Two events in the Upper Valley this week highlighted the challenges facing rural health care systems in the Twin States, along with a tentative step forward in making that care sustainable.
On Monday evening (July 15), about 30 people gathered in the Windsor Welcome Center for an event, hosted by the Green Mountain Care Board and the Vermont Agency of Human Services, to gather feedback on challenges facing the state’s health care systems.
“Vermont is looking at a runway that is 1,500 feet long and ends in a cliff,” consultant and physician Bruce Hamory, of the New York-based firm Oliver Wyman, told the audience.
Lack of transportation, high insurance premiums and a scarcity of providers push patients to seek care in emergency rooms, and the expense eats away at hospital profit margins.
Emergency room visits cost hospitals more than a primary care provider or urgent care center because of the operating expenses and because they have to treat everyone regardless of ability to pay and aren’t always reimbursed, Hamory said. People who don’t have primary care providers and use emergency departments are usually sicker by the time they decide to seek care, he said.
In 2023, nine out of the state’s 14 hospitals operated in the red. Some are eliminating less profitable services such as pediatrics and obstetrics, and there is a danger that smaller, rural hospitals may shutter their operations altogether if they cannot remain solvent, Hamory said.
Though dire, the news was met with determined optimism by the legislators, health care professionals and administrators in attendance.
“We can’t fix what we can’t see,” state Rep. Rebecca Holcombe, D-Norwich, said.
Mount Ascutney Hospital and Health Center interim CEO Win Brown encouraged big thinking even when solutions are expensive or daunting in scale. “We probably need to think boldly and have some moon shots,” he said in a question-and-answer session following Hamory’s talk.
Nearly half of the nation’s patient care records are kept on Epic Systems software, Brown said. Providing that software for every hospital and clinic in the state would cost millions, but it would “take out incredible amounts of friction in the system,” and is a bold idea worth considering, he said.
Meanwhile, in Canaan, a new partnership between the Mascoma Community Health Center and Laconia, NH-based health care provider HealthFirst, which began in November, aims to provide primary care and some specialty services for people in the Mascoma Valley.
It is a model of just the sort of community-based care provider that Hamory described as the future of sustainable rural care.
U.S. Senator Jeanne Shaheen, D-NH, recently secured $189,000 in congressionally directed spending to help the Canaan facility connect under- and uninsured patients with access to health care.
Where the Canaan health center struggled to stay afloat on its own, the partnership will “bring extra resources and the backbone of a larger organization with an overlap of admin, so we don’t have to add new costs,” Health-First CEO Ted Bolognani, said.
HealthFirst also has expanded the services available at the Canaan location, adding behavioral health and resuming dental care.
“We’ve seen a wild expansion in the need for behavioral health,” Bolognani said. The health center has two mental health care providers working four days per week providing in-person visits as well as telehealth. It also provides school-based services to 100 children in five local districts.
Mike Samson, director of Mascoma Community Health, which owns the building and provides outreach and patient recruitment for HealthFirst, is particularly excited about the return of dental services to the location after a two-year absence due to lack of staff.
Funded through loans and private donations and operating independently from HealthFirst, the practice will have three dentists and seven treatment rooms beginning Aug. 1.
It will dedicate 25% of its services to low-income patients such as those insured through Medicaid.
Neither Vermont nor New Hampshire have dental schools, and the Upper Valley is a dental care “desert,” dental services director Thomas Duplinsky said.
“There are more dentists in New Haven (Conn.) than there are in all of New Hampshire,” he said.
In a stroke of luck for the Canaan facility, Duplinsky, who has taught dentistry at the Yale School of Medicine for the past 30 years, bought a house in Canaan in 2021. Samson recruited him to help with the dental side of the Mascoma health center, and Duplinsky has been recruiting residents to work at the center in exchange for student loan forgiveness.
Recent meetings drew attention to the thin profit margins that place rural health care providers in a constant struggle to stay afloat.
“We’re not stable yet financially,” Bolognani said. HealthFirst relies on grants, with at most 60% of its operating costs derived from patient care revenue. “But we’re going to make a go at continuing to provide health support for the community.”
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