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The regulatory order forcing the Massachusetts General Brigham healthcare system to rein in costs is about to expire, and New Hampshire is wondering what that means for Wentworth-Douglass Hospital in Dover.

“I am concerned about it,” said D.J. Bettencourt, commissioner at the New Hampshire Insurance Department.

Mass General Brigham merged with Wentworth-Douglass in 2018, making the Seacoast region hospital part of MGB’s massive healthcare system. MGB is so big the state of Massachusetts intervened in 2022 to slow the network’s rising patient costs that were warping the Bay State’s healthcare market.

The Performance Improvement Plan imposed by the Massachusetts Health Policy Commission is set to end next month, and there is worry that MGB will start ramping up costs again throughout its system, including at Wentworth-Douglass.

Matt Cover, an employee benefits consultant with Willis Towers Watson, a global insurance advisory firm, said hospitals and large healthcare systems are looking for increases, teeing off of public perception that hospitals suffered during the COVID years.

“As their contracts come up for renewal, hospitals all across the country are demanding unprecedented price increases. These are large corporations trying to squeeze higher profits out of a healthcare system that is already too expensive. Patients, their families, and their employers will ultimately bear the burden of these price hikes,” Cover told NHJournal.

The trend of hospitals consolidating into healthcare systems was long presented as a way to improve care and save money for patients, especially when those mergers needed state approval. But data from a Harvard Medical School report show the savings never happened, and patient care was only marginally better.

“One of the key arguments for hospital mergers and practice acquisition was that health systems would deliver better-value care for patients. This study provides the most comprehensive evidence yet that this isn’t happening,” said Nancy Beaulieu, a research associate in the Department of Health Care Policy at Harvard Medical School’s Blavatnik Institute.

The Massachusetts Health Policy Committee intervened in 2022 after years of skyrocketing costs associated with MGB pushed up costs for all health systems and insurance carriers in the Bay State.

The HPC found Mass General Brigham, the state’s largest health provider, was also charging more than any other provider. In fact, the Committee found that MGB’s commercial contracts cost $293 million from 2014 to 2019.

After posting operating losses last year attributed to inflation and workforce shortages, MGB reported bringing in $102 million in positive operational revenue in the third and fourth financial quarters. The system brought in $18.8 billion during the 2023 fiscal year. MGB’s premium revenue went up to $1.5 billion, a 63 percent increase from the previous year. 

Those numbers represent MGB’s operation under the Performance Improvement Plan to bring down costs. Now that oversight of MGB’s prices is ending next month. New Hampshire has no role in reviewing MGB’s costs and spending. But if the end of the Massachusetts order starts impacting Wentworth-Douglass, Bettencourt said New Hampshire can take action.

“Should that dynamic change or should Wentworth-Douglass be affected as a result of MGB’s attempt to get into compliance with the Performance Improvement Plan, we will work with our commercial insurance carriers, officials at Wentworth-Douglass Hospital, and the New Hampshire Hospital Association to understand its implications for New Hampshire consumers. Should there be adverse consequences, we will respond appropriately within the preview of our regulatory oversight under state law,” Bettencourt said.

The 2018 merger is supposed to leave Wentworth-Douglass locally controlled by its Board of Trustees. However, there are indications that MGB is subsuming more of the identity and control of the Dover facility. Wentworth-Douglass is now rebranded as Mass General Brigham Wentworth-Douglass, and the hospital lost its president and CEO position at the top, replaced by a president and COO position.

Wentworth-Douglass initially agreed to answer questions from NHJournal but did not respond after more than 24 hours.

New Hampshire ranks as one of the best states in the country to be a nurse, even as providers like hospitals and assisted living facilities struggle to staff up.

A new WalletHub analysis ranks New Hampshire as the fifth best state to be a nurse based on the strong opportunities for advanced training, high pay, and good working environments. Jan Carney, associate dean for Public Health and Health Policy at the University of Vermont, said this is an excellent time to enter nursing.

“The long-term outlook for the nursing field is outstanding,” Carney said.

Though Maine came in as the second-best overall state, the Granite State easily outperformed the rest of New England. Connecticut ranked 13, Rhode Island 25, Massachusetts 29, and Vermont is near the bottom at 42.

Among the data points used for the rankings, New Hampshire placed first when it comes to the number of nursing job openings per capita. The Granite State isn’t alone in New England when it comes to needing more nurses. Massachusetts, Maine, and Vermont all land in the top five states with the most openings per capita.

According to Susan Reeves, the executive vice president of Dartmouth-Hitchcock Medical Center, the state’s nursing shortage is driven by an aging population, high housing costs, and a lack of affordable child care. 

Reeves recently told WMUR that Dartmouth-Hitchcock, the state’s largest healthcare system, uses temporary staff and employment agencies to fill as many as 400 nursing positions because it cannot find permanent staff. New Hampshire faced a nursing shortage before the COVID-19 pandemic, and factors like the state’s lack of workforce housing have only worsened the situation.

“We’re dealing with issues such as child care and housing, which is a huge constraint to bring talent to our areas to serve in our hospitals,” she said.

Dartmouth-Hitchcock Medical Center in Lebanon is in the middle of one of the more expensive housing markets in the state. The healthcare leader is taking the housing issues head-on, developing its workforce housing developments in the hospital’s surrounding area.

Brendan Williams, president of the New Hampshire Healthcare Association, also saw a connection between housing and healthcare jobs. He supports Gov. Chris Sununu’s workforce housing initiative. 

“The governor is on the right track working to increase housing stock, though that will not produce immediate relief, obviously,” Williams said. But it is not enough by itself, he added.

“In the near term, the Medicaid increase the House authorized is essential to making caregiving more attractive. Wages have soared to record highs and are outside Medicaid means. The Senate, we hope, will do as much as the House, if not more.”

And more should be done to bring new nurses into the field and keep them working, says Rebecca Sutter, George Mason University nursing professor. Between the nurses in the Baby Boom generation retiring and the high burnout rate for new nurses, the need for nurses will continue to be a concern for years to come. Public policy leaders and healthcare facilities need to focus on a sustainable strategy to train and retain nurses.

“Healthcare organizations and policymakers need to address the nursing shortage through strategies such as increasing funding for nursing education programs, providing incentives for nurses to remain in the workforce, and improving working conditions for nurses,” Sutter said.

Granite Staters are paying too much for healthcare, have too few options, and don’t want to be stuck with government-run plans that are part of the Affordable Care Act.

That was the view of several panelists who participated in a radio roundtable on the Pulse of New Hampshire Friday, led by host Jack Heath. 

Heath said the politics of healthcare have become too fraught with Republicans and Democrats dug in. “Republicans would prefer private healthcare options, but they run away from the issue,” Heath said.

Americans for Prosperity New Hampshire head Greg Moore is also a former director at the N.H. Department of Health and Human Services. He said that in poll after poll, New Hampshire residents say they want better choices.

“People don’t like high costs, and they don’t like government-run healthcare,” Moore said. “There are other options, like giving everyone an HSA (health savings account).” 

There are ways to create more competition in the healthcare marketplace that will help drive down costs; he said. Moore favors options like changing the tax code to give individuals the same healthcare tax benefits that businesses currently enjoy.

The Main Street Freedom Alliance radio roundtable on health care hosted by Jack Heath on April 14, 2023.

And it’s not just individuals who are sick of the costs and regulations. Christie Elliot Peters, co-owner of Elliot Controls, an Amherst HVAC company that specializes in automated building controls, said her employees would love to be able to sign up for the company health plan rather than the Affordable Care Act Granite Advantage plan. But the plans her small business is able to secure can price out some workers. She said the costs have been going up almost every year for decades.

“When I trace back, the jumps we have had in rates result from legislation that was supposed to fix the problems or because of the Affordable Care Act,” Peters said.

State Sen. Keith Murphy (R-Bedford) owns Murphy’s Tap Room with locations in Manchester and Bedford. He told Heath he spends hundreds of hours every year trying to get the best plans to offer his 65 employees, But he said the plans are so expensive many of his younger workers opt out.

“When you’re 23, you’re immortal, you think,” Murphy said.

D.J. Bettencourt, deputy commissioner at New Hampshire’s Insurance Department, said Washington regulations that favor individual plans over small businesses are hurting the economy, especially in the Granite State. With New Hampshire companies struggling to hire workers, a good healthcare plan can be the difference between getting and keeping qualified employees.

“The government is trying to improve the individual market and not helping the small business market,” Bettencourt said.

He said New Hampshire’s economy relies on small business owners like Peters and Murphy. “We are a small business state; they are the engine of our economy,” he said.

Bettencourt noted between the aging New Hampshire population and the large swath of people signed up for Granite Advantage; insurance carriers see less reason to offer their plans in New Hampshire given the small pool of potential customers. 

“Layer on government regulations with that smaller pool, it’s even less attractive for (insurance) companies.”

That leaves people and businesses with fewer, more expensive options.

State Rep. Jess Edwards (R-Auburn) told the roundtable people want more choice in their healthcare options, but the government simply cannot get out of the way. Part of the problem is the unwillingness of Democrats to revisit the Affordable Care Act. 

“Democrats would not support plans to let people out of [the ACA] and get on plans offered by small businesses,” Edwards said.

Republicans also seem unable to address the problem in a meaningful way on their side of the aisle. Bettencourt noted the GOP had a trifecta in 2017 — control of the U.S. House, Senate, and White House — and could still not pass legislation to give people more choices.

“They were like the dog that caught the car,” Bettencourt said.

Moore said Democrats are bent on pushing for more government involvement in the healthcare market as part of the ultimate push for universal healthcare.

“Democrats want to increase the number of people on government insurance,” Moore said. “We need a third way.”

Listen to the entire discussion here.

Senate Republicans want to help New Hampshire families succeed and stay healthy with a range of proposals as part of their newly unveiled 2023 legislative agenda. It covers taxes, school choice, access to healthcare, and the state’s First-In-The-Nation status. 

 “This year, we are making it our mission to focus on helping our struggling families who are facing rising costs across the board,” Senate President Jeb Bradley (R-Wolfeboro) said Wednesday at a State House press conference.” After enduring more than two years of hardships wrought by federal financial mismanagement, it is critical we continue to help our New Hampshire families.”

With the House of Representatives essentially tied between the two parties, the state Senate is likely to play an even larger role than usual in legislating. Bradley, who took over the top spot after the retirement of Chuck Morse, is seen by members of both parties as a savvy political operator who can navigate partisan political waters.

Bradley makes no secret of the fact he is focused on fiscal issues. He touted continued business tax cuts and pledged his party would “never, ever implement income, sales or capital gains tax.” He also said any budget surplus should go to property tax relief and the state’s Rainy Day fund.

While Republicans celebrated the additional cuts in Business Profits Taxes and Business Enterprise Taxes that took effect January 1, Democrats denounced them.

“These tax cuts are being downshifted to towns and WILL come back to hardworking New Hampshire families in the form of sweeping property tax increases across the board,” said New Hampshire Democratic Party communications director Colin Booth on Twitter. “But don’t expect the @NHGOP to take any credit when that happens.”

But state revenue has increased since the business tax cuts have begun phasing in, as has state revenue to cities and towns. In the last budget, the state provided $100 million to local governments to take pressure off property taxes.

Asked for data showing fewer state dollars going to cities and towns as a result of the business tax cuts, Booth declined to respond.

Senate Majority Leader Sharon Carson (R-Londonderry) focused on education in her remarks. “We will defend academic opportunities for our students by continuing to support our state’s Education Freedom Account Program and empower parents by providing transparency into their children’s learning environment.”

Carson also touted plans to “reform the state’s bail system,” which will likely undo previous changes that critics say have kept dangerous people on the streets.

“Our comprehensive agenda brings Granite Staters to the forefront. Exactly where they should be,” Carson said.

Senate Democratic Leader Donna Soucy (D-Manchester) said her conference will announce its agenda next week but previewed its goals of working on issues like property tax relief, access to affordable housing, and, of course, access to abortion up to birth.

“Protecting the civil rights of women should be one of the top priorities of the legislature and the Senate Democrats will never back down from supporting women making their own reproductive healthcare decisions,” Soucy said in a statement.

Democrats in Concord spent Wednesday trying and failing to allow for proxy voting and attendance via online video services like Zoom. Democratic House members have been suing the state for the last two years to allow members to attend sessions and vote remotely. They have yet to prevail in court, and their most recent appeal was rejected by the U.S. Supreme Court.

The other Democratic priority on Wednesday was trying to get the rule allowing members to carry concealed weapons in the State House changed. Democrats failed there as well, meaning House members will remain armed if they choose while in session.

The GOP, as part of its agenda, is also pushing for a law to protect New Hampshire’s First-In-The-Nation status in the presidential primary process. The Democratic National Committee announced new rules late last year that would force New Hampshire out of the top spot in the nominating process. Sen. Regina Birdsell (R-Hampstead) said Wednesday she plans to spearhead the effort to fight off any challenge to New Hampshire’s position.

“Unfortunately, we found that our historic tradition has been under attack by those looking to maybe repurpose it for their political gain,” Birdsell said. “Know that we will respond aggressively to anyone that attempts, like the DNC or anyone, who attempts to take that away from us.”

The end of the federal COVID Public Health Emergency is coming, and that could result in tens of thousands of New Hampshire residents without health insurance. 

When the pandemic hit, some Americans were left without jobs and health insurance. The COVID Public Health Emergency allowed people who lost their insurance to sign up for their state Medicaid plan. But that help is coming to an end soon.

The Granite State is ready, though, with organizations preparing people to sign up for coverage in the Affordable Care Act Marketplace.

“I believe New Hampshire is way ahead of most other states,” said Keith Ballingall, president of Market Health Connect. “The state right now contains different partners to make sure we’re all working together.”

Market Health Connect is one of several companies working in the state to get people signed up for health insurance ahead of the ending of the Public Health Emergency.

President Joe Biden recently extended the so-called Public Health Emergency until the middle of January, creating a perfect storm for Ballingall and his team at MHC. The end of the emergency coincides with the open sign-up period for the marketplace, meaning thousands more people will be looking for coverage.

Keith Ballingall, president of Health Market Connect

New Hampshire residents who are on Medicaid through the Public Health Emergency are now getting pink letters informing them they will lose their coverage when the emergency officially ends. Ballingall and his team are reaching out to those people now to get them ready to sign up for a new plan.

Ballingall said about 50,000 people are already anticipated to be looking for health care during the open sign-up period, and another 50,000 to 60,000 will be looking because they got pink letters from the state.

“When the Public Health Emergency ends we will have a 60-day window to help,” Ballingall said.

MHC has people, called navigators, positioned throughout the state serving specialized populations, he said. New Hampshire attracts people from all over the world, and there are dozens of languages spoken in the Granite State.

“I think we’re doing a very good job having a very diverse team ourselves,” he said.

The health care navigator program is community-driven, he said, with the navigators living in their regions, understanding the people there, and able to provide real on-the-ground help.

Donna Toomey, one of MHC’s healthcare navigators, is based in the Lakes Region and reaches out to people wherever she can find them.

“I have been doing this work for over 20 years,” Toomey said. “I am very rooted in my community.”

Toomey goes to public meetings and holds open hours at town halls and tax collector offices. She talks with local police and firefighters, goes to schools and attends wellness fairs and old home days, and even meets people at homeless shelters to connect with people who will need help in the coming weeks.

Navigators like Toomey can make sure people will still be able to go to the doctor and get care even if they get a pink letter.

“We’re starting applications for the Marketplace now if people are going to lose their coverage when the emergency ends. That way they won’t lose coverage,” Toomey said.

Ballingall said navigators at MHC can work with people now and do all the necessary paperwork so that they are prepared for the end of the Public Health Emergency, no matter how many people will need assistance.

“At some point, it’s going to go back to the traditional rolls, and we’ve got to find someplace for them to go,” Ballingall said.

Many people who got a pink letter will go to a new plan on the Marketplace, though some may remain signed up for state Medicaid, he said.

The challenge is to reach so many people before the end of the Public Health Emergency. Toomey said the state has made the process as easy as possible, and applications can be done in 15 minutes. The key is to be ready before the January rush.

“I think the name of the game is sooner rather than later,” Toomey said.

People who have received a pink letter can start the process by connecting with a navigator at MHC through the website, www.hmcnh.com.