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V O L . X X I I I N O. X X I S E P T E M B E R 1 8 , 2 0 1 7 26 T he obstetric department at Calais Regional Hospital had births in , but needs close to births per year to break even. It's a quick statistic that hints at a world of di culty for health care provid- ers trying to remain viable in rural Maine. Due to low patient volume, Calais Regional closed its obstetric unit in August — a re ection of the challenges rural health care providers are grappling with throughout Maine. ose chal- lenges — occurring on various fronts that include nancial issues, remote geography and shifting demograph- ics — are threatening services within facilities or the existence of facilities themselves. Yet health care, like schools and housing, is one of the pillars of an economically vibrant community — capable of being the make-or-break point for employers deciding on loca- tions and employees looking for jobs. So say health care and economic development experts, as well as rural employers, who agree the situation could get worse before it gets better, given policy uncertainties at both the national and state levels. But they also agree it's important for all interests to work together to ensure future sustainabil- ity of the rural health care sector. " e community has to invest in its hospital, and that's by using it," says Calais Regional CEO Rod Boula. "It's basically 'use it or lose it.'" Cutbacks are trending Calais Regional is just one provider forced to look at cutbacks or merg- ers in recent years. Other examples include the closure of obstetrics at Blue Hill Memorial Hospital in and Penobscot Valley Hospital in Lincoln in ; cessation of overnight emer- gency care in Jackman, and the closure of the emergency room at St. Andrews Hospital and Health Care Center in Boothbay Harbor, in , followed by the end of in-patient services. Experts say things could worsen. Maine's health care sector has been relatively stable until recently, says Steven Michaud, president of the Maine Hospital Association in Augusta. "However," he continues, "I've never seen it as di cult as it is right now for all hospitals, but in particular with rural hospitals." He cites nancial losses and di culties recruiting physicians and other practitioners as top challenges. "Calais is an example," he says. " ey're not only eliminating OB, but they're a payroll-to-payroll hospital with no reserves." at's not necessarily the case throughout Maine hospitals, he says. But the situation is trending up — "unlike anything we've seen." Why the acceleration? It has to do with the money mechanisms funding the A ordable Care Act, including cuts to Medicare in order to pay for exchange subsidies and Medicaid expansion. " e theory was, although these were payment cuts to hospitals, hospitals should be able to absorb the cuts because they'd see more revenue with more people covered by insurance," including Med- icaid, he says. " e reality is that those cuts, over time, have really taken hold." e advent of high-deductible, high co-pay insurance plans are also contributing to shortfalls, Michaud says: "People can't pay those co-pays, but they still get care. at's a lot of bad debt to hospitals." And the aging population, with greater medical needs, is another con- tributor, he says. Although Maine hasn't seen any hospital closures for years, he says, "I fear that, in the next ve to years, we'll see a signi cant dislocation in rural Maine — meaning service reductions and even losing providers. Unless something changes, and I just don't see what that is. It's hard to see how there's going to be signi cant bipartisan consensus on xing Obamacare, and we are every year ght- ing Medicaid cuts on the state level." Risks for community health centers All of Maine's community health cen- ters are also at risk, says Darcy Shargo, interim CEO at the Maine Primary Care Association in Augusta. Community health centers are o cially called Federally Quali ed Health Centers and are administered by the U.S. Department of Health and Human Services' Centers for Medicare & Medicaid Services. Shargo's associa- tion provides education, advocacy, and F I L E P H O T O / A M B E R WAT E R M A N Health ills Rural health care providers struggle. Employers eye wider implications • • • • • • H E A LT H C A R E F O C U S In rural Maine, patients travel A llison Behrle, a pediatric gastroenterologist at Eastern Maine Medical Center in Bangor, moved to Maine a year ago and became interested in how far some of her patients traveled to see her. "I have patients coming from Fort Kent, Caribou and Presque Isle," she says. " ere are quite a few patients up north who travel three to four hours to get here. So it's tough for people. It's a whole day for them." A couple of patients come from Vinalhaven, which adds ferry travel. She accommodates long-distance travelers with scheduling that will work for them, and coordinating visits with other practitioners they might need to see, so they don't have to make the trip multiple times. And the hospital has overnight accommodations. "We're hoping to start outreach clinics for patients who can't get here," she adds. Steven Michaud, president of the Maine Hospital Association, says he's 'never seen it as dif cult as it is right now for all hospitals, but in particular with rural hospitals.'

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