It has been nearly three months since the Maine Department of Health and Human Resources ruled that St. Andrews Urgent Care Center in Boothbay Harbor would need to begin operating 24 hours a day and 7 days a week, and it has been nearly a month since the DHHS said it would reconsider the mandate. This week, residents of Boothbay Harbor and the surrounding area participated in the public hearing the reconsideration made necessary.
Attorneys representing MaineHealth and the Boothbay Region Health and Wellness Foundation met in the Boothbay Harbor Town Office on Monday, Aug. 11 to present their legal arguments before DHHS Chief Administrative Hearing Officer Jim Bivens. They were joined by members of the public who were also allowed to present their personal testimonies to Bivens in attempts to sway the decision toward or away from the 24/7 mandate.
It was only on May 29 that DHHS Commissioner Mary Mayhew issued a Certificate of Need for the continuous operation of St. Andrews’ Urgent Care Center.
"I have determined that the ordinary economic development of healthcare for the Boothbay region would be adversely affected, and this specific application would have to be denied if the applicant who provided acute emergency care was not required to maintain an appropriate urgent care presence," Mayhew wrote in her statement.
Following that ruling, however, MaineHealth filed a reconsideration request, which directly led to the additional public hearing that took place this week. Following the filing and acknowledgment of the reconsideration, the requirement was suspended that MaineHealth would have had to begin 24/7 operations within 90 days of May 29.
Attorneys Linda Yarmosh and Gerald F. Petruccelli represented the Wellness Foundation and MaineHealth respectively. The hearing began with both attorneys making their opening statements with Yarmosh largely arguing for the continuation of the 24/7 ruling and Petruccelli arguing for dismissal of that ruling.
Petruccelli then brought witnesses to speak before Bivens. The first witness, Jim Donovan, the president and CEO of Lincoln County Healthcare, read a pre-filed testimony before Yarmosh was allowed to cross-examine him. He discussed the purpose of his testimony and stated monetary figures that described operating expenses MaineHealth would incur if the urgent care center needed to begin operating 24 hours a day.
Donovan said St. Andrews would likely sustain losses anywhere from $675,000 in a "best case" scenario to $733,000 in a "likely case" scenario each year because of additional operating expenses.
He explained that these losses would occur "for a service for which there does not appear to be a cognizable need, in a certificate of need sense, which would justify either of these levels of additional expense."
Yarmosh countered by asking Donovan about the scope of "need" and describing what she felt Mayhew intended when making her previous ruling that 24/7 care was necessary and appropriate.
"So, need is just based on numbers?" she asked Donovan.
Donovan responded by saying that need was based on a combination of factors and that emergency services located at Miles Hospital and other area hospitals could cover cases where patients' lives were in danger.
"(Mayhew) is not requiring that you break even with your care. Correct?" Yarmosh continued. "There is the anticipation that the need will be so great that some (monetary) losses will be appropriate."
Yarmosh's cross-examination also included questions to Donovan about the number of transfers St. Andrews makes to other area hospitals each year, the possibility of using alternative staffing models to lower expected costs, and the possibility of performing as a 24/7 care facility as a test run to find out, in reality, how St. Andrews would operate under that circumstance.
Similar questions and analysis followed with the testimony of Dr. Mark Fourre, an emergency physician and chief medical officer for Lincoln County Healthcare, and Jeff Curtis, the chairman of the Board of Trustees for Lincoln County Healthcare.
Yarmosh argued further to those individuals that presenting care sooner rather than later would benefit the majority of patients, and she attempted to determine the power of the Board of Trustees by analyzing its role in the MaineHealth objection to Mayhew's ruling.
At times, her questions were directed toward the expertise of each individual. However, Petruccelli made formal objections to her use of questions that would have caused the witnesses to speculate. Bivens expanded upon one objection when Yarmosh asked Donovan to try out the operation of 24/7 care.
"I am going to have to stop this," Bivens told Yarmosh. "You are asking for speculation."
Following a recess for lunch, parties returned to the town office to hear from witnesses Yarmosh provided. These included David Racicot, a Boothbay Harbor resident and retired family physician, Gerald Homer, a Boothbay Harbor resident and retired hospital administrator, and Nancy Oliphant, a practicing Boothbay Harbor family physician. They each read their pre-filed testimonies, and Petruccelli was given the option to cross-examine them.
Racicot provided his opinion that doctors at an urgent care facility could provide quicker, more appropriate care and could make transfers to Brunswick or Portland if necessary.
Petruccelli continued to press the issue of cost, however, and brought up the discrepancy between ambulance ride costs versus emergency room costs — saying that the former was typically less expensive — and asked Racicot who would eventually pay for all the additional services if the urgent care center was to operate at night.
"These administrators are intelligent people," Racicot replied. "I'm sure they can figure it out."
Racicot had previous experience as a medical director for the U.S. Navy, and through that admission, he opened the door to a financial discussion stating that his hospitals would make things work out with any budget they were awarded. Petruccelli, though, pressed the fact that budgets and monetary dispersal for private enterprises and government entities operate entirely differently — a fact that Racicot agreed to.
Petruccelli also dissected Racicot's and Homer's claims that staffing St. Andrews with mid-level clinicians during the hours of 8 p.m. to 8 a.m. could alleviate the monetary concerns that MaineHealth previously described. To counter their claims, Petruccelli brought up yet another witness, Wayne Printy, the chief financial officer of Lincoln County Healthcare, who further laid out the exact financial figures MaineHealth had predicted.
Out of approximately $700,000 in projected losses in a "likely case" scenario, Printy said the switch to mid-level practitioners would only save approximately $70,000.
"You are not going to manage your way out of this problem," Printy said.
With the official testimonies finished, Bivens opened the floor to the public. He first allowed anyone in support of the 24/7 ruling to speak. Several residents came to the front of the room to read their statements to Bivens, the attorneys and the rest of the public in attendance. They all touched various aspect of the overall issue with personal stories about their healthcare experiences.
Edward Jager, a Southport resident, told a story about his daughter's recent trip to the hospital, and he explained that the community is invested in the sort of proper care his daughter received.
"This community has a history of raising funds for specific projects," Jager said. "This community could raise money if it was needed to keep (St. Andrews) open."
Howard Wright Sr., a Southport resident, discussed the issue of trust between health providers and local citizens.
"There is a trust here I feel LincolnHealth and MaineHealth needs to reestablish," Wright said.
Others told stories about their aging families, emergency room visits, late-night medical concerns, trips to the hospital along snowy roads and the important part emergency care played in their decisions to move to the region year-round. Some people expressed a growing need for emergency care because of the aging population of the region; some blamed MaineHealth directly for mismanagement and high costs.
Bivens then opened the floor to anyone in opposition of the 24/7 ruling.
No one came forward.
In their closing arguments that followed the public comments, Petruccelli expressed his disappointment with what he heard from the public.
"It is disappointing to hear so much disappointment (directed at MaineHealth)," Petruccelli said.
"Lincoln County Healthcare and MaineHealth are working very hard," he continued. "I can only hope these things get resolved."
Yarmosh, in closing, again expressed her desire to see St. Andrews Urgent Care Center operate 24 hours a day to at least see how it would function under real-life conditions.
"We are making all these decisions based on data provided by Lincoln County Healthcare," she said. "We deserve the chance to see how this plays out."
Bivens said he would submit to Mayhew the written public comments and the written arguments each attorney will provide him. She will make her ruling on the situation following receipt of the documents and further consideration of the region's healthcare needs.