Berkshire Medical Center North (BMCN):

The Case for Restoring a Full Service Hospital for Northern Berkshire County
Following the sudden closure of the 121-bed North Adams Regional Hospital (NARH), which left
thousands of residents without access to local healthcare, Berkshire Health Systems
(BHS)/Berkshire Medical Center (BMC) purchased NARH now BMC North and has been
operating a satellite emergency room out of the facility, while providing inpatient care only at its
Pittsfield campus. BMC has linked its willingness to provide inpatient care to receiving Critical
Access Hospital (CAH) designation, which grants rural hospitals higher Medicare reimbursement
for services. The following report clearly shows that restoration of inpatient beds is not only
necessary, but is financially viable. Receiving CAH status would be desirable, but not necessary,
for the ongoing viability of inpatient services in Northern Berkshire County. This conclusion is
based on:
1) An analysis of the cause of NARHs financial problems and ultimate bankruptcy;
2) An examination of the issues at stake in BMCs attempted purchase of NARH before the
closure;
3) The inpatient needs in North County and loss of patients to Vermont hospitals;
4) Financial security of BHS and the availability and promise of resources on the part of
BHS and the Commonwealth
The report concludes with the finding that Berkshire Medical Center should restore inpatient
services at its North County campus as soon as possible and that all stakeholders, including BHS
and local and state policymakers should take whatever steps are necessary to ensure that the
health care needs of this community are provided for within this community.
History of Financial Problems
For more than a decade, North Adams Regional Hospital (NARH) turned a profit on patient care,
from the ER and outpatient centers to inpatient services. 1 But when NARH closed abruptly in
March, the hospital simply pointed to its finances and the challenges facing rural hospitals as
the culprits, leading many to believe that a hospital could not be sustained in North County. The
truth, however, is that NARHs parent company, Northern Berkshire Healthcare (NBH) made a
series of non-hospital real estate investments, assuming nearly $65 million in debt through
revenue bonds between 1996 and 2004, which, in the end, cost this community its hospital.
Following the assumption of $12.8 million in revenue bonds in 1996 to refinance old debt, NARH
took on another $25 million in 1999 to purchase Sweet Brook Transitional Care & Living Centers
and Sweetwood Continuing Care Retirement Community. This was an alarmingly large
assumption of debt which bore no connection to the provision of hospital services. The real
estate investment scheme immediately unraveled and the Sweets began costing NBH money.
NBH then took aggressive steps cutting staff and reducing operating costs in order to lend
money to the Sweets.2 Ultimately, NBH sold the Sweets in 2010 for $7 million under pressure
from bondholders. In the meantime, NBH took on another $27 million in revenue bonds in 2004,
in part to pay off a portion of the 1996 debt. The 2004 revenue bonds immediately went into
default, as the organization could not meet some of the financial covenants required by
bondholders.

1 Publicly-available information from 2000 to 2012; later data not yet available
2 In re Northern Berkshire Healthcare, Inc., et al. (Chapter 11 Case No. 11 31114 (HJB)). United State
Bankruptcy Court District of Massachusetts, Western Division. January 5, 2012

By the time NBH filed for bankruptcy in 2012, its debt burden still hovered around $44 million. In
its court filings, NBH attributed its financial problems almost entirely to becoming highly
leveraged through the series of bond issuances listed above. The final impetus for NBHs 2012
Chapter 11 filing was bondholders refusal to make a voluntary deal to restructure the debt,
again affirming the catastrophic impacts this debt took on North Adams Regional Hospital. And
while NARH publicly wanted to lay blame for the closure on the healthcare environment or rural
location, the data demonstrate that, despite constant competition with the larger and more
prosperous Berkshire Medical Center, NARH turned a profit on patient care every year, a fact
supported by BMCs interest in purchasing it.
The Deal that Wasnt & Ultimate Closure
Prior to the decision to shut NARH down, executives were in talks with Berkshire Health Systems
(BHS; parent company of BMC) to purchase the North Adams hospital. BHS was reportedly willing
to purchase the full-service hospital, but would not take on more than $4 million of its
outstanding debt. During negotiations, the State offered to enhance Medicaid reimbursement to
the struggling hospital in order to offset some of the acquisition costs facing the prospective
owner. Debt-holders would not agree to the deal, and at the last minute, BHS walked away,
leaving NARH to file for bankruptcy and close its doors. 3 But just two months after the closure,
BMC had crafted a deal to open a satellite emergency department in North Adams and ultimately
purchase the hospital for $4 million (a fraction of its value) without committing to provide
inpatient care.
A report released last fall by the Maine-based Stroudwater Associates, a firm contracted by the
Department of Public Health to evaluate the healthcare market in the Northern Berkshires, found
that there is a need for inpatient services at BMC North yet indicated that Critical Access Hospital
designation should be a precondition for providing inpatient services in North Adams. While BHS
did not identify CAH status as necessary during its negotiations to purchase NARH prior to its
closure, it has since claimed that it is a requirement for providing inpatient care. 4 In the months
since acquiring the North Adams hospital, BHS has committed capital to expanding outpatient
services, continues to assess the needs and possibilities for services in North Adams, and has
repeatedly pledged to apply for Critical Access Hospital designation. Yet, Berkshire Health
System has yet to file an application with the Centers for Medicare & Medicaid Services, the
federal body that certifies Critical Access facilities. Why?
The Stroudwater Report: Service Needs
Although Stroudwaters focus on the necessity of Critical Access designation was off the mark,
what Stroudwater confirmed is that Northern Berkshire residents have asthma, heart disease,
and most cancers at higher rates than other communities, and face public health issues including
obesity and alcohol and tobacco addiction. 5 The fastest-growing segment of the population is the
elderly, many of whom are disabled. And compounding health problems are barriers to access,
like the lack of financial resources and transportation. The combination of these factors makes
North County a medically vulnerable population. 6 The Stroudwater report affirmed the
communitys need for inpatient services, saying that market demand showed an existing need
for 18-21 beds for acute inpatient medical services and 11-12 beds for inpatient behavioral
health and substance abuse services. 7
3 Robert Weisman. North Adams Regional Hospital to close: Financial woes, patient drop force a
Friday closing; Unions says theyll fight move that will idle 530, Boston Globe. March 25, 2014
4 The nurses at NARH have consistently supported CAH designation, but the federal government
repeatedly denied status petitions
5 Stroudwater Associates. Healthcare Market Assessment: Northern Berkshire County,
Massachusetts. September 17, 2014. Hereafter, Stroudwater
6 Stroudwater, p.18
7 Stroudwater, p.50
2

1. Inpatient Medical/Surgical Services

In 2012 and 2013, of the more than 39,000 ER visits at NARH, 9,769 visits were considered high
severity, and nearly 5,000 constituted an immediate threat to life. 8 Many of these patients
needed access to emergency surgical care, which was available when NARH was a full-service
hospital. Today, the safety of those same patients would be jeopardized by a forty-minute
ambulance ride, delaying their access to care. And Stroudwater argues that inpatient
medical/surgical services must also hinge, not on the need for those services, but on the
viability of physician recruitment and high volumes of specific procedures to retain them. 9
When NARH was in direct competition with the larger and more profitable BMC, attracting and
maintaining physicians was a challenge, and procedure volume suffered. Now that the North
Adams hospital is a campus of BMC, BMC physicians can perform surgery and treat their patients
at either campus, just as Baystate Healths Springfield-based physicians travel to the even more
remote communities of Franklin County. Stroudwater suggests that transportation to Pittsfield
from North County is not too much of a burden for critically ill patients; surely BMC physicians
can make the trip in reverse to treat their patients.
2. Inpatient Psychiatric Services
A 2013 Community Health Needs Assessment conducted by NARH revealed the following data
from the Department of Public Health:
-

Mental health disorders are the seventh leading cause of death for [North County];
Mental health disorders and alcohol abuse are the second and eight leading causes related to
hospital discharges;
Both mental health and alcohol abuse exceed the states percentage rate for hospital discharges 10

The DPH data show that demand for inpatient psychiatric care in North County is substantial and
the Stroudwater report concurs. But absent CAH status, Stroudwater advises that the Brien
Center, an outpatient human service agency, build its capacity and expand outreach services
despite the fact that, in 2013, the average wait time for outpatient services in the region was
between seven and ten weeks.11 The underfunded human service industry, already struggling to
provide supports for individuals whose care can be managed on an outpatient basis, cannot be
expected to adequately serve those who need inpatient care. And while outpatient psychiatric
care can be an important, complementary service to inpatient treatment, it is no replacement for
inpatient, around-the-clock nursing and medical care.
3. Inpatient Obstetrics Services
The Stroudwater report states that obstetrics (OB) services were the most often-cited needs for
inpatient care in North County, and the nearly 1,100 babies born in North Adams in the most
recently-reviewed years support that claim. The firm recommends refocusing on prenatal care
and forcing women in North County to deliver their babies at BMCs Pittsfield campus. Citing
physician recruitment as a roadblock to service provision, Stroudwater again forgets that BMC
North is no longer NARH, but a campus of Berkshire Medical Center with access to the largest
Mother Baby Unit in the Berkshires and its many physicians who can easily provide healthcare
to women and their babies in North Adams. 12 Providing OB care at BMC North would eliminate
real dangers of a lengthy drive from North County to Pittsfield, especially in emergency situations
or for women with high-risk pregnancies, but Stroudwater recommends against inpatient OB care
at BMC North.

8 Stroudwater, p.35
9 Stroudwater, p.38
10This data comes from the Department of Public Healths Community Health Information
Profile, and was included in NARHs Community Needs Assessment, p.65
11 Stroudwater, p.54
12 BMC website
3

Stroudwater maintains that in hospitals like BMC North with

fewer than 500 deliveries per year, providing
comprehensive care for obstetric patients in these small
units is extremely inefficient, not cost-effective, and
2009 2010 2011 2012
frequently impossible, and may also have worse outcomes
for mothers and babies.13 Yet BMCs other operation,
NARH
273
289
273
235
Fairview Hospital, boasts the full-service Family Birthplace,
where fewer than 200 babies are born each year. Of
Fairvie
166
172
170
153
course, the data also reveal that in addition to significantly
w
fewer babies born in the more affluent Great Barrington
community, less prenatal care is paid for by public payers 14 in Great Barrington than in North
Adams, indicating that concerns about providing obstetrics care in North County are less about
need and safety, and more about the payment per delivery.
Foregone Revenue & Impacts on Surrounding Community Healthcare
While Stroudwater identifies North Countys needs for inpatient services, the report assesses the
North Adams hospitals financial viability based on outdated information rather than as a part of
Berkshire Medical Center. As a result, Stroudwater makes assertions about BMC Norths
sustainability that simply do not make sense. For example, Stroudwater questions the viability of
operating BMC North as a full-service hospital due to a 2011 analysis the firm conducted when
North Adams Regional Hospital was a stand-alone hospital competing with Berkshire Medical
Center for physicians, patients, and procedures and still struggling with its own legacy of
Sweetwater/Sweetbrook debt.15 What was also true was that insurance companies paid NARH far
less than BMC, which has the highest commercial payer rates of any teaching hospital in the
state.16 But these figures are no longer relevant because, as BMC North, the hospital can now
enjoy BMCs commercial payer price level and the purchasing power and efficiencies that being
part of a system can offer.17
Births:
NARH and Fairview (20092012)

Stroudwater also claims that providing inpatient care at BMC North

will cost Berkshire Medical Center an additional $2.1 million annually. The firm provides
insufficient data to back up its claim, but even if this number approaches accuracy, BMC was
willing to purchase NARH as a full-service hospital less than a year ago and certainly calculated
that the purchase would be cost-effective. This claim also fails to factor in the revenue lost to
13
14
15
16
17

Stroudwater, p.52
Birth Data
Stroudwater, p. 50
Center for Health Information and Analysis. Hospital Profiles. March, 2014
Ibid.
4

Vermont hospitals. The Center for Health

Southern Vermont Medical
Information and Analysis reviewed the North Adams
Center Budget Analysis:
hospital to determine, among other things, the
.
.
.
100 additional
communities in which patients cared for at that
medical/surgical
cases and 50
hospital live. According to the most current data, of
the
births due to NARH closing . . .
eight cities and towns represented, three of them are
in
Mainly due to greater
Vermont, a short distance from North Adams. In
volume from the NARH
2012, 69% of all patients from Stamford, VT, and
50%
18
service
area.
from Pownal, VT, were treated at NARH. Even 30%
of
patients from Bennington, VT where Southwestern Vermont Medical Center (SVMC) provides
inpatient services were treated at NARH. The distances from Stamford and Pownal to North
Adams were ten and twenty minutes, respectively, while a trip from either town to Pittsfield
would take nearly 45 minutes. Bennington patients treated in North Adams are very unlikely to
travel nearly an hour to the Pittsfield BMC campus for services available in their local hospital.
Likewise, some North County residents in need of care may choose the short drive to SVMC,
which offers inpatient medical/surgical services and a Birth Center, rather than BMC in Pittsfield,
which may further limit the patient care revenue available to BMC from Northern communities.
SVMC has, in recent months, commenced an aggressive strategy to attract both Vermont and
Massachusetts patients who were left without a hospital following the NARH closure. For 2015,
SVMC management has budgeted approximately 100 additional medical/surgical cases and 50
births due to NARH closing.19 And SVMC maintains that the volumes which we have seen as a
result of the closure [have] assisted in SVMCs positive financial performance in FY 2014 and in
the FY 2015 budget development. The Hospital volume increases in the budget are mainly due to
greater volume from the NARH service area.20 If an out-of-state hospital stands to gain revenue
from the patients no longer served in North Adams, BMC ought to consider that providing
inpatient care at BMC North may very well be an income-generator for the system. Providing
inpatient care in North Adams could also reduce the stress on BMCs Pittsfield campus, which
continues to struggle with an increasing number of patients.
In a statement to the press in early December, BMC compared the average number of discharges
in Pittsfield prior to the closure of North Adams Regional Hospital with the months following the
closure, and found the hospital had treated ten percent or 1,500 more patients in that sixmonth period.21 While it is impossible to know whether every additional discharge at BMC was
the result of the NARH closure, the most recent state data show that NARH treated
approximately 3,000 patients per year (or 1,500 per six-month period), suggesting a strong
correlation between the NARH closure and BMCs increased patient volume. 22 In recent weeks,
nurses at BMC have raised concerns that the hospital cannot adequately handle the increased
inpatient volume without providing more nurses to care for those patients. The closure of NARH,
and the continuing lack of inpatient care in North County, is evidently impacting healthcare
throughout the region.

18 Center for Health Information and Analysis. Appendix, Massachusetts Hospital Profiles: Data
Through Fiscal Year 2012. March, 2014
19 Operating Budget Summary Fiscal Year 2015. SVMC. Delivered to the Green Mountain Care
Board on June 25, 2014
20 Stephen D. Majetich, CFO of SVMC. Responses to Questions. Letter to Michael Davis, Green Mountain
Care Board. August 11, 2014

21 Jim Kinney. Nurses union complains of staffing at Berkshire Medical Center in Pittsfield,
patient volume up 10 percent since closing of hospital in North Adams, Masslive. December 03,
2014
22 Center for Health Information and Analysis. Appendix, Massachusetts Hospital Profiles: Data
Through Fiscal Year 2012. March, 2014
5

Financing the Future of BMC-North

In October, the Health Policy Commission awarded BMC $3 million to create a Patient-Centered
Medical Neighborhood [PMCN] and enhanced behavioral health care in the Northern
Berkshires.23 The program, which BMC expects to cost nearly $16 million, will focus on
coordinating care with community healthcare providers and service agencies to address heart,
cardiovascular, and renal diseases, diabetes, and behavioral health needs. 24 The PMCN also
targets a dramatic reduction in ER visits and hospital admissions and readmissions. Reducing
unnecessary hospitalizations and providing some healthcare services to North County patients
are positive steps, but limited both by the short supply of primary care physicians, which will
make it difficult for residents to access care through the PMCN, and the reality that hundreds of
North County residents will still need inpatient care.
One Western Massachusetts hospital system has taken a more comprehensive approach to
addressing the healthcare needs of the communities it serves. After more than a year of
conversations with nurses and other community members about the need for more inpatient
care in Franklin County, and an ER nearly bursting at the seams, Baystate Franklin Medical
Center (BFMC) reopened shuttered med-surge floor in November. 25 Hospital CEO Steve Bradley
noted that the Greenfield hospital increased its inpatient capacity rather than simply sending
more patients south to Springfield because, No one wants to be in the hospital . . . But if you or
a family member need care, you want to be able to receive that care as close to home as
possible. 26
The costs of providing inpatient care to the residents of the Northern Berkshires are not
unmanageable, especially given how profitable Berkshire Health Systems facilities BMC and
Fairview have been. In all but one of the last ten years, BMC has posted surpluses between $8M
and $43M, and over the last five years, Fairview Hospital has had surpluses between $1.1M and
$4.8M.27 In FY14, Berkshire Health System hospitals had total margins (that is, revenue over
expenses) of 7.3% and 7.6% respectively, double the average hospital margin of 3.8%. 28 In real
numbers, BHS made a total of $23.9 million in profit in 2014 ($21.2m at BMC and $2.8m at
Fairview), an impressive performance for a Massachusetts hospital system according to
independent hospital financial analysts. Earlier this fall, Fitch Ratings upgraded BHSs debt rating
to A- and called the systems outlook stable, in part due to its low-cost acquisition of NARH and
its new market dominance.29 By all measures, BHS is a profitable and stable system. BHS has
already devoted resources to operating the satellite emergency room; it has expressed a desire
to expand various outpatient services; and its planned expenditures on the Medical
Neighborhood are not insignificant. It is clear that BMC/BHS must bring the same commitment to
establishing inpatient services in North Adams as it has to each of these endeavors and so, too,
should state officials. During negotiations between Berkshire Health System and North Adams
Regional Hospital prior to NARHs bankruptcy filing, the Commonwealth reportedly offered to
enhance Medicaid reimbursement to the North Adams hospital. If the Commonwealth recognized
the need for this hospital to provide inpatient care then, it ought to still be willing to make good
23 David Seltz, Executive Director. Health Policy Commission. Letter to David Phelps, President
and CEO of BMC. October 24, 2014
24 Berkshire Medical Center CHART Phase 2 Operational Response.
25 Kathleen McKiernan. BFMC reopens in-patient wing, The Recorder. November 24, 2014
26 Kathleen McKiernan. BFMC reopens in-patient wing, The Recorder. November 24, 2014
27 Acute Hospital Financial Performance. Center for Health Information and Analysis. Only five
years of data is currently available for Fairview
28 Massachusetts Acute Hospital Financial Performance: Fiscal Year 2014: Data through June 30, 2014,
Center for Health Information and Analysis
29 Fitch Removes Berkshire Health System, MA Revs from Rating Watch & Upgrades Rtg to 'A-'; Otlk Stable.
Fitch Ratings. October 17, 2014

on that offer, given community demand and the Stroudwater report, which supports that
demand.
Conclusion
The primary obligation of a hospital is to meet the healthcare needs of the communities it
serves. The next consideration is whether or not all of those needs can be met based on the
finances available to the hospital. Berkshire Medical Centers early moves to continue operating
an emergency facility in North Adams and securing the grant to implement expanded outpatient
services are clear indicators that BMC understands the healthcare needs of North County are
many. All evidence points to a sustainable community hospital, and the Stroudwater report and
community input are indisputable: inpatient services are needed in North County. BMC has the
financial resources and market dominance to restore and deliver a full spectrum of services to
the Northern Berkshires in a fiscally responsible manner. This should be done now without further
delay.