Banding Together

How a recently formed hospital alliance aims to expand access and improve outcomes – while reducing costs – in a rural setting.

February 2024 – The Journal of Healthcare Contracting

Value-based care is a highly sought after goal – yet often an elusive one – for healthcare providers of all shapes and sizes. No where is this more evident than the rural setting, where large geographic distances, reduced access to services, rising costs and lack of scale all come into play for providers.

To tackle those challenges, an alliance of 23 rural hospitals in North Dakota recently announced the formation of the Rough Rider High-Value Network.

The network, based in Cando, N.D., was formed to strengthen rural healthcare for providers and patients throughout the state. The network announced its formation at the end of 2023 as a collaboration between individual and independent critical access hospitals that all collaborate to address rural health challenges and enhance community health.

The hospitals work together on clinical and operational initiatives to strengthen the availability, affordability, and quality of care in communities across the state of North Dakota.

“The Rough Rider Network consists of 23 hospitals that came together to capitalize on the economies of scale that they all represent in unison. The goal is a triple aim of improving access to care, quality of care, and reducing the cost of healthcare,” said Alfred Sams, president, Rough Rider High-Value Network. “Those goals rely on being able to tackle all of the barriers in being an independent hospital, but also coming together and being able to pool resources with other hospitals while maintaining independence.”

The Rough Rider Network is committed to enhancing the sustainability of rural healthcare throughout North Dakota. Uniting a network of critical access hospitals and clinics, the alliance aims to combine resources while remaining independent.

“Independence is an important aspect for all of our members,” said Nathan White, CEO, Rough Rider High-Value Network. “Members, however, also must focus on surviving in their current environment, both clinically and financially. The alliance offers two benefits to members, investment in services, and then, on the clinical integration side of things, each individual hospital being able to take advantage of the pooling of their resources. The ability to dive into value-based healthcare and reduce the risks from a collective perspective is critical.”

The rural setting

For hospitals and health systems in rural areas, focusing foremost on local cases and community health is critical. An alliance allows rural hospitals to broaden their resource availability and more effectively deliver healthcare to communities by investing in medical advances, controlling the rising costs of providing care, and enhancing care coordination, according to the network.

“The geographic isolation in the North Dakota area presents challenges for hospitals, especially during inclement weather,” said Sams. “It is often frozen here for five months with ice and snow, and so we have a geographic boundary that isolates some of our facilities. We also have hurdles in attracting and maintaining our work staff such as doctors, specialists, and nurses.”

White adds: “Access inequities can present a tremendous challenge for independent rural hospitals. Older populations have disparities in health outcomes, and independent hospitals lack scale and suffer from price disadvantages and service disadvantages.”

Expanded healthcare capabilities are necessary for rural and independent providers, such as systems for controlling the rising costs of healthcare and enhancing care coordination. These goals are often difficult to achieve as an independent provider alone.

“Interdependence drives independence,” said Ben Bucher, CEO of Towner County Medical Center in Cando, N.D., and chair of the Rough Rider HVN board. “The Rough Rider High-Value Network is built on the principle that independent rural hospitals can come together to meet these challenges and emerge stronger while remaining independent.”

Benefits of a health alliance

Through the Rough Rider Network’s clinically integrated network (CIN), member hospitals will collaborate to support new specialty programs including surgery, ophthalmology, obstetrics, and mental health, which would be difficult for individual hospitals to support on their own. The CIN also aims to reduce administrative burdens and streamline measuring quality, according to the network.

Additionally, the Clinical Integration Committee (CIC), with a medical provider on the committee from each member hospital, will oversee clinical and quality initiatives within the alliance. The Rough Rider CIN will collaborate with payers on value-based insurance products that will enable patients, providers, and payers to succeed by enhancing the patient and provider experience.

“Managed IT solutions, aggregated accounting solutions, mobile radiology, imaging reads, and more, are all services that can be integrated through the alliance that enhance the ability to focus on patients and provide better care,” according to Sams.

The Business Integration Committee, with operations leaders from each of the joined hospitals, will oversee the development and operation of shared service offerings. The committee also provides a forum for leaders to discuss business challenges and develop solutions.

“Within our network, every facility has a clinical representative on the clinical integration committee. Each hospital puts forth a member and they come together and discuss pertinent topics, quality measures, best practices, and help the system take on a unified approach to patient care and best practices,” according to Sams.


The Rough Rider Network received state funding of $3.5 million to assist with facilitating its goals, and to support North Dakota patients and hospitals in the value-based care transition, according to the network.

“We tackle the challenges that are the hospital’s most demonstrated needs,” White said. “If the majority of our members are interested in a particular shared service, we will try to negotiate that for our members. If 70% of the members are interested in a different solution, we will move forward with that change.”

The Rough Rider High-Value Network plans to integrate a menu of shared services between hospitals that will promote more efficient operations going forward. These shared services would include pharmacy, laboratory, telehealth, information technology, health information exchange, clinical staffing, supply chain, and more.

“The reality is that many payers are moving their financial incentives toward value-based care arrangements. That is happening with Medicaid expansion in North Dakota, too. So, we knew at Rough Rider that there was a lot of financial and clinical gain from moving towards value-based care models,” said White. “By coming together, hospitals are aggregating the base of their covered lives while also investing in shared solutions to manage challenges and improve population health.”

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