Planned maternity ward closure draws AG’s attention, raises concerns among health care leaders

By: - August 15, 2022 5:35 am

Midwife Kate Hartwell will close the Concord Birth Center, which she opened in 2006, next year because the cost of malpractice insurance has tripled and reimbursement rates from commercial insurers and Medicaid are too low. (Courtesy)

The Attorney General’s Office is not alone in voicing concerns this month with Frisbie Memorial Hospital’s plans to close its labor and delivery services due to cost. Its concerns relate to their 2020 merger agreement with HCA Healthcare to keep those services in place for at least five years. 

Health care and community leaders are raising concerns, too, but for different reasons. 

This would be the 11th maternity ward to shutter since 2000 and leave just 15 hospitals and five free-standing clinics, with midwives, delivering babies in the state when births here are up. And one of those clinics, the Concord Birth Center, plans to close next year, for the type of financial reasons that plague all providers. As a result, people are now driving farther to deliver a baby and increasingly having them in unplanned places, such as emergency rooms, at home, and on the side of the road, said Trish Tilley, director of the Division of Public Health Services at the state Department of Health and Human Services.

It’s not optimal for various reasons, she said. 

“This is both a public health concern and, quite frankly, an economic development concern,” Tilley said. “We … heard in testimony this past session how communities need to have basic services for their entire population in order to attract new residents to their community. It’s hard to attract young families if you don’t have a hospital that provides comprehensive care, including labor and delivery.”

Economics and concerns about the quality of labor and delivery care are to blame, Tilley said. 

Because delivery dates can be estimated but often not scheduled, hospitals and birth centers must have well-trained staff available 24 hours a day, seven days a week. Yet, they receive no payment from insurance, Medicaid, or patients unless health care staff are working with patients. That downtime can also undermine the quality of care, Tilley said. 

“You want to make sure that those providers are as up to date as possible, and certainly one of the ways that you do that is seeing a lot of births, and you’re seeing a lot of things that could happen or things that could go wrong,” she said. “Work quality and finances go hand in hand.”

Mary Lawlor opened the Monadnock Birth Center in Swanzey in 2008 and is staying afloat only by taking on debt because small increases in private insurance reimbursement rates and stagnant Medicaid payments have not kept pace with costs. 

“The only reason I’m open is sheer determination and borrowing lots of money lots of the time,” she said. “I sometimes say we pay to do Medicaid births. We don’t get paid to do them.” 

The low payments from both private insurance and Medicaid don’t make sense to Lawlor when studies have shown that for low-risk pregnancies, birth centers use fewer medical interventions and average half the cost of labor and delivery services at hospitals. Furthermore, she said, midwives at birth centers also provide childbirth and nutrition education, home visits, additional office visits, and initial newborn screenings.

“We are achieving incredibly excellent outcomes,” Lawlor said.

Lawmakers passed Senate Bill 408 this year to increase the Medicaid reimbursement to birth centers like hers, but Gov. Chris Sununu has not yet acted on it and providers don’t know what the increase will be. Sununu has signed House Bill 1661 increasing the Medicaid reimbursement rate to hospitals. He also signed House Bill 1256 increasing the rate for ambulance services, which Tilley said are increasingly needed for all care in rural areas.

Sen. Sue Prentiss, a West Lebanon Democrat, helped lead the effort to increase the Medicaid reimbursement rates for ambulances and birthing centers. She said she’s been worried for years as she’s watched labor and delivery options decrease.

“Any of those areas that close, it shifts the burden … to the local health care system potentially until they get to where they’re going to deliver that baby,” she said. “And a lot of times, that becomes emergency medical services.” 

The Concord Birth Center will close next year because owner Kate Hartwell can no longer afford medical malpractice insurance and low reimbursement rates from commercial insurance and Medicaid. (Courtesy)

Kate Hartwell decided to close the Concord Birth Center, which she opened in 2006, when her malpractice insurance became no longer affordable. And she stopped taking Medicaid and private insurance in April and now cares for patients who can pay the approximately $5,000 cost themselves. Increased reimbursement rates will help but not enough to keep her practice open, Hartwell said.

“It took me about six months to come to this decision,” she said. “I decided that what I want for my life and my family couldn’t operate in the same existence while owning a birth center. I feel sad and I feel responsible for a huge loss in the community until I think about it and know it’s the right decision for me and my family.” 

Frisbie Memorial Hospital has cited costs in its decision to cease delivery.

“Due to our area’s aging population and years of declining births, and faced with the challenges of operating a low birth rate center, we have made the difficult decision to close the birthing center,” said spokesperson Ellen Miller. The hospital will continue to provide pre- and post-natal services.

The Charitable Trusts Unit at the Attorney General’s Office raised concerns about the decision last week in a letter to the hospital, noting the 2020 merger agreement to maintain those services for at least five years. That requirement can be set aside only in the case of “actual financial loss.” 

Diane Murphy Quinlan, director of the unit, told the hospital her office would be evaluating whether the hospital “made a good faith effort” to avoid those losses. If the state concludes the hospital failed to do so and that closure is delayed, the hospital would still have the authority to cease those services after 2025.

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Annmarie Timmins
Annmarie Timmins

Senior reporter Annmarie Timmins is a New Hampshire native who covered state government, courts, and social justice issues for the Concord Monitor for 25 years. During her time with the Monitor, she won a Nieman Fellowship to study journalism and mental health courts at Harvard for a year. She has taught journalism at the University of New Hampshire and writing at the Nackey S. Loeb School of Communications. Email: [email protected]