Last night I participated in a requiem for St. Andrews Hospital in Boothbay Harbor, Maine, and for the lost innocence of rural communities.
Just over a year ago, Lincoln County Health (LCH), part of MaineHealth, announced that they would be closing St. Andrews Hospital and Emergency Room, the community’s bedrock for more than 100 years. The community was justifiably outraged at this unexpected news and the peninsula’s four towns put together a task force of selectmen to explore alternatives. A healthcare needs assessment was conducted and legal advice was obtained. Subsequently, the Boothbay Region Health and Wellness Foundation* was formed to continue the work of the Task Force as well as to plan for unmet health needs on the peninsula.
Through the Task Force and Foundation, hundreds of people volunteered, some working a few hours per week and others working full-time for 13 months, and raised more than $160,000 for expert opinions and legal fees in donations and in-kind contributions. A succession of five attorneys was consulted, each with a slightly different area of expertise. The core group of volunteers visited 11 Critical Access Hospitals across the state to learn how they remained financially viable. [Critical Access Hospital designation is given to small, less than 25 bed, hospitals in isolated regions of the country who meet specific criteria. They receive slightly better Medicare reimbursement than other hospitals, in recognition of their specific problems and community benefits.] As Board Treasurer Margaret Perritt recounted:
“We had weekly public meetings…replayed on Channel 7 (community TV) for those who could not attend…We formed working groups and we held office hours. We hired a lawyer. We raised money to pay the lawyer. We visited 11 CA Hospitals…We had community suppers. We put out donation cans around town. We wore our hearts everywhere—on our bumpers; in our yards; on power poles; on our clothing and on our Christmas trees. We hired a consultant. We raised money to pay the consultants. We gathered local Health Statistics, did needs’ assessment, did strategic planning. We negotiated with LCH/MH. Wrote letters to the Attorney General. We petitioned at the polls. We formed a Foundation. We had votes at Town Meetings. We met with the Attorney General. We raised MORE money. We mounted legislation. We testified in Augusta. The Task Force handed the baton over to the Boothbay Region Health and Wellness Foundation. We hired MORE lawyers. We did legal research. We met with the Governor. We did a Population Health Study. We wrote letters to Legislators. We wrote letters to Medicare. We did Strategic Planning. We lobbied Regulators. We did extensive media outreach. We talked with Trustees. And we hired MORE lawyers.”
The lessons of “How we lost control of St. Andrews fate” are valuable for other communities considering hospital affiliations. One of the biggest problems—which was also the case in the ill-fated Memorial Hospital merger in Cumberland, MD—is that the community was mistakenly under the impression that this was a community hospital, owned by the town. In fact, this was the first deadly error. St. Andrews became a private nonprofit corporation in 1955, with the land being given to it for $1. As Foundation chair Patty Seybold, patiently walked us through the timeline, the next grave error was merging with MaineHealth in 1996, through an “affiliation” in which no money changed hands, but St. Andrews became a subsidiary of MaineHealth. Sadly, at each step, the hospital boards appeared focused on optimizing reimbursement—especially from fickle commercial insurers—rather than on patient needs or possible future outcomes. Each step the Board took was an “it seemed like a good idea at the time” moment, with unintended consequences.
In 2007, St. Andrews (SAH) entered into a shared governance agreement with Miles Memorial Hospital in Damariscotta, forming Lincoln County Healthcare. At that time, an astute SAH board member added a clause that would maintain St. Andrews Emergency Room. Unfortunately, the measure, which passed uneventfully, was non-binding, and could be overruled by the parent LCH Board—which also became identical to the MaineHealth Board—and that is exactly what happened.
In 2008, acute care beds were transferred from SAH to Miles, once again prompted by higher reimbursement at Miles. The “death by a thousand cuts” continued, as further services were similarly removed. Last year’s transfer of the Operating Room and all its equipment—largely purchased with donations—removed the last profitable center at SAH.
The latest insult is the move to take St. Andrews valuable critical access designation and “relocate” it to Miles. Since one of the requirements for CAH designation is having a 24-hr ER, this deal sealed the fate for the Boothbay community’s desire to maintain its ER.
Former Boothbay Harbor selectwoman Valerie Augustine Young detailed why we will not be able to get an injunction—a temporary restraining order—to block the ER closure. Four criteria must all be met:
1. The party must demonstrate that it will suffer irreparable injury if the injunction is not granted.
2. Such injury by the plaintiff must outweigh any harm inflicted to the defendant with the granting of the injunction.
3. There must be a likelihood of success on the merits of the case.
4. The public interest will not be adversely affected by granting the injunction.
On top of showing that the plaintiff (injured individual) would likely prevail against LCH, the plaintiff has to post a prohibitively large bond to cover for possible monetary damages to LCH.
The possible grounds for action explored were:
1. Breach of Fiduciary Trust
2. Antitrust claim
3. Misrepresentation to St. Andrews Village retirement cottage owners, who bought properties advertised as being within “minutes” of acute care services.
4. The additional tax burden on the communities cause by the ER closure. Appropriations for the ambulance service will be rising by $400,000 per year, as they will no longer be able to rely on volunteers and will need additions to their fleet. Turn around times will likely increase from 30-40 minutes to 2 hours per trip, according to Scott Lash, Operations Manager of the ambulance service.
Gifts and Deeds
Let’s turn back for a moment to final sore points for the community. I want to emphasize that the community thought that St. Andrews was their hospital. They have poured millions of dollars into it by donations. Ironically, because funding was by gifts, rather than taxation, the community now has much less basis for action.
In 20-20 hindsight, a key problem now is that neither the property deeded by the Gregory family nor the millions of dollars in donations had restrictions on how they must be used. And, because it is a private nonprofit charitable corporation, the community has no control.
The closure of St. Andrews is likely to result in the loss of 50 jobs—in a town of 3120/region of 7000, which will be a major blow to the economy. A drop of $1.3 million is anticipated related to the job losses. Estimates are that real estate values will plunge by 10%. As noted, there is this sizeable increase in taxes for the ambulance service. Retirees are already planning to move from the peninsula, being justifiably afraid that the delay in receiving timely care is too risky for them. There is one 2-lane, windy road off the peninsula, jammed with traffic in the summer and sometimes blocked by ice or downed trees in the winter. One can readily imagine that lives will be lost by this ill-considered decision.
Lincoln County has large health care needs; it has the highest number of former smokers, substance abusers, and people diagnosed with cancer in the state, according to Lincoln County Health Needs Assessment by University of New England. How can LCH claim that reducing beds and increasing the distance for patients to receive care, separating them from friends and family, improves care?
One other likely huge problem, that I mentioned before, is that if Miles succeeds in acquiring SAH’s critical access designation, they will have to reduce their beds to 25. With the closure of St. Andrews, this reduces beds for all of Lincoln County to 25—for a population that swells to 55,000 in the summer. This leaves us with 0.4 beds/1000, far less than even LCH’s own consultant recommended, and compared to 2.2 beds/1000 average in the rest of the state. This strikes me as particularly irresponsible, given that Lincoln County (which contains the Boothbay and Pemaquid peninsulas) has the oldest population of any county in the entire country. Just wait for the next bad influenza season…the region will lack the capacity to care for its own.
The Foundation has already asked Medicare to reconsider allowing LCH to reduce the number of hospital beds in the county to such dangerous levels—on a par with Afghanistan and Pakistan. They will also be monitoring for harms done to individuals, as this would reopen the possibility of bringing a successful lawsuit. So the fight continues…
Another irony in LCH’s zeal to close St. Andrews is that there is little doubt in the minds of some observers, myself included, that within 5 years MaineHealth will close Miles hospital in Damariscotta, claiming that it is not cost-effective to maintain, and that all should come to the Mother Ship in Portland (~1.5 hours away) for care.
Rising from the Ashes
One of the many impressive things to me about this community and the Foundation is their spirit and resilience. While tirelessly pursuing the legal strategies, the Foundation has also been looking forward as to how to meet the many needs of the community. They are like the phoenix rising-except that here it is a seagull.
A strategic planning group has been working for months and has a number of initiatives in mind. These include an elder “empowerment” program, extending Chip Teel’s successful “Full Circle America” to the peninsula. This program allows elders to remain in their homes by providing a variety of services and safety monitoring by discretely placed video monitors (e.g., in the kitchen or high-traffic areas of the home). Immediate attention will also be given to health education, starting with information about the upcoming health insurance exchanges, and then focusing on chronic disease prevention and management. Another priority is the mental health and substance abuse, which plagues the region. In 2011, 9.3% of hospital admissions were for mental health problems. Yet LCH and MaineHealth have not provided for a psychiatrist or substance abuse program. So much for MaineHealth meeting its mission statement. Mental health and substance abuse are often not attended to by traditional health systems due to low reimbursement. These planned Foundation initiatives are just the beginning.
I hope that this post-mortem will serve as a warning and help other communities considering affiliations or mergers for “economies of scale.” It is critical to maintain control over your board. Ideally, large gifts or deeds should be directed towards specific purposes. Perhaps most importantly, there needs to be community involvement and transparency in planning processes. Too often, such bad deals as this are done behind closed doors, and then announced to the community as a fait accompli.
I remain troubled by the broader question I asked earlier:
To what extent are community hospitals local assets, akin to public utilities, even though they are run as private businesses?
When a major change to a hospital that was heavily funded by contributions from the public, such as reduction of services or even closure, is proposed, shouldn't there be community input into the decision-making process?
I await answers as to how to achieve this.
Until then, I remain consoled and encouraged by the spirit, resilience, and caring shown by the Boothbay communities. It is a fine place to be.
Jane Good, one of the Save St. Andrews leaders, closed the meeting by sharing the call she had received from Mathew Chandler, Maine’s Director of Health and Human Services-Rural Health and Primary Care, about the letter he had received protesting the movement of the CAH designation from St. Andrews to Miles Hospital. He took the time to telephone her to let her know that his department did not deal with the matters at hand but that he would see that it went to the appropriate office. He told her “everyone in Augusta (the Maine State Capitol) was watching this.” At the end of the conversation, he added “I would like to share something else with you. I would love to live in a community like yours.” Jane replied, “Yes you would.”
Many clenched back tears of anger and sorrow. A memorial service will be conducted October 1, when the Emergency Room closes--on the sidewalk across the street from St. Andrews, as LCH will not allow a gathering on their property. This is but one further example of the way LCH/MaineHealth have ignored the sentiments of the community and needlessly fueled resentment towards them.
Postscript: Farewell Vigil
A group of determined protestors held a farewell ceremony at St. Andrews after the "Urgent Care" closed for the night on October 1st. Lincoln County Healthcare's CEO, Jim Donovan, who had denied permission for the peaceful service, could be seen occasionally peering out from inside St. Andrews, where he remained, protected by security staff guarding the entrance to the former hospital.
Here are portraits of LCH's fierce adversaries:
Opposition leader Jane B. Good laid a wreath into the waters at the dock that served the hospital's maritime patients, and posted a thank you by the hospital's helipad.
A tearful crowd listened respectfully as Rev. Maria Hoecker, minister of St. Columba’s Episcopal Church, offered a prayer for the community.
Bagpiper Peter Beckford played “Amazing Grace” and “Auld Lange Syne.”
Finally, we all gathered as Jane let a single heart aloft.
That's how we said goodbye to the beloved friend of the community, respectfully protesting her untimely and unnecessary death.
Big Fish Eats Little Fish - a Warning for Rural Hospitals
Boothbay Health and Wellness Foundation
* Disclosure: I am now a member of the Board for the Foundation, at their invitation.
"Molecules to Medicine" banner © Michelle Banks
No Problems, Only Challenges – Frits Ahlefeldt
$old Out - Community Sentiment - Judy Stone
Phoenix - courtesy of Christos Karapanos
Farewell balloon release courtesy of Kevin Burnham and Boothbay Register