Some may be disappointed that the September 5 meeting between the towns’ hospital task force and Lincoln County Healthcare didn’t produce more tangible results. 

After two and half hours, Lincoln County Healthcare did not alter their decision or change their timeline, nor did the task force decide to suspend its quest to maintain the emergency room and swing beds slated to end in April. But for the first time since the proposed changes were announced on July 31, the conversation about St. Andrews Hospital was not dominated by acrimony, accusations or conjecture. It felt like progress.

Task force Chairman Chuck Cunningham said, “It was a good first meeting between the task force and Lincoln County Healthcare. We look forward to more conversations as we work toward a solution to this very complicated problem.”

Lincoln County Healthcare CEO Jim Donovan agreed, “I think it was an excellent discussion. It was important for us to hear and respond to the task force’s questions. I hope we can continue this dialog.”

All task force members and Boothbay Town Manager Jim Chaousis attended the meeting. Lincoln County Healthcare was represented by its CEO, senior management staff and the Board of Trustees executive committee. Meeting topics ranged from St. Andrews history and governance, the clinical changes over time at St. Andrews, broader issues affecting rural healthcare and the underlying reasons for the decline in services at St. Andrews Hospital. The meeting was driven primarily by the task force’s questions but Lincoln County Healthcare did most of the talking. 

By the end, there was general agreement that the public needed to hear directly from Lincoln County Healthcare so that concerns, rumors and allegations could be addressed. Although task force members seemed impressed by the arguments and discussions offered by doctors and administrators, some, like Southport Selectman Smith Climo, were not persuaded.”We got some great information but it hasn’t changed my mind. I still think we are better off keeping the hospital where it is,” Climo said.

No delay in April date

Chaousis said the April date for changes did not allow the community, particularly the ambulance service, enough time to prepare, and asked for a time extension. 

“The first people we met with were the ambulance service,” Donovan said. He said VP of Hospital Operations Cindy Leavitt and Emergency Department Director Dr. Tim Fox were working with the ambulance service to identify necessary changes. 

“We are committed to helping them through this change,” Stacey Miller, VP of Physician Services said. Leavitt and Miller are in charge of Lincoln County Healthcare’s internal transition team and have been attending task force meetings and working to fulfill town data requests.

Donovan said he expected the time allotted for transition to be sufficient to address all the regulatory, licensing, operational and community education needed to implement the changes. Board Vice President Jeff Curtis said it was preferable to institute changes before the busy summer season. Chaousis and task force members were not persuaded. 

What is driving the changes?

There was a lot of discussion about the factors affecting rural healthcare in general and St. Andrews in particular - the large population of poor and elderly, the dependence on Medicare and Medicaid reimbursements that are below costs, the loss of patients to larger hospitals with specialists, high volume practices and lower prices, and the difficulties of maintaining core staff and infrastructure for few patients. 

Lincoln County Healthcare’s short answer for what’s driving change: declining patient volume. Lincoln Medical Partners Director Dr. Mark Fourre answered the question with more depth and history by reviewing the clinical changes at St. Andrews over the years, beginning with the end of obstetrics in the 1990s. 

“These changes haven’t been made because of some foregone conclusion, there just were not enough patients. Gradually, these decisions have been made by clinicians over time,” Fourre said. 

Fourre said seeing fewer patients and doing less procedures affects both a clinician’s skill levels and a facility’s ability to attract and retain good staff. “At Miles, full-time physicians are at the cusp of being able to maintain skills and Miles is three-plus times the size of St. Andrews. We struggle to get enough procedures in that environment,” he said.

Edgecomb Selectman Stuart Smith asked, “Why is volume going down and what characteristics are driving down volume?”

“There has been a 15 year trend of outmigration to bigger hospitals from smaller hospitals. People are making choices. Has it hurt rural healthcare? Absolutely. Is it our responsibility to react? Absolutely,” Donovan said.

Board Vice Chairman Jeff Curtis said volume declines affect finances as well, but finances were not determinant. “We do a lot of things in our healthcare system in Lincoln County that are not profitable, that we subsidize because it’s the right thing to do,” Curtis said, “The decision was made when we heard our providers aren’t comfortable on the front line. You can’t sit as a board and say just do it anyway. It’s really about quality; it’s about safety.”

Emergency department

Fourre said an emergency patient would probably be better off in an ambulance going to another hospital than arriving at St. Andrews ER, because of its small staff and limited resources. Fourre preceded Dr. Fox as Lincoln County Healthcare’s Emergency Department Director, was an attending physician at Maine Medical Center for two decades and developed the Emergency Medicine Residency Program there. He is also a senior medical director for MaineHealth and serves on Lincoln County Healthcare’s Board of Trustees.

“I would argue that the closer you are to dying, the better off you are spending an extra 20 minutes in an ambulance. Because you need blood, you need surgeons, you need 10 people in the room,” Fourre said.

Climo was unconvinced, “I do not see how from a medical perspective this will enhance outcomes for people. What do we have to do, what would it cost to maintain that (level of service) at St. Andrews? This is a number you have to come up with.” 

“There’s no number,” Donovan said. Fourre said first, the cost would be “astronomical” and second, it would be impossible to find doctors with the skills required who would be willing to “hang around waiting” for a patient to show up. “That’s the part I can’t get across,” Fourre said.

What’s the future?

Boothbay Harbor Selectman Valerie Augustine expressed concern the declining trend would lead to more cutbacks in healthcare services. “How do we deal with the small volume problem? What if eventually you say Miles can’t support an ER?”

Chief Medical Officer Dr. Russ Mack said he shared her anxiety about the future. “We’re under intense pressure. We’re always one doctor away from an emergency because we don’t have enough physicians to cover a particular specialty,” Mack said. He explained the difficulties of attracting specialists to rural communities and how the aging of Maine’s physicians will exacerbate the specialist crunch. 

Mack said Lincoln County Healthcare was working with other regional hospitals to address these circumstances but there is still a lot of uncertainty. “It may be in the future you cannot have your appendectomy in Damariscotta. You may not even be able to have it in Brunswick. You may have to travel to the medical center (Portland) to have that done,” Mack said.

For Lincoln County Healthcare, the future is primary care, Donovan said. The healthcare organization intends to put more emphasis on keeping people out of the hospital and emergency room through better accessibility and a team approach to primary care. “That’s where we need to put our energy. That’s where we believe we will have the best influence on the health of this community and the affordability of services for this community,” Donovan said.

Conversations have begun but both groups remain on their set courses. The task force will continue in its efforts to maintain the hospital; it meets each Tuesday at 7 p.m. at the Boothbay Town Office. Meanwhile, Lincoln County Healthcare will continue in its plans for change.