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The Maine Community Exchange
www.rurdev.usda.gov/me
Right-Sizing
Rural America
Vol. 4 Spring/Summer 2008 A Publication of USDA Rural Development in
Message from However, when brought about by col- care organizations have been assisted
USDA Rural laboration, knowledge, and cooperation, in extending quality care to a larger
Development it can be beneficial to Maine people. number of patients over a wider geo-
State Director graphic area.
USDA Rural Development offers tools
Michael W. Aube which can be combined with local re- Through pooling resources to enhance
sources to support local decisions and local strategies and investing in new
“invest in place” to sustain rural com- technologies that complement local
C onsolidation
is an issue
that affects us in
munities.
For instance, as a result of recent
delivery systems, rural communities
can take advantage of opportunities to
expand their horizons.
many ways. Our children, our health, Distance Learning Telemedicine Pro-
our safety all can be impacted by deci- gram investments, seven educational Guest columns included in this publi-
sions to consolidate services. Due to facilities are equipped with technology cation are exclusively the views of the
recent efforts (which are explored fur- that allows them to share information
with other students in the state and author.
ther in this publication), Maine is facing
change, and change is can be difficult. throughout the country, and five health
Health Access Network recently cel-
ebrated an investment by USDA Rural
Development and Bangor Savings Bank
for construction of its new facility.
In this Issue:
The new location at 175 West Broad-
way in Lincoln will allow for six separate
State Director’s Message……...…....1
administrative sites to be combined in
the new location. This consolidation will “Right-Sizing” Rural America…....…1
allow for expanded access to care in one
convenient location. An Update on Maine School
Consolidation…..….....….....….....…..2
“Rural Development has been so critical
to financing the ability to offer health care It Is About Students….....….............2
Pictured are: Health Access Network Medical Director to so many people in Maine. It has such
Noah Nesin, M.D.; Health Access Network Chief Execu- an important role to play in the health The Inside View: How Consolidation
tive Officer Dawn Cook; United States Senator Susan M. care community and to people insured or will Change Corrections in Waldo
Collins; USDA Rural Development State Director Michael uninsured.” County……….…...……...……...…......3
W. Aube; and Bangor Savings Bank Senior Vice President -United States Senator Susan M. Collins
Patrick Kelly. Consolidation of Health Care
Services in Maine………….……...….4
“Right-Sizing” Rural the age-old debate about
America: Technology “consolidation” is just one Streamlining Health Care in Maine..4
of the many things -- in the
Reshuffles the Deck age of the internet and dis-
Roving Reporter Rural Rover Asks:
How Will Consolidating Services
on Consolidations tributed computing -- that Impact Maine Residents….……........5
will no longer be the same.
By Thomas C. Dorr In Our Fall Issue….…….....................8
For decades, rural com-
munities have been losing
Technology is reshap-
schools and hospitals for
ing our world at an ever-
the same reasons they
increasing pace. While Thomas C. Dorr,
have lost businesses and
change can be unsettling, Agriculture Under
other services. (Continued
it also creates new oppor- Secretary, USDA
on page 6)
tunities. For rural America, Rural Development
The Maine Community Exchange
Committed to the future of rural communities.
I believe, and the experts believe, for others. The promise that school
An Update on Maine School that fewer, better resourced districts districts
will produce better opportunities for would return
Consolidation students. that money
to property
By Susan Gendron There has naturally been some appre- taxpayers
Guest Columnist hension about the new School Admin- in the form
istrative Reorganization Law, enacted of lower mill
K-12 public school enrollment is last June by the Legislature. It repre- rates did not
declining rapidly – more than 4,000 sents a significant change to the way materialize.
students just last year, a 10 percent students are educated in Maine by And now the
drop in the past decade; costs are sky- requiring larger, comprehensive K-12 state spend-
rocketing; and we have an important school districts in order to improve ing limits
responsibility to prepare all Maine stu- efficiencies and the delivery of educa- that govern
dents to succeed in the 21st century. tional services. spending
Maine has prided itself in its invest-
elsewhere in state and local govern-
ments in education but also has raised The interesting thing is that it is not ment will be required for education
questions about what is affordable and such a significant change at all: spending. Meanwhile, enrollments
how do we balance the cost among Regional School Units (RSUs), as re- are declining rapidly in many school
the state and quired by the law, look a lot like School districts. Even some larger school
local com- Administrative Districts, (SADs) which units will find it hard to sustain vital
munities. have worked quite well in all parts of programming, much less consider in-
the state for almost 50 years. In fact, novative additions.
Our aca- the statutory language that governs
demic per- these new RSUs is taken almost word- Reorganizing our school governance
formance for-word from previous SAD law. structures is a big change, and yet
is declining preserves local schools in each com-
compared to So if RSUs look so much like SADs, munity. Students will continue to at-
the rest of why did Maine pass a law to reorga- tend the same schools with the same
the nation. nize school districts? Two reasons: principals and play on the same sports
Susan Gendron
(Five years educational opportunities and sustain- teams. For SADs, larger RSUs won’t
ago Maine ranked 5th in the nation in ability (money). look that different from what they are
math test scores. Now we are in the used to. But students will benefit as
middle of the pack.) An independent As evidenced by the current bud-
get shortfall, state funding is getting vital programming is preserved and
review of our educational system by a larger group of schools and school
Michael Fullan, an international expert, tighter. While Maine has injected over
$500 million more into K-12 education board representatives participate in
recommended Maine tackle its infra- designing the curriculum and program-
structure. The large number of school over the past three years (as a result
of LD1), that steep ramp-up of money ming, drawing on the educational and
districts in our state has led to a lack financial strengths of a larger com-
of a coherent approach to achieving for education is quickly flattening.
The 2008-09 increase in subsidy is a munity.
the Maine Learning Results.
minimal $5.5 million, meaning slight in- -Susan Gendron is Commissioner for
creases for some units and reductions the Maine Department of Education
It Is About Students ganization is of the community in which they reside
one portion of – should have the opportunity for a
By Peter Geiger a much larger rich, rigorous and relevant education.
Guest Columnist vision needed Students in rural Maine, urban, and
for improving suburban areas of the state need to
As this article was written, the school education for graduate from high school with the
district reorganization issue was yet to Maine stu- necessary and required knowledge
be resolved in the Maine legislature. dents. and skills to be successful in whatever
Rather than bemoan what has or has they choose to do. We can’t lose sight
not happened, I want to share with you The Coalition of the fact that the skills needed for
the reason I personally support district is a statewide this century are different than when
reorganization and why the Maine organization Peter Geiger people of my generation graduated.
Coalition for Excellence in Education that believes (continued on page 6)
has been an advocate. District reor- that all Maine students – regardless
2 The Maine Community Exchange
Committed to the future of rural communities.
The Inside View: years that it is state legislators who Finally, while the majority of our
make state laws which are pros- citizenry will likely be excited to see
How Consolidation will
ecuted by state attorneys, in front the jail go, it is just the first step in
Change Corrections in of state judges, with clients sent to the erosion of their local control.
Waldo County state probation officers, who ulti- We all know that the closer our tax
mately land in county jails. This new dollars are
By Scott Story system will help by having many of to us, the
Guest Columnist the cost drivers in the bill-paying thriftier we
business as well. Make no mistake, can be with
Please keep in mind that as this I don’t presume to blame the people them.
article is being written, legislation is above for our corrections costs, it is
framing all of this, so some change a systemic problem that will require I always
from the original plan is quite systemic change. refer to the
likely. Having said that, we have little town
put together some fundamental as- While you can’t paint corrections meetings
sumptions of what should take place statewide with a broad brush, cer- many of us
regardless of the finer details. tain services and commodities can attend ev- Scott Storey
be purchased and or performed with ery spring
On the positive side of this plan is consistency throughout. Food ser- where we
the State’s commitment to freeze vices, medications, medical servic- argue over a $500 contribution to
the property tax assessment for the es, pre-trial services, post-conviction some social service group. The
costs of corrections in the counties and re-entry programming are all bottom line is that we have control
as well as support any increases necessary in this system and should over it. The further you get away
in costs that are considered to be be examined for the possibility of from local government, the less
within an “acceptable” growth rate efficiency through bulk purchases control you have.
by the newly formed Board of Cor- or contracts. This could produce
rections. This in itself is property better quality correctional services Consolidation can be taken to any
tax relief considering the increases as well as increased savings to the level that the people want. Five
in the costs of corrections over the taxpayer. towns into one, sixteen counties into
past several years. If the State is three, six New England States into
willing and able to stick with this A concern of many is that the fund- one, where does it all end? I heard
commitment, future county budgets ing will not be there at the state level a legislator once comment that
will not be cannibalized to support to adequately fund the growth in the counties were an archaic form
corrections, as we unfortunately the system, with cannibalization of of government that was a couple
have been dealing with over the last same at the county level to make hundred years old and outdated.
few years of trying to stay under the up deficits in funding. This could I would contend that this country is
LD 1 cap. affect Waldo County as one of those still governed today by a document
facilities originally slated for closure that was adopted in 1787, the United
Consolidation in Waldo County and in the State’s original takeover plan. States Constitution, older than most
elsewhere with the state assuming Such an action could potentially counties, but it still works!
the increased costs will now put leave municipalities with additional
the bills in the hands of those who expenses and inconveniences they -Scott Story is Sheriff for Waldo
will have the largest influence on presently do not incur. County Office of Corrections
the populations. I have argued for
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The Maine Community Exchange 3
Committed to the future of rural communities.
Consolidation of Health Care of office visits, and the volume of pro- Still there are pressures to con-
Services in Maine cedures performed rather than for the solidate, particularly for smaller, rural
outcome of care for the patient. providers. For better or worse, the solo
By Frank Johnson family physician practice is becoming
Guest Columnist Several studies have concluded that as dated as a Marcus Welby re-run.
30% of the nation’s direct expenditures Rural hospitals struggle to find the
It’s inevitable that the health care balance between serving the com-
industry is confronted by cost pres- munity needs and remaining solvent.
sures to consolidate services. Since As a result of these challenges, many
the health care sector often doesn’t providers have become part of larger
respond to economic forces in the health systems. This arrangement is
same manner as other industries, we designed to create efficiencies and
shouldn’t assume that consolidation to support the smaller practices and
will necessarily produce efficiency. institutions.
Unlike other sectors of the economy
the health care industry doesn’t get re- Does it work? Many would argue that
warded for high quality and efficiency. it has worked. Clearly the large health
Payment is based almost exclusively for health care are for poor quality. systems are often better equipped to
on volume of services. Poor quality has been defined as the invest in and support needed informa-
underuse of evidence-based medi- tion technology. These investments
The fact that many Maine hospitals cine, unwarranted variation in rates are of great value to small practices
and physician practices have invested of services, overuse of marginally and community hospitals. We are
hundreds of thousands of dollars to effective or unnecessary services and anxious to see if the consolidation into
improve patient safety and clinical system flaws. Slightly more than 50% larger health systems will reduce the
quality is a testimony to their mission of Americans with chronic illnesses are wide geographic variation in the use
and commitment to high quality care. receiving recommended treatment. of certain procedures and services.
Until recently it’s a very rare instance How efficient can a system be when There’s also the fact that integrated
when providers see a financial re- nearly a third of the payments are for health system models have the poten-
ward for providing safe, high-quality, care that does nothing to improve our tial to improve care for chronically ill
efficient care. We have a perverse health? patients and may be able to challenge
reimbursement system that pays for the current reimbursement system.
the tests that are ordered, the number (continued on page 7)
Streamlining Health Care in Our public health system has been sive com-
Maine successful in reducing the rate of munity health
tobacco use, the number of infant coalitions or
By Trish Riley deaths and improving our health, but a Healthy Maine
more strategic approach to health care Partnerships.
Maine’s demography influences our delivery would strengthen our capacity The Public
health. With 1.3 million people spread to prevent disease, particularly chronic Health Work
out over a geography as large as the illness. Group has
rest of the New England states com- established
bined, we are challenged to effectively But, making changes in health status a roadmap to
and efficiently deliver public health at requires personal and local action and complete a
the local level. collaborations among providers and consolidated,
patients. In 2004, the Governor’s Of- more ef-
fice of Health Policy and Finance with ficient and Trish Riley
We need improvements because
Maine spends more per capita on the Maine CDC convened the Public effective
health care than all but one other state Health Work Group to build a public statewide
and, chronic illness is a cost driver. health infrastructure that will more ef- public health infrastructure.
Nearly 37% -- or $1.2 billion of Maine’s fectively bring information, education,
increase in health spending (1998 – and support to the local and regional As a first step, over 150 grants and
2005) is attributable to leading chronic levels. contracts were consolidated to 28 by
illnesses that are often preventable the Maine CDC, the Office of Sub-
– cardiovascular disease, cancer, The Public Health Work Group has stance Abuse, in DHHS in collabora-
chronic lung disease and diabetes. completed its planning work and has tion with the Maine Department of
established eight public health districts Education. (continued on page 7)
with a robust system of comprehen-
4 The Maine Community Exchange
Committed to the future of rural communities.
Roving Reporter Rural Rover
Message from USDA Rural Develop-
ment Mascot Rural Rover: A. Last year’s school consolidation law is a huge accom-
plishment. Education accounts for the largest expenditure
Welcome to my column, where you can of state and local revenues. It’s 48%
find out answers to your questions on of the state budget Fifty-seven
topics of interest to rural Maine- you might percent of combined state taxes
even say I have a “nose for news!” If and property taxes are spent on
you’ve never met me, I am Rural De- schools. That’s billions of dollars
velopment’s Mascot, Rural Rover, and I
spent on K-12 education in Maine.
travel around Maine sharing information about the Programs of
Every dollar possible must be spent
USDA Rural Development. Don’t be left in the doghouse- read
on classroom instruction, not excess
my column!
administration. Many Maine com-
munities have embraced school
This Issue Rural Rover Asks: What is consolidation. Some are still strug-
the Impact of Consolidation on Maine gling with this change. But for the
Residents? well-being of our students, taxpayers, Martha Freeman,
and economy, there’s no going back. Director, Maine State
This issue, I met with Martha Freeman, Director of the Maine The Governor’s Office of Health Policy Planning Office
State Planning Office, to find out what the issues and Finance has also done much
are concerning consolidating essential services in Maine. to create data-sharing, health planning, and efficiencies
to help us develop a health care system in Maine. Right
Q. What do you feel may be behind the hesi- now, county and state corrections officials are finishing a
tancy of some to embrace consolidation? joint plan for creating a unified corrections system. Having
those officials planning together is an accomplishment in it-
A. The Maine economy has been in rapid transition for self. Getting the Legislature’s endorsement is a necessary
10 to 20 years. Our economy was based in manufactur- next step. Also, achieving the Legislature’s endorsement of
ing—textiles, shoes, paper—and natural resource extrac- a summer study of reorganizing the state natural resource
tion—forest products, farming, fishing—for decades. In departments is important.
the United States, labor-intensive manufacturing began to
diminish a generation ago as industries moved overseas. Q. What are the specific benefits you foresee
Maine held onto some of its higher-paying manufactur- as a result of consolidation in the next two
ing jobs longer than many states. But technology and the years?
global economy have changed all: today we make more
paper in Maine than ever before, but technology permits A: Consolidation efforts aim at two goals: The first is to
this with fewer workers using new skills. Land development use resources frugally so that we’re investing in programs
in Maine, even in rural areas, pressures farmers. Those to help our citizens compete in the global economy, while
who make their living from the sea struggle with declining preserving Maine’s unique character. With school consoli-
stocks, the costs of fuel, and competition. Maine people dation, we’ll see educational opportunity increase for Maine
are experiencing a great deal of change in their economic children wherever they live. The second goal, strangely, is
lives. At the same time, we’re asking them to embrace to protect yet modernize Maine’s penchant for local control.
change in some fundamentals of the Maine community— If we don’t have more regional approaches to governing, if
in schools, jails, and hospitals. we don’t take advantage of technology to spread services
at less cost, if we don’t have cooperation among different
Also, we’re Mainers! We have two centuries of history be-
levels of government and nonprofit administration, we’ll
hind us that involves 16 counties, over 280 school districts,
be able to claim we’ve preserved local control—but we’ll
and almost 500 organized municipalities with community
actually have given up effective control of Maine’s des-
hospitals serving many of them. All of this spread over a
tiny. Decisions will be made in one town or at one level
land area the size of the rest of New England with just
of government that impact fellow citizens—from land use
1.3 million inhabitants. And those inhabitants have a me-
to school facilities to health care—without their participa-
dian age of 41.1 years, making us the oldest state in the
tion. We won’t be exercising truly effective control over the
nation. No wonder we hesitate when asked to change.
quality of our lives and our state. For example, within the
county jail system there are currently 400 empty inmate
Q. What accomplishments have been made beds. Yet some counties must board out inmates, the state
in Maine regarding consolidating health care, system is overcrowded, and five new jail projects are being
education, and correctional facilities? contemplated. We can’t afford this type of uncoordinated
approach to essential services.
The Maine Community Exchange 5
Committed to the future of rural communities.
“Right-Sizing” Rural Amer- It’s the same story in education. The pacities in this area. In addition, the
ica: Technology Reshuffles case for school consolidation tradi- agency has invested over $1.6 billion
tionally rested on the need to increase in loans for projects to provide rural
the Deck on Consolidations enrollment to support an expanded broadband service. Rural America
(continued from page 1) curriculum. That, of course, is still is going online, and there is no going
a factor, but computer-based and back.
Very simply, everywhere one looked, distance learning allows schools
economies of scale drove consolida- to access remote resources and These technologies allow rural busi-
tion. Bigger tended to mean better, achieve economies of scale at much nesses, hospitals, and schools com-
and cheaper. That’s a tough combi- lower size thresholds. Rural schools pete with larger rivals. They mean
nation to beat. big organizations can
decentralize operations,
Technology, however, is chang- which creates opportu-
ing the game. Rural communi- nities for smaller com-
ties are finding new opportuni- munities. They make
ties to compete effectively as small towns, with their
service providers. quality of life and cost of
living advantages, more
Rural health care is an excel- attractive places to do
lent example. Gone are the business.
days when a small rural hos-
pital needed to be all things to The playing field is being
all people. Today, a rural Critical that might otherwise be candidates leveled. Broadband and distributed
Access Hospital can specialize in for consolidation have new ways to computing represent the greatest de-
routine, ambulatory, and emergency compete. centralization of information since the
care. It can be linked via broadband invention of the printing press -- and
to world-class medical center diag- To help rural communities exploit in an increasingly knowledge-based
nostic and consultative resources, these opportunities, USDA Rural economy, that spells new opportunity
while patients in need of specialty Development’s Distance Learning and for rural America.
services can be transported for treat- Telemedicine Program, since 2001,
ment. Small rural hospitals have a has invested over $300 million to -Thomas C. Dorr is Agriculture Under
new niche – and a new lease on life. assist 7,745 rural schools and health Secretary for USDA Rural Development,
care facilities in developing their ca- Headquartered in Washington D.C.
It Is About Students The status quo is unsustainable...there The Maine Coalition for Excellence in
(continued from page 2) simply is not enough money to fund Education asked that policy makers
education the way it should be funded develop a student-focused plan for
Today’s economy requires that our stu- with all the other competing priorities. district reorganization with the prin-
dents are prepared with a higher level cipal objective of improving student
of literacy than ever before. A number Those of us in business realize that performance and creating richer op-
of reliable reports have been issued during reorganization, savings are not portunities for students. Acknowledg-
warning that Maine must streamline necessarily realized in the first couple ing Maine’s current economic environ-
the way public education is delivered. of years, but the end result is a more ment, now, more than ever, we need
Declining student enrollment, rising efficient, quality operation. This same to use our educational resources more
property values, and legitimate com- premise has to pertain to education if effectively to produce better student
peting priorities were highlighted as we are to fulfill our responsibilities to learning in every school across the
reasons the status quo of administer- Maine students. Otherwise, we risk state. Maine students deserve nothing
ing and maintaining over 280 districts falling farther behind in skills and edu- less.
is not practical and that we were head- cational attainment. The potential for
ing for the “perfect storm.” Clearly, greater success in education is within -Peter Geiger is the Chair of the Maine
fewer, better resourced districts will our reach if we collectively keep our Coalition for Excellence in Educa-
produce improved opportunities for focus on what is best for students. tion and Executive Vice President of
students and relief for taxpayers. Geiger Bros.
6 The Maine Community Exchange
Committed to the future of rural communities.
Many purchasers of health care would the Titanic. Changing a system that
argue that consolidation alone will not has evolved over seventy years poses
Consolidation of Health Care provide a cure for our health care sys- a daunting challenge. But the pros-
Services in Maine (continued tem. We need to change the way we pects of improving safety, quality and
buy health care services. In the short- efficiency without introducing a more
from page 4) term that means introducing incentives rational payment system based on
that encourage patients to receive value rather than volume appear very
What are the pitfalls? Despite financial care from providers who can dem- remote.
limitations, many small providers have onstrate better quality and efficiency.
used their ingenuity to deliver high- The state employee health plan tiers If consolidation can help facilitate
quality, efficient care. Individually and benefits for hospital and primary care the widespread implementation of
collectively several rural Maine hospi- services based on patient safety and evidence-based medicine, reduce the
tals have implemented systems to dra- selected clinical quality performance. use of unnecessary (but profitable)
matically improve medication safety There are financial incentives to go the procedures, and foster efficiency, we
protocols. We certainly don’t want to higher-rated providers. The plan is to should embrace it enthusiastically.
promote consolidation that might stifle introduce costs into the value equa- Until then, consolidation of the health
innovation. There is also some appre- tion. care market should be judged by its
hension that the large health systems results rather than its promises.
can be difficult to move. Believe me, In the longer-term we must radically
after over 30 years in state govern- change the current provider reim- -Frank Johnson is Executive Director
ment I can attest to the fact that inertia bursement methods. There have been of the State Office of Employee Health
can be a barrier to systems improve- small steps toward paying providers and Benefits Plan
ments. for performance but these have been
like re-arranging the deck chairs on
local level. In addition, Maine CDC strategic approaches to secure more
Streamlining Health Care in has out-stationed staff to the districts efficient and effective care.
Maine (continued from page 4) and is working with local communi-
ties to strengthen the Local Health The public health infrastructure will
This consolidation created a more Officers system. Over the next two play an integral role in achieving the
efficient and effective Healthy Maine years Maine CDC will complete the goals of Maine’s State Health Plan –
Partnerships system by strategically implementation of a more streamlined “to make Maine the healthiest state
coordinating funding for tobacco, statewide public health infrastructure with the most effective and efficient
substance abuse, physical activity, to develop a plan to improve immuni- health care delivery system.”
nutrition, school health coordination, zation rates in the state; to publicize
cancer screening, chronic disease pre- and promote worksite wellness among -Trish Riley is Director, Governor’s
vention combined into a single Healthy the smallest businesses in Maine and Office of Health Policy and Finance
Maine Partnership contract to assist to work at the local level to examine for the State of Maine
in more strategic interventions at the data regarding how health care costs Source: Draft State Health Plan,
vary district to district and develop 2008-2009
Websites Related to Issues on Consolidation
Maine Coalition for Excellence in Educatrion www.mainecee.org
The Maine State Planning Office www.maine.gov/spo
The Governor’s Office of Health Policy and Finance www.maine.gov/governor
The Maine Department of Education www.maine.gov/education
The Maine Department of Corrections www.maine.gov/corrections
The Maine Community Exchange 7
In Our Fall Issue: The Maine Community Exchange will explore
cultural tourism and its role in Maine’s economy, as well as exam-
ples of successful projects that are sustaining rural communities
and what is planned for the future of cultural tourism in Maine.
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8 The Maine Community Exchange
