In a pattern being repeated across the country, the Boothbay, Maine peninsula’s hospital has been shuttered, and the communities just lost their bid to even have a 24 hour urgent care on the peninsula.

Citing financial need—which has been disputed—Lincoln County Healthcare (LCH), part of MaineHealth, closed St. Andrews Hospital, a critical access hospital (CAH), transferring that valuable designation to Miles Hospital in Damariscotta. This has left the entire county, with the oldest population in Maine, with only 25 beds (down from 63) and limited services, though the population surges to more than 40,000 in tourist season. The number of beds has dropped to .45/1000, compared to the Maine average of 2.7, despite having the oldest population in the state, and LCH’s own commissioned Navigant report that projected a 45 bed need in 2015. How could DHHS allow this downsizing to such a low, unsafe patient to bed ratio?

Many things are galling in this story, in addition to the usual greed. One of the most egregious is that these shifts in hospital services were all done without even bothering with a Certificate of Need process, let alone any discussion with or participation by the community. It was presented in Aug, 2012, as a fait accompli.

A group of citizens formed the Boothbay Region Health and Wellness Foundation to challenge the hospital closure, as well as to look at other options for care on the peninsula. (disclosure—I am a member of the Foundation).

LCH declared that they would only keep the Urgent Care Center open 8am-8pm, and would not accept ambulances. This means that anyone seriously ill must travel at least a half hour (in good weather, with no traffic) on a windy, dangerous road, if they want to go to a limited CAH, or at least 45 minutes to the next larger hospital. This is extraordinarily difficult and dangerous for the elderly or ill, and even more so in bad weather, or at night. Additionally, the rehab and hospice beds were stripped from Boothbay, and elderly must now be separated from their family support for these services.

After the Foundation objected to this, DHHS Commissioner Mary Mayhew tried appeasement, by requiring the healthcare system to at least provide 24-hour walk-in urgent care service, for 18 mo. LCH protested even this small gesture.

The community girded up for yet another fight to try to preserve basic health care services, well described here, here in CON testimony, and in my previous posts, below. A reconsideration hearing of the need to maintain 24 hr services for 18 mo was held in August, 2014—only the 2nd hearing since the reconfiguration began in 2007, without a CON. Curiously, despite the objection of the Foundation, the DHHS insisted on withholding the results of their hearing, until after the November 4 election. Then, dismayingly, Mayhew rescinded her previous decision, no longer holding LCH accountable at all to the expressed needs of the community.

LCH had stripped 25 beds from St. Andrews, then claimed that, without a favorable ruling from DHHS, they could not afford to replace any of them. They won, and are now beginning a CON process to reinstate 12 beds, at a cost of $2.8 million, though they note their decision is not finalized. LCH’s foresight and remarkable planning are telling. Even they acknowledge that, because they removed beds (over community objections, and with no requirement for a CON or oversight), that they were forced to deny 139 out of 257 skilled nursing bed referrals due to a lack of beds (October 2013 to Sept. 30, 2014). Also, Between Oct. 1, 2013 and March 31, 2014, 34 LincolnHealth emergency department patients were transferred to other hospitals because there were no acute beds available in the county. “This lack of availability was not because of other acute patients, but due to skilled care patients in swing beds that could not be placed in skilled nursing facilities,” according to LCH.

Local impact

As noted in Breach of A Community’s Trust, the closure of St. Andrews is expected to result in the loss of 50 jobs (in a town of 3100) 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,” impacting local merchants, housing, and tax revenues, and resulting in a downward spiral. “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 increasing $400,000 year, with costs born by the residents. Per 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. In fact, there is only one road off the peninsula—winding and dangerous Rt. 27. It is sometimes impassible due to bad weather or accidents, leaving people on the peninsula stranded without access to any hospital. In addition to dangerously long transport times, the community can no longer rely on a volunteer rescue service.

Fiscally irresponsible

This is the only phrase to describe LCH/MaineHealth’s action. From the beginning, James Donovan, the CEO of LCH, said, “Essentially there are no savings (from the changes)…” Yet while he was destroying healthcare on the peninsula, his compensation rose to $364,754, an 11.8% increase over just 2 years. Pretty handsome for reducing beds from 63 to 25 for a county with a per capita income of $27,975, household income of $51,152. Dr. Mark Fourre, Donovan’s partner in this, earned $315,114 for his contribution.

And now LCH is facing millions of dollars to replace beds that they removed shortsightedly, without consideration of their future needs.

Global issues

A similar pattern happened in Cumberland, Md, when two hospitals that had been long time rivals merged, again without fiscal need and again with the deal being made behind closed doors, without community input or assent. More recently, we have seen a similar move in North Carolina, when the Vidant Pungo Hospital shut down in Belhaven. As in Maine, NC had rejected Medicaid expansion, placing additional financial pressures on hospitals. Within days, a 48 year old woman (who had insurance) died of a heart attack while awaiting a helicopter transfer. This prompted Belhaven’s mayor, Adam O'Neal, a conservative Republican, to walk 237 miles to Washington, D.C. “to protest the closing of the hospital, which he attributes to an “immoral” hospital operator, and, according to author Dana Milbank of the Washington Post, “the failure of Republican leaders in his state to accept the new Medicaid funding the hospital needed to stay afloat.”

“If the governor and the legislature don’t want to accept Medicaid expansion, they need to come up with another program to assure that rural hospitals don’t close, [else] they’re allowing people to die to prove a point. That is wrong, and I’m not going to be a party to that.” He added, “Rural citizens dying should not be soldiers of the South’s defiance to the new health care law.”

The Center for Budget and Policy Priorities, a Washington think tank, notes that rural communities are disproportionately reliant on Medicaid, so suffer more by their Governors refusing to accept the expansion monies. Most of the rural hospitals that have closed recently were in such Southern states. Since early 2010, 43 small rural hospitals have closed; the pace of closures is quickening, and more hospitals are teetering. And as they close, delays in accessing hospitals result in more deaths, particularly for the those with heart attacks, strokes, or trauma, where that first “golden hour” is critically important for survival.

These sad stories—of community health being destroyed in Cumberland, Boothbay, and Belhaven—are illustrative of several problems in healthcare. Increasingly, regulators protect big business (what happened to concerns about monopolies?) and show no concern about community needs. Major decisions are made without public hearings and, in some cases, bypassing even the pretense of a CON process. These systems claim to be “nonprofit,” yet are not responsive to local needs, and reward their CEOs with disproportionately high salaries. LCH has clearly not responded to the OneMaineHealth's health needs assessment, let alone the expressed needs of the citizens, as demonstrated by the dearth of mental health and substance abuse services in Lincoln County.

The state and federal regulators all seem to be in cahoots with these big businesses, all in the proclaimed name of “cost-savings” and efficiencies. Yet they ignore details, to say nothing of people's needs. For example, studies in JAMA noted that lower competition and increased hospital ownership of practices may actually lead to higher costs—10-20% higher in California, and 8-16% higher across the US. Patients are also faced with higher costs when seeing hospital physicians, because of imposition of a “facility fee.

I have no doubt that MaineHealth will soon say that Miles Hospital is too expensive, and will close it, further funneling all the patients they can down to the mothership in Portland, an hour and a half away—ignoring the personal toll this has on ill patients and their families, as well as the economic burden of these stressful day trips. This also ignores wide-ranging data on worse patient outcomes for patients separated from their families. MaineHealth, like other corporations, seems to ignore the economic impact on communities where hospitals are shuttered. In each of these small communities examined, closure of the hospital hurt other businesses and made it difficult to attract new ones.

These cases raise broader questions, as well. To what extent are community hospitals local assets, akin to public utilities, even though they are run as private businesses?

When a hospital that was largely funded by contributions from the public is privatized, shouldn’t community involvement be maintained?

Shouldn’t the public have input as to what services are needed in their communities?

Private nonprofits are not subject to public access laws and are not required to share their meetings or documents with the public. Communities do not learn of decisions affecting their services until they are a fait accompli. This is a disastrous pattern, and needs to be changed.

And there is one question that the Foundation has been unable to receive an answer to: Under Maine law, who can approve a retroactive CON? Does Maine’s DHHS have the statutory authority to do so? If so, why even bother with the sham of a CON process?

Mary Mayhew, Attorney General Janet Mills, Gov. LePage, we await your answer.

Previously in this series:

Breach of a Community’s Trust

Hospital merger déjà vu

Big Fish Eats Little Fish – a Warning for Rural Hospitals

Requiem for a Hospital

Note: small portions of this post have been abstracted from previous posts in this series.

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"Sold Out" by Judy Stone