Established in 1986, Bi-State Primary Care Association, serving New Hampshire and Vermont, is a nonprofit 501(3) charitable organization that promotes access to effective and affordable primary care and preventive services for all, with emphasis on underserved populations. We work to ensure that all individuals have access to appropriate, high-quality, integrated primary and preventive health care regardless of insurance status or ability to pay.
Bi-State represents NH’s 16 Community Health Centers (CHCs), which serve nearly 110,000 Granite Staters. CHCs provide comprehensive integrated primary and preventive care, which includes medical, behavioral health, substance use disorder treatment, and oral health services. Integrated care is essential to addressing the whole person, including behavioral health and substance use disorder needs of our state.
Comprehensive primary care is an effective way to integrate behavioral health and Medication Assisted Treatment (MAT) for individuals with substance use disorders in our state. CHCs provide comprehensive primary care and employ family physicians, general internists, OB/GYNs, nurse practitioners, and physician assistants who form the basis of a primary care practice. These practitioners work alongside medical assistants, registered nurses, care coordinators, clinical social workers, mental health counselors, marriage and family therapists, and licensed alcohol and drug counselors to provide an integrated model of care, helping patients connect with the services they need under one roof to maintain and improve their overall health.
In September 2017, there were nearly 60 provider vacancies reported to Bi-State’s Recruitment Center that need to be filled in the next 3-6 months.1 The openings are for primary care physicians, psychiatrists, nurse practitioners, physician assistants, and psychiatric nurse practitioners who work in CHCs, hospital- operated or private practices. These same organizations report an additional 49 openings for a variety of bachelors and masters level clinical staff who are part of the integrated care team. Practices in rural NH experience extended vacancy periods and have far fewer candidates who express interest. It can take a rural practice over 18 months just to recruit one family physician. Long vacancy periods lead to long wait times to access care.
The NH State Loan Repayment Program (SLRP), administered by the Department of Health and Human Services, provides funding to health care professionals who work in medically underserved areas for a minimum of three years. It is a best practice and the most effective tool for practices in rural and underserved areas of the state to attract and retain providers. The demand for SLRP assistance is considerably greater than the funds available. Currently, there are 32 qualified providers on the wait list for loan repayment. The longer the wait list, the more likely it is that these providers will find other practice options that can pay higher wages and/or provide private loan repayment. This means NH loses the opportunity to recruit and retain this once interested workforce.
For nearly 20 years, the SLRP operated using General Funds in the amount of $400,000 per year. In June 2015, the General Fund appropriation was reduced by $169,034 each year. That session, in response to community need, SLRP added eligibility for new sites and provider types. The new sites include all community mental health centers and DHHS Bureau of Drug and Alcohol Services funded treatment centers (outpatient services only). The new provider types include Master Licensed Alcohol and Drug Counselors and Licensed Alcohol and Drug Counselors. Without an increase in General Fund appropriations, this expansion has reduced the availability of funds, not only for behavioral health specialists, but also for primary care clinicians, thus negatively affecting access to integrated behavioral health, MAT and primary care services across our state. Adding $1.1 million (past legislative request) to the SLRP each year will support the recruitment and retention of 20 doctors (including family physicians and psychiatrists) and 18 nurse practitioners or physician assistants (inclusive of psychiatric nurse practitioners) over the course of the next two years, thus increasing the state’s ability to attract, recruit and retain a workforce to provide integrated behavioral health care, MAT and primary care services.
NH’s CHCs serve nearly 110,000 patients; approximately 36,000 Medicaid enrollees (22% or 1 in 5 of all NH Medicaid enrollees); and 17,000 uninsured NH residents (1 in 4 uninsured).2 The health centers contract with NH DHHS using a federal Title V Maternal and Child Health Services Block Grant and state General Funds to achieve population health goals and to fund programs such as care coordination, case management, interpretation services, and health education, to name a few. The contracts, commonly referred to as primary care contracts, were reduced by 42% in 2011 and were never fully restored.
Added investments of $2.5 million per year of the biennium will improve access to care. Recent studies show that, on average, each patient receiving care at a CHC saved the health care system 24% annually.3 The contracts pay for support services such as case management. Case management helps those with substance use disorders coordinate integrated care, and improves their access to treatment as well as their health care outcomes. A strong primary care infrastructure supports the continued integration of behavioral health with primary care, which results in increased access and capacity for the treatment of mental health and substance use disorders.
Many New Hampshire sites report having limited capacity to train the future workforce. A common concern is not having capacity to provide clinical experiences for health professional students while they are in training. This is often due to the strain on existing providers as a result of high patient demand and other vacant positions within the practice. Practices also struggle to recruit and employ recently graduated Licensed Drug and Alcohol Counselors for their license due the requirement of 3,000 hours of clinical supervised work after graduation. Practices often lack a supervisor with required matching credentials to provide this oversight. Making adjustments to these requirements can be done without endangering the safety of the public. These adjustments will reduce barriers and delays for training and deploying behavioral health and substance use disorder specialists in practice settings where their services are needed.
The state has only one Family Medicine Residency Program from which to recruit. The NH Dartmouth Family Medicine Residency at Concord Hospital graduates 8 family physicians each year. Dartmouth reports approximately half of their graduates remain in the state upon graduation. The creation of an additional family medicine residency will increase the pipeline of family physicians to fill the dozens of vacancies in our state, expanding not only the primary care capacity but the capacity to provide integrated care and MAT in primary care settings across the state.
Bi-State and our CHCs look forward to continuing to work with our Governor, elected and state officials, policy leaders, and the business community to address New Hampshire’s health care workforce shortage.
1 Vacancies are reported to Bi-State’s Recruitment Center on a voluntary basis and do not reflect all of the openings in the state. The NH Community Behavioral Health Association maintains its own vacancy tracking system as do some of the hospitals such as Dartmouth Hitchcock Medical Center, Southern NH Regional Medical Center and Elliot Health System.
2 Health Resources and Services Admin., Uniform Data System, NH Rollup (2015).
3 See Richards et al. Cost Savings Associated with the Use of Community Health Centers, Journ. of Ambulatory Care Mgmt., 50-59 (Jan./March 2012).