A century of healing
By Patrick Springer
The Forum - 12/05/1999

Dr. Nils Tronnes came to Fargo in 1904 to work at a small hospital named St. Olaf's in a remodeled home near Island Park.

The Norwegian immigrant found an environment offering great promise for a doctor.

"The hygienic conditions in town were bad," he later wrote. "The water mains throughout the city carried dirty river water. Consequently, typhoid fever was endemic. Epidemics were frequent, with dozens of cases around town and no hospital facilities for transients and poor people."

Tronnes decided to stay in Fargo, but not at St. Olaf's. Later he became a founder of Fargo Clinic and affiliated St. Luke's Hospital, which decades later merged to become MeritCare Medical Center.

Another doctor, D.C. Darrow, had a small hospital in his home across the river in Moorhead at the time, but later helped establish Dakota Clinic, whose doctors were instrumental in building Dakota Hospital, now Dakota Heartland.

Both clinics, Fargo and Dakota, became enthusiastic followers of delivering medicine in a way that now is commonplace: the large group practice, modeled on the multi-specialty Mayo Clinic, where primary care doctors and specialists are partners.

Both clinics were born in the 1920s. The idea for the Fargo Clinic came from a meeting in an office located above a drug store. Tronnes was an advocate of group practice, still a novel notion.

The Veterans Hospital in Fargo also had its beginnings in the 1920s. A delegation of business leaders traveled to Washington, D.C., in 1925, when the city was designated as the site of a new hospital for veterans, whose numbers swelled after World War I. The first patient was admitted in 1929.

For years the main general hospital in Fargo-Moorhead was St. John's, which moved into a new building in 1904 after its first four years in the bishop's residence. It was the place where solo practitioners, Dakota Clinic doctors, and later physicians from The Neuropsychiatric Institute admitted most of their patients.

Throughout the years, advances in technology played a major role in shaping delivery of health care - perhaps never so dramatically as the early 1960s, a tumultuous time of fateful alignments.

Doctors from both Dakota Clinic and The Neuropsychiatric Institute were prodding the Sisters of St. Joseph of Carondelet, based in St. Paul, to upgrade and modernize equipment at St. John's Hospital. The Catholic order of nuns was unwilling or unable to invest the money needed, and both groups of doctors left - a mass defection from which the hospital never fully recovered.

The doctors from TNI, now called the Neuropsychiatric Research Institute, affiliated with St. Luke's Hospitals, and the Dakota Clinic doctors were the primary driving force behind construction of Dakota Hospital.

"Some of us mortgaged our homes to build that hospital," says Dr. E.P. Wenz, a retired orthopedic surgeon from Dakota Clinic. "If that hospital had gone under, we'd have lost our houses."

Advances in medicine and technology changed the delivery of health care in myriad ways, setting off a period of rapid expansion. Beginning in the 1960s, for instance, Fargo Clinic began offering cardiology, and later cardiac surgery.

"We began a full-fledged program in heart care that included open-heart surgery," says John Q. Paulsen, a retired MeritCare Medical Group executive vice president.

Dakota offered a specialty in kidney dialysis, and Wenz was the first surgeon in the Dakotas to provide total hip replacement surgery. More specialties and subspecialties followed in the 1970s and 1980s, as competition between the rival medical centers intensified.

"We've become so specialized that Dr. 'X' sees them for one thing and Dr. 'Y' sees them for something else," says Dr. Eric Barth, a retired Dakota internist and pulmonologist. "There's been a decrease in the interpersonal relationship."

All those specialists and sub-specialists and the technologies to sustain them require a big patient base - and that need for referrals drove a period of rapid expansion by the two large clinics, which merged with or acquired satellites in rural towns around eastern North Dakota and western Minnesota.

"That marked a real change in terms of the way our relationship developed with doctors in the region," Paulsen says.

As the clinics grew, the number of hospitals shrank, through consolidation. More and more health care is delivered to outpatients, rather than inpatients, reducing the need for hospital beds. St. Ansgar Hospital merged with St. John's Hospital in 1986, and six years later the joint Heartland Hospital was acquired by Champion Health Care, a Texas chain.

By the 1990s, managed care was well established as a means of trying to hold down costs. Health Maintenance Organizations, or HMOs, never got a significant foothold in Fargo-Moorhead, but less restrictive forms became popular, with penalties in the form of higher out-of-pocket payments for patients seeing a doctor outside their health plan.

The movement to managed care meant that even the independent doctors, always an important part of the triangular shape of health care in Fargo-Moorhead, were tied more closely together as Heartland Independent Network. The alliance was to help gain efficiencies and make it easier to sign contracts with insurers.

But the biggest development in the 1990s - and one that has yet to fully play itself out - was a rift between Dakota Clinic and Dakota Hospital that, in some respects, was reminiscent of the one that gave rise to Dakota Hospital.

The hospital and clinic had a falling out, among other things, over efforts to renegotiate revenues from lab and X-ray services the clinic provided. The hospital board turned to Champion, to assume half-ownership of the hospital, over the objections of clinic doctors.

The partnership was called Dakota Heartland, although the Heartland campus, the former St. John's, was phased out in 1997 and 1998.

The awkward marriage was rocky from its start, and in 1997 Dakota Clinic announced its plans to build a hospital and clinic in partnership with Blue Cross and Blue Shield of Minnesota.

A sign for the new center, scheduled to open in December 2000, bills it as the future of health care. But what the future holds for a town with a surplus of hospital beds is clouded with uncertainty: After decades of consolidation, will Fargo-Moorhead be able to support three competing general hospitals?