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The New Hampshire Attorney General’s Office gave its blessing Monday to the takeover of Manchester’s Catholic Medical Center by for-profit HCA Healthcare, Inc.

Attorney General John Formella announced his office reached an agreement with HCA and CMC to make sure the new ownership will continue CMC’s mission to provide healthcare and serve the community. 

“This settlement represents a thoughtful approach that both addresses the insurmountable financial challenges CMC is facing and ensures that the healthcare needs of New Hampshire residents continue to be met,” Formella said.

The deal has been in the works for years as CMC sought financial salvation. The nonprofit hospital has been losing up to $3 million a year. The Attorney General’s Office review was the last step in finalizing the deal with HCA.

“CMC’s decision to sell the hospital is largely the result of financial distress that has brought CMC to the brink of bankruptcy,” Formella reported in his role as the state’s Director of Charitable Trusts. “On top of large losses over the last several years, CMC has projected losses of $41.5 million for its 2024 fiscal year, and its debt totals around $160 million. In April 2024, CMC laid off 142 employees attempting to reduce its losses, but providers and patients continue to leave the hospital, reducing revenues at a greater rate than any reduction in expenses.”

The purchase, which the report notes is “not an affiliation or partnership,” will provide financial stability the hospital has long sought.

In a statement, the Diocese of Manchester said maintaining the hospital’s Catholic identity “was essential to the CMC Board of Trustees and Bishop Peter Libasci in deciding a future course of action for the hospital. CMC was created in a close relationship with the Diocese of Manchester including that the Bishop of Manchester approves certain activities of the hospital and the assets of CMC transfer to the Diocese upon the sale of CMC. Going forward, these assets will be held and used exclusively by a foundation that will continue the legacy of CMC’s commitment to provide Catholic health care in the community.”

As part of the deal, HCA first got Vatican approval to take over CMC by signing an agreement to operate within the Catholic Church’s ethical standards for medical care.  

Formella’s agreement with HCA will see that the key funding is in place for hospital expansion and as well as continuing charity care for the Manchester community. 

“As part of HCA Healthcare, CMC and our new colleagues will have access to much-needed resources that will pave the way for financial stability and continued growth. We are committed to making significant capital investments and enhancing key service lines that will benefit not only Manchester patients but patients across New Hampshire with expanded choice and ensure they have the highest-quality care available close to home,”  said Dr. William Lunn, president of HCA Healthcare’s Capital Division.

HCA will contribute $2 million over the next three years to local community health initiatives like Healthcare for the Homeless and Poisson Dental Clinic. 

“With HCA Healthcare, CMC’s legacy of excellence will not only endure but flourish — expanding access to care, enhancing services, and remaining deeply rooted in our Catholic mission,” Alex Walker, president and CEO of CMC said.

Mayor Jay Ruais called Monday’s announcement a pivotal moment for the city.

“CMC’s partnership with HCA Healthcare ensures immediate access to the financial and operational resources necessary to sustain its more than 130-year legacy of providing high-quality Catholic healthcare to our region,” Ruais said. “I am pleased that vital and beloved community programs, such as Healthcare for the Homeless and Poisson Dental, will also continue to serve our community for years to come.”

HCA is a Tennessee-based for-profit company that operates 180 hospitals throughout the U.S., including three in New Hampshire. Critics oppose HCA’s acquisition of CMC, pointing to its actions at Frisbee Memorial Hospital, where the company shut down the labor and delivery department after promising to keep it open. 

HCA’s proposed deal with CMC was hounded last year by nurses from HCA’s North Carolina Mission Hospital in Asheville who said HCA operated in an unsafe manner that put their lives and the lives of patients at risk. The nurses came to New Hampshire to stage protests, publish newspaper ads, and talk to the media, all in an effort to stop the sale.

“The community needs to know what happened to our hospital, because the same thing will happen to their hospital,” Kelly Coward, a nurse and union representative at Mission Hospital in Asheville, told NHPR last year.

Those nurses, all members of the National Nurse United union, stopped their protest a day before the Oct. 23 attorney general’s public hearing at CMC. The union kept silent through the fall and had no statement Monday about the deal’s approval. 

On Oct. 22, National Nurse United announced it had reached a contract deal with HCA for 17 hospitals in 6 states, including the Mission Hospital in Asheville. 

Former state Sen. Lou D’Allesandro, who represented Manchester for decades, backs the HCA deal.

“CMC must be saved, and we must make sure that all contingencies are met,” D’Allesandro told NHJournal Monday. “I am a strong supporter and will continue to work on behalf of all the citizens of Manchester to have quality medical care continue to be provided.”

Bishop Libasci says he’s pleased with the result.

“We may look forward now to a strong, vigorous, Catholic hospital on Manchester’s West Side and Catholic healthcare throughout the state of New Hampshire,” Libasci said.

EDITOR’S NOTE: An earlier version of this article erroneously reported that the Diocese of Manchester owns CMC. NHJournal regrets the error.

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.

After months of vocal opposition to government-imposed vaccine mandates on private businesses, Republicans on the state House Education Committee passed one of their own. They approved an amendment banning any “entity” — including private businesses — from requiring COVID-19 vaccines.

“The Education Committee passed HB255 in the name of medical freedom,” said House Speaker Sherman Packard (R-Londonderry). “Employers are struggling to fill vacancies, gas and food prices are rising, and chaos reigns at the border – the president has shown his ineptitude to lead. He has instead chosen to rule by mandates. That is not the New Hampshire way – and today’s small victory proved that.”

If the Biden administration’s vaccine mandate goes into effect — it’s currently being challenged in court — it will supersede New Hampshire law. House GOP leadership acknowledged Tuesday’s vote was to send a message, not set policy.

“I applaud the members of the Education Committee who took this amendment up today and did the right thing for New Hampshire,” said House Majority Leader Rep. Jason Osborne (R-Auburn). “While it is my hope that the president pays attention to the message we sent him on the heels of his visit today, I will not hold my breath. I look forward to passing this bill at our first opportunity when it comes before the House in January.”

Critics noted the irony of calling a measure that forbids private business owners from setting their own vaccine policy a “medical freedom” bill.

Gov. Chris Sununu opposed the move for the same reason his administration is suing to stop the Biden administration from imposing vaccine mandates.

“As the governor has repeatedly said, he is opposed to the government either prohibiting or mandating vaccines on private businesses,” Sununu spokesman Ben Vihstadt told the New Hampshire Bulletin when asked about the House Education Committee’s bill. 

Democrats, many of whom also believe government should have the power to decide the vaccine policies of private businesses, dismissed the legislation as a “political stunt.”

“Republican leadership hand-picked the vote, permanently removing from the committee the one Republican member who may oppose this absurd proposal,” said Rep. David Luneau, D-Hopkinton. “This political stunt should be a concern to everyone. The House Speaker’s decision to gerrymander the proceeding is a disgrace.”

Luneau is referring to Pittsfield Republican Jim Allard, who was removed from the committee by Speaker Packard in advance of the vote.

Neither Packard nor Allard responded to requests for comment.

The regulation extends beyond businesses to cover “any political subdivision of the state, corporation, association, club, firm, daycare, public or private school, public or private institution of higher education, partnership, society, nonprofit, joint stock company, or any other entity, including any governmental entity or religious entity.”

Even churches would be banned by government edict from setting vaccine rules for their own clergy and employees.

Supporters of the legislation, including the anti-vaccine organization ReOpenNH, argued government force was required to prevent private businesses from imposing rules on their employees. Business groups pointed out employers impose rules on their employees all the time.

David Juvet with the New Hampshire Business and Industry Association said the state needs to leave those decisions up to private business owners.

“BIA staunchly opposes legislative proposals that would prohibit private employers from mandating vaccination for its workers should they want,” Juvet said. “Requiring vaccination is a safety measure to protect employees and customers and others who may visit the place of business. It’s not unlike other employer requirements from hard hats to hair nets and even dress codes.”

Steve Ahnen, president of the New Hampshire Hospital Association, said the bill would make it harder for hospitals to keep patients safe.

“It would really hinder their ability to do what they need to do to protect the health and safety of staff and patients,” he said.

Ahnen said vaccines are mandated for a host of illnesses across the healthcare industry. While he doesn’t want to see anyone lose their jobs, hospitals need to be able to take care of the health of the patients and staff. The anti-mandate bill would impede that effort.

The libertarian New Hampshire Liberty Alliance also opposed the legislation. “While we support legislative efforts to mitigate the harm of the federally imposed mandates, this amendment negatively impacts freedom of association by restricting the actions of private entities who wish to require vaccination independent of federal mandates,” it posted on the group’s website in advance of Tuesday’s hearing.