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Sullivan County Faces Critical Gap in Primary Care Access

  • Dr. Laurie Montague examines Cecile Currier of Unity after Currier came to Montague Family Medicine complaining of a headache in Claremont, N.H., on Nov. 8, 2013. <br/>Valley News - Sarah Priestap

    Dr. Laurie Montague examines Cecile Currier of Unity after Currier came to Montague Family Medicine complaining of a headache in Claremont, N.H., on Nov. 8, 2013.
    Valley News - Sarah Priestap Purchase photo reprints »

  • Gordon Black, Family Nurse Practitioner at the new Sugar River Family Practice in Claremont, N.H., on Nov. 8, 2013. <br/>Valley News - Sarah Priestap

    Gordon Black, Family Nurse Practitioner at the new Sugar River Family Practice in Claremont, N.H., on Nov. 8, 2013.
    Valley News - Sarah Priestap Purchase photo reprints »

  • Brenda Hannah, owner of Simply Comfort Restaurant, chats with her neighbor, Jesse Demars, owner of The Java Cup, while Hannah prepares a salad at her restaurant in Claremont, N.H., on Nov. 8, 2013. Hannah only has to travel next door to receive medical care from Nurse Practitioner Gordon Black, who opened Sugar River Family Practice on October 1st of this year. <br/>Valley News - Sarah Priestap

    Brenda Hannah, owner of Simply Comfort Restaurant, chats with her neighbor, Jesse Demars, owner of The Java Cup, while Hannah prepares a salad at her restaurant in Claremont, N.H., on Nov. 8, 2013. Hannah only has to travel next door to receive medical care from Nurse Practitioner Gordon Black, who opened Sugar River Family Practice on October 1st of this year.
    Valley News - Sarah Priestap Purchase photo reprints »

  • Medical Assistant Lorna Adams, left, briefs Dr. Laurie Montague on a walk-in patient in Montague's office at Montague Family Medicine in Claremont, N.H., on Nov. 8, 2013. The clinic will be not accepting insurance in January 2014, and instead, allowing unlimited visits for a monthly fee. <br/>Valley News - Sarah Priestap

    Medical Assistant Lorna Adams, left, briefs Dr. Laurie Montague on a walk-in patient in Montague's office at Montague Family Medicine in Claremont, N.H., on Nov. 8, 2013. The clinic will be not accepting insurance in January 2014, and instead, allowing unlimited visits for a monthly fee.
    Valley News - Sarah Priestap Purchase photo reprints »

  • Dr. Laurie Montague examines Cecile Currier of Unity after Currier came to Montague Family Medicine complaining of a headache in Claremont, N.H., on Nov. 8, 2013. <br/>Valley News - Sarah Priestap
  • Gordon Black, Family Nurse Practitioner at the new Sugar River Family Practice in Claremont, N.H., on Nov. 8, 2013. <br/>Valley News - Sarah Priestap
  • Brenda Hannah, owner of Simply Comfort Restaurant, chats with her neighbor, Jesse Demars, owner of The Java Cup, while Hannah prepares a salad at her restaurant in Claremont, N.H., on Nov. 8, 2013. Hannah only has to travel next door to receive medical care from Nurse Practitioner Gordon Black, who opened Sugar River Family Practice on October 1st of this year. <br/>Valley News - Sarah Priestap
  • Medical Assistant Lorna Adams, left, briefs Dr. Laurie Montague on a walk-in patient in Montague's office at Montague Family Medicine in Claremont, N.H., on Nov. 8, 2013. The clinic will be not accepting insurance in January 2014, and instead, allowing unlimited visits for a monthly fee. <br/>Valley News - Sarah Priestap

Claremont — Three years ago, Brenda Hannah moved to Claremont and began looking for a primary care doctor.

She had come north from Alabama to be with her ailing father. But still recovering from back surgery that she’d had just six months before, Hannah needed to get connected with a physician right away. Her search was more difficult than she anticipated.

“I looked and it was actually slim pickings,” said Hannah, 52, a New Hampshire native who speaks with a slight drawl from her 24 years living in the South. “A lot of them, from what I understand, couldn’t make a go of it in Claremont.”

For a variety of reasons, access to primary care has been a challenge for Sullivan County residents. Physicians have either retired or moved out of the area, some for personal reasons and others perhaps driven by the economics of providing care in one of the state’s lowest income communities.

There is some debate about the degree to which the city struggles to retain primary care doctors. Valley Regional Hospital officials say they have the resources to meet the demand. Meanwhile, independent practices say there is a huge gap in care that must be addressed.

What is not in dispute is the need for more investment in primary care and the challenges of providing it in Sullivan County.

Expanding access to primary care is a major goal of the Affordable Care Act, and health reform advocates say that the system needs to be redesigned to keep people healthy and out of the hospital in order to control rising health care costs. Expanding health insurance coverage and getting people connected with a primary care doctor are important steps in meeting these goals.

But the way New Hampshire has implemented provisions of the Affordable Care Act could make it difficult to get Claremont’s newly insured residents connected with a doctor. Valley Regional was not included in the “narrow network” of hospitals covered in the plans offered through the state’s health insurance marketplace.

Sullivan County is the only county in the state that does not have a hospital included in that network, and Valley Regional officials have accused the marketplace’s lone insurance carrier, Anthem Blue Cross Blue Shield of New Hampshire, of turning its back on the state’s poorest communities. In an opinion piece published Friday in the Valley News, the hospital’s CEO, board chairman and chief of staff said the for-profit insurance company was cherry picking the state’s healthiest, and therefore most profitable, patients.

“With Valley Regional being the dominant provider of health care in Sullivan County, Anthem has effectively excluded many county residents as well as those in other New Hampshire communities where health needs tend to be greater,” they wrote in the piece.

A proposal before the state Senate to expand New Hampshire’s Medicaid program may also cut Valley Regional out of the options for low-income Sullivan County residents. This comes as Valley Regional is recruiting new primary care doctors and nurses and rethinking how it provides care.

Meanwhile, several other practices are making changes to meet the demand for primary care. New London Hospital, which is included in Anthem’s network, is preparing to build a new health center in Newport next year. A new family practice opened on Pleasant Street in Claremont last month and another practice is trying to get rid of insurance altogether by having patients pay directly.

Claremont’s working-class residents have struggled long enough to find a doctor who can see them when they need to be treated, health professionals and residents say. Now is the time to change that.

“Just over hearing people at the grocery store (say), ‘My daughter got strep throat and they couldn’t get in until next week.’ Things like that cannot wait,” said Hannah. “We have some good (doctors) in town, but not enough of them.”

Meeting the Need

In an ideal world, Dr. Laurie Montague said she would see around 1,200 to 1,500 patients at her practice in Claremont, Montague Family Medicine. Instead, she has a patient list of 4,000, many of them uninsured. Her practice, which includes two physician assistants, sees between 60 and 80 patients a day.

One reason for the large volume is simple economics. Reimbursements from insurers have gotten so low that she needs to see a higher volume of patients just to cover costs.

But another reason for the high patient load is because Montague runs a walk-in clinic. For a flat fee of $60 per visit, patients are able to be seen that same day, a rare service in town.

“I’ve gotten a huge following of uninsured people,” Montague said Thursday afternoon. “Because they have not been able to get access to primary care anywhere else.”

Claremont is a working-class community of more than 13,000, where the median household income is less than $39,000, far below the state average of $64,664, according to the U.S. Census. Many residents of the city and its surrounding towns do not have insurance, and for those who do, the deductibles for the plans offered through their employers are so high that it is essentially useless, Montague said.

“What is the employer providing for the employee?” she said. “Nothing but a piece of paper.”

Jody Metcalf is in just such a situation. The 35-year-old Charlestown resident runs a home day care and has insurance through her husband’s employer. But the plan, which covers her family of four, has a $10,000 deductible, meaning that her out-of-pocket expenses have to reach five figures before the insurance kicks in. With two young children, ages 6 and 3, Metcalf spends a lot on health care.

“Doctor visits, medication, we have forked over a lot of money,” she said. “There are times when I second-guessed. Do we really need to go in? Are you really sick? Because it’s expensive.”

Starting next year, the federal health reform law puts new restrictions on how much insured individuals will spend out of pocket — $12,500 for a family and $6,250 for an individual — and also require certain preventive care services to be covered. But for Sullivan County residents who buy insurance through the new statewide marketplace, getting access to that care may be a challenge.

Anthem restricted its network of providers to just 16 of New Hampshire’s 26 hospitals. This allowed Anthem to negotiate lower prices by offering hospitals a larger volume of patients.

None of the “in-network” hospitals are based in Sullivan County, although New London Hospital’s Newport clinic would be included.

Many of Valley Regional’s patients struggle to find transportation to the hospital as it is, Valley Regional CEO Peter Wright said. Forcing them to drive farther would do little to improve access to primary care, despite having insurance.

“If they have to drive long distances, it means they’re going to seek care less often,” Wright said in an interview last week.

“The people who are in the high-risk pool are more than likely lower income and thus don’t have the means to travel.”

In response, Anthem has defended its network, saying it meets state and federal requirements for adequacy and pointing out that 95 percent of its customers will have plans that include all of the state’s hospitals.

Medicaid patients stand to be affected, as well. New Hampshire lawmakers are considering an expansion of the Medicaid program, and one proposal calls for shifting people onto private insurance through the marketplace. Roughly 12 percent of Valley Regional’s patients are on Medicaid and 10 percent are self pay.

Seeing the demand for services in-town, Gordon Black opened Sugar River Family Practice last month. Black, a nurse practitioner, had operated a walk-in clinic on Opera House Square until recently. Other walk-in clinics were opening up in Lebanon and elsewhere around the state, and Black said he didn’t want to compete with them. Besides, the real need in Claremont is for more primary care.

“If someone can’t get into primary care, the only option is the emergency room,” Black said last week. “The resources are taxed.”

Black’s practice occupies the second floor of a downtown building on Pleasant Street. It is an old space, with dark wood moldings and creaky floors, and the street level entrance is not readily apparent. In his first month, Black saw about 50 patients.

“It’s slow going, but we’re definitely getting calls,” he said.

Black works with Melissa Hall, a licensed practical nurse, and has recently hired someone to provide women’s health services. But his entrance into Claremont’s health care market will go only so far to meet the need. Black is not included in Anthem’s network for plans purchased on the marketplace, and he doesn’t accept Medicaid.

“I’d like to serve them,” he said. “They need this. But I can’t lose money. I have to keep this place open or else nobody benefits.”

Changing Models of Care

Montague has been practicing medicine in Claremont since 2007, and before that for several years in rural Wisconsin. Over the years, she has become so frustrated in dealing with insurance that she has decided to remove it from the equation.

Starting next year, Montague is moving to a “direct primary care” practice, in which patients pay a flat fee, between $25 and $50 per month per individual, or $150 for a family, for unlimited care . No insurance is required. No co-pays or deductibles, she said. And people are allowed to come to the clinic however many times they need for urgent care, physicals, vaccinations, labs and other basic services.

The direct care model has experienced something of a revival, in recent years, as a way to get the administrative burdens of insurance out of the cost equation for patient care. Another direct care practice, Dartmouth Health Connect, opened a year and a half ago in Hanover for Dartmouth College employees and their families.

Montague said the response among her patients has been positive, and she and her staff are excited for the transition.

“We used to pay docs with loaves of bread and chickens,” she said. “In some ways, we need to get back to that.”

Others are skeptical that the model can work, especially in Claremont.

“I’m skeptical about its success in a community that struggles with health care to begin with,” said Wright, of Valley Regional. “You either have folks who can’t afford it, who can’t afford insurance, so that might be appealing. But if they can’t afford insurance, then economics are a challenge and a $25 or $50 bill every month may be a problem for them.”

There is also some doubt about why patients would pay such a fee when most insurance under the Affordable Care Act will cover preventive care, for free, including some types of cancer screening. For healthy individuals, the plans that go into effect next year should be sufficient, said Dr. Oliver Herfort, Valley Regional’s chief medical officer.

“From a financial standpoint of view, it doesn’t make any sense to have a physician available to you 24 hours a day if you’re healthy and have insurance and pay extra for that service that you may not tap into,” he said. “It’s basically adding an extra little insurance.”

Montague said she will offer more types of care, such as urgent care visits, beyond what is paid for in the plans offered through the Affordable Care Act. And those plans still have deductibles that have to be met.

Equally important, Montague said, is that she will be available to her patients whenever needed.

If they want to send her a text message or email her with a question, they will have the option to do so, she said. Under the current model, she doesn’t have that kind of freedom, as she can’t bill the insurance company for a text or email. The pressure to bill for every little aspect of care is gone under the direct-care model.

Herve Ferland welcomes fast access to a doctor. It is part of the reason he switched to Montague after his previous physician retired.

“He was a great doctor,” said Ferland, 47, of Lempster, N.H. “But I wound up with a nurse practitioner and that wasn’t going to suit my needs. She wasn’t on the same level.”

Still, nurse practitioners, a licensure level that is below a medical doctor, can still meet most of the primary care needs of patients, said Herfort.

Patients will have to adjust their expectations for physician access, he said, if the health care system is to become sustainable. Health reformers at Dartmouth-Hitchcock and elsewhere have emphasized a team approach to care, with a variety of medical professionals who work together to treat the patient. And some of those professionals are qualified to offer assessments of a person’s health — diagnosing a bladder infection or rash, for example — without having a physician present.

“As much as patients want to see their physician, often they don’t have to see their physician,” Herfort said. “Physician time is valuable in other ways. Just having access doesn’t mean it is something good, per se. It might make you feel good, but the value, it’s often just overrated.”

Many patients also do not need to get treated the same day. If someone has a car problem, it’s unlikely they can see a mechanic within the hour, he said. But that’s what people expect.

“There’s a gap between what patients need and what they want,” Wright said.

All Hannah wants is for herself and family to be able to get treated when she needs it. Hannah sees Black, who is not a physician, but who she says has provided her outstanding care. His office is conveniently located above the restaurant she owns and runs, Simply Comfort.

Hannah is covered under her husband’s plan and she cannot afford to offer insurance to her three employees, one of whom is her daughter-in-law.

Hannah believes that Claremont needs more providers, but recognizes that it won’t mean much if patients can’t pay. If they don’t have insurance, they end up paying out of pocket, as her daughter-in-law does. If they buy insurance through the marketplace, they may have to travel to Newport or Lebanon, and who knows if they can afford the gas money or even have a car.

It pains Hannah to think about the dilemma her friends, family and neighbors face.

“It breaks my heart when people don’t go to the doctor because they can’t afford it,” she said.

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.