Dakota Rural Health Grant program.
Outside of acute care settings, innovation is also underway. The Cavalier County Job Development Authority (CCJDA), Cavalier County Memorial Hospital, and the Cavalier County Health District have recently received a federal Rural Health Outreach Grant. The purpose of this rural partnership is to form the Wellness Interventions Lasting a Lifetime (WILL) Network which will encourage wellness and healthy lifestyles, and provide education on disease awareness, management and prevention to residents of Cavalier County, the northwest section of Pembina County, and the northern portion of Ramsey County. Prior to submitting the proposal, the Center for Rural Health conducted an area wide needs assessment survey focusing on the theme of wellness programming. There have been three rural based Economic Development Commissions that have had the Center conduct wellness oriented needs assessments.
Rural Mental Health: The CAHs of Harvey, Kenmare, Bottineau, and Rolla formed the Rural Mental Health Consortium in 1994. Serving 11,500 square miles in central and north central North Dakota, these hospitals use a Critical Pathway System of case management, clinical nurse psychiatric specialists, licensed independent social workers, and tele-psychology to see approximately 300 patients per month. Five rural communities are served and contract services are provided to area schools and nursing homes. Referrals are made to Minot based psychologists. The Network was created through a federal Rural Health Outreach grant and followed up with a federal Network Development grant. The current funding base is a small amount of carry over funds, reimbursement, and some additional support from the four rural hospitals. One of the advantages of this model is the bulk of services are provided in the hospital setting. This minimizes the issue of stigma because people’s cars are seen in front of the hospital as opposed to being in front of what people see as the “mental clinic”. Network providers have said that common mental health issues seen by the consortium included depression (particularly agriculture related), ADHD, and community education on depression and farm stress. Identified barriers include reimbursement, lack of insurance in farm areas, travel time, and distance.
Wellness in the Valley Suicide Prevention operates in Valley City and serves all of Barnes County and parts of Cass, Griggs, Ransom, Steele, Stutsman, and LaMoure Counties. It involves a collaboration of Valley City Mercy Hospital, City/County Public Health, and Meritcare Clinic. The program is supported by funds from a federal Rural Health Outreach grant and was created to respond to the crisis in rural suicides: 9 suicides and 12 attempts over 12 months. The program follows the Surgeon General’s National Strategy for Suicide Prevention. It employs a Gatekeeper Training Program which focuses on teaching symptoms of depression, common mistakes during suicide prevention, addresses teen suicide behaviors, and the role of primary care in treating depression. The program has trained approximately 2,000 people in three years. It has initiated and facilitated several support groups: mental health, family, and survivors of violent death. They have addressed over 400 farmers in Barnes County on depression and stigma.
A completely different type of network is the Family to Family Network is a unique program based in the Center for Rural Health that reaches rural families who are raising children with special needs. The Family to Family Network is a state-wide support network based on the philosophy that parents who have successfully adapted to their children's disabilities or special health care needs, are the best support for other parents of children with special needs. The Network provides emotional support and understanding, shared experiences, and support in accessing resources. This model allows rural families to be connected with others who are experiencing the same issues in raising a child with special needs and giving them the information and support needed to The Network has reached over 600 families in 50 counties since its beginnings in 1997.
EXAMPLES OF STATE SUPPORTED HEALTH CARE REPORTS
Minnesota, Nebraska and California each have chartbooks with an overview of health care in their states. These reports address topics including demographics, health insurance coverage, public health insurance programs, health care spending, health care workforce, and health service availability. New Mexico published a similar report in 2000 that provided a broad picture of the health care system in that state. Hawaii, Wisconsin and Pennsylvania publish reports with a narrower focus on health status and health risks, and other states may provide similar information through their vital statistics divisions.
Nebraska Health Information Project Databook, 2003 Databook: http://www.unmc.edu/nebraska/databooks/2003-databook/default.htm
Minnesota Health Care Markets Chartbook, 2005: http://www.health.state.mn.us/divs/hpsc/hep/chartbook/index.html
California Health Care Chartbook: Key Data and Trends, 2004: http://www.kff.org/statepolicy/7086/upload/California-Chartbook-Complete-PDF.pdf
State of Health in New Mexico, 2000: http://www.health.state.nm.us/StateofNM2000/
Wisconsin County Health Rankings, 2005: http://www.pophealth.wisc.edu/UWPHI/research/rankings_2005/rankings_2005.htm
Family Health Statistics for Pennsylvania and Counties, 2005: http://www.dsf.health.state.pa.us/health/lib/health/familyhealth/
2005/Family_Health_Statistics_Report_2005.pdf
Toward a Healthy Hawaii 2010:
http://www.hawaiioutcomes.org/Attachments/
CHP%20Release2_Final/HOI_State_book.pdf
Louisiana -- covers health status, health care facilities, health care workforce
2003 Louisiana Health Report Card
http://www.dhh.louisiana.gov/offices/reports.asp?ID=275&Detail=311
Texas -- covers health status, public health insurance, and health care workforce
The State of Health Care: A Few Indicators and Current Issues
http://www.healthpolicyinstitute.org/pdf_files/SOHC.pdf
Virginia -- demographics, health status, and health insurancecoverage
Virginia Atlas of Community Health, http://vaatlas.vahealthycommunities.com/
From StateHealthFacts.org -- North Dakota: Medicaid & SCHIP,
http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=47&rgn=36
Related Literature: Grossman et. al., reported that rural patients with severe injuries were seven times more likely to die en-route, if the emergency response time was greater than 30 minutes. Esposito et al.11 found that pre-hospital transport times were twice as long for rural patients than those residing in urban areas, clearly indicating a problem with timely delivery of emergency care in rural areas.} (Source: Kyle Muus' personal communication with Carol Thurn, Division of Drivers’ Licenses and Traffic Safety, ND Department of Transportation, 11/21/2005).
