Ernie Dowd was shocked when he received a form letter last week from the BMH Medical Group telling him he would be reassigned by the end of the month to a different primary care practice because his current provider had resigned.
Dowd, 71, had seen his family nurse practitioner, Wanda Minenna, at Windham Family Practice in West Brattleboro only a few weeks before, and all seemed well. He can, and often does, walk to the cozy office in a white house with green shutters on Route 9 where he has gone for checkups for more than 25 years.
He has been rattled by the forced transition, and is not looking forward to joining the internal medicine practice downtown, where he said his wife has seen three different doctors over the last five years.
“Part of treating a patient is knowing a person, as well as the physical things,” Dowd said. He was very comfortable with Minenna. “Now I’m forced to go to a stranger.”
Brattleboro Memorial Hospital CEO Chris Dougherty said that the medical group expects to be able to place all 600-plus of Minenna’s patients with one of its affiliated primary care providers, most in offices near the hospital just a few miles away. He regrets the disruption, but said that her resignation left them no choice.
Minenna said she was the one left without a choice. The manager at the medical group had just told her she would be required the following week to start working at an internal medicine practice at the hospital, after she had explained for months that she wanted to keep practicing family medicine and did not want to leave the office in West Brattleboro.
The sudden loss of one of Brattleboro Memorial Hospital’s primary care providers, and the only one based in West Brattleboro, is the latest version of a story that plays out regularly across Vermont and the country: An independent provider looking for professional and financial support turns to the local hospital, which has conflicting priorities. The relationship between them sours, leading to the kind of disruption in patient care that the provider had been trying to avoid.
In West Brattleboro, that story began during the first year of the Covid-19 pandemic, when Dr. Craig Goldberg, an osteopath who has operated the independent West Brattleboro Family Practice in the same white house for more than 29 years, faced a loss of income and staff.
The economics of independent primary care has become only more challenging in recent years, as the uncertainties and stresses caused by the pandemic added to existing administrative and financial strain. Increasingly, providers are joining institutions, particularly hospitals or federally qualified health centers, to survive.
Statewide, 31 fewer primary care providers were in independent practice in 2021 than in 2017, according to the University of Vermont’s Larner College of Medicine workforce survey. Almost three-quarters of all providers now work for a hospital or federally qualified health center. But there are perils to those arrangements.
In 2019, for example, UVM Health Network folded a longtime downtown Barre primary care practice it had acquired into its primary care practice based at Central Vermont Medical Center in Berlin. In 2022, Northwestern Medical Center in St. Albans cut ties with an independent clinic it had absorbed five years before.
Changes in West Brattleboro started when Goldberg decided he would scale back his primary care practice for good, turning it into a “direct” or “concierge” service, in which patients sign up to pay a monthly subscription for whatever care is needed. The number of independent providers using this model doubled from eight to 16 in the state between 2017 and 2021, the UVM survey found.
Goldberg asked the hospital, which owns the building, in December 2020 to consider placing a provider there to meet the needs of individuals and families who wouldn’t, or couldn’t, switch to that kind of care payment model.
“I would have that person absorb the majority of the medical practice and I would stay with my osteopathic practice and retain only a smaller number of medical patients,” Goldberg said in an interview.
The hospital agreed and, after a search, in late 2021 hired Minenna to fill that role.
Minenna, who has degrees in both nursing and family therapy, said her attraction to the position was precisely its location in a small home-like environment. She also wanted the experience of working alongside a colleague like Goldberg. The practices jointly employed medical and clerical support staff. They also shared a belief in a holistic kind of primary care practice, which integrates a variety of healing practices, she said.
Minenna is now moving to a temporary position working with migrant farmworkers in California, but said she would like to return to Vermont. Preparing to leave has been difficult, as patients visited her unannounced in tears. “I am so sad for these patients,” she said. “I am devastated. They are devastated. It’s just not right.”
The hospital’s primary care presence in West Brattleboro is not necessarily over, Dougherty said. “We are in the process of assessing what the clinical needs are,” he said.
The hospital needed to close it at least temporarily in order to resolve a problem with how the electronic medical record system they use was set up there. They were having trouble using it to bill for services, Dougherty said.
But based on the number of patients previously enrolled there, Dougherty said that there would probably not be a full-time clinician there again. “I can tell you, there just doesn’t appear to be the need,” he said.
Dougherty added that additional primary care providers may be coming to Brattleboro. North Star Health, the federally qualified health center that emerged from the Springfield Hospital bankruptcy proceedings, received a $4.2 million federal earmark via Sen. Bernie Sanders, I-Vt., to open a facility in Windham County.
Goldberg called Minenna “an amazing nurse practitioner, who was very skilled.” He said that he doesn’t understand why the hospital could not find a solution to whatever technical problems arose in order to keep her in West Brattleboro.
“You try to do anything you can to try to prevent an experienced clinician from having to leave, and try to prevent having to displace patients,” Goldberg said. “There were no problem-solving conversations like that.”
Goldberg emphasized that his practice would continue to be open, but that Minenna’s leaving was a real loss for the community and creates challenges for her patients. “It’s unavoidable that there will be discontinuity of care for a lot of these people,” he said.
