This story was originally produced by the Laconia Daily Sun. NHPR is republishing it in partnership with the Granite State News Collaborative.
In the wake of the loss of three primary care physicians from Concord Hospital's Laconia Clinic, health care professionals in the Lakes Region say they’re worried about patient outcomes, and hospital officials have left them with more questions than answers. But hospital representatives assure the public there are no intentions of consolidating primary care to Concord.
Three primary care doctors — Valentin Milchev, Gurvinder Bali and Daniel Kallmerten — all working out of the hospital’s internal medicine department — were unceremoniously fired at the end of September, leaving as many as 6,000 patients in limbo as they try to reschedule appointments.
A hospital spokesperson said the Concord Hospital system offers 15 primary care practices, four of which are located in Belmont, Laconia and Meredith, but doctors who’ve recently retired say there’s no way Lakes Region primary care practices can reasonably absorb the number of patients affected by the change. Many of those patients may be forced to travel to Concord to seek medical care or find a new health care system altogether.
Hospital spokesperson Dawn Beers confirmed Wednesday Milchev, Kallmerten and Bali were no longer employed by Concord Hospital and other physicians would be rotating to Laconia to provide care for patients during the transition.
“Our goal is to add [two to three] additional primary care providers in the Lakes Region over the coming year,” she wrote in an email.
She said there are 30 primary care providers employed by their practices in the Lakes Region between offices in Laconia, Franklin, Belmont, Gilford and Meredith which, in aggregate, provide care to 35,000 patients. The internal medicine practice in Laconia employs three providers, and practices in Belmont and Franklin are accepting new patients.
Internal medicine in Laconia is "committed to ensuring our patients' health care needs are met during this transition,” Beers wrote. “Providers within the Concord Hospital Health System (CHHS) are rotating up to IML to help meet patient needs.”
Noting the hospital is actively recruiting for more primary care providers, Beers said last week a new physician is expected to join the team in November. Patients whose primary care provider is no longer employed there are instructed to call the patient referral line at 603-224-7879 or toll-free at 800-322-2711 to locate a doctor who’s taking new patients. Those with urgent or acute needs are encouraged to contact internal medicine directly and medication refills will be processed as soon as possible.
But patients are reporting months-long wait times to get a new appointment with another doctor, bringing up the question of how outcomes for patients with acute care needs or patients with pending diagnoses will be met. What would happen with a patient who was ordered to conduct blood tests who then lost their primary care physician in the meantime, for example?
Dr. Taj Shafique, a surgeon, began his career in 1996, and retired from Concord Hospital this year. He wondered the same, noting there would be some number of affected patients who are dealing with acute medical problems or new cancers, for example.
“This is patient abandonment of approximately 5,000-6,000 people,” he said in an interview. “I guarantee there’s a significant number of those who are dealing with acute issues.”
The key question, Shafique thought, has to do with why three doctors were fired immediately. He wondered why they were let go, paid out the duration of their contract, and not allowed time to make proper arrangements for their patients.
Drs. Frederic Fernholz, a 36-year retired urologist with the Laconia Clinic, and Arnold Miller, a 35-year retired orthopedic surgeon, both said Tuesday that normally, when a doctor is set to leave their practice, they notify their patients at least 30 days in advance and provide them instructions and other resources to assist in finding a new provider. They’ll offer a list of recommended physicians and write their patients referrals, answering any questions they may have and offering advice regarding navigating the ordeal.
When asked why patients were not afforded a 30-day notice of the departure of those physicians, Beers declined to elaborate, instead noting patients were notified more generally and that communication could be improved.
“As with any provider departures, patients were notified of these vacancies and have options to see other primary care providers with additional health system physicians rotating through the practice,” Beers wrote by email. “We recognize any change in provider personnel can be challenging to our patients and there are always opportunities to improve our customer service and communications with our patients.”
“It’s good etiquette to do that,” Fernholz said, wondering if the timing of the employment decision came in an attempt to prevent both internal and external backlash. “That’s a lot of patients that they offloaded.”
Miller said patients experiencing acute care needs would be unlikely to secure an appointment with a new provider within a week or so, and noted some with specific medical needs or extenuating circumstances can’t afford to wait months to see a doctor.
“They haven’t set up any way to handle this,” Miller said. “What about prescriptions?”
Fernholz noted when Concord Hospital-Laconia lost local oncology, that presented patients with a large burden, forcing some to travel to Concord to seek treatment. That’s not just inconvenient — some patients are unable to travel, do not have the money to make frequent trips or do not have access to reliable transportation.
And both doctors said the decision could have been a financial one, noting the medical industry nationwide is moving toward reliance on nurse practitioners rather than physicians for primary care. Even if that does reflect the “new direction” referred to by hospital executives in firing Kallmerten, Fernholz and Martin wondered why they’d make the move all at once.
Hospitals can temporarily fill vacant positions through the use of “locum tenens” physicians, but that route is generally much more expensive. Locum tenens physicians are independent contractors who usually demand a higher rate than full-time physicians.
Fernholz, who was still working at the time Concord Hospital purchased LRGHealthcare, said hospital executives initially promised to maintain all services for five years, if financially feasible, and to work to increase the availability of primary care. That transaction occurred in May 2021, less than four years ago.
Miller said normally during a merger of this kind, some major aspects of the health care system are consolidated, and many doctors assumed some level of consolidation would take place after the purchase. More importantly, the operations of primary care are usually maintained locally. He is concerned they may be consolidated in Concord.
“It seems like this was done with no planning with concern for the patient,” Miller said.
But Beers wrote, unequivocally, Concord Hospital Health System has no plans to consolidate primary care in Concord. She pointed to the hiring of 67 providers in the Lakes Region over the past three years, $25 million in patient-forward investments, the establishment of rheumatology and orthopedics practices and the expansion of various medical specialties as evidence of their commitment.
“This kind of a decision is pretty major,” Shafique said. “The infrastructure on primary care is already very stressed and then you go and fire three people? The immediate termination is patient abandonment — they’ve taken a wrecking ball to the whole primary care in this area.”
Miller and Fernholz said the growth of Laconia and the surrounding areas, pointing specifically to the revitalization of downtown and the forthcoming development of the former State School property on Parade Road, will necessarily drive higher demand for primary care physicians as the population increases in tandem with those developments.
A hospital spokesperson declined a request for an interview with any member of the hospital's executive leadership, noting they have "other communication initiatives planned to address this concern with the community."
The Winnipesaukee Public Health Region is considered rural, according to the New Hampshire Department of Health and Human Services. Approximately 30% of residents statewide live in similarly rural public health regions, and patients there experience the greatest barriers to medical care. Rural residents travel further to see a primary care doctor and do so much less frequently than other residents.
Rural residents in New Hampshire were less likely than other residents to have visited a primary care physician over the previous year. Rural residents were also diagnosed with late-stage breast, colon and rectum cancers at higher rates than their non-rural counterparts.
Data from the New Hampshire Department of Health and Human Services shows the state’s most vulnerable patient populations reside in these rural public health regions. The Winnipesaukee region has among the lowest ratios of primary care providers to patients across the state at 22.07 providers per 100,000 people — only the Greater Sullivan Public Health region has a lower ratio at 18.73 providers per 100,000 patients. For comparison, the capital area, which includes Concord, has about twice as many providers per 100,000 patients as Winnipesaukee, with a ratio of 44.96.
A New Hampshire Fiscal Policy Institute study projects employment in the health care sector will increase by 5.8% between 2022 and 2032, adding about 42,000 jobs at a pace of about 4,000 each year. Among health care professions, nurse practitioners and physician assistants are projected to comprise the largest proportion of those annual increases at 50.7% and 30.4%, respectively.
“Physician shortages within the primary care sector is likely a contributing factor for this predicted growth from 2022 to 2032, as other employees may fill some of the duties previously performed by physicians in health care settings,” the study reads in part.
“You cannot abandon patients,” Shafique said. “It’s unethical and immoral, if not illegal.”
“My feeling is Concord Hospital has some explaining to do,” Fernholz said.
These articles are being shared by partners in the Granite State News Collaborative. For more information, visit collaborativenh.org.
