By Thomas Mee, Chief Executive Officer, North Country Healthcare
Beginning in 2014-15, key executives and boards of the four North Country non-profit, critical access hospitals, including Weeks Medical Center, Androscoggin Valley Hospital, Upper Connecticut Valley Hospital and eventually Littleton Regional Healthcare started to develop a plan for a regional integrated health care system to react to worsening industry trends threatening critical access hospitals here in the North Country and throughout the country.
The trend for hospitals to affiliate has significantly increased over the past decade; since 2010 nearly 100 rural hospitals across the country have closed. And in February, Navigant Consulting Inc. of Chicago reported that 473 of the 2,045 remaining — including five unidentified hospitals in New Hampshire — are at high risk of closure.
Against this backdrop, the four North Country hospitals entered into a formal Affiliation Agreement in 2016 — forming what is today known as North Country Healthcare. This process was overseen by the N.H. Attorney General’s office and the N.H. Director of Charitable Trusts Unit, Tom Donovan, and was required to undergo the scrutiny and input of all of the communities served in a series of public forums before being approved by the Director of Charitable Trusts office. This was an important step to ensure that the patients of the North Country had a voice in this groundbreaking affiliation, and that the public interest was truly being served.
In the original bylaws of North Country Healthcare, some of the most crucial purposes of the affiliation included:
- To preserve the ability of each affiliate to provide its core services.
- To align the missions, clinical services and economic interests of the affiliates.
- To develop a highly coordinated health-care network that will improve the quality, increase the efficiencies and lower the costs of health care delivery in the communities served by the affiliates.
- To protect the ability of the affiliates to perform their existing charitable mission in the future.
- To broaden the charitable missions of the affiliates to embrace a commitment to the New Hampshire North Country.
By all quantifiable metrics, the North Country Healthcare entities achieved of these purposes, and the “winners” of the affiliation were not solely the affiliates themselves, but most notably every patient of the North Country. In fact, the North Country Healthcare model was so successful, it had been held out to the nation as a model to be considered by all to ensure the survivability of the rural health hospital and provider.
It was for all the aforementioned reasons that I made the decision to join North Country Healthcare as its CEO in January of 2019 after an exhaustive nationwide search. Put simply, after a long career in ultra-competitive, urban settings, I viewed the North Country Healthcare opportunity as an opportunity to do the most important work of my career, and I fully intended for this opportunity to be the last “job” of my long health-care career. The lure of joining such an altruistic system, where collaboration rather than competition was viewed as the recipe for success, made the North Country Healthcare opportunity rise to the top of multiple other options.
My selection was approved by the North Country Healthcare Board, whose trustees represented all hospitals and communities. I accepted the position in relative short order, for all the reasons I’ve previously articulated. Sadly, this is precisely when the mission of North Country Healthcare started to unravel. Within literally days of the announcement of my acceptance, the largest hospital within the North Country Healthcare system provided notice of their intent to withdraw from North Country Healthcare. This should be very troubling to the communities we serve for at least one of two potential reasons:
- After three years of documented and profound success under the North Country Healthcare structure, preceded by years of due diligence to create the North Country Healthcare model, the withdrawing hospital made a substantially impactful decision in a period of days, starting with the announcement that an “outsider” was recruited and signed to lead the system in a CEO capacity, and ending with their “pre-notice” to the North Country Healthcare board chair mere days later.
- If the aforementioned scenario is not the case, then the lack of process and governance is especially more troubling. Quite candidly, if conversations were occurring prior to January 2019 relative to a potential withdrawal, they were conducted in the absence of board oversight. We know for certain that board members from the withdrawing hospital, who ended their terms on Dec. 31, 2018, including the board chair, knew absolutely nothing about their hospital potentially considering a withdrawal from North Country Healthcare. While the first scenario is, at best, an example of inadequate due diligence and subsequent board oversight, this latter example would represent a complete disregard relative to the fiduciary and leadership obligations of the both the board and the administrators in charge.
A key executive from the withdrawing hospital has stated publicly that they withdrew because their doctors “would never listen to a [expletive] nurse from Michigan.”
I make no apologies for the fact that I remain a licensed registered nurse. I am proud to say that, due to my vast clinical background, I can speak the language of all health-care constituents, and that I have personally provided clinical support to thousands of patients myself. I am also proud of the fact that during my tenures as president and CEO, I have saved a 400-bed acute care facility from closure, ultimately taking it to the top decile in overall performance, and successfully securing capital funds in the amount of $500 million to build a brand new replacement campus for a hospital that only four years prior was insolvent. I am a nurse from Michigan who ultimately was voted by his peers as the Hospital Leader of the Year in the state of Michigan in 2016, in recognition of my achievements.
Spending 32 years in health care causes one to grow a thicker skin, so I do not take such comments as hurtful or demeaning. However as a professional and engaged registered nurse it shows a blatant disregard for the most visible, most supportive and most crucial member of the hospital multidisciplinary team. It’s truly unfortunate that in the year 2019, professional nurses are still viewed in such a capacity. On a nationwide basis, more and more hospitals are seeing the benefits of hiring clinicians with advanced business training into executive leadership positions — replacing the old paradigm where hospital CEOs rarely had a clinical background.
North Country Healthcare and our withdrawing partner are currently engaging in mediated settlement discussions — quite simply struggling to identify an exit strategy that minimizes harm to any of our respective communities. It’s important that we not forget history, specifically the fact that the original catalyst for these discussions was a dire financial performance at 16-bed Upper Connecticut Valley Hospital in Colebrook.
It’s a not well-known secret that many clinical service lines in the hospital environment are subsidized by other higher margin services. For one example only, it would be highly unlikely that any stand-alone obstetrics program could exist without organizational level support from other service lines like orthopedics or cardiology.
The notion of affiliating multiple hospitals under a system umbrella accomplished the same. As mentioned earlier in one of the bylaw bullets, the pooling of financial resources in the form of patient revenue, coupled with lower costs achieved via reaching economies of scale, enables all entities within the system to thrive, even if they were not necessarily profitable on their own. It’s very much a team methodology where often times individual members make sacrifices for the betterment of the whole, in this case the North Country of New Hampshire.
Without question, the action taken by the withdrawing hospital will compromise that overall mission as they’ve chosen to focus locally at the expense of a region. The resultant system will obviously be smaller in size, and the concerns that were first identified three years ago will potentially return. The spirit of collaboration will return to an environment of competition, where too often patients become units of service and components of market share, rather than being recognized as a whole being with social and spiritual needs in addition to their physical needs.
While no one questions that the withdrawing hospital had the contractual right to take that action, the communities we serve deserve a process that is at least as equally open and transparent as the original affiliation process was.
Not-for-profit hospitals are assets of the communities in which they reside, and those same communities deserve to know all the facts surrounding such an important decision.
Regardless of the final chapter, North Country Healthcare will continue as a system of hospitals, plus home care and hospice services. We remain as committed as ever to consistently function with the patient at the center of our decision-making, and to continuously take steps to improve the health status of all residents of the North Country as a region, rather than an individual market.
Thomas Mee RN, BSN, MBA, is the chief executive officer of North Country Healthcare, an affiliation of hospitals in northern New Hampshire.