Genesis HealthCare, owner of 16 nursing home facilities in NH, declares bankruptcy

‘Instability’ in the skilled nursing industry is a concern, but closings not expected

By Kelly Burch, Granite State News Collaborative

Genesis HealthCare, one of the nation’s largest nursing home owners — and operator of 16 skilled nursing facilities in New Hampshire — has filed for bankruptcy protection. 

No facilities are expected to close due to the bankruptcy proceedings, a spokesperson for Genesis told VTDigger. 

"“There will be no expected impact to patient care as a result of this filing,” the spokesperson said. “Our daily operations remain unchanged, and our commitment to those we serve continues uninterrupted.”

Still, the news is jarring to some in the skilled nursing space in New Hampshire. As Genesis is the operator of 16 of New Hampshire’s 74 skilled nursing homes, "I’m worried about… any instability in the sector,” said Brendan Williams, president and CEO of the N.H. Health Care Association, adding, “I’m not suggesting there will be closures.” 

Langdon Place of Keene, a senior living facility previously owned by Genesis HealthCare, was acquired by a company that purchased two other former Genesis facilities. The national nursing home giant filed for bankruptcy protection July 9. (Hannah Schroeder/Sentinel Staff)

Genesis, which is based in Kennett Square, Pa., filed for Chapter 11 bankruptcy protection on July 9 in the Northern District of Texas. VTDigger reported that the company’s debts include over $12 million owed to the New England Health Care Employees Pension Fund and $8 million per month “in settlement and defense costs arising from alleged personal injury and wrongful death claims, most of which date back many years.” 

Genesis has a widespread presence in the Granite State, with locations in Bedford, Claremont, Concord, Exeter, Franklin, Hampton, Laconia, Lebanon, Keene, Manchester, Milford, Peterborough, Rochester and Winchester. All told, it has 218 facilities in 19 states.

Williams pointed out that any possible impact of the bankruptcy could be felt most acutely in towns in rural areas such as Sullivan County and the Monadnock Region, where Genesis facilities have an outsized presence. 

“If, for example, Genesis were to close its nursing home in Claremont, where would those people go?” he said. 

New ownership at 3 facilities

At least three nursing home facilities previously run by Genesis HealthCare changed hands last year, when locations in Keene, Nashua and Bedford were taken over by 603 Healthcare. The company manages eight facilities across New Hampshire, according to a press release. 

Sean Stevenson, owner and CEO of 603 Healthcare, was senior vice president of operations at Genesis until 2021. State documents show he has a 5% ownership stake in the companies that own the three formerly Genesis facilities, while the remaining 95% ownership is held by two New York-based brothers, Robert and Philip Rausman, who also own skilled nursing facilities in New York.  

In a December 2024 story about the sale of Langdon Place of Keene, Stevenson told The Keene Sentinel, "We plan to enhance services for our customers in any way we can and continuously support our center caregivers."

He added, “We have a tremendous opportunity and responsibility to collaborate with our local healthcare providers and to be a trusted partner in the continuum of care.”

This is a developing story. If you have any tips or concerns about Genesis HealthCare please reach out to reporter Kelly Burch at burchcreative@gmail.com. These articles are being shared by partners in the Granite State News Collaborative. For more information, visit collaborativenh.org.

Hospital consolidation threatens New Hampshire’s health care safety net

Mergers can affect funding, staffing and patient populations at state’s federally qualified community health centers

By Kelly Burch-Granite State News Collaborative

Since Catholic Medical Center in Manchester was purchased by the national for-profit HCA Healthcare in February, Manchester’s low-income patients have faced some uncertainty. 

In the past, patients seen at Amoskeag Health, Manchester’s community health center, could get approved for reduced copays based on their income. Catholic Medical Center would honor those reduced copays, removing a hassle and streamlining patients’ access to affordable care at the hospital, said Kris McCracken, president and CEO at Amoskeag Health. 

Since the merger, the use of that program has been paused.

“I hope we can establish a similar arrangement with HCA … [but] I haven’t even met with them yet,” said McCracken. “You’ve got to rebuild that relationship.”

That’s just one example of the way that hospital mergers around the state are affecting New Hampshire’s 11 federally qualified community health centers. They are seen as the safety net of the health care system, providing primary care to everyone, regardless of their ability to pay. The centers are funded primarily by federal grants and Medicaid reimbursements, but also rely on community benefit grants from local hospitals — some of which disappear after a merger occurs, FQHC leaders say. 

In addition to affecting the grants, hospital mergers can lead to higher employment costs for the health centers, create a higher proportion of patients who are unable to pay (since for-profit organizations can decline to provide care for those people) and erode a sense of community cooperation between hospitals and the centers. 

“As some of these mergers occur, it feels like the senior leadership gets a little further away from the community,” said Gregory White, CEO of Lamprey Health Center, a federally qualified health center with locations in Nashua, Newmarket and Raymond. “Sometimes when that happens, instead of doing things with you, [things] happen to you.”

While the challenges are real, leaders of the health centers also emphasize that, with work, there can be functional and cooperative relationships with larger hospital systems. 

“Just because they’re a big health care system doesn’t mean they’re not a good partner,” McCracken said. 

Loss of local control and local grants

One of the touchiest subjects when it comes to hospital mergers and federally qualified health centers involves community benefit grants. These grants are provided by hospitals to serve a specific community need. They also are a way of acknowledging the role that the community health centers play in the health care system, McCracken said. 

If a community has two or three private practices, often linked to larger health care systems, the local community health center is “kind of taking the leftovers,” she said — patients who are uninsured or unable to pay for care. For the community health centers, there’s often no balance between paying patients and charitable care, she said. 

“You’re the safety net for the folks who are the neediest in the community,” she said. 

While that’s the role of the health centers, McCracken said, it requires support from the hospital systems that are benefiting from serving more profitable patients. 

“We’re here to be the safety net … but if all we have is safety net patients, that means we need more community investment,” she said. 

Amoskeag Health never received a community benefit grant from Catholic Medical Center, due to the hospital’s religious guidelines, and doesn’t anticipate receiving one from HCA, McCracken said. Amoskeag Health does receive grants from Dartmouth Health and Elliot Health System, which also gives a grant to Lamprey Health. 

In the past, however, when hospitals have gone through mergers, “it felt like we lost touch with them,” and community benefit grants have gone away, White said. He, like many community health center leaders who spoke to the Granite State News Collaborative, declined to elaborate; some of them expressed concern about jeopardizing their relationship with hospitals, and thus access to future grants. 

Changing patient populations and cost concerns

Ed Shanshala, CEO of Ammonoosuc Community Health Services Inc., has concerns about larger hospital organizations, especially for-profit companies, buying into the New Hampshire health care system. The ethical obligations to patients and legal obligations to shareholders are too difficult to balance, he said. 

Ammonoosuc Community Health Services Inc. has locations in Littleton, Warren, Whitefield and Woodsville. The organization recently announced its Franconia location will close soon because of funding concerns. 

Jillian Peabody of Amoskeag Health with a patient. Low-income patients at the federally qualified health center in Manchester have faced uncertainty about their health care since the for-profit HCA Healthcare’s acquisition of Catholic Medical Center. (Courtesy of Amoskeag Health)

If for-profit hospitals are "going to carve out the most beneficial and profitable [patients], those of us who serve the collective are going to be left unable to serve the most vulnerable population,” Shanshala said. 

Mergers can also affect where patients choose to receive care, and the services they have access to, said Robert MacLeod, CEO of Mid-State Health Center in Plymouth.

“We sometimes see increased costs and fewer choices, especially when systems prioritize keeping patients within their own network,” he said. “That can limit our ability to refer to the most appropriate or affordable specialty care, and in some cases, services like maternity care or certain specialties may be reduced based on financial pressures.”

MacLeod has another concern: that the buying power of large hospital systems could ultimately exclude federally qualified health centers from working with certain insurers. 

“As larger systems gain more negotiating power with payers,” he said, federally qualified health centers “may find it harder to compete or collaborate under the same terms. We may face tighter reimbursement rates or be excluded from certain payer networks, even when we offer high-quality, cost-effective care.”

Shanshala is likewise skeptical of the widespread claims from hospital systems that mergers reduce costs. 

“Although there’s been a promise of efficiencies through aggregation of health care, it’s not clear they’ve ever delivered on economies of scale, delivering on a lower price point for patients,” he said. “I’ve personally never experienced lower prices.”

Personnel costs are a massive burden for federally qualified health centers, taking up about three-quarters of operating budgets. Large health systems can make things even worse.

“With consolidation, especially very large players like Mass General, there’s pressure on salaries that we just can’t compete with,” said White. (Boston-based Massachusetts General Hospital acquired Dover’s Wentworth-Douglass Hospital in 2017.)

McCracken used an analogy: If federally qualified health centers are kayaks on a bay, large health care systems are like giant ocean liners, throwing such a wake that the kayaks are often rocked. 

“It’s not that they’re trying to do anything to any of us,” she said, “but their presence is so overwhelming in the health care space.”

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey athttps://tinyurl.com/3au39uctabout your healthcare experiences. For more information, visitcollaborativenh.org.

Amid a ‘proliferation in services,’ N.H. lacks a thorough way to track health care industry’s growth

After scrapping its Certificate of Need Board, state has no ‘window’ into what drives ever-rising costs

By Paul Cuno-Booth-Granite State News Collaborative

Over the past decade, larger health systems — many based out of state —  have snapped up community hospitals in New Hampshire, touting flashy new investments, even as some residents voice concerns about other services being cut. 

Regional hospital groups have formed, and split up. Urgent care clinics, outpatient surgical centers and other independent facilities have proliferated. 

When the Certificate of Need Board was scrapped in 2016, New Hampshire also lost a key source of transparency into the state’s health care market, says Lucy Hodder, a professor at the University of New Hampshire Franklin Pierce School of Law who focuses on health law and policy. (Franklin Pierce School of Law photo)

What does all that mean for patients, employers and their ever-growing health care costs? It’s hard to say — because no one is really keeping tabs in a systematic way, some New Hampshire health care experts said.

“We have seen a proliferation of services that no one is even tracking,” said Lucy Hodder, a professor at the University of New Hampshire Franklin Pierce School of Law who focuses on health law and policy. “That results in duplication, high cost, patient frustration. We see investment in services that aren’t needed as opposed to those that are. We lack any real look into the future as to how we want to use our health care resources.”

Hodder and others say that lack of transparency hinders efforts to figure out how to preserve access to essential health services while controlling costs, which remain a major concern. In a 2024 survey from New Futures, a health policy organization, more than two-thirds of Granite Staters said they’d recently put off going to the doctor, skimped on medication or otherwise delayed or skipped medical care because of cost.

New Hampshire used to track the growth of health care services more closely, through a regulatory body known as the Certificate of Need Board, which reviewed proposed capital investments by hospitals and other providers.

Most agreed that the board process was flawed, and critics said it failed in its primary mission of containing costs, because it quashed competition from new market entrants that could offer care at lower prices. The Legislature dissolved the board in 2016.

Hodder agreed the Certificate of Need Board had issues — but, by scrapping it, New Hampshire also lost a key source of transparency into the state’s health care market

As part of its work, the board tracked metrics on everything from MRI machines to open heart surgeries, shedding light on where those services were located, whether they were enough to meet the community’s needs, how affordable they were, what wait times looked like, and whether services were being duplicated in a way that could drive up costs.

Today, no one is tracking that data in a coordinated way, she said. She worries the result has been a “clandestine arms race,” as large health systems try to stay afloat by investing in the most lucrative services, regardless of need.

“Our entire economy is reliant on accessible and affordable health care, and this [board] provided a window into whether we have it and what it looks like in New Hampshire,” Hodder said. “And we don’t do that anymore.”

‘It prevented competition’

The idea of requiring health care providers to obtain a “certificate of need” to justify major construction projects or service expansions stems in part from the work of a pioneering Dartmouth College researcher, Dr. Jack Wennberg. Wennberg found the supply of health care resources in an area — such as having more hospital beds — could lead to higher utilization, and therefore higher costs, without necessarily producing better outcomes. 

By the early 1980s, spurred by since-repealed federal requirements, nearly every state had a certificate of need process. But it’s questionable whether they had the intended effect, and more than a dozen states have since repealed their certificate of need laws. 

A systematic review published in 2020 in the journal BMC Health Services Research found the evidence is mixed on whether certificate of need laws reduce health care spending, but the costs — including the potential to restrain competition — generally outweigh the benefits.

In 2010, a legislative study committee concluded that New Hampshire’s certificate of need process was flawed in various ways. The dominance of large health care providers on the board created conflicts of interest, and loopholes sometimes allowed them to evade review, and there was no consistent consumer advocate voice. The report also found the board’s support staff was underfunded, and it lacked a larger plan for improving affordability and access.

The committee recommended replacing the board with a more robust, independent body. Lawmakers instead voted in 2012 to sunset the board four years later.

Nick Vailas, a health care entrepreneur and former state health and human services commissioner, says the Certificate of Need Board — which he at one point served on — ‘prevented competition.’ (Screenshot)

Nick Vailas, founder and CEO of the Bedford Ambulatory Surgical Center and a former state health and human services commissioner, cheered that decision. He had been appointed to the board, he said, for an unusual reason — the governor at the time wanted his help getting rid of it.

Vailas described the board as beholden to hospital interests that had an incentive to keep out lower-priced competitors. He experienced that firsthand, when HCA Healthcare — the country’s largest for-profit health system and parent company of Portsmouth Regional Hospital — fought his plans to open a freestanding surgical center in the area. The case eventually made it to the  state Supreme Court, where Vailas prevailed.

“It prevented competition, which we all know is a natural check and balance for keeping prices in check,” he said.

He credits the board’s repeal with ushering in a wave of imaging centers, labs and other independent facilities that offer patients lower-cost options. 

“You want the high-quality, highest-valued providers to survive,” he said. “So we need more free market in health care.” 

The problem, Vailas said, is there’s too little transparency about prices, so consumers have a hard time making informed decisions about which providers offer the best care for the lowest price. It’s something he’s trying to address through a private company he started, Delphi.

“Could we do better health planning and reviewing? Absolutely. It’s all based upon data collection,” he said. “Then what do you do with data? I don’t believe the government is sophisticated enough at this point to do that, and nor do I believe it’s absolutely necessary.”  

Bearing the brunt of rising costs

Without a body like the Certificate of Need Board, no one’s taking a hard look at how the growth of health care services is affecting costs in New Hampshire, says N.H. Sen. Cindy Rosenwald, D-Nashua. (Courtesy photo)

State Sen. Cindy Rosenwald, a Nashua Democrat who sat on the 2010 legislative study committee, said she thought the board should have been overhauled rather than scrapped. Without it, she said, no one’s taking a hard look at how the growth of health care services is affecting costs. 

“As a result, any hospital that wants to start doing X, if they can make their own business case for it, they’re free to do it,” Rosenwald said.

‘’We can have it all — but then we can’t keep saying, well, why is health care so expensive?’ says Maria Proulx, president of Anthem Blue Cross Blue Shield in New Hampshire, who served on the Certificate of Need Board briefly before it was disbanded in 2016. (Courtesy photo)

To Maria Proulx, president of Anthem Blue Cross Blue Shield in New Hampshire, the question is not whether the Certificate of Need Board was good or bad. It’s whether the state is addressing the questions it was set up to address — such as what services are actually needed and what’s unnecessarily inflating costs. 

“We can have it all — but then we can’t keep saying, ‘Well, why is health care so expensive?’” said Proulx, who served on the board briefly before it was disbanded.

For example, she said, it might be nice to have a lab every 5 miles, or a large array of services at every local hospital. But “in health care, convenience can be very expensive.”

The Certificate of Need Board may or may not have been the right way to wrestle with those tough questions of need versus convenience, she said — often, the market can sort those things out. What’s important is that those discussions happen. Otherwise, employers and patients will continue to bear the brunt of rising costs.

“Sometimes I feel like I can only get the attention of people when there’s a crisis, or when a hospital merger is proposed, then it’s like everybody cares,” she said. “But then it happens, and we all go on, and we sort of lose sight of it again until another big event happens.”

Hodder said the state’s launch of a new Health Care Consumer Protection Advisory Commission is a step in the right direction. That commission was set up by the New Hampshire attorney general’s office, with a mission to better understand the state’s health care market and how to make it work better for consumers. The commission recently announced it is funding a new center at the University of New Hampshire to study those issues.

“The attorney general decided, as it was reviewing bigger and bigger mergers and hospital consolidation, that it needed to fund an entity to look at the impact,” she said.

At the same time, she expressed concern about the recent elimination of the Prescription Drug Affordability Board in the recently approved state budget. It was formed in 2020 to look at the drivers of high drug costs and recommend ways the state can save money. 

Rosenwald sees that as a “missed opportunity” to control costs for taxpayers and, ultimately, patients.

“That is the only entity in the state that’s actually taking a comprehensive look at what the taxpayer dollars are paying for prescription drugs,” she said of the affordability board. “And that’s a significant driver in cost.”

Hodder said she wants state officials to declare that affordable and accessible health care is a priority, and set goals. 

“There are a lot of hidden incentives in health care,” she said. “The patients right now are left holding the bag.”

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey athttps://tinyurl.com/3au39uctabout your healthcare experiences. For more information, visitcollaborativenh.org.

‘Critical Condition’: How has consolidation affected N.H. hospitals and patients?

The Granite State News Collaborative and its partners have undertaken a new series that explores who owns the hospital in your area, how that impacts your health and what kind of care hospitals offer. In addition to hosting “The State We’re In,” Melanie Plenda also serves as executive director of the Granite State News Collaborative, a group of more than 20 news organizations covering every corner of New Hampshire that tells stories that matter. The collaborative and its partners have been working on a new series, called “Critical Condition,” and it looks at the state’s hospitals, exploring how financial conditions impact the care we receive. Here to talk about the series is collaborative editor Jeff Feingold. 

This article has been edited for length and clarity.

By Rosemary Ford and Caitlin Agnew

Melanie Plenda:

Jeff, tell our audience about the series and what it will take a look at. 

Jeff Feingold:

It started with what's been going on in New Hampshire and all around the country actually — consolidation. In New Hampshire, larger hospital systems have been buying up hospitals over the last 20 years, but even more recently it's been more concentrated.

There used to be 26 independently owned acute care hospitals in New Hampshire, and now there are only five that are not affiliated. The rest are owned by Dartmouth Hitchcock, which has five other hospitals besides Dartmouth Hitchcock Medical Center,  and HCA Healthcare, which is a giant for-profit corporation that owns hundreds and hundreds of hospitals and other health facilities around the country. They own four hospitals in New Hampshire. Other hospitals are owned by Beth Israel in Beth Israel Leahy and Mass General as well as Concord Hospital, which owns Laconia, which previously bought Franklin Hospital. So we're in that situation now where there's just more and more concentration of ownership of hospitals.

Melanie Plenda:

Why does it matter who owns a hospital? Or how many hospitals are owned by the same parent company? 

Jeff Feingold:

There's a reason that these hospitals are merging. There have been financial problems in healthcare, as I'm sure all the viewers out there understand. The costs involved in health care have gone through the roof, and many hospitals can't really make it on their own anymore. So they find buyers, or buyers find them, and that's why there's consolidation. The consolidation allows them to streamline their services and look for more efficiencies with the goal of lowering costs and things like that. The issue in some cases, the owners are also making decisions to eliminate services at the hospital that they've acquired. 

A perfect example is what happened in Rochester with Frisbie Hospital, which was being acquired by HCA. What they did was, after two years, eliminate labor and delivery services. That means that all those patients in need of labor and delivery services or another service that was eliminated have to travel to Portsmouth, which also happens to be an HCA hospital, or another hospital and find a new doctor. They also might have transportation issues, cost issues, because the hospital that they were used to is no longer offering the same services or the services that they require. That can make a big difference in a patient's life.

Melanie Plenda:

How has New Hampshire been affected by these hospital consolidations already? 

Jeff Feingold: 

That is what the project is about. There was a piece in The Boston Globe not too long ago about how EMTs and other first responders are being trained in labor and delivery techniques up in the North Country, because there's no obstetric care there. As we know, New Hampshire is infamous for having an inadequate transportation system, so it's really difficult for someone who has a lower income, who doesn't have a car, is elderly or is a disabled person to obtain services when a hospital no longer provides those services that they used.

Melanie Plenda:

What does this mean for those seeking health care in the state?

Jeff Feingold:

It's making it more difficult. It also is making it more expensive, because what happens is that when a service is more concentrated in an area, the prices will go up. That's one of the major concerns of people who watch hospital consolidation trends — the cost of health care — and it is continuing to rise even with these supposed synergies, as they say in the business world, the streamlining of these efficiencies. 

Another concern is that insurance rates might also rise, because as these hospitals gain more power with the hospital systems they can negotiate rates differently than other hospitals with the insurance companies, and that means it's very hard to just keep track of that kind of stuff.

Melanie Plenda:

What role does the state government play in all this? 

Jeff Feingold:

That is a major piece in our series. The initial story was written by Meera Mahadevan on how this whole consolidation thing works. It is an excellent piece — I recommend everybody to read it. 

What she found is that one of the things we just don't know enough about is this hospital consolidation phenomenon because the state basically doesn't track this stuff. We used to have a process called a certificate of need process, and we had a Certificate of Need Board, which would approve all major acquisitions of technology, the big-high priced items, expansions and additions to hospitals. But back in 2016, the state eliminated it saying there were issues with the certificate of need process. 

But what happened is the state no longer has an entity that keeps track of all that’s going on. What that has left us with is basically all the oversight of health care systems is provided by the attorney general, John Formella. 

Melanie Plenda:

How is recent news impacting the series — or is it? For example, the recent cuts to Medicaid.

Jeff Feingold:

Unfortunately, New Hampshire hospitals rely on Medicaid funding because that's a steady flow of income. It's not as much money as they would get from a patient that has commercial insurance or can pay out of pocket, but it's still a steady flow of money. 

With Medicaid cuts, that flow of money will be lower, and that'll affect hospital finances once again. What would happen is it may risk putting another hospital in the kind of position where it has to be acquired — or the worst case would be if it has to close — because they don’t have an adequate stream of income. I'd say it's another pitfall for hospital financial people to get through. It's not a good thing. It's a stream of income that is going to be lower, and that's not what the hospitals need right now, especially hospitals on shaky ground.

Melanie Plenda:

What stories have been done so far? What’s coming next? 

Jeff Feingold:

The stories that have been done so far are the piece by Meera, and a second piece on the Health Care Consumer Protection Advisory Commission. She did a really thorough look at that, and that actually inspired us to do future stories, such as what's the deal with primary care in New Hampshire? Because a lot of primary care practices have shut down or there's just not enough primary care physicians in New Hampshire to provide for people to make appointments. She's  also looking at the state of primary care in New Hampshire and what is basically happening with labor and delivery and other services as they are being cut. 

Another piece that's coming up is an article by Paul Cuno Booth, formerly of New Hampshire Public Radio. We're lucky to have him working with us now. He's writing about the demise of that Certificate of Need Board, and, more specifically, what's going on with oversight. How is New Hampshire going to be able to get this information?

Another piece that we're working on is on the role of urgent care facilities, which is really interesting because it turns out because of this shortage of primary care physicians, people are going to urgent care, or they're even encouraged to go to urgent care, for what they used to go to for primary care support. That's a really interesting topic all by itself.

Melanie Plenda:

How can people follow these stories?

Well, they can certainly go to our website and check out our Critical Conditions page. But many of our partners are picking these stories up. I would encourage them to look there because I know that several of them pick up everything we've been writing on this, and just judging by the interest in these they're really eager to publish our work. 

It's a story that affects a lot of people. A lot of people are interested and I think that we're coming up with some great information that people will be happy to find out about.

Melanie Plenda:

Interesting! Jeff Feingold, editor with the Granite State News Collaborative, thank you for joining us. 

“The State We’re In” is a weekly digital public affairs show produced by NH PBS and The Marlin Fitzwater Center for Communication at Franklin Pierce University. It is shared with partners in the Granite State News Collaborative, of which both organizations are members. For more information, visit collaborativenh.org.

(Full Version) New Hampshire’s ‘favorable’ conditions for hospital acquisitions

By Meera Mahadevan, Granite State News Collaborative

Why are big out-of-state hospitals eager to make a foray into the New Hampshire health care market? The answer partly lies in the fact that the state is uniquely situated, both geographically and politically.

Josephine Porter, strategic advisor for the N.H. Center for Justice & Equity, says when a community hospital is acquired, ‘there is concern that the benefit the hospital provides to the community no longer reflects the community needs.’ (N.H. Center for Justice & Equity photo)

Access to more patients just across the state border is attractive to hospitals in Massachusetts that have faced uphill regulatory battles in their own state, analysts say. New Hampshire also does not have large employers, like Massachusetts does, with the muscle to push for change in health care costs.

“New Hampshire, despite being small — the patient mix tends to be favorable,” said Josephine Porter, strategic adviser for the N.H. Center for Justice & Equity. “There’s good health insurance coverage (here), on the commercial side.”

Of New Hampshire’s 1.4 million residents last year, about 62%, 853,000 people, received private health insurance through their employer or by purchasing their own coverage, according to Lucy Hodder, director of Health and Life Sciences Law and Policy programs at the University of New Hampshire’s Franklin Pierce School of Law. Her data shows that 16% had Medicare and 9% Medicaid.

In addition, Porter said, “if I’m a big hospital system, and if there's an opportunity to explore a merger and acquisition, there is some benefit to looking at New Hampshire because the process isn’t as arduous here as it might be in someplace else.”

A decade ago, New Hampshire got rid of one big regulatory hurdle: the Certificate of Need Board. It required New Hampshire hospitals and clinics to get state permission before building or expanding facilities. New Hampshire formed the board in 1979 but shuttered it in 2016 after a long legislative battle over the board’s pluses and minuses. Critics said it created obstacles by requiring that, before a facility was built, evidence had to be produced to show it was needed. 

“There are other states where there are more stringent certificate of need boards and regulatory authorities,” Porter said. “There are certain parameters that have to be addressed that New Hampshire doesn’t have. There are many more steps in other states than what New Hampshire has.”

Lucy Hodder, director of the Health and Life Science Policy programs at the University of New Hampshire’s Franklin Pierce School of Law, says price pressures on hospitals could continue the consolidation trend. (Franklin Pierce School of Law photo)

Currently, the state Attorney General’s Office is the only entity overseeing hospital mergers through its antitrust bureau and charitable trusts unit. The state Insurance Department reviews health plan proposals for insurance premium increases and evaluates them, but it does not have a say over mergers. The Department of Health and Human Services licenses facilities, but also does not oversee mergers. 

The Attorney General’s Office has been ringing the alarm bell over hospital consolidations and their potential to reduce competition for the last several years. In fact, in 2022, it opposed Dartmouth-Hitchcock’s plan to purchase Granite One Health, a combined entity that included Catholic Medical Center in Manchester, saying the move would limit competition.

But earlier this year, Attorney General John Formella said he was compelled to approve HCA’s acquisition of Catholic Medical Center, in part because the Manchester hospital was in such dire financial situation that patients stood to lose services entirely if it shut down. So with the approval, the AG sought what he called compromises, including a requirement that hospital systems acquiring a New Hampshire asset would have to contribute money that would benefit New Hampshire health care consumers. 

The Legislature established a trust fund, known as the Healthcare Consumer Protection Trust Fund, and would direct the hospital that is doing the buying to contribute money toward the fund. Under that directive, Beth Israel Lahey, following its purchase of Exeter Hospital in June 2023, was required to deposit $10 million over 10 years into the trust fund. And HCA must pay $7.5 million over 10 years. 

“As we welcome a large out-of-state system into New Hampshire, we must be mindful of the potential risks the transaction poses to health care consumers,” Formella said after Beth Israel Lahey purchased Exeter Hospital two years ago.

In addition to the trust fund, the Healthcare Consumer Protection Advisory Commission was formed to help advise the AG on how to spend and manage that money. Expenditures from the fund need approval from the seven-member commission, the governor, and the N.H. Executive Council. The commission has been meeting monthly since July 2024. It is composed of the AG himself or a designee by him, two state lawmakers, a state insurance department designee, chief legal officer at the NH Department of Health and Human Services, and two members of the public, including one physician. 

Regulators have also stipulated that trust fund spending should prioritize forming a research entity to monitor, analyze and publicly report on the New Hampshire health care market. 

Toward that end, the advisory commission received proposals from the University of New Hampshire and Dartmouth College, and UNH was selected. Last November, the commission voted to spend up to $1.6 million from the trust fund for a three-and-a-half-year contract with UNH to create the Center for Studying Healthcare Markets. The governor and the executive council approved it on May 21. 

The goal is to evaluate the impact of health care consolidation and examine regional best practices from neighboring states in New England. Bradley Herring, a professor of health economics at UNH, will lead the research. 

In addition, commission members said transportation needs are atop New Hampshire patients’ concerns and they discussed whether a portion of the trust fund should be used to help people get to and from their appointments.

In light of consolidation, “we hope to look at things like, is it harder to get to a doctor? Does it cost more to get services I need? Can I have access to hospital-based services the same way I had before?” said Yvonne Goldsberry, chair of the commission. “Our goal is to get out there and hear different cases. We want to hear from consumers what the impacts have been from the consolidations and then hopefully we will be better informed about what to use the money for. “

Lobbyists have also asked the commission to explore the idea of what is known as a cost-growth benchmark, similar to policies in Massachusetts, Rhode Island and Vermont. It’s a cost-containment strategy that limits how much a state’s health care spending can grow each year. 

In addition, some are asking the state to establish a patient advocate office to help contain costs and hold the industry accountable.

In a statement to the commission in February, Jake Berry, vice president of policy at Concord-based health care advocacy group New Futures, said: “While New Hampshire has successfully implemented an Office of the Consumer Advocate to represent residential customers of the state’s regulated public utilities, and an Office of the Child Advocate to ensure the best interests of New Hampshire children are protected, the state does not have a similar independent agency to advocate on behalf of New Hampshire health care consumers and patients.”

Now, the health commission is beginning to study the impact of consolidations on consumers with a series of public hearings, including one planned in Exeter in June and one in Claremont in July.

The first hearing held by the state Healthcare Consumer Protection Advisory Commission on May 28 in Rochester attracted some 75 people, many of whom offered comments about the effects of the 2020 acquisition of Frisbie Hospital by the for-profit HCA Healthcare. Speakers included employees of the hospital, who praised the merger, and members of the public decried the deal, citing facilities closures and failure to be notified about changes in medical staff. (Photo by Meera Mahadevan)

The first hearing, held May 28 in Rochester, attracted over 75 people, with several HCA employees and a few members from the public showing up to speak. 

Nurses and hospital administrators at Frisbie praised the merger in their presentations to the commission, citing positive turnaround data, including shorter wait times at the ER. But members of the public who spoke said facility closures and patients not being properly notified of doctor departures following the Frisbie acquisition had been very difficult for them. 

“I’m a survivor of mergers and acquisitions,” said Marsha Miller, an 81-year-old Rochester resident who lives across from the hospital, but she added that Frisbie is no longer “her” hospital.

“I have institutional memory of what Frisbie used to be and what it is for my husband who is very ill. The lack of care in the ER is why we became patients at Wentworth-Douglass Hospital. … People who left took their institutional memory with them.” She said facility closures in Sanbornville and Barrington in 2021 – a year after HCA’s acquisition of Frisbie – were some of patients’ first introductions to HCA. 

“We have to deal with perceptions, which is that HCA is bad,” she told the commission. Referring to HCA employees’ favorable comments about the merger, she added: “Nobody knows all of these wonderful things. These changes are not a part of my reality. … I want to be clear. This community relies on Frisbie and its foundation.”

The commission hopes to hear more from people about how the hospital mergers have affected their lives.

“A lot has happened in the health care industry,” Formella told the audience in Rochester. “We are going to continue to see a lot of change. And we are going to need to be having a lot of conversation – a lot of thoughtful dialogue about where the state goes from here.” 

He told reporters after the hearing that asking the public to speak at a podium in front of a row of commission members might not be the most effective way of soliciting comments. He said it might be less intimidating and more productive for two or three commissioners to meet the public in a coffee shop. 

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey at https://tinyurl.com/3au39uct about your healthcare experiences. For more information, visit collaborativenh.org.

(Full Version) Amid a flurry of hospital mergers, what is the effect on health care in New Hampshire?

Industry consolidation raises concerns about cost, access and impact on patients

By Meera Mahadevan, Granite State News Collaborative

Editor's Note: This story is part of Critical Condition, a special series co-produced by the Granite State News Collaborative and its local news partners. Together, we’re exploring how hospital consolidation is reshaping health care in New Hampshire—impacting costs, access, and the future of care in our communities. We want to hear from you: Tell us about your experience with health care in New Hampshire.

Map of Hospital Transactions 2025

Financial pressures, staffing shortages and scarce regulatory oversight have led to a  frenzy of consolidations among hospitals in New Hampshire in recent years.

That frenzy has raised significant concerns about reduced access to health care and the quality of that care at a time when patients are increasingly worried about ever-rising health care costs.

Of the state’s 26 acute care hospitals, only five remain stand-alones. And some of the state’s largest recent hospital acquisitions have been made by large out-of-state organizations, including a for-profit health company based in Tennessee and giant academic medical centers in Massachusetts, leaving some to wonder if they have their fingers on the pulse of New Hampshire residents’ health care needs. 

Further complicating the issue is that the Granite State has not routinely or formally tracked the impact of these mergers and acquisitions on patients and does not have research data that would shed light on cost, access and workforce implications. 

But that could soon change with the recent post-merger formation of the seven-member Healthcare Consumer Protection Advisory Commission, which will advise the state attorney general’s office on these matters.

Lucy Hodder, director of the Health and Life Science Policy programs at the University of New Hampshire’s Franklin Pierce School of Law, says price pressures on hospitals could continue the consolidation trend. (Franklin Pierce School of Law photo)

“I think the pressures on health care providers and health systems are significant,” said Lucy Hodder, director of Health and Life Sciences Law and Policy programs at the University of New Hampshire’s Franklin Pierce School of Law, and one of the state’s leading experts on health care policy.

“With policies reducing access to health insurance for many, and the costs and losses to health plans associated with specialty drugs like GLP1s (weight-loss drugs such as Ozempic and Wegovy), there will be lots of pressure on hospitals to reduce rates,” Hodder said. “This will result in more consolidations. Our biggest problem? We don’t have a plan.”

While hospitals say consolidations benefit patients and are inevitable amid rising costs, doctors on the front lines say their patients often feel left behind.

“There was this whole patient population which was totally devastated,” said Dr. Archana Bhargava, a medical oncologist who worked for 18 years at Frisbie Memorial Hospital in Rochester, which was bought in 2020 by Nashville-based HCA, the country’s largest for-profit health system.

HCA eventually whittled down Frisbie’s cancer unit and completely shut down its labor and delivery division. 

The closure of the cancer unit, Bhargava said, “was really hard. Every day there were only tears.They didn’t know how they were going to travel even beyond what they were already traveling to come to Frisbie.”

Access to care “is a very, very big issue” when hospitals consolidate, she said, and “when big systems decide to pick up a failing, smaller community hospital, there should be a certain level of responsibility for access to care.” 

A survey of 1,300 New Hampshire residents conducted by the Altarum Institute, a health care-focused research and consulting firm, revealed that Granite Staters are concerned about hospital costs, in addition to overall health care burdens.

Sixty-nine percent of survey responses identified hospitals as a primary contributor to rising health care costs, said Sam Burgess, health care policy coordinator at the advocacy group New Futures, which partnered with Altarum.

A look at the mergers 

HCA Healthcare Inc., which operates 182 hospitals in the U.S. with total revenue of $70.6 billion in 2024, established its New Hampshire presence in New Hampshire in 1983, when it acquired Portsmouth Regional Hospital and Parkland Medical Center in Derry. Its market share in the state grew bigger this year when the company’s purchase of Catholic Medical Center in Manchester was approved.

In addition, academic centers across the border in Massachusetts — which have faced tough opposition to expansion from their own state regulators — have been eager to add patients by dipping into the New Hampshire market. For example, Massachusetts General Hospital acquired Dover’s Wentworth-Douglass Hospital in 2017, and the Beth Israel Lahey health system acquired Exeter Hospital in 2023.

In addition, Dartmouth-Hitchcock, the state’s largest health system, which now owns five hospitals — Alice Peck Day in Lebanon, Cheshire Medical Center in Keene, New London Hospital and Valley Regional in Claremont — along with its flagship academic medical center in Lebanon. 

New Hampshire is not alone in the consolidation wave. Nationally, about 2,000 hospital and health system mergers were announced from 1998 to 2023, according to KFF, a California-based health policy research and polling organization formerly known as Kaiser Family Foundation. 

The percentage of community hospitals that are part of a larger health system increased from 53% in 2005 to 68% in 2022. And, the share of physicians working for a hospital or a practice owned at least partially by a health system increased from 29% in 2012 to 41% in 2022.

Health care mergers and acquisitions can take many forms and get quite complicated. They can happen when a health system acquires a hospital within the same market or state, known in the industry as horizontal mergers. When a hospital or an insurance company acquires an independent physician practice, it’s known as a vertical merger. A cross-market merger happens when two providers that operate in different geographic markets merge. And, entities can form affiliations without an outright ownership deal — known as soft consolidations. Moreover, corporations such as CVS, Amazon, and UnitedHealth, along with private equity firms, have acquired many physician practices.

Efficiencies and higher costs

Hospital officials say mergers offer benefits, such as efficiency in supply chains and shared resources among merged entities. And if an acquisition prevents an outright hospital closure, it may help preserve jobs and medical services that would otherwise be eliminated.

Steve Ahnen, president of the N.H. Hospital Association, says patients benefit when a smaller hospital partners with a larger institution because it provides access to specialists and specialty services. (N.H. Hospital Association photo)

Steve Ahnen, president of the N.H. Hospital Association, said patients benefit when a small hospital partners with larger institutions because it gains access to specialists and specialty services. 

“The cost of employing the high-quality level of doctors, nurses and technicians to provide lifesaving care continues to go up,” Ahnen said. “Our operating challenges have gone up. We also face a number of challenges from payers. 

“There has also been a significant consolidation in the payer market, which has given rise to significant challenges as hospitals negotiate rates. Plans are finding more and more ways of denying care, creating this mousetrap.”

But health care analysts say consolidations generally lead to higher prices and don’t always show clear gains in either access or quality of care. Costs often rise after consolidation because hospitals negotiate with insurers to determine prices, and a health system’s bargaining power increases when it owns several hospitals in the same market.

Burgess, the health policy analyst at New Futures, said, “HCA has a strong foothold in the state, and that’s likely to reduce bargaining power for health plans in the state,” perhaps leading to higher costs for insurers.

Not much data on patient care

A hospital’s quality of care can be measured in many ways, such as patient experience, one-year mortality rates, 30-day readmission rates, the rates of MRSA (a type of antibiotic-resistant bacteria) and other infections, safety problems, surgery problems, and what steps a hospital took to prevent errors. 

But data does not exist specifically on how mergers have affected quality of care at New Hampshire hospitals. 

As a KFF research brief notes, “There are many dimensions and measures of quality that have been or could be used to assess the effects of consolidation and it could take time for changes in quality to materialize.”

Hard data does exist, however, when it comes to costs going up after a merger or acquisition. For instance, Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University, testified in front of a U.S. House subcommittee in 2019 that consolidation leads to substantial price increases. 

Research has shown “that hospitals and doctors who face less competition charge higher prices to private payers, without accompanying gains in efficiency or quality,” Gaynor told lawmakers. “Research shows the same for insurance markets. Insurers who face less competition charge higher premiums, and may pay lower prices to providers.”

Gaynor said one analysis found that prices at hospitals acquired by out-of-market hospital systems increase about 17% more than prices at unacquired, stand-alone hospitals.

Consolidations can also result in workforce cutbacks, as the merged entities seek efficiencies that can take a toll in New Hampshire, where health care is the largest workforce sector. That status is a big change from 10 years ago, when retail and trade was the largest employment sector, said Annette Nielsen, an economist with the state Economic and Labor Market Information Bureau. As of March 2025, the health care sector employed 99,700 people in New Hampshire.

Most recently, in February — almost five years after announcing its intent to purchase Wentworth Douglass Hospital — Mass General Brigham announced a series of layoffs,  the largest in the health system’s history. About 1,500 non-clinical employees lost their jobs throughout its network of hospitals, including in New Hampshire.

Another concern about hospital consolidations, say doctors and analysts, is that out-of-state entities don’t always have an accurate picture of what a New Hampshire community needs.

Josephine Porter, strategic advisor for the N.H. Center for Justice & Equity, says when a community hospital is acquired, ‘there is concern that the benefit the hospital provides to the community no longer reflects the community needs.’ (N.H. Center for Justice & Equity photo)

“If you’re getting acquired by an organization that is not local, the decision-making authority for what community benefit looks like is also not local,” said Josephine Porter, strategic adviser for the N.H. Center for Justice & Equity, a nonprofit that advances issues of health equity. “There is concern that the benefit the hospital provides to the community no longer reflects the community needs. That community benefit does need to address hyperlocal priorities, and if those decisions are not being made locally, then there can be a problem.”

‘Nobody cares for us’

One of the biggest concerns for members of the state’s Health Care Consumer Protection Advisory Commission is the impact that mergers have on a patient’s access to care, including maternity and behavioral health services. 

They have good reasons to be nervous.

HCA shut down its labor and delivery services at Frisbie Memorial Hospital two years after purchasing it, even though it originally said it would not do so until five years after the merger. Obstetrics tends to be a high-cost venture for hospitals, with less-than-attractive returns. Birth rates are also going down in New Hampshire, making it harder for hospitals to continue to offer services, and making it difficult for patients to get access to the services elsewhere.

“You know how many patients I used to get at Frisbie who did not have a car that would function and be reliable?” said medical oncologist Bhargava. And, she said, even if they had a family member who could drive, that person would often be working and not be able to take time off. 

“There were many times we had patients who were completely unsupported,” Bhargava said, “and God bless these nurses; sometimes I’ve seen nurses slip in taxi money for these patients to get back home.

“You start traveling from Rochester until you hit a wealthy pocket in Wolfeboro and a wealthy population here and there, but the rest of New Hampshire is very underserved,”  Bhargava said. “There are very socially and economically challenged people. If they don’t have health care close to them, they are going to die in their homes. Imagine an elderly couple living on some measly Social Security income. Do you think they will have an hour and half to go to Dover or Portsmouth?

“I had a patient who used to live in Ossipee,” Bhargava said. “She said — literally with tears – ‘Nobody cares for us because we are poor.’ It was a very sad thing to hear. Many of these patients (fall) in the poor category but that doesn’t mean they are illiterate. They wrote a lot of letters to the governor asking why isn’t health care closer to home for them and obviously it didn’t get heard.”

Staff shortages 

But the hospitals argue they are facing enormous challenges of their own. More than one-third of nonprofit acute care hospitals in the state reported they’re running in the red, said Ahnen, the state hospital association president. 

He said workforce shortages have led to high job-vacancy rates across all hospital departments — 14% for nurses, 20% for surgical technicians, 22% for respiratory therapists — even as health-care needs have kept hospital beds full, to the point where they cause a backlog in the emergency department. 

Ahnen also said studies reporting that costs go up after a merger are skewed and are not always accurate. 

“That research relies on outdated studies,” Ahnen said. “Charles River Associates also does studies, and it shows that hospital consolidations resulted in higher quality and lower cost.”

While hospitals struggle, independent companies see an opportunity.

For instance, Derry Imaging — which has seven locations in New Hampshire — is working to attract patients to use its services by directly comparing its cost for an x-ray with what a hospital charges for the same service. 

The company advertises that patients can save 40% to 70% over “expensive hospital imaging costs.” On its website, it says the average cost of a chest x-ray at a Derry Imaging facility can cost $95, compared to what it says is an average cost of $390 at hospitals within 15 miles of the company’s facilities. It also lists average costs for ultrasounds, CT scans and MRI scans at its facilities — all lower than the cost it cites at hospitals.

“MRI services at other providers or hospitals can cost as much as $3,000,” the company says on its website. “At Derry Imaging, the same MRI scan can be 40-70% lower. For patients with large out-of-pocket costs, that price can make a huge impact on your budget.”

‘Difficult to survive’

Experts predict the hospital consolidation trend will continue in New Hampshire over the next several years.  

The first hearing held by the state Healthcare Consumer Protection Advisory Commission on May 28 in Rochester attracted some 75 people, many of whom offered comments about the effects of the 2020 acquisition of Frisbie Hospital by the for-profit HCA Healthcare. Speakers included employees of the hospital, who praised the merger, and members of the public decried the deal, citing facilities closures and failure to be notified about changes in medical staff. (Photo by Meera Mahadevan)

“The financing of the health care system is complicated — it causes a lot of pieces to have to move all at the same time in order to make change,” said Porter of the N.H. Center for Justice & Equity. 

“Hospitals have had a lot of change in the last 15 or 20 years, not just in treatments that are available, but the entire delivery system, with acquisition of physician practices,” she said. “We have had a movement from hospitals running a hospital to a hospital running a health care system that might have outpatient ambulatory care facilities or mobile X-ray units. 

“All these dynamics make for a complicated system, and we’ve seen a lot of change and seen a lot of struggle to keep up with that change and figuring out what the right financing model looks like.” 

The result, she said, is that “it’s going to continue to be difficult for a community hospital to survive without a larger infrastructure. My hope is that as it continues to happen, we solve for the need to have larger systems that can also solve for hyperlocal needs — the needs around transportation, which services are required. The recognition that lower volume, less profitable services have to be salvaged somehow. There’s room for innovation in these models.”

According to Hodder of Franklin Pierce School of Law, “We have always had a close relationship with health care providers in the community — our communities are attentive to hospitals. We have so many of them.

“It’s going to continue to put pressure on our hospitals to compete with each other, which will result in higher cost, which is eventually going to hurt the system, and there will be pressure to consolidate. Some are going to win and some are going to lose in the process.” 

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey athttps://tinyurl.com/3au39uctabout your healthcare experiences. For more information, visitcollaborativenh.org.

(Shorter Version) Amid a flurry of hospital mergers, what is the effect on health care in New Hampshire?

Industry consolidation raises concerns about cost, access and impact on patients

By Meera Mahadevan, Granite State News Collaborative

This story is part of Critical Condition, a special series co-produced by the Granite State News Collaborative and its local news partners. Together, we’re exploring how hospital consolidation is reshaping health care in New Hampshire—impacting costs, access, and the future of care in our communities. We want to hear from you: Tell us about your experience with health care in New Hampshire.

Map of Hospital Transactions 2025

Financial pressures, staffing shortages and scarce regulatory oversight have led to a frenzy of consolidations among hospitals in New Hampshire in recent years, raising significant concerns about reduced access to health care and the quality of that care at a time when patients are increasingly worried about ever-rising health care costs.

Of the state’s 26 acute care hospitals, only five remain stand-alones. And some of the state’s largest recent hospital acquisitions have been made by large out-of-state organizations, including a for-profit health company based in Tennessee and giant academic medical centers in Massachusetts, leaving some to wonder if they have their fingers on the pulse of New Hampshire residents’ health care needs. 

Further complicating the issue is that the Granite State has not routinely or formally tracked the impact of these mergers and acquisitions on patients and does not have research data that would shed light on cost, access and workforce implications. But that could soon change with the recent post-merger formation of the seven-member Healthcare Consumer Protection Advisory Commission, which will advise the state attorney general’s office on these matters.

Lucy Hodder, director of the Health and Life Science Policy programs at the University of New Hampshire’s Franklin Pierce School of Law, says price pressures on hospitals could continue the consolidation trend. (Franklin Pierce School of Law photo)

“I think the pressures on health care providers and health systems are significant,” said Lucy Hodder, director of Health and Life Sciences Law and Policy programs at the University of New Hampshire’s Franklin Pierce School of Law. “With policies reducing access to health insurance for many, and the costs and losses to health plans associated with specialty drugs like GLP1s (weight-loss drugs such as Ozempic and Wegovy), there will be lots of pressure on hospitals to reduce rates,” Hodder said. “This will result in more consolidations. Our biggest problem? We don’t have a plan.”

While hospitals say consolidations benefit patients and are inevitable amid rising costs, doctors on the front lines say their patients often feel left behind.

“There was this whole patient population which was totally devastated,” said Dr. Archana Bhargava, a medical oncologist who worked for 18 years at Frisbie Memorial Hospital in Rochester, which was bought in 2020 by Nashville-based HCA, the country’s largest for-profit health system.

HCA eventually whittled down Frisbie’s cancer unit and completely shut down its labor and delivery division. 

A survey of 1,300 New Hampshire residents conducted by the Altarum Institute, a health care-focused research and consulting firm, revealed that Granite Staters are concerned about hospital costs, in addition to overall health care burdens.

Sixty-nine percent of survey responses identified hospitals as a primary contributor to rising health care costs, said Sam Burgess, health care policy coordinator at the advocacy group New Futures, which partnered with Altarum.

A look at the mergers 

HCA Healthcare Inc., which operates 182 hospitals in the U.S. with total revenue of $70.6 billion in 2024, established its New Hampshire presence in New Hampshire in 1983, when it acquired Portsmouth Regional Hospital and Parkland Medical Center in Derry. Its market share in the state grew bigger this year when the company’s purchase of Catholic Medical Center in Manchester was approved.

Academic centers across the border in Massachusetts — which have faced tough opposition to expansion from their own state regulators — have been eager to add patients by dipping into the New Hampshire market. For example, Massachusetts General Hospital acquired Dover’s Wentworth-Douglass Hospital in 2017, and the Beth Israel Lahey health system acquired Exeter Hospital in 2023.

In addition, Dartmouth-Hitchcock, the state’s largest health system, which now owns five hospitals — Alice Peck Day in Lebanon, Cheshire Medical Center in Keene, New London Hospital and Valley Regional in Claremont — along with its flagship academic medical center in Lebanon. 

New Hampshire is not alone in the consolidation wave. Nationally, about 2,000 hospital and health system mergers were announced from 1998 to 2023, according to KFF, a California-based health policy research and polling organization formerly known as Kaiser Family Foundation. 

Efficiencies and higher costs

Steve Ahnen, president of the N.H. Hospital Association, says patients benefit when a smaller hospital partners with a larger institution because it provides access to specialists and specialty services. (N.H. Hospital Association photo)

Steve Ahnen, president of the N.H. Hospital Association, said patients benefit when a small hospital partners with larger institutions because it gains access to specialists and specialty services. 

“The cost of employing the high-quality level of doctors, nurses and technicians to provide lifesaving care continues to go up,” Ahnen said. “Our operating challenges have gone up. There has also been a significant consolidation in the payer market, which has given rise to significant challenges as hospitals negotiate rates. Plans are finding more and more ways of denying care, creating this mousetrap.”

But health care analysts say consolidations generally lead to higher prices and don’t always show clear gains in either access or quality of care. Costs often rise after consolidation because hospitals negotiate with insurers to determine prices, and a health system’s bargaining power increases when it owns several hospitals in the same market.

Not much data on patient care

Data does not exist specifically on how mergers have affected quality of care at New Hampshire hospitals. As a KFF research brief notes, “There are many dimensions and measures of quality that have been or could be used to assess the effects of consolidation and it could take time for changes in quality to materialize.”

Hard data does exist, however, when it comes to costs going up after a merger or acquisition. For instance, Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University, testified in front of a U.S. House subcommittee in 2019 that consolidation leads to substantial price increases. 

Research has shown, he said, “that hospitals and doctors who face less competition charge higher prices to private payers, without accompanying gains in efficiency or quality.”

Consolidations can also result in workforce cutbacks, as the merged entities seek efficiencies that can take a toll in New Hampshire, where health care is the largest workforce sector. Most recently, in February, almost five years after announcing its intent to purchase Wentworth Douglass Hospital, Mass General Brigham announced the largest number of layoffs in its history.  About 1,500 non-clinical employees lost their jobs throughout its network of hospitals, including in New Hampshire.

Another concern about hospital consolidations, say doctors and analysts, is that out-of-state entities don’t always have an accurate picture of what a New Hampshire community needs.

Josephine Porter, strategic advisor for the N.H. Center for Justice & Equity, says when a community hospital is acquired, ‘there is concern that the benefit the hospital provides to the community no longer reflects the community needs.’ (N.H. Center for Justice & Equity photo)

“If you’re getting acquired by an organization that is not local, the decision-making authority for what community benefit looks like is also not local,” said Josephine Porter, strategic adviser for the N.H. Center for Justice & Equity, a nonprofit that advances issues of health equity. “There is concern that the benefit the hospital provides to the community no longer reflects the community needs.”

‘Nobody cares for us’

One of the biggest concerns is the impact that mergers have on a patient’s access to care, including maternity and behavioral health services. 

HCA shut down its labor and delivery services at Frisbie two years after purchasing it, even though it originally said it would not do so until five years after the merger. Obstetrics tends to be a high-cost venture for hospitals, with less-than-attractive returns. Birth rates are also going down in New Hampshire, making it harder for hospitals to continue to offer services, and making it difficult for patients to get access to the services elsewhere.

“You know how many patients I used to get at Frisbie who did not have a car that would function and be reliable?” said medical oncologist Bhargava. And, she said, even if they had a family member who could drive, that person would often be working and not be able to take time off.” 

She added: “There are very socially and economically challenged people. If they don’t have health care close to them, they are going to die in their homes.”

‘Difficult to survive’

The hospitals argue they face enormous challenges of their own. More than one-third of nonprofit acute care hospitals in the state reported they’re running in the red, said Ahnen. 

He said workforce shortages have led to high job-vacancy rates across all hospital departments — 14% for nurses, 20% for surgical technicians, 22% for respiratory therapists — even as health care needs have kept hospital beds full, to the point where they cause a backlog in the emergency department. 

Experts predict the hospital consolidation trend will continue in New Hampshire over the next several years.  

The first hearing held by the state Healthcare Consumer Protection Advisory Commission on May 28 in Rochester attracted some 75 people, many of whom offered comments about the effects of the 2020 acquisition of Frisbie Hospital by the for-profit HCA Healthcare. Speakers included employees of the hospital, who praised the merger, and members of the public decried the deal, citing facilities closures and failure to be notified about changes in medical staff. (Photo by Meera Mahadevan)

According to Hodder of Franklin Pierce Law, with so many local hospitals in New Hampshire, “it’s going to continue to put pressure on our hospitals to compete with each other, which will result in higher cost, which is eventually going to hurt the system, and there will be pressure to consolidate. Some are going to win and some are going to lose in the process.”

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey at https://tinyurl.com/3au39uct about your healthcare experiences. For more information, visit collaborativenh.org.

(Shorter Version Critical Condition Sidebar) New Hampshire’s ‘favorable’ conditions for hospital acquisitions

By Meera Mahadevan, Granite State News Collaborative

Why are big out-of-state hospitals eager to make a foray into the New Hampshire health care market? The answer partly lies in the fact that the state is uniquely situated, both geographically and politically.

Josephine Porter, strategic advisor for the N.H. Center for Justice & Equity, says when a community hospital is acquired, ‘there is concern that the benefit the hospital provides to the community no longer reflects the community needs.’ (N.H. Center for Justice & Equity photo)

Access to more patients just across the state border is attractive to hospitals in Massachusetts that have faced uphill regulatory battles in their own state, analysts say. New Hampshire also does not have large employers, like Massachusetts does, with the muscle to push for change in health care costs.

“New Hampshire, despite being small — the patient mix tends to be favorable,” said Josephine Porter, strategic adviser for the N.H. Center for Justice & Equity. “There’s good health insurance coverage (here), on the commercial side.”

Lucy Hodder, director of the Health and Life Science Policy programs at the University of New Hampshire’s Franklin Pierce School of Law, says price pressures on hospitals could continue the consolidation trend. (Franklin Pierce School of Law photo)

Of New Hampshire’s 1.4 million residents last year, about 62%, 853,000 people, received private health insurance through their employer or by purchasing their own coverage, according to Lucy Hodder, director of Health and Life Sciences Law and Policy programs at the University of New Hampshire’s Franklin Pierce School of Law. Her data shows that 16% had Medicare and 9% Medicaid.

In addition, Porter said, “there is some benefit to looking at New Hampshire because the process isn’t as arduous here as it might be in someplace else.”

A decade ago, New Hampshire got rid of one big regulatory hurdle: the Certificate of Need Board. It required New Hampshire hospitals and clinics to get state permission before building or expanding facilities. New Hampshire formed the board in 1979 but shuttered it in 2016 after a long legislative battle over the board’s pluses and minuses. Critics said it created obstacles by requiring that, before a facility was built, evidence had to be produced to show it was needed. 

“There are other states where there are more stringent certificate of need boards and regulatory authorities,” Porter said. “There are many more steps in other states than what New Hampshire has.”

Currently, the state Attorney General’s Office is the only entity overseeing hospital mergers through its antitrust bureau and charitable trusts unit.

The Attorney General’s Office has been ringing the alarm bell over hospital consolidations and their potential to reduce competition for the last several years. In fact, in 2022, it opposed Dartmouth-Hitchcock’s plan to purchase Granite One Health, a combined entity that included Catholic Medical Center in Manchester, saying the move would limit competition.

But earlier this year, Attorney General John Formella said he was compelled to approve HCA’s acquisition of Catholic Medical Center, in part because the Manchester hospital was in such dire financial situation that patients stood to lose services entirely if it shut down. 

The Legislature established a trust fund, known as the Healthcare Consumer Protection Trust Fund, and would direct the hospital that is doing the buying to contribute money toward the fund. Under that directive, Beth Israel Lahey, following its purchase of Exeter Hospital in June 2023, was required to deposit $10 million over 10 years into the trust fund. And HCA must pay $7.5 million over 10 years. 

In addition to the trust fund, the Healthcare Consumer Protection Advisory Commission was formed to help advise the AG on how to spend and manage that money. Expenditures from the fund need approval from the seven-member commission, the governor, and the N.H. Executive Council. The commission has been meeting monthly since July 2024.

Last November, the commission voted to spend up to $1.6 million from the trust fund for a three-and-a-half-year contract with the University of New Hampshire to create the Center for Studying Healthcare Markets. The goal is to evaluate the impact of health care consolidation and examine regional best practices from neighboring states in New England.

In addition, some are asking the state to establish a patient advocate office to help contain costs and hold the industry accountable.

The health commission has begun holding a series of public hearings, including one planned in Exeter in June and one in Claremont in July.

The first hearing, held May 28 in Rochester, attracted over 75 people, with several HCA employees and a few members from the public showing up to speak. 

The first hearing held by the state Healthcare Consumer Protection Advisory Commission on May 28 in Rochester attracted some 75 people, many of whom offered comments about the effects of the 2020 acquisition of Frisbie Hospital by the for-profit HCA Healthcare. Speakers included employees of the hospital, who praised the merger, and members of the public decried the deal, citing facilities closures and failure to be notified about changes in medical staff. (Photo by Meera Mahadevan)

Nurses and hospital administrators at Frisbie praised the merger in their presentations to the commission, citing positive turnaround data, including shorter wait times at the ER. But members of the public who spoke said facility closures and patients not being properly notified of doctor departures following the Frisbie acquisition had been very difficult for them. 

“I have institutional memory of what Frisbie used to be and what it is for my husband who is very ill,” Marsha Miller, an 81-year-old Rochester resident who lives across from the hospital, told the commission. “We have to deal with perceptions, which is that HCA is bad.”

Referring to HCA employees’ favorable comments about the merger, she added: “Nobody knows all of these wonderful things. These changes are not a part of my reality.”

Attorney General Formella, told the audience, “A lot has happened in the health care industry. … And we are going to need to be having a lot of conversation – a lot of thoughtful dialogue about where the state goes from here.” 

This story is part of Critical Condition: What hospital consolidation means for care, access, and your community, a special series co-produced by partners in the Granite State News Collaborative. These stories are being shared by media outlets across New Hampshire. We want to hear from you! Take our short survey athttps://tinyurl.com/3au39uctabout your healthcare experiences. For more information, visitcollaborativenh.org.