The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation and Cooperation

May 15, 2008 | Volume 93

Authors: Douglas McCarthy, M.B.A., Rachel Nuzum, M.P.H., Stephanie Mika et al.



Resource constraints and the desire to preserve the local economy have made necessity the mother of invention in North Dakota, driving health care providers and policymakers to try new approaches to care and to institute better practices relatively quickly. Collaboration to support primary care and the concept of a medical home, organization of care through cooperative networks of providers, and innovative use of technology to meet patient needs and hold down costs are examples of how North Dakota is able to provide its citizens with accessible, quality, and efficient health care despite the challenges of a rural setting. Rural communities have a unique context of community trust and interdependence, a social capital that allows them to innovate in meeting patients' needs. A strong sense of mission, vigilance to process and outcomes, and enhanced communication and collaboration among health care providers are key to improvements made in North Dakota health care.

Executive Summary

North Dakota faces challenges common to other rural areas of the country that are relatively disadvantaged in attracting health care professionals and in deploying resources to serve small, geographically dispersed communities. Despite these challenges, the state's health care system appears to be performing better than many others in providing its citizens with accessible, relatively high-quality, and efficient health care services, as evidenced by the findings of two recent reports.

  • North Dakota ranks in the top quartile of states on The Commonwealth Fund's State Scorecard on Health System Performance, which ranks states according to their performance across 32 key indicators of access, quality, utilization, equity, and health outcomes (Exhibit 1 and Appendix A).
  • The latest Dartmouth Atlas of Health Care finds that North Dakota is one of the most efficient states in treating chronically ill Medicare patients in the last two years of life, with costs more than 25 percent below the national average.

Exhibit 1

The Commonwealth Fund's Commission on a High Performance Health System made a site visit to North Dakota in July 2007 to learn more about the state's achievements, focusing on three key areas: 1) supports for primary care and the concept of a medical home (discussed below), 2) organization of care through networks of coordination and cooperation; and 3) the innovative use of technology to meet patient needs and hold down costs. Commission members were impressed by the spirit of cooperation that was evident in the dynamics of health care provision in North Dakota. This cooperative ethos is driven by resource scarcity and fostered by a rural community culture that enhances a sense of mutual accountability among health professionals and their patients.

Health care providers, payers, and policymakers in rural North Dakota have learned that only through cooperative, interdependent relationships and a willingness to innovate in both the organization and regulation of services can they achieve the reach, care coordination, and economies of scale that are necessary for delivery of quality and efficient care in rural settings. These innovations provide insights and lessons that may be transferable to other rural areas of the country and to urban areas as well.


D. McCarthy, R. Nuzum, S. Mika et al., The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation and Cooperation, The Commonwealth Fund, May 2008.