FIFTH BIENNIAL REPORT | 2019 HEALTH ISSUES FOR THE STATE OF NORTH DAKOTA SCHOOL OF MEDICINE & HEALTH SCIENCES ADVISORY COUNCIL SCHOOL OF MEDICINE & HEALTH SCIENCES ADVISORY COUNCIL This Report was prepared by the UND School of Medicine and Health Sciences Advisory Council David Molmen, MPH Craig J. Lambrecht, MD Grand Forks, Chair, Northeast Campus Bismarck, North Dakota Hospital Association Joshua Wynne, MD, MBA, MPH Senator Tim Mathern, MPA Grand Forks, Executive Secretary Fargo, North Dakota Senate Vice President for Health Affairs and Dean Casey Ryan, MD UND School of Medicine & Health Sciences Grand Forks, State Board of Higher Education Thomas F. Arnold, MD Representative Jon O. Nelson Dickinson, Southwest Campus Rugby, North Dakota House of Representatives Representative Lois M. Delmore Shari L. Orser, MD Grand Forks, North Dakota House of Bismarck, North Dakota Medical Association Representatives Stephen J. Tinguely, MD Senator Robert S. Erbele Fargo, Southeast Campus Lehr, North Dakota Senate Mylynn Tufte, MBA, MSIM, BSN Dean Gross, PhD, FNP-C Bismarck, North Dakota Department of Health Fargo, North Dakota Center for Nursing Breton M. Weintraub, MD, FACP L. Gary Hart, PhD Fargo, Veterans Administration Medical Center Grand Forks, UND Center for Rural Health Courtney M. Koebele, JD Christopher D. Jones, MBA Bismarck, North Dakota Medical Association Bismarck, State Department of Human Services John M. Kutch, MHSA Minot, Northwest Campus Disclaimer This Biennial Report represents the good-faith effort of the UND School of Medicine and Health Sciences and its Advisory Council to provide current and accurate information about the state of healthcare in North Dakota. Numerous sources were used in gathering the information found in this Report. We welcome corrections, which we will incorporate in subsequent editions of the Biennial Report. Acknowledgement We acknowledge the exceptional contributions of the following individuals in the preparation of the Report: Mandi-Leigh Peterson, Robin Besse, Karen Vanderzanden, Nathan Fix, Sonja Bauman, Kristen Leighton, and Delphine Tamukong of the North Dakota Healthcare Workforce Group; Dr. Tom Mohr, associate dean for Health Sciences; Dr. Rashid Ahmed, associate dean of research, Dr. Jana Zwilling, and Dr. Rhoda Owens, of the College of Nursing and Professional Disciplines; Brad Gibbens, of the Center for Rural Health; Jessica Sobolik and Brian Schill of the Office of Alumni and Community Relations; and Laura Cory of Information Resources. In addition, we thank Dr. Gary Schwartz, chair of the Department of Population Health; Rebecca Quinn, Dr. Shawnda Schroeder, and Lynette Dickson of the Center for Rural Health. Cover photo courtesy of North Dakota Tourism. i Biennial Report 2019 UND School of Medicine and Health Sciences INTRODUCTION AND UPDATE The First Biennial Report: Health Issues for the State of North Dakota was prepared in the fall of 2010 by the University of North Dakota School of Medicine and Health Sciences (SMHS) Advisory Council, a legislatively mandated group of 15 stakeholders in the North Dakota healthcare enterprise. It was published in 2011 to coincide with the 62nd Legislative Assembly of North Dakota and was produced with the cooperation of the senior leadership team of the SMHS. The primary stimulus for the preparation of the Report was a revision in the North Dakota Century Code (NDCC) that was instituted in 2009 by the 61st Legislative Assembly in which the duties of the SMHS Advisory Council were modified. The modified duties included a requirement to submit a report biennially. The duties of the SMHS Advisory Council as specified in NDCC Section 15-52-04 are as follows: 1. The advisory council, in consultation with the school of medicine and health sciences and the other agencies, associations, and institutions represented on the advisory council, shall study and make recommendations regarding the strategic plan, programs, and facilities of the school of medicine and health sciences. 2. Biennially, the advisory council shall submit a report, together with its recommendations, to the agencies, associations, and institutions represented on the advisory council, to the University of North Dakota, and to the legislative council. 3.a. The report must describe the advisory council’s recommendations regarding the strategic plan, programs, and facilities of the school of medicine and health sciences as developed under subsection 1. The recommendations for implementing strategies through the school of medicine and health sciences or other agencies and institutions must: (1) Address the healthcare needs of the people of the state (2) Provide information regarding the state’s healthcare workforce needs b. The recommendations required under subdivision 3a may address: (1) Medical education and training (2) The recruitment and retention of physicians and other healthcare professionals (3) Factors influencing the practice environment for physicians and other healthcare professionals (4) Access to healthcare (5) Patient safety (6) The quality of healthcare and the efficiency of its delivery (7) Financial challenges in the delivery of healthcare 4. The council may consult with any individual or entity in performing its duties under this section. The First Biennial Report provided the first comprehensive analysis of the existing state of health in North Dakota and its healthcare delivery enterprise. The Report found that rural depopulation, out-migration of the young from the state, an ii Biennial Report 2019 UND School of Medicine and Health Sciences increasingly older adult population, low population density, and localized population growth in the major cities and in the Oil Patch would result in an increasing imbalance between the demand for healthcare and the supply of providers that would necessitate the need for more physician and nonphysician providers in North Dakota and better healthcare delivery systems. The Report concluded that North Dakota had a paradox regarding its healthcare workforce, characterized as shortages amid plenty. The size of the physician workforce in North Dakota was found to be at or better than national norms for most specialties, including all the primary-care disciplines. Despite this, there was a significant distribution problem, with the greatest number of providers located in the urban regions of the state and a shortage (especially primary-care providers) in the rural areas. The Report also offered an analysis of what the future was likely to hold, and concluded that the current shortage of physicians was only going to increase as the population aged and grew in the future. It also found that the shortage of workers in the healthcare field over the next 15 years would not be limited to physicians. The Report determined that an entire cadre of additional healthcare providers - from nurses to physician assistants to occupational and physical therapists to medical laboratory specialists and others - would be needed to ensure that effective, efficient, and appropriate healthcare would be available to all North Dakotans. The Report concluded with a proposal for a multifaceted plan to address the healthcare needs of North Dakota, emphasizing necessary steps to reduce disease burden, increase the healthcare workforce through enhanced retention of graduates as well as expansion of class sizes, and improve the state’s healthcare delivery system through more cooperation and coordination of the various healthcare delivery facilities. Coincident with the release of the Report, the SMHS Advisory Council prepared and released its plan for addressing the identified healthcare workforce needs of North Dakota. Called the Healthcare Workforce Initiative (HWI), the plan identified specific steps to reduce disease burden and increase the provider workforce through programs designed to increase provider retention for practice within the state as well as expand the provider network through class size increases. The HWI received strong support from University of North Dakota leaders, the SMHS Advisory Council, and a wide variety of constituencies around the state. During the subsequent 62nd session of the North Dakota Legislative Assembly, it was determined that the HWI would be implemented in two phases. The first phase was implemented immediately following the end of the 62nd Legislative Assembly in the summer of 2011, and consisted of a variety of programs to reduce disease burden (including the initiation of a Master of Public Health training program as a joint undertaking by the University of North Dakota and North Dakota State University, and a program to address geriatric patient needs), increase retention of healthcare professional graduates, and partially increase class sizes. The Second Biennial Report: Health Issues for the State of North Dakota was an update on the developments and changes that occurred between 2011 and 2013. iii Biennial Report 2019 UND School of Medicine and Health Sciences It reanalyzed the health of the citizens of North Dakota and the status of our healthcare delivery systems, utilizing updated data and more refined projection tools. The Report was similar to the first report in its organizational approach— analysis of the current state of affairs, projections for the future, and proposed plans to deal with the identified healthcare delivery challenges. The Report summarized the most up-to-date statewide healthcare data available, and it carefully analyzed the data to extract the most salient and informative implications