Cathy Houle, MD, a family physician in Hettinger, ND, 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,” 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.
      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 under way 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,” Wakefield said.