Capital Beat: The bipartisan, $100 million plan to bring in health care workers

Monitor staff
Published: 2/2/2019 11:01:16 PM

Jay Couture has grown used to her employees not sticking around. The CEO of the Portsmouth and Exeter-based Seacoast Mental Health Center has seen a steady churn of clinicians come and go for decades.

Employees come in, green-eyed and ready to jump in to help patients in crisis. They get training and supervision, not to mention a wealth of practical experience as they work toward higher certifications.

Then they get those licenses and move on to a provider with better pay.

Couture has seen it again and again. And the rest of the industry is well aware. A fellow CEO of another provider, which recently hired five of Couture’s clinicians, called to compliment her about it.

“You have really well-trained staff,” Couture was told.

“Yeah, thanks,” she joked back.

It’s a painful reality familiar to community mental health centers across the state. Saddled with some of the lowest Medicaid reimburse ment rates in the country – some of which haven’t been increased since 20 06 – many say they simply don’t have the resources to pay their staff well, resulting in low retention and high vacancy lists.

For Seacoast Mental Health Center, that’s meant 15 unfilled positions in a staff of 180. For community mental health centers as a whole, the total vacancies have topped 200.

This week, New Hampshire lawmakers are pitching a sweeping proposal to help lift up providers by boosting reimbursement rates across the state. But it won’t come cheap.

Introduced by Democratic Sen. Cindy Rosenwald, Senate Bill 308 would increase the rates by 12 percent over two years, significantly expand the state’s loan repayment program, and create investments intended to make New Hampshire attractive to out-of-state health care workers.

The price tag: $115 million. The plan includes $38 million for a five percent rate increase in Fiscal Year 2019, and $56 million for a seven percent hike in FY2020.

Providers and hospitals say the bill is a needed fix to an unsustainable situation.

Churn and burn

For Couture, the staffing hardships have been compounding for years. The last time the Legislature helped raise the Medicaid rates relevant to her clinics was in 2006.

“It’s been a while,” she quipped.

The problem isn’t theoretical. For providers serving low-income populations, the Medicaid rate makes up a bulk of their payments and has a direct effect on wages.

Eighty-five percent of Couture’s revenue comes from Medicaid; 85 percent of her expenses are salary and benefits, she said.

Twelve years of stagnant rates, she added, is “really the same as getting cuts.” Twelve years of cuts means wages stay low, positions are shuffled around, and vacancies grow.

“That’s more than a decade of trying to sustain a workforce with a growing demand for service without additional funds,” Couture said.

The problem is made worse by other factors. As more health care organizations integrate their services, providers are increasingly hiring from the same shrinking pool of employees.

In that environment, salaries make all the difference.

“If I could raise salaries to be more competitive with a primary care practice, a hospital, or other provider types that are looking to hire the same therapist I am, that would be helpful,” Couture said.

Selling New Hampshire

Bumping up wages can only go so far, providers say. Students first need to get in the door.

Home-grown physicians aren’t enough; New Hampshire only has one residency program for primary care doctors, at Concord Hospital, and only eight are presently residents, according to Stephanie Pagliuca, director of the Bi-State Primary Care Association in New Hampshire and Vermont.

Meanwhile the state has around 50 openings for primary care physicians, Pagliuca added.

So New Hampshire has to look elsewhere, at a time when physicians across the country are in thin supply. And that means selling New Hampshire.

“We’re really competing with other states,” she said. “We’re competing against each other, in some respects, within New Hampshire, with urban and rural areas kind of looking to recruit the same small number of primary care providers.”

One key tool, advocates say: student loan repayment. For years, New Hampshire’s state loan repayment program offered just $169,000 a year for all its loans. And while the Legislature approved $600,000, Senate Bill 308 would explode that amount to $5 million.

Providers say the loan relief is a must-have. “When we talk to doctors, when they’re coming into training, they’re not sheepish about asking about loan repayment,” Pagliuca said. “They’re like, ‘How much comes with that for loan repayment?’ ”

No relief, she added, and many won’t even consider the workplace.

Rosenwald’s mammoth legislation features an array of other investments and changes, all of which would normally receive their own bills. It would mandate the creation of online background check system to help nurses and others cut through days and weeks of approval times. It would expand a program to improve the New Hampshire brand for out-of-state health care workers. And it would expand existing scholarships to include specific grants for in-state medical students.

The aggregate? A coordinated effort to turn some New Hampshire’s health care fortunes around, providers say.

“Most people who are here would like to stay,” Pagliuca said. “It’s just finding the right opportunity with the debt load that they have and their considerations in terms of where they want to work and live.”

Bipartisan dreams

Then of course, there’s the price tag. As lawmakers head into budget season, it’s unclear how the bill, a major appropriation with so-far overwhelmingly Democratic support, will be received by Republican legislators. It’s also unclear how it might integrate with his budget address on Valentine’s Day.

Advocates and lobbyists say the office of Gov. Chris Sununu is aware of the bill, set to be formally unveiled Monday. And a spokesman for Sununu said the governor is supportive of its main ideas.

“The issues encompassed in SB 308 are a priority of Governor Sununu’s – many of which will be included in his budget proposal,” the spokesman, Ben Vihstadt, said.

Still, the proposal is unlikely to sail through without some negotiation. Wolfeboro Sen. Jeb Bradley, the lone Republican Senate sponsor on the bill, said while he’s signed onto the effort, he hopes that Democrats will be open to compromise on the final numbers, particularly as the state seeks to balance increased funds to DCYF, mental health beds and substance abuse efforts.

“This is the beginning of a process, and legislation looks a lot different at the end of the day,” Bradley said. “...I get that there needs to be an increase (in rates). Whether five and seven percent is the number that we can afford, that’s what the process will determine.”

Bradley added: “I think those of us that have dealt with Medicaid over the last several years – and I don’t think anybody has more than I have – understands the pressure that is on providers for Medicaid rates. That being said, I hope that my colleagues that ahve signed onto this bill are willing to compromise.”

But even with hearings weeks away, Rosenwald is keeping hopeful. The goal, she said, was bringing dozens of bills filed through years – with successes and failures – under one roof.

“We need to look at the workforce more holistically,” she said. “Everybody acknowledges that workforce is a challenge for us.”

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