LEWISTON — A year ago, doctors were leaving Central Maine Healthcare.

The hospital system’s physician turnover rate for the 2017-18 fiscal year stood at 27.1%. It lost about 81 of its 300 doctors — pediatricians, primary care physicians, specialists, surgeons — within 12 months.

“Every couple of days there are several more resignations,” a provider within the hospital system told the Sun Journal August 2018.

A year later, that turnover rate, according to system officials, has dropped to 4.2%.

Michele Talka, vice president and chief human resources officer, can list the reasons for the dramatic turnaround: Doctors on the cusp of retirement chose last year to walk away rather than deal with changes at Central Maine Healthcare. Those who remained got used to the way the new administration did things or their concerns were addressed. New doctors — the system has been on a hiring spree — are OK with the leadership in a way those past doctors were not.

“The level of angst,” Talka said, “has gone down.”

But while health system officials say they’re hiring — and keeping — more doctors, physician assistants and registered nurses, others say problems remain.

“We haven’t seen any changes,” said David Welbourn of the Pondicherry Group, a citizen group that earlier this year called for Central Maine Healthcare to give up Bridgton Hospital and its affiliated medical practices.

‘YOU COULD SEE THAT THERE WAS TRANSITION’

Nonprofit CMH is one of the largest hospital systems in the state. It owns Central Maine Medical Center in Lewiston and Bridgton and Rumford Hospitals, as well as a large collection of primary care offices and other medical practices around central Maine.

The system’s turmoil started last summer with three votes of no confidence in new system CEO Jeff Brickman, all made by medical staff who said they were upset with Brickman’s management style, the cuts he’d made or changes he’d put in place.

The turmoil continued with the resignation of the president of the Bridgton and Rumford hospitals, a call from the Pondicherry Group for the system to pull out of Bridgton and the sudden resignation of board member Phil Libby. Earlier this year, the Centers for Medicare & Medicaid Services threatened to stop paying for Medicaid and Medicare patients if CMMC, the system’s flagship hospital, didn’t quickly address serious problems found by investigators. The hospital fixed those problems.

But for patients, the most obvious issue last year was the exodus of medical professionals across CMH.

Average turnover rates for doctors in hospital systems statewide or nationally are hard to come by, but health-care data company SK&A said last year the average annual turnover rate for office-based doctors in the U.S. was 8%. It said the average turnover for all hospital employees — doctors, nurses, support staff and others — in the U.S. was 18.6%.

CMH’s turnover rate that year was 27.1%. System leaders acknowledged that was a problem.

Last August, they told the Sun Journal they were working on boosting recruitment and retention and were taking to heart the medical staff’s concerns. They also said, however, that at least some turnover was virtually guaranteed; not every doctor would fit the new administration.

“Change is hard and they may decide that they aren’t up for the change,” David Tupponce, executive vice president for the system and president of CMMC, said at the time.

In the year since, Central Maine Healthcare has been hiring.

System leaders said they’ve hired 118 doctors, physician assistants and nurse practitioners, plus 134 registered nurses. A spokeswoman said the system hired more providers this past year than it had the previous two years combined.

The new hires are scattered across the system and include surgeons, specialists, primary care providers and a dozen emergency-room-based registered nurses.

Some of those new hires directly replaced people who left. Others filled newly created positions.

“(CMH) also took advantage of turnover to not simply replace but strategically staff for our growth and take into consideration the needs of all the communities we serve,” said spokeswoman Kate Carlisle. “Re-imagining some positions, creating different responsibilities and job descriptions that made more sense allowed us to deliver an even higher level of value-based care system-wide.”

Not all doctors were replaced with other doctors. Some were replaced with nurse practitioners or physician assistants — a practice that’s becoming more common across the country.

Talka, the head of human resources, said nurse practitioners and physician assistants can handle 90% of what the average patient needs, but they’re easier to recruit than doctors and they are not as expensive to employ or for patients to see.

“We’re almost, not quite, but we’re almost at a 50-50 balance between physicians and advanced-practice professionals,” Talka said. “It’s just been going in that pattern for the last few years and it’s continued that way. Now it’s deliberate. I think before it might have been more coincidental, but now it’s more deliberate on our part. We actually talk about, ‘Do we need to back-fill this position with a physician?'”

But CMH has been hiring some doctors, too. Among them: gastroenterologist Sean McGarr.

“I wanted to be part of a system that was bigger and growing and that had the support of folks,” said McGarr, who started with CMH last November after about five years in private practice and seven years with MaineGeneral Medical Center in Augusta.

McGarr had heard about the turmoil at Central Maine Healthcare, but it didn’t scare him. A lot of people there were worried about the unknown, he thought, and a lot of it was blown out of proportion.

“There was a lot of transition going on. I mean, there’s no doubt about it. You could see that there was transition,” he said. “But a lot of people didn’t even have a chance to meet the administration. A lot of them, I don’t know if they really researched. I know I researched my folks and I researched their backgrounds and I knew where they were coming from and the type of places where they had been.”

He liked what he saw.

“I’ll be honest, I took a liking to Jeff (Brickman) and Mr. Brickman’s stance. I knew these type of tough decisions were going to come, with the thought of maybe even having to downsize a little in order to grow, so to speak,” McGarr said. “And I liked the fact that he had to make some hard decisions that weren’t necessarily well-liked but could potentially turn an organization around, in the sense of being strong for many, many years.”

While some staffers had said Brickman was poor at communicating and his administration didn’t listen to medical staff, McGarr found the opposite.

“He was available. He was accessible. We spoke. We talked, which was very new to me,” McGarr said. “What I found, this was truly a physician-run organization. I think physicians feel they have a setting at the table. They have a voice.”

From his perspective, last year’s high turnover seemed necessary.

“I think the people that wanted to go are gone and the people who needed to go have left,” said McGarr, now medical director for gastroenterology and endoscopy at CMH. “I think the people who are really invested in the great, great cities of Lewiston and Auburn are still here. And I think the people that are really invested in the system, in the organization, are still here.”

IMPROVEMENTS

CMH leaders say all those new providers — and plenty of older ones — are sticking around.

The system’s physician turnover rate dropped to 4.2%, and only four doctors left in the first half of this year, according to Carlisle. The turnover rate for physician assistants and nurse practitioners is similar — 3.9% for the past fiscal year, with only three leaving in the first half of 2019, Carlisle said.

Talka believes there are a number of reasons for the swift turnaround. Some doctors who stayed realized that looming changes — particularly to employee contracts and the electronic medical records system — weren’t quite as bad as they feared.

“A lot more training has happened, a lot more optimization has happened, and people’s comfort levels have increased,” Talka said of the new electronic medical records system. “So that piece has now diminished. I can’t say it’s gone away. If you talk to anybody who’s done an EMR implementation, it takes years for people to really get comfortable and to have it fully operational. We’re 18 months into it, so we’ve probably got another 18 months before people are like, ‘Yeah, this is OK.'”

She said CMH leaders have addressed other concerns raised last year, including the system’s lack of communication. She believes that work will be helped along by a newly hired chief physician executive.

“That will be his job to continue that journey of communication and relationship building,” Talka said.

She also believes recent hires are OK with the system’s leadership in a way past doctors weren’t, which has helped slow turnover.

“It’s allowed us to bring in a whole new group of physicians who have seen this kind of change in other places,” she said. “So it’s not as foreign to them or concerning to them, because they know this is what’s going on in health systems across the country.”

CMH officials say the system’s patient numbers have also improved this past year. More people are going to a CMH doctor, having surgery or being admitted to a CMH hospital.

Maureen Harpell, a longtime family nurse practitioner with Naples Family Practice — a CMH practice not far from Bridgton Hospital — agrees that things were rough last year. She heard about it every time she went grocery shopping at the local Hannaford.

“It’s usually by the sour cream and the yogurt. People will come up to me and say, ‘What about this? Have you heard this?'” she said. “It was challenging. People were saying, ‘My internist is leaving; what am I going to do?'”

Like Talka, she believes things have improved. She would have heard about it otherwise.

“All I’ve been hearing over the past five, six months are good things,” she said.

Bridgton’s new walk-in clinic has made “a huge difference,” she said. The hiring push has helped. Her own office will soon add another nurse practitioner, bringing the practice from three health care providers to four.

In the Bridgton area, she said, “We’re back to the same access we had before the great exodus last summer.”

CONCERNS REMAIN

But other current and former staff members and some patients aren’t so sure that things have gotten better.

“We’re broken,” said one CMH employee who asked to remain anonymous.

They believe turnover has improved because the system already lost every doctor who could quit. They believe the system relies too heavily on temporary doctors who don’t know the system, the community or their patients. They worry that CMH is replacing too many doctors with nurse practitioners and physician assistants and that relying so heavily on those providers could hurt patient care.

An employee said concerns about the new electronic medical records system have grown, not diminished.

“Wrong orders, deleted notes. Poor training. Almost no ongoing support. However, the biggest problem is the medication list, which is probably the most important part of the medical record,” the employee said.

That employee said some services remain thin outside the hub of Lewiston, which makes it difficult for patients who live in more rural areas to get care. Some patients agree.

“If people call up needing a doctor, it’s very, very hard to negotiate the system and get the care that people want,” said Welbourn, a Bridgton resident and member of the Pondicherry Group.

He said he and his friends are still seeing temporary doctors — traveling providers contracted to practice with CMH for a set time. He couldn’t say whether the hiring push has improved overall access to care, but he hasn’t seen a lot of change.

“I haven’t heard of people saying, ‘Oh, I got right in,'” he said. “I don’t think anybody’s ever said to me, ‘Oh, one of the new docs was there and I got right in.'”

He said staffing and care still feel problematic, at least in Bridgton. While he was able to be seen at the new walk-in clinic in town, he said it took staff there three weeks to provide test results that were supposed to take a few days.

“The first week I called, they said it’ll be back within the week. I called them at the end of the week and they said, ‘Gee, I don’t know anything about that,'” he said. “I called a week later and they said, ‘We’ve got it, but there’s nobody here who can explain it to you.’ And then a week later I sort of got a cursory explanation: ‘This is what the doctor told me to tell you.'”

“Stuff like that, it doesn’t mean that we’re not getting care. It means that it’s hard to get care that’s timely and expert and trustworthy and well-communicated and billed properly,” he added. “Other than that, everything’s great.”

While Harpell, the Naples nurse practitioner, feels that things have improved in the past year, she believes that it’s still CMH’s error if people — especially in the Bridgton area — still don’t feel like they’re getting the care they need. Practices are open. Providers have been hired. Good, expert care is available, she said.

“I think maybe we haven’t gotten the word out well enough yet,” Harpell said.

She said she and her fellow staff members love caring for the community. She knows the community loves them right back — and that may be why problems hit everyone so hard.

“I think one of the reasons the community was so hurt by everything that happened last year is because this is their hospital. We are their family and (they are) our friends and our neighbors,” she said. “And so what we’re trying to do right now is just let them know we’re here. We’re here. We’re not going anywhere. And I really think you can get as good care as you could anywhere.”

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