This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American
I’m back in Boothbay Harbor for a much anticipated summer vacation, and have promptly become immersed again in the fight over Lincoln County Healthcare (LCH) and MaineHealth’s plan to close St. Andrews hospital, beginning with the Emergency Room, causing it to lose valuable Critical Access Hospital designation. I wrote some about this last summerhereand here, but it has suddenly been made much more personal.*
The very next night after my arrival, my husband, DH**, developed abdominal pain. After several hours of progressively worsening pain, we decided to go to the ER. We explored our four options, and decided it was best to stay on the Boothbay peninsula initially, with its tiny critical access hospital. I had toured there last summer, and had been impressed by its capabilities. It was close and seemed capable.
So about 10:30 pm, we drove over 5 minute around the harbor, and were seen by a physician within 10 minutes—longer than expected because he was tied up with another patient—and hours less than it would have been elsewhere.
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The staff promptly performed lab work and x-rays, and then discussed options for follow-up care, as he will need surgery. Miles Hospital, in Damariscotta, was offered and immediately rejected; while they are competent for uncomplicated problems, I wanted him to be somewhere that could handle any complication. Mid-Coast Hospital is not part of LCH’s customary referral pattern, though is considered a “strategic affiliate.” Then there is the mother ship, Maine Medical, in Portland. So late the next morning we traveled the 1.5 hours to see a surgeon. To my dismay, we learned that, since DH was improved, surgery was elective, and could not be performed for at least 3 weeks. There had been a sewage leak in the Operating Rooms, causing all elective cases to be cancelled; their press office did damage control with a remarkably bland, uninformative statement.
That late night experience really brought home how important it is to the residents of the Boothbay peninsula to keep viable, 24-hour care in the immediate area. The region is isolated and the peninsula has narrow, windy roads that are difficult to drive in good weather, let alone in the middle of the night or in bad weather.
What is happening in the Boothbay region is a microcosm of pressures on small, rural hospitals everywhere. Let’s look again at the arguments for or against closing Boothbay’s St. Andrews Hospital and what has happened in recent months.
Critical Access Hospitals
A CAH designation is given to tiny hospitals with less than 25 beds, in rural areas. CAH certification allows hospitals receive special cost-based reimbursement from Medicare, to help stabilize them financially and thereby reduce hospital closures. This is vitally important in sparsely populated parts of the country.
When I left Boothbay last fall, Lincoln County Healthcare (LCH), the mid-level parent organization of St. Andrews, wanted to sacrifice the CAH designation, saying it was not worth much. Now, they are trying to take the valuable CAH designation and have it transferred to Miles. While I am glad LCH now recognizes the value of CAH designation, this would mean downsizing hospital beds to just 25 for the entire region. There are 16 CAH just in Maine—of a total of 39 hospitals in the state.
CAH and Demographics
One of the things I find most astonishing is the lack of foresight or planning from LCH. Lincoln County had a year round, permanent population of 34,224 in 2011. This swells to approximately 55,000 in the summer, with visitors drawn to the Boothbay and Pemaquid peninsulas.
According to the World Bank, the numbers of hospital beds per 1000 population ranges from a high of 8.3 (Germany) to 5.9 (Cuba) down to 1.3 (Iraq), 0.6 (Pakistan) and 0.4 (Afghanistan).
If LCH succeeds in transferring the CAH designation to Miles, it will reduce the number of beds in Lincoln County from the already low 1.36 beds/1000 (permanent residents) to ~0.45 during the tourist season.
Acting to worsen the low percentage of hospital beds per person is even more irrational given that Lincoln County has the oldest population in Maine and also has surprisingly high health care needs.
A Lincoln County Health Needs Assessment by University of New England noted that, of Maine counties, Lincoln has the highest number of former smokers, substance abusers, and people diagnosed with cancer in the state, with high rates of health problems across the spectrum.
Given the demographics and needs of the county, the decision to reduce the number of beds and services seems very poorly considered. I—and many others here—hope that the various agencies that need to grant approval for this plan will deny it.
Mission Statements meet Reality
Propaganda from the corporate health system states, “Lincoln County Healthcare’s mission is to ensure access to high-quality, patient-centered and affordable health care to the people of our region…
LCH’s parent company, MaineHealth, touts that its mission is to
“_ Maintain an integrated not-for-profit, community-owned, comprehensive delivery system providing the continuum of care from prevention and health maintenance through tertiary services, rehabilitation, chronic care and long-term care.
_ Have as its primary goal, the continual improvement of the general health of the communities served.
_ Provide high quality, safe and accessible health services delivered with care and compassion in a cost effective manner…”
and claims its system “shall
_ Measurably improve the health status of our communities.
_ Focus on our patients/customers and exceed their expectations.”
So how are they doing?
How does closing a community’s hospital and Emergency Room, forcing residents to go off peninsula for care, improve the community’s care or health?
What steps have LCH/MaineHealth taken to meet the needs outlined in the county health assessment? In 2011, 9.3% of hospital admissions were for mental health problems. Yet there is no psychiatrist nor substance abuse program here.
Exceeding “customers’” expectations? Not exactly. 86% of peninsula voters in last fall’s election voted that they wanted to maintain St. Andrews Hospital’s Emergency Room and Critical Access Hospital designation, overwhelmingly rejecting LCH/MaineHealth plans.
Community Impact
The Boothbay peninsula has a permanent population of ~7000. The closure of St. Andrews is expected to result in the loss of 50 jobs and over $1.3 million related to direct and indirect job losses. Additionally, a loss of $1.5 million annually is anticipated by losing the CAH designation and an additional $250,000 loss from skilled nursing beds. As Town Manager Jim Chaousis observed, “The hit on the region's identity will be irreparable.”
“Real estate industry execs expressed concern about the ability to sell homes...and the negative impact on real estate valuations.” For each 1% drop in real estate prices, it costs the region $25 million. If prices drop 10%, the loss in property value is $250 mm.
The costs for the ambulance service are also expected to skyrocket, increasing $400,000 year, with costs to be born by the residents. Transport times will increase. According to Scott Lash, operations manager for Boothbay Regional Ambulance Service, the change will triple average ambulance response times from about half an hour to one hour, 45 minutes.
There are less tangible costs. Philanthropic giving in Boothbay is extraordinarily generous, on the order of $6 million/year. According to the iVantage report, “There was strong consensus that the generous past history of philanthropic support of the hospital would no longer occur based on the process and substance of the LCH decision.” Many interviewees also noted that retirees would be unlikely to settle in Boothbay, given the absence of a nearby hospital.
Fiscal irresponsibility
In addition to the economic wounds inflicted on the community by LCH/MaineHealth’s decision, there are other reasons locals are angered. For example, “Facing a doubling of the expected mid-year deficit, LCH laid off four full-time employees, terminated 10.6 unfilled positions and ended outpatient surgery at St. Andrews Hospital for the remainder of the fiscal year.” Yet at the same time, Bill Caron, CEO MaineHealth draws salaries and benefits of $1,128,006 and Richard Petersen, CEO Maine Medical, makes $1,039,940. Even Jim Donovan, CEO of LCH, makes more than $300,000/year, quite a sum in this economically depressed area. This would be more palatable if they were perceived as actually helping the local community; that is far from their image among people I have met.
Other than perhaps increasing profit for MaineHealth, the decision to close St. Andrews remains rather inexplicable to me. Donovan, the CEO of LCH, said, “Essentially there are no savings (from the changes)…We are shoring up quality and safety. Savings from expense reductions are wiped out by the loss of (St. Andrews) critical access hospital designation.” There were other options for maintaining quality that were not adequately explored. They chose not to, seemingly hell-bent on closing St. Andrews.
Breach of Fiduciary Trust
One of the biggest sources of pain in the community is the sense of betrayal by LCH/MaineHealth. The community feels betrayed on several levels:
LCH/MaineHealth are violating the historic mission of the community. “The original Articles of Incorporation of St. Andrews in 1955 stated that the purpose of the corporation was to ‘establish, operate, and maintain... a public hospital.’ Changes in 1975, 1997, 2007 and 2012 retained that purpose, leaving it unchanged for almost 60 years…The decision to close the hospital by MH/LCH is contrary to the stated purpose of the Corporation…”
The prime waterfront land for the hospital and subsequently millions of dollars have been donated by the community to support St. Andrews. Residents buying into an adjacent retirement community were promised that St. Andrews Hospital, an acute care facility, was “convenient” and located within “minutes.”
The breach of fiduciary trust extends not just to the hospital patients but to the community at large. LCH/MaineHealth have focused on their own profit at the expense of the community’s well-being. In fact, they bear responsibility for raising our taxes and for not maintaining our real estate values and local economy. It is their ethical obligation.
As one report concluded, ‘This is a violation of law and a breach of trust with the State, St. Andrews’ supporters and benefactors, and the Boothbay peninsula communities.’
Personal reactions
Only since coming back to Boothbay have I fully appreciated the depth of the anger and sense of betrayal the community has. For example, Jane B. Good, the owner of Hair it Is styling salon, has been a Southport Island resident for 35 years. Through her business, she regularly meets a broad cross-section of the community, and “has her finger on the pulse” of the area like few others do. She spoke movingly about the warm, supportive, close community that existed there until last year’s decision. She says that has now been replaced by “fear and anger” and that this is “tearing community apart.” Jane says she has 3-5 clients/day who say “they are terrified they will die because they won’t be able to get to the hospital in time.” What a sorry legacy MaineHealth is leaving here.
Last week, I was moved to see the outpouring of support for St. Andrews. Despite the cold and rain, hundreds of people cheered and waved as the “Save St. Andrews” float passed by in the Windjammer’s parade. St. Andrews truly is the heart and love of this community.
Predictions and Alternatives
MaineHealth/LCH are currently proposing to replace St. Andrews Emergency Room with a mostly-daylight-hours urgent care center. If LCH succeeds in “stealing” the CAH designation from St. Andrews and transferring it to Damariscotta, it will further decimate health care in the county. I predict that within 1-2 years, MaineHealth will close the urgent care “bone” they have tossed Boothbay, saying it is not adequately utilized. I further believe that within 5 years, they will also decide that maintaining Miles is no longer profitable, and that all patients should go to the Mother Ship in Portland for economies of scale.
LCH is deluding itself to think that most care from Boothbay will go to Miles after the hospital here is closed. After driving the 10-or-so miles to get off of the peninsula and onto Route 1, people will not “turn right” and go to a tiny hospital farther from the big city unless their problem is very minor. Instead, they will turn left and head to MidCoast Hospital in Brunswick. Only for more serious illnesses will they go to Portland, or perhaps to Lewiston.
So what are the options?
I have no doubt that legal action will be taken against LCH/MaineHealth to reclaim the assets that have been taken from Boothbay. People here are determined to see justice done.
There is precedent for undoing the takeover. In New Hampshire, Elliot vs Optima Health, the Attorney General undid the merger as a violation of the hospital’s historic mission. In the Lifespan case (“The Fiduciary Duty of a Charitable Corporation’s Sole Corporate Member: New Law and New Questions”), the Court ruled that the trustees of a non-profit (like LCH) have a fiduciary responsibility to protect the interests of those people served by a non-profit subsidiary (like St. Andrews)—not just to the corporation. And, in the old days, anti-trust laws might have precluded such bullying monopolies.
In my dreams, I hope that LCH/MaineHealth will come to their senses and return St. Andrews Hospital and its misappropriated assets to the community to manage—perhaps initially managed by the Boothbay Region Health & Wellness Foundation, until the community could elect other overseers. The most exciting thing that is emerging from this debacle is the formation of the Boothbay Region Health & Wellness Foundation,* whose goal is a community designed-community based healthcare system that will include urgent care, mental health and substance abuse care, primary care, wellness and preventive medicine and education. The people behind this are passionate advocates, committed to the well-being of all of the people on the peninsula.
Boothbay has rallied around their hospital, in this classic David and Goliath battle. I have no doubt they will similarly support the Foundation.
* Disclosure: I am now a member of the Board for the Foundation, at their invitation.
** DH's story used with permission
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