Might CHaD Shift South?

Lebanon — The future of Children’s Hospital at Dartmouth may be elsewhere as Dartmouth-Hitchcock leaders contemplate scenarios, including moving inpatient beds and specialists out of the Upper Valley, to treat more of the region’s children closer to where they live.

Officials at Dartmouth-Hitchcock, including faculty at Dartmouth College’s Geisel School of Medicine, are intensely studying options for expanding pediatric care in the state’s more populous southern tier, according to interviews with hospital officials and documents obtained by the Valley News.

Such an expansion could include enhanced partnerships with the Elliot Health System in Manchester and Boston Children’s Hospital, part of Harvard Medical School. Spokespersons for Elliot and Boston Children’s did not respond to requests for comment late last week.

Nothing has been decided and Dartmouth-Hitchcock CEO Jim Weinstein insists that the children’s hospital will remain based in Lebanon.

However, the financial pressures facing the institution, the changing demographics of northern New England and the larger goal of creating a more sustainable health care system are driving Dartmouth-Hitchcock to take a serious look at how it provides pediatric care in the Twin States.

“CHaD is not going away. I’ll say that six times,” said Weinstein, who then went on during an interview to repeat the sentence six times. “But I will be clear that we do need to think about what’s the best thing for the kids, not just today but over the long term. And that’s part of our due diligence.”

One proposal, known as the “Strawman Model,” would move pediatric inpatient services to Manchester, according to a 10-page summary presented this month to Geisel’s faculty council, which provides faculty input to medical school administration.

The Strawman idea is driven by clinical goals and market factors: improved service in the part of the state with the largest concentration of children, competition from Elliot Hospital — which established New Hampshire’s Hospital for Children in 2011 — and also the “concern that the Boston programs (Boston Children’s, Mass General) are poised to assume a significant amount of care of children in southern N.H.,” the document said.

As an academic medical center, Dartmouth-Hitchcock has a three-legged mission comprised of clinical care, research and education, each of which stands to be affected by any reorganization of the children’s hospital.

A committee of Geisel leaders will get together during a four-hour retreat in early December to consider a Strawman scenario, according to Leslie Fall, vice chairwoman for the pediatric office of medical education.

Led by Fall, the committee’s charge is to figure out what it would take to create “excellence in the academic mission” under a Strawman model, according to the faculty council summary. For example, would Dartmouth need to build an apartment complex in Manchester for medical students, and would it need a second research office there? The committee is expected to issue a report to Dartmouth-Hitchcock leaders before the end of the year.

“I want this group to look at it and say, ‘If you were building this from scratch ... what would you build and what would you make sure happens?’ ” Fall said.

Geisel faculty and independent pediatricians in the region have wondered what shifting resources south would mean for patients as well as medical residents, new doctors who could find themselves traveling further afield for their training. They also have questions about the impact on residency recruitment and the ability to get grant funding.

While those are valid concerns, the reality is that New Hampshire’s population is centered in the southern part of the state, Fall said. And if Dartmouth-Hitchcock is going to live up to all parts of its mission, then it needs to make sure residents and clinicians “have all the patient care opportunities that can be afforded to them,” Fall said.

Dartmouth-Hitchcock may have a three-legged mission, but the “seat of the stool” is providing the best care for New Hampshire’s children, Fall said. Health care and the demands for pediatric services are changing at a rapid rate, she said, and Dartmouth-Hitchcock needs to change with too for the best interests of patients and the institution.

“We all have skin in this game and it’s really easy to get pulled into ‘What does this mean for me?’ ” she said. “And that’s an important question too. But right now, the more important question is what does it mean for the seat of the stool? What does it mean for the best care for the children in this state?”

Mixed Reactions

The children’s hospital is just one part of the Dartmouth-Hitchcock system, but it is among the most beloved institutions in the Upper Valley.

A video of CHaD patients lip-synching to the Katy Perry pop-song Roar went viral when it was posted to YouTube last month and has been viewed by nearly 3 million people. Events such as the CHaD Hero Half Marathon attract thousands of participants and have raised millions of dollars for the hospital over the years.

There is great pride, both in the broader Upper Valley community and inside Dartmouth-Hitchcock, in having a well-respected children’s hospital in Lebanon.

“I think it plays a wonderful role,” said Nancy Turkington, a pediatrician in Hanover who did her residency at CHaD from 1997 to 2001. “The fact that our kids can get top-notch medical care, right in their own community, is fantastic.”

Many children getting inpatient care at CHaD live outside the Upper Valley, and often come from southern New Hampshire, hospital officials said. However, Turkington and other area pediatricians wonder about the effect that a refocusing of resources to the south would have on sick kids from this area.

“I think that there are going to be a lot of patients traveling very far to see specialists,” said Turkington. “If they move ... then anyone in this area is going to have to go to Burlington or Nashua or Manchester, wherever they go. That’s a long way for a child with a chronic illness. Those kids are going to really suffer.”

Doug Williamson, a pediatrician at Alice Peck Day Memorial Hospital in Lebanon, said he was unaware of the discussions about relocating a portion of CHaD to Manchester. He regularly refers patients to the hospital, perhaps once a week, but occasionally has sent a child elsewhere because Dartmouth-Hitchcock did not have the necessary specialist.

Having CHaD a few miles down the road has been a nice convenience, he said.

“I think we’ve gotten very spoiled,” said Williamson, who also did his residency training at CHaD in the 1990s. “I think it’s been very convenient. So (if CHaD moves), it’s certainly going to change where (patients) go.”

Mark Harris, a physician at Upper Valley Pediatrics in Bradford, Vt., has a close relationship with CHaD. He refers patients there and also helps train medical students and residents at Geisel. He works with around seven medical students and 10 pediatric residents a year.

Perhaps the medical students would continue to come to Bradford because they would still be living in Hanover, but he doubted that pediatric residents would be willing to drive from Manchester if that’s where they ended up being based.

A move south could also affect Geisel’s recruiting, Harris said. Living and working in Manchester doesn’t have the same cache as Hanover, he said. And there is an advantage to nonpediatric residents from having the children’s hospital located on the main campus of Dartmouth-Hitchcock Medical Center.

“There are lots and lots of other training programs at DHMC where the training involves exposing the trainees to pediatric patients. Neurology, dermatology, radiology, anesthesiology, all those specialists, they’re required to learn how to take care of children as well as adults,” Harris said. “And if the hospitalized children are 100 miles away in Manchester, that’s going to influence the training program not only in pediatrics, but it’s going to influence the training programs in lots of other specialties as well.”

As for what is driving these conversations, Harris said he believed it was financial concerns.

“I don’t think, personally, that the conversation is being driven based on providing better service to the pediatric population of New Hampshire,” Harris said. “I think it’s being driven by the economics, trying to capture patients who otherwise might go to Boston Medical Center or the like.”

Not everyone who has a stake in the children’s hospital is so concerned.

Dawn Stanhope is the executive director at David’s House, which provides a place for families of CHaD patients to stay while their loved one is hospitalized.

David’s House recently expanded to accommodate more families, and Stanhope said regardless of what happens, she believed there would always be a need for her organization’s services.

Stanhope has been kept abreast of the discussions through a hospital liaison and said she understands the pressures on Dartmouth-Hitchcock to work collaboratively with other providers. Until Dartmouth-Hitchcock makes a definitive decision about the children’s hospital, however, she’s proceeding with business as usual.

“We don’t have a crystal ball and don’t know what the future holds,” she said. “Things are pretty status quo. If there are changes that happen, we’ll just go with the flow.”

Keith Loud, CHaD’s director, acknowledged the anxiety that some staff and members of the community may feel, but said they should not worry about the children’s hospital abandoning the Upper Valley.

Difficult conversations have to happen, though. Every aspect of health care, whether for adults or kids, is changing in the United States. And if hospital leaders aren’t willing to consider change, however radical it may seem, the institution would be ill-prepared to confront the challenges of 21st century care.

“In some ways it would have been more dangerous for us to not engage in this type of planning. I think any organization in health care, any organization in general, has to constantly be evaluating its future,” Loud said. “To not be brave enough to consider all possibilities and not to do that due diligence, that in and of itself would or could have led to CHaD’s demise more than any other considerations we’re giving.”

Years of Discussion

Founded in 1992, the Children’s Hospital at Dartmouth has developed a strong base of financial support in the Upper Valley. Last fiscal year, it raised more than $3.7 million, mostly through community fundraisers such as the CHaD Hero Half Marathon, which this year had 3,100 participants and collected nearly $700,000.

Despite that support, the children’s hospital has struggled financially for much of its existence. Last year, it had a $15.5 million operating loss spread across its 15 sites around the Twin States, according to Dartmouth-Hitchcock spokesman Rick Adams.

That loss is due largely to the low reimbursements CHaD receives from Medicaid. Nearly half of the pediatric care provided at the hospital is paid by Medicaid, according to Adams. Most of CHaD’s Medicaid patients live in New Hampshire, and the Granite State has among the lowest Medicaid reimbursement rates in the nation.

Beyond that, the hospital also struggles with being located in a less populous part of the state. According to the latest Census figures, Grafton County has less than a quarter of the population of Hillsborough County, where Manchester is located.

Also, the proportion of its residents who are children is smaller. In 2012, 17.6 percent of Grafton’s 89,000 residents were under the age of 18. In Hillsborough, 22.5 percent of the county’s 400,000 residents are under 18.

For all these reasons, the discussions around expanding into southern New Hampshire are nothing new.

“We’ve recognized for actually many years that CHaD has been in a very challenging financial situation, almost entirely due to the very poor reimbursement environment from both states,” said John Modlin, the former director at CHaD who stepped down in June, in a recent telephone interview.

Many children’s hospitals struggle financially. Even the largest among them, such as Boston Children’s Hospital, rely on donations and grant money to stay viable.

Unlike Boston Children’s Hospital, CHaD is not a stand alone institution and relies on its parent organization, Dartmouth-Hitchcock, for financial support. Recently, however, pediatric care has become more competitive in New Hampshire, in large part due to Elliot’s decision to open a children’s hospital in 2011.

That competition, combined with New Hampshire’s demographics — old, and getting older — and an already difficult reimbursement environment added urgency for CHaD’s leaders.

“We recognized that in order to maintain our mission, we were going to have to change in some way, shape or form,” Modlin said. “It wasn’t a matter of if. It was a matter of how and when.”

All the discussions around change have made people nervous, both among CHaD staff as well as the educators at Geisel. Rumor spread around the organization this summer about the children’s hospital closing. In July, Weinstein and Loud addressed the rumors in a letter to staff entitled “The Future of CHaD is Strong.”

“We’ve heard the rumors that CHaD is closing but that is simply not true,” the letter began. It went on to address “possible collaborations with regional partners relating to the future of pediatric health care delivery in New Hampshire” and also some of the financial and demographic challenges in the state. But the message throughout was clear: the children’s hospital would remain in place.

“We believe the future of CHaD is bright, and we are in it for the long haul,” it concluded.

In an interview this month, Weinstein explained the rumors as an unfortunate result of transparency.

“One of the problems I have is I’m very open about all of the discussions (about CHaD’s future),” he said. “And people take those in different ways. When I talk about exploring relationships, it’s not uncommon that somebody assumes, ‘What does that mean to me as an individual?’ ”

Weinstein was adamant that no decisions have been made about partnering with other institutions or anything regarding CHaD’s future. He said Dartmouth-Hitchcock was “not going to disrupt a great kids program... until we’re absolutely sure that there’s some reason to do that.” The organization is still in the “fact-finding mode” and not yet ready for significant change.

And the conversations about the children’s hospital have not occurred in a vacuum, he said. They have been part of the larger discussions around how Dartmouth-Hitchcock can collaborate with other health care providers to lower costs and improve the quality of care.

Dartmouth-Hitchcock already has established relationships with Boston Children’s Hospital and Elliot. In 2011, the same year that Elliot opened its children’s hospital, Boston Children’s and CHaD began a new collaboration to enhance specialty pediatric care in Manchester. That July, Boston’s gastroenterologists and nephrologists began providing outpatient care and endoscopy services in Manchester. They also jointly recruited a cardiologist who splits time between the two organizations. An in September, Elliot and Dartmouth-Hitchcock announced a new partnership with Harvard Pilgrim Health Care called ElevateHealth, which aims to improve coordinating care for patients and lower insurance premiums.

“This is part of the same path we’ve been on and we will continue on,” Weinstein said. “We want to understand what’s best for the people of New Hampshire in the creation of this sustainable model that’s value-based, not volume based. It’s not about market share and it’s not about staying in fee for service. ... It’s about continuing our obligations to patients.”

Chris Fleisher can be reached at 603-272-3229 or cfleisher@vnews.com.