Speakers praise Valley Regional, Dartmouth Health merger at Claremont event

Lukas Dunford, Valley News

CLAREMONT — Legislators and hospital workers largely lauded the merger of Valley Regional Hospital and Dartmouth Health, which was finalized last summer, at a forum hosted this week by the New Hampshire Healthcare Consumer Protection Advisory Commission.

They also raised concerns about broader health care issues during the forum, which took place at Claremont Savings Bank Community Center on Wednesday.

“Here in rural New Hampshire, and the valley is rural, we’re seeing a lot less opportunity for small community hospitals to survive in the model that they had in the past, and we need to consider that moving forward,” said Claremont resident Jim Esdon, program coordinator of Dartmouth Health Children’s Injury Prevention Center. “Dartmouth Health brings those resources and that really strong community component to this.”

Dr. Matt Foster, President and CEO of Valley Regional Hospital and Mt. Ascutney Hospital and Health Center, speaks during a public meeting held by the New Hampshire Health Care Consumer Protection Advisory Commission at the Claremont Savings Bank Community Center in Claremont, N.H., on Wednesday, July 23, 2025. Foster noted that many attendees spoke about issues like transportation, access to food and housing for health care workers. "We have to think beyond the four walls of a hospital," he said, in order to improve community health outcomes. (Valley News - Alex Driehaus) Valley News — Alex Driehaus

Established by the New Hampshire Legislature in 2023, the commission holds state proceeds received from the settlements and judgments of health care mergers. The commission, which is part of the New Hampshire Department of Justice, uses the money “for the purpose of benefiting New Hampshire healthcare consumers,” according to its website.

As part of last summer’s merger between Dartmouth Health and Valley Regional, Dartmouth Health agreed to pay $2 million to the state commission.

The Claremont forum, which drew more than 60 people, was the second the commission has held so far, and was a part of its planning process for allocating its resources. The first forum took place in May in Rochester, N.H., where many community members gave testaments about their access to health care decreasing. They also asked for continued conversation with for-profit Hospital Corporation of America, which acquired Rochester’s Frisbie Memorial Hospital in 2020, according to the commission’s draft minutes.

The commission has around $20 million to spend over the next eight to 10 years and wants to direct it toward the issues they find in common among health care consumers across the state, said New Hampshire Attorney General John Formella, a member of the commission.

The commission’s first project was to launch a new research center at the University of New Hampshire to study the impact of mergers on the health care market in the state. Last October, the commission invested $1.6 million into the research center to be used over four years.

As hospitals trend toward consolidation, the state’s attorney general is responsible for enforcing antitrust laws, which seek to prevent monopolies from forming.

“When smaller community hospitals become part of larger health care systems, that can do a number of things,” Formella, a Hanover High School graduate, said. “It can cause competition to go down, it can cause loss of services in the local community, it can cause prices to go up, (but) it can certainly bring benefits as well.”

Those who spoke at the meeting were generally in support of the merger between Valley Regional and Dartmouth Health, which operates nine hospitals and clinics in New Hampshire and Vermont.

New Hampshire Attorney General John Formella, center, speaks during a public meeting while seated between fellow members of the New Hampshire Health Care Consumer Protection Advisory Commission, Chair Yvonne Goldsberry, left, and Dr. Marie Ramas at the Claremont Savings Bank Community Center in Claremont, N.H., on Wednesday, July 23, 2025. The meeting was intended to serve as an opportunity for members of the public to share their experiences with the health care system, in particular following Valley Regional Hospital's merger with Dartmouth Health. (Valley News - Alex Driehaus)

“I think that there is a lot that is really promising about this connection between Dartmouth Health and Valley Regional Hospital,” Executive Councilor Karen Liot Hill, D-Lebanon said, citing increased access to Dartmouth Health’s resources for the Claremont area that comes with the merger.

People also spoke about broader issues, including housing, transportation and nutrition.

In a recent assessment of the needs of Dartmouth Health’s five-hospital region in New Hampshire, the clearest issue was “the competition between social needs of life and health care needs,” Greg Norman, senior director of community health at Dartmouth Health, said at the meeting.

The assessment found that access to secure housing, reliable transportation, child care and affordable food have gotten “profoundly, overwhelmingly worse in terms of health in our communities” Norman said.

Liot Hill also suggested that access is a particular challenge for rural communities.

“I am here particularly to advocate for transportation to be something that you consider,” said Liot Hill. She suggested that the Advance Transit model in Lebanon and Hanover, which Dartmouth Health significantly invests in, be adopted for Valley Regional access.

State Rep. Hope Damon, D-Croydon, proposed expanding food security funding and preventive care: “If we made access (to diabetes) treatment more readily available, we would enormously save in preventing complications,” Damon said.

Matthew Foster, CEO of both Valley Regional and Mt. Ascutney Hospital and Health Center in Windsor, emphasized Valley Regional must expand its partnerships to other service providers.

“We have to think beyond the four walls of the hospital if we’re going to improve the health of Sullivan County and Claremont,” Foster said.

Gary Merchant, a former Democratic state representative and former manager of business and technology at Dartmouth Hitchcock, suggested renewing River Valley College’s health programs through the resources of Dartmouth Health.

The health programs, including occupational therapy assistant and licensed practical nurse programs, were once “booming” with an enrollment over 1,000, but were grappling with housing issues at the time, said Chuck Kusselow, the former director of admissions of River Valley Community College and current member of the Advisory Committee for Dartmouth Health’s Geriatric Center of Excellence.

The college discussed building a dorm for the programs, as one of the major issues was students not having a place to stay, Kusselow said.

Jim Esdon, center, of Claremont, N.H., speaks from the audience during a public meeting held by the New Hampshire Health Care Consumer Protection Advisory Commission at the Claremont Savings Bank Community Center in Claremont, N.H., on Wednesday, July 23, 2025. Edson emphasized the importance of community health workers in connecting people to resources that they may not otherwise have access to. (Valley News - Alex Driehaus) Valley News photographs — Alex Driehaus

Formella proposed that the commission could set up housing and/or tuition stipends for such students. “There might be some large medical organization in the area that wants to partner with us on that,” he said, smiling at Dartmouth Health officials.

Largely absent from the event were community members, as most speakers were either people who had worked for the two hospitals or elected officials — many checking both boxes.

Toward the end of the meeting, Formella expressed a desire to hear from more unaffiliated community members.

“I’m mindful of the fact that most people are not going to want to come to a meeting like this and stand at a podium, and talk to us in this format,” Formella said. “And so, that’s one of the takeaways I have from tonight in our future.”

Lukas Dunford can be reached at ldunford@vnews.com or 603-727-3208.

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.

NH’s Maternity Deserts

Sheryl Rich-Kern, Business NH Magazine

The hour-long drive from Colebrook to Berlin winds through a rugged stretch of dense forests, river views and quaint towns scattered across the North Country. It’s pretty, but for Hayley Wallace, a mother of three kids, it’s a long haul.

Wallace, whose three children range in ages from 5 to 12, has been pregnant five times, the last two as a surrogate. The most recent baby was delivered in March for the intended parents. While many view surrogacy as an emotional challenge, Wallace says the real test was logistical.

The drive to prenatal appointments at Androscoggin Valley Hospital (AVH) in Berlin was manageable, but when blood tests revealed anemia at 28 weeks, she faced a two-and-a-half-hour commute each way to Dartmouth Health in Lebanon for regular monitoring.

“It made it really difficult to try and get my kids to school and figure out who was going to pick them up,” she says. “I mean, I made it work because I had to make it work. But it was more difficult than it needed to be.”

Wallace’s struggle is becoming more common. In 2000, there were 26 hospitals with labor and delivery units; today there are 15. The closures, driven by declining birth rates, financial pressures and staff shortages, are turning large swaths of the state into maternity care deserts.

This isn’t solely a NH problem. A study in the Journal of the American Medical Association reported more than 500 hospitals in the U.S. closed their maternity departments since 2010, mostly in rural areas. 

Demographic shifts have accelerated the trend. In 2023, NH recorded its lowest birth rate since 1979, according to the Carsey School of Public Policy. Fewer unplanned pregnancies, thanks to publicly supported family planning centers and other educational resources, have also contributed. In 2022, NH had the lowest rate of teen pregnancies in the U.S., according to the Centers for Disease Control and Prevention.

At the same time, rising costs for childcare, education and housing prompt some women to delay having kids or opt out entirely. “We’d be remiss not to include the lack of maternity care into the equation,” says Mackenzie Nicholson, senior director at MomsRising NH, a policy advocacy organization for women and moms. Prospective parents, she notes, want to live where medical care is close to home.

That’s becoming a tougher proposition. Maternity care is one of the costliest services hospitals provide. From 2018 to 2020, pregnancy, childbirth, and postpartum care cost an average of $18,865 per delivery, with nearly $3,000 in out-of-pocket expenses for parents with private insurance, according to the Peterson-KFF Health Tracker. Since then, those figures have continued to climb. Insurers often fail to fully reimburse providers, leaving hospitals to absorb significant losses.

Staffing shortages compound the strain, says Dr. Karen Maynard, an obstetrician at Southern NH Health in Nashua and a member of its board of trustees. Births rarely happen on a set schedule, meaning hospitals must staff highly trained nurses and anesthetists around the clock.

The COVID-19 pandemic only deepened the crisis. “A lot of people in the medical field that were on the edge of thinking, ‘I may want to step out,’ stepped out,” Maynard says.

Grant Expands Access in North CountryIn Coös County, the state’s most rural and largest county, maintaining maternity services remains critical, says Natalie Valliere, clinical coordinator for women’s services at Androscoggin Valley Hospital (AVH). She points out that Upper Connecticut Valley Hospital closed its labor and delivery unit in 2003; Weeks Medical Center followed in 2008. That leaves AVH and Littleton Regional Hospital, both more than an hour away for many northern residents, as the only options.

A federal grant is helping to close that gap. Launched in 2023, the Rural Maternal Obstetric Management Strategies (RMom) program, funded by the Health Resources and Services Administration, supports pregnant and postpartum individuals in northern Grafton and Coös counties. The program brings together three area hospitals and centers like Coös County Family Health. It also collaborates with the North Country Health Consortium, the Family Resource Center in Gorham, and the Women of the Mountains Birth Initiative to provide education, support and home visiting services.

For example, a pregnant patient at 32 weeks experiencing blurred vision and headaches might end up at Androscoggin Valley Hospital with severe preeclampsia. Thanks to RMom funding, first responders are trained to spot and handle hypertensive emergencies, making sure the patient gets to the hospital safely. Nurses who shadowed specialists at Dartmouth Health can quickly assess the situation and arrange a transfer to Dartmouth’s Neonatal Intensive Care Unit.

Telehealth is also improving access. Pregnant women in places like Colebrook can now connect virtually with maternal-fetal medicine specialists at Dartmouth without making five-hour round trips.

A team of community health workers and doulas is also available to help families with transportation, food and other essentials. “These small community hospitals don’t see many high-risk patients, but they need to be ready for whatever walks through the door,” says Daisy Goodman, a nurse-midwife at Dartmouth Health.

Hospital MergersTo stay afloat, many small hospitals have merged—some with Dartmouth Health, the state’s largest nonprofit system, others with for-profit groups. The latest example was the financially strapped Catholic Medical Center (CMC) in Manchester, which was acquired by HCA Healthcare, one of the nation’s largest for-profit hospital chains.

That worries advocates like Nicholson, who points to Frisbie Memorial in Rochester. After merging with HCA in 2020 and pledging to maintain maternity care, the hospital closed its labor and delivery unit just two years later. “It’s concerning,” Nicholson says. “They [HCA] really do put profit over people.”

In a March 2023 press release about HCA reaching a settlement with the state to close labor and delivery services at Frisbie, the then Frisbie CEO stated, “The reduced number of babies delivered at the hospital and across the region, and the departure of OB/GYN caregivers necessitates the shift of labor and delivery services to our sister Portsmouth Regional Hospital facility and other community caregivers.”

If CMC were to close its maternity unit, it would increase pressure on Manchester’s only other hospital, Elliot Hospital, which delivered 2,248 babies in FY2024 and houses southern NH’s only Level III NICU, receiving transfers from hospitals like Portsmouth Regional.

In an April 15 press release, CMC said it “remains committed to providing compassionate, patient-centered maternity care,” averaging about 1,000 births annually. The hospital also plans to add five or six certified nurse midwives.

Any conversation about access must include equity, Nicholson says. More than 11% of NH’s population is non-white and continues to grow. Black and Latino women remain three to four times more likely to die during childbirth than white women. “That statistic should scare everyone,” Nicholson says.

Many experts predict that health care mergers will continue. Nationally, there were 72 hospital mergers and acquisitions in 2024, the most since the 79 deals in 2020, according to a Healthcare Financial Management Association report. Lucy Hodder, professor and director of health law programs at UNH Franklin Pierce School of Law, says these acquisitions can reduce access to essential care, as for-profit hospitals are quick to shutter unprofitable services like obstetrics in favor of high-margin procedures.

Some hospitals are investing in their labor and delivery programs. In April, Concord Hospital unveiled one of the 10 newly-renovated maternity suites at The Family Place, its labor and delivery practice. Mothers can deliver their babies in the suites where they stay and the rooms include upgraded amenities, including a jacuzzi tub for pain management.

Maternal health, Hodder says, extends beyond the delivery room. It includes prenatal and postpartum care, family planning and behavioral health—services that don’t make money but save lives.

When the opioid crisis surged, explains Hodder, health leaders moved to better support pregnant women struggling with addiction. A NH Moms in Recovery program catering to pregnant and postpartum women started in 2013.

More recently, state lawmakers extended postpartum Medicaid coverage from 60 days to a full year. This was a critical move, as overdose risk among pregnant and postpartum women is highest seven to 12 months after delivery.

A new bipartisan bill, SB 246, which was set aside in committee, would have required Medicaid to cover maternal depression screenings from pregnancy through well-child visits for up to six months. It would also fund rural EMS training for labor emergencies and support independent birth centers.

Medicaid expansion played a key role in widening access to care for parents, even if they didn’t fall into the traditional low-income categories. By raising income eligibility to 138% of the federal poverty level, the expansion opened the door to insurance for nearly 60,000 people who previously fell through the cracks, according to the NH Fiscal Policy Institute.

That access now hangs in the balance. New Hampshire is one of eight states with a “trigger law” that will automatically repeal the expansion if the federal government reduces its share of funding.

These potential cuts are “keeping administrators up at night,” says Dr. Joseph Ebner, chief medical officer and obstetrician with Speare Memorial Hospital in Plymouth. About 60% of the hospital’s obstetric patients are on Medicaid, a figure that is even higher for pediatrics.

Labor and delivery units at small hospitals are “loss leaders,” Ebner says, but are essential to community trust.

Goodman of Dartmouth Health worries these Medicaid cuts could undermine maternal mental health services. “What about perinatal depression? Someone who’s been successfully treated during pregnancy—are we really going to take their medication away postpartum, when they need it the most?”

Family Planning Budget CutsAnother looming threat to women is cuts to family planning programs. The NH House is proposing to slash $840,000 from four family planning program centers serving Manchester, Nashua, Coos County, and the Lakes Region. The centers provide low to no-cost sexual and reproductive health care services, including regular checkups, lab work and emotional support.

At Amoskeag Health in Manchester, one of the affected clinics, nearly 300 babies are delivered each year. Most of its 16,000 patients are low-income, on Medicaid or uninsured. If the program is cut, more than 400 women would lose access to prenatal care, contraception and postpartum support.

“Eliminating the Family Planning Program will likely lead to an increase in teen pregnancies and unwanted pregnancies, particularly in families already struggling financially,” says President and CEO Kris McCracken. “Such a change would place an even greater strain on these families and could force many into difficult choices, including the decision to terminate pregnancies due to a lack of resources and support.”

Independent Birthing CentersExpectant parents seeking a more intimate birth experience once had five independent birthing centers to choose from across NH. Today, only three remain. The Concord Birth Center closed in 2023. The Monadnock Birth Center in Swanzey shuttered a year later, ending a 16-year run. About a third of Monadnock’s patients were on Medicaid, founder Mary Lawlor says.

“We were paying to do Medicaid births, not being paid to do them,” she says. “There wasn’t a single year that I didn’t lose money. I had to borrow money pretty much every year I was open.”

Katherine Bramhall, co-owner of Gentle Landing Birth Center in Hanover, acknowledges the financial pressures. She opened her practice in 2021 in response to the 2018 federal Strong Start study, which found that free-standing, midwife-led birth centers significantly improve maternal health outcomes. Nonetheless, running an independent birth center remains an uphill battle. Bramhall describes a system where commercial insurance companies routinely deny claims without review, forcing providers to fight for reimbursement.

Despite this, Gentle Landing is thriving, with Bramhall expecting to deliver 65 babies this year, up from 40 in previous years. She attributes this growth to increasing demand for personalized, low-intervention birthing options. “There’s got to be hope for families,” she says. 

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.

Disrupting the patient care model

Two local doctors are working with an independent provider to increase contact time

Krysten Godfrey Maddocks, NH Business Review

Nick Vailas

While Elliot Hospital does its best to anticipate community needs through its network of providers, entrepreneur and health care business owner Nick Vailas says it’s time to revisit how Greater Manchester provides health care.

Whether primary care providers are working at nonprofit or for-profit hospitals, their patients are being rushed through the system and they are feeling more burnt out than ever.

The average patient spends 13 minutes with their primary care provider and will wait 20 days on average for an appointment. On average, a primary care provider is responsible for seeing up to 20 patients a day and managing a patient panel of about 2,000 people, he says.

“The fundamental problem with health care today is that people don’t have a personal relationship with their physician,” Vailas says. “There may be exceptions with mid-level providers, but many of us years ago were able to and we’re lucky.”

Not only is access to primary care limited, but Vailas says the lack of patient advocacy health care systems offer is making health care more confusing, complicated and expensive for patients. Spouses and other family members must advocate for their loved ones, who are often too sick to understand their options.

“You’re running in the dark because health care is a maze. It’s complicated,” he says.

While mid-level practitioners like physician assistants or nurse practitioners help expand health care access, they don’t necessarily make routine care more affordable.

Dr. Jennifer Fishbein

“If your doctor is employed by a large hospital system, guess what? You end up in the most expensive alternative, which is a hospital system for routine diagnostics and care,” Vailas says. “The cost differential is huge. The leading cause of bankruptcy today is health care debt.”

Vailas opened Delphi Enhanced Primary Care in July 2024. Modeled after traditional health care systems, Delphi emphasizes personal relationships with the two doctors it employs as an alternative to hospital-owned practices. For a $120 monthly fee, patients can see Dr. Jennifer Fishbein or Dr. Jeffrey Calegari in Bedford on the same day or the next day. The fee works like a membership fee and does not cover the cost of patient visits. The practice bills for services just like any other practice.

Dr. Jeffrey Calegari

Under the Delphi model, Vailas aims to cap each of his physician’s patient panels at 600 to ensure access. The program is already financially successful, and he’s already looking to expand. He’s also reaching out to employers, who might be able to save money on employee health insurance programs by partnering with Delphi.

“There’s a ton of research that shows that even though the employer may be paying the access fee, employees will cost you less, especially if you’re self-insured,” he says.

What Delphi offers is access, advocacy and cost transparency. Staff members work with patients to help navigate them through the system and make recommendations based on need, coverage, and cost. Most people don’t even know what their insurance covers, which makes it particularly challenging for patients who have high-deductible health care plans, Vailas says.

“We cripple people who are already on fixed incomes. To me it’s wrong, because the system is blind. And then you go in blindly through a financial minefield where you could pay a $70 lab fee or a $500 lab fee for the same lab,” he says. “Since we’re independent, no one is trying to coerce our physicians to choose the higher cost alternative. Physicians who work for large health care systems have no idea what the price points are, nor do they concern themselves with it. They just want to treat their patients and keep them within the system.”

Vailas owns several ancillary health practices in New Hampshire. He owns six Apple Therapy Services locations, Nashua Ambulatory Surgical Center, and Orchard Surgical Center in Salem; as well as BASC Imaging in Bedford and Orchard Imaging in Salem. He calls these practices part of the “Vailas health care network” and says they have “far lower” price points than competing hospital entities.

It’s hard to know how or whether HCA’s acquisition of CMC will affect access to care in Greater Manchester, Vailas says, because there’s already been what he calls “an exodus” of primary care in the community. He does not believe that HCA’s for-profit status necessarily matters.

“The research shows there is no difference in the amount of charity care being done or any greater benevolence when you’re for-profit vs. nonprofit,” he says. “There’s a lot going on. That’s why I love what we’re doing. We can help people who are sick. We can help save them money. And most importantly, we can give them a doctor who they know and can have a relationship with.”

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.

Critical Condition: HCA’s takeover of CMC has changed the health care landscape

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 (including NH Business Review). 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.

By Krysten Godfrey Maddocks, NH Business Review

In February, Hospital Corporation of America, the largest for-profit hospital system in the U.S., completed its acquisition of Catholic Medical Center in Manchester for $110 million.

State lawmakers and health care providers are trying to anticipate how this shift in ownership will affect access to health care for patients in the Queen City area and competition in the southern part of the state.

Now that CMC is no longer a nonprofit hospital, it will no longer be subject to the federal and state rules governing charity care and community health services or benefits. Nonprofit charitable hospitals must develop community benefit and health improvement plans to maintain their tax-exempt status, whereas for-profit hospitals are not required to continue services or add providers to meet community needs.

HCA Healthcare is considering a freestanding emergency department for Catholic Medical Center, “which has proven effective in Plaistow and Seabrook by helping to alleviate hospital ED wait times,” spokeswoman Laura Montenegro says. (Photo by Jodie Andruskevich)

With its acquisition of CMC, HCA now owns four of the 26 acute care hospitals in New Hampshire. Previous HCA hospital acquisitions could provide a blueprint of what’s to come.

Just five years ago, HCA acquired Frisbie Memorial Hospital in Rochester, which had also operated as a nonprofit hospital. In 2022, Frisbie announced it would stop offering labor and delivery, moving those services to HCA-owned Portsmouth Regional Hospital — becoming the 11th hospital in the state to stop offering birthing services since 2000.

HCA-owned Parkland Medical Center in Derry ceased its labor and delivery services in 2020.

Under HCA management, CMC will provide labor and delivery.

On average, CMC providers deliver about 1,000 births each year. Beginning July 3, Dr. Thomas Zarka, an OB-GYN at Women’s Health Associates of Derry, and his partner, Dr. Robyn Stewart, began delivering babies at CMC.

This comes at a critical time, as Dartmouth Health had announced in fall 2024 that it would be pulling its labor and delivery team from CMC on June 30, 2025. Zarka, who has been in practice for 18 years, and Stewart briefly worked at CMC after Parkland’s labor floor closed. In addition to labor and delivery, Zarka specializes in advanced robotic laparoscopy, menopausal care and adolescent gynecology.

Both doctors have been delivering babies at St. Joseph Hospital in Nashua, and performed surgeries at Parkland. Their move to CMC this summer gives Greater Manchester patients better access to labor and delivery and allow for smoother transfers between Parkland’s Emergency Department and CMC’s Labor and Delivery Department, Zarka says.

Women’s Health Associates of Derry also plans to collaborate with New England Midwifery, comprised of six nurse midwives based at CMC, who will manage inpatient and outpatient care and provide 24/7 coverage for labor, delivery and post-partum care. The new hospital-based midwifery group will handle low-risk pregnancies, working alongside Zarka and Stewart in the labor and delivery room.

“Midwifery in general tends to be less interventional, a little more holistic, and midwives tend to stay with patients more frequently during the labor,” Zarka says. “It’s often what most women would like and choose from the get-go.”

Under CMC’s previous model, Dartmouth Health OB-GYNs worked alongside midwives and residents. Often, residents oversaw deliveries to gain experience. Zarka says that the new model at CMC will better support continuity of care and allow the midwives to do the parts of their jobs they enjoy fully.

“They’ve (CMC’s) been working more as a gatekeeper model where they essentially admit and take care of all the laboring patients that are low risk. But then the resident (often) steps in and does the delivery, which, from the midwife standpoint, that’s not what they’re trained to do,” Zarka says. “Their fun is delivering babies, so I think they’re excited for this transition.”

Ultimately, Zarka believes patients will benefit from more personalized, consistent care at CMC without the additional layer of residents and rotation-based care.

“They’re going to either have a physician or a midwife,” he says. “They’re going to have the people that they’ve been seeing all along and not (have their babies) delivered by a stranger.”

In July, Dartmouth Health relocated its labor and delivery services from CMC to Elliot Hospital’s Birth Center. This allows Dartmouth Health to expand its own OB-GYN residency program and strengthens the relationship between Dartmouth and Elliot.

The two already collaborate on general surgery, bariatric surgery and inpatient pediatric care. Currently, Elliot partners with Manchester OB/GYN Associates, Amoskeag Women’s Health, and Bedford Commons to provide women’s health and obstetrical and gynecology services.

“Our commitment is always to provide essential health care services needed by mothers and children in our region,” says Dr. Gregory Baxter, CEO and president of Elliot Hospital. “For many years, we have enjoyed the support of strong partners in obstetrics. These existing partnerships remain essential for our community.

“Now, we are pleased to add the obstetric providers from Dartmouth, building on our longstanding relationship with Dartmouth Health,” Baxter says. “We have expanded our capacity to support this new activity, which adds to The Elliot’s service, which was already the busiest in New Hampshire.”

Baxter expects that Dartmouth Health will bring four to five OBGYN physicians, four to five midwives, and two to three rotating residents to Elliot. These providers will also offer gynecology services and surgery, in addition to labor and delivery services.

CMC this spring announced specific plans to continue labor and delivery services, and more recently commented about how they plan to backfill primary care services. New Hampshire, like the rest of the country, faces a primary care provider shortage. The state is estimated to have one primary care provider for every 1,025 people.

Primary care remains a key focus in CMC’s organizational planning, spokeswoman Laura Montenegro says.

“The growth of our primary care network is driven by the needs of the communities we serve — ensuring timely, local access to the foundational care patients rely on,” she says.

CMC currently manages 11 primary care practices and one urgent care location. (Appledore Medical Group is an affiliate of HCA Healthcare.)

“We continue to recruit and expand in direct response to where care is most needed,” Montenegro says.

Elliot Hospital’s board of directors continues to focus on primary care access. According to Baxter, several CMC primary care providers have already left the area, joined other hospital systems, or have opened independent practices. Elliot Hospital continues to prioritize primary care and recruit new providers to meet the growing demand, Baxter says.

Certified nurse midwives Kelli McKay, Isabel Brewster, Kerri Hoyt, Christy Aberg work for CMC’s new hospital-based midwifery group, which will handle low-risk pregnancies, working alongside doctors in the labor and delivery room. (Courtesy of CMC)

“We’re adding sometimes 300 to 500 patients a month, which challenges us to find space, locations and providers for them,” Baxter says. “Under the leadership of Dr. Kevin Desrosiers and our other physician leaders, we’re able to recruit. It remains to be seen how primary care is going to shake out and what resources are brought to bear either by us, by other institutions or by HCA themselves.”

Currently, Elliot serves 120,000 patients and has added 20,000 patients to its primary care panel over the past four to five years. The hospital owns 18 primary care practices, of which 14 were accepting new patients as of early 2025.

Dr. Kevin Desrosiers, chief physician executive at Elliot, says that the hospital carefully monitors physician-finder activity and gaps in primary care. They will either add providers where the need is greatest or slightly expand the panels of existing providers. Although it takes months to recruit, credential and onboard new providers, Desrosiers says it “tends to be something that’s within the tolerance of the community to gain access to a primary care physician.”

The demand for health care is dynamic, and often spikes during cold and flu seasons. Leading up to the HCA transaction, CMC already had difficulty managing capacity, Desrosiers says. Elliot Hospital saw additional patients visit their emergency department during these periods and has already taken steps to manage influxes of patients — particularly for those not experiencing a true emergency.

“It obviously takes way too long to build a new brick and mortar and try to stand that up, especially if you’re not sure of the demand,” Desrosiers says.

Historically, the hospital has relied on patients to self-triage and navigate the system for themselves. However, emergency care is expensive and can come with hours-long waits to see a doctor.

“The public sees us as an access point,” Baxter says. “The challenge is that it (the ER) is not the most cost-effective way to do care, and we are on an odyssey of trying to help our community understand that,” he says.

For those experiencing ailments or injuries after hours, Elliot offers a virtual triage program, called VirtualER, to help direct patients to the right levels of care — even if they don’t have a provider affiliated with hospital system. The program launched in December 2023.

“You can register through the internet and get online with a doctor who is actually working at the Elliot, one of our emergency doctors, and they can help you understand if you actually need the emergency room, if you can wait until tomorrow to see your primary care doctor; or, if you need to go to the urgent care, we can figure out which one has the shortest wait and get you in there right away,” Desrosiers says.

Elliot’s virtual platform can also help patients get appointments for X-rays and labs before they see their doctor the next day.

So far, more than 70% of people who have accessed virtual ER services have been able to get their care completed virtually. Of the remaining 30%, most can complete care with a virtual visit along with a lab draw or radiology appointment. The remaining patients can visit the urgent care or emergency department.

“There’s only about 5% to 10%, depending on the month, who actually need to come into the ER,” Desrosiers says. “Creating virtual capacity with these tools that exist — whether it’s electronic or AI — are ways that we think we can responsibly utilize public trust dollars to enhance access and not leave that access laying around because we overbuilt.”

As outlined in the Attorney General’s report, HCA Healthcare, too, is committed to enhancing access to care in Greater Manchester, including emergency care, Montenegro says.

“One model under consideration is the freestanding emergency department, which has proven effective in Plaistow and Seabrook by helping to alleviate hospital ED (emergency department) wait times,” she says.

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.