Case analysis “emerging US health care system “

Read case 1 from book “****” page 1-32. In 3-5 pages address the questions below in section 1 and 2 in an APA format

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Many people regard Hillsboro County as a comfortable place to raise a family. It is an area known for its social and economic stability. While the residents are generally aware of national and world events, the local media coverage is dominated by news about the area’s
youth teams, social and fraternal organizations, church outings, and high school sports. Multiple gen-
erations of families live in Middleboro and the surrounding towns that make up Hillsboro County.

demogrAphic chArAcTeriSTicS
Middleboro and Hillsboro County are classifi ed as non–metropolitan areas. Middleboro has been
the economic, political, and social hub for Hillsboro County. Th e average family size is 2.57
people. Basic demographic data are given in tables 1.1 through 1.3 at the end of this case. (Note
that the entire casebook is set at the start of 2020, so all tables are dated for the preceding years.)

Th e other major town in Hillsboro County is Jasper, located 23 miles southeast of Middleboro.
Jasper is a growing community that benefi ts from being close to Capital City, the state capital. Jasper
is becoming a bedroom community for Capital City and is continuing to develop as an economy
that is independent from Middleboro.

On the web at

ache.org/books/
Middleboro2

C A S E 1

THE COMMUNITY

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EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 1/26/2020 3:19 PM via GRANITE STATE COLLEGE
AN: 1839062 ; Seidel, Lee F., Lewis, James B..; The Middleboro Casebook: Healthcare Strategy and Operations, Second Edition
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T h e M i d d l e b o r o C a s e b o o k2

geogrAphic chArAcTeriSTicS
Surrounded on two sides by relatively high mountains, Middleboro is 45 miles northwest
of Capital City and 70 miles east of University Town, the location of State University.
Access to Middleboro is limited to rail (freight), bus, automobile, and truck. The majority
of private and commercial travel is done on the auxiliary four-lane, east–west interstate
highway, which is typically closed an average of three days per year because of weather
conditions. Commercial air travel is available in Capital City. The mountains on the east
and west make winter travel outside Middleboro especially difficult. The fertile valleys on
the north and south are known for agricultural activities.

Outside of Middleboro and Jasper, the population lives in small, scattered villages.
The only transportation linkages to Middleboro from these scattered communities are the
rural county and state highways. Limited bus service is available throughout Hillsboro
County. Middleboro serves as the regional transportation hub, and the bus station in
Middleboro offers connections to major population centers in the state. Jasper is also
served by this bus system. Recently, a commuter bus system began linking Jasper with
Capital City.

Hillsboro County stretches 45 miles to the north, 15 miles to the west, 28 miles to
the east, and 37 miles to the south of Middleboro. Seventy-one percent of the total area
is developed, and the remainder is taken up by forest, the state park, and rivers. This area
experiences four distinct seasons, but tourists find it especially attractive during the fall and
spring. Sports of all types play an important role in the life of its communities. Table 1.4
indicates the miles between the communities located in Hillsboro County.

Middleboro is located along Swift River, which was instrumental in the commercial
development of the city in the early 1800s. Before the turn of the century, Swift River and
the commercial barges that traversed it were the city’s primary linkage with the rest of the
state. Now the river is used for recreational purposes, and some limited redevelopment of
the riverside property has begun.

Swift River divides Middleboro into two almost equal parts. The north side of the
river is the site of the central business district, large manufacturing plants, the railroad
station, older residential neighborhoods, and the county government. During the 1970s,
federal funds were used to develop low-income housing on the north side. The south
side of the river, which is closer to the interstate highway, is the site of newer residential
neighborhoods, the new Middleboro High School, and small shopping centers. To date,
the City of Middleboro has not approved any significant development—residential or
commercial—in the vacant 150-acre land adjacent to the interstate highway.

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EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 1/26/2020 3:19 PM via GRANITE STATE COLLEGE
AN: 1839062 ; Seidel, Lee F., Lewis, James B..; The Middleboro Casebook: Healthcare Strategy and Operations, Second Edition
Account: lifelong

C a s e 1 : T h e C o m m u n i t y 3

SociAl And educATionAl chArAcTeriSTicS
The population of Hillsboro County is predominantly of German, Irish, and English
extraction. Racial minority groups compose about 13 percent of the population. Most of
the African Americans arrived in the 1960s, and most of the other racial groups arrived in
the late 1970s. The number of households headed by a female is 10.6 percent.

The median education level of the population older than 25 years is 10.7 years.
Approximately 13.5 percent of the population has completed college, and 89.3 percent
has completed high school. The current dropout rate from area high schools is 3 percent,
an improvement over the 17 percent rate experienced 20 years ago.

Middleboro is the site of numerous elementary schools (K–6), a regional middle
school (7–8), and a high school (9–12) that serve students from all over the city. Other
communities in the county can send their children to Middleboro schools, using tuition
arrangements on a space-available basis. Although all the schools are owned and operated by
the City of Middleboro, a separately elected Middleboro School Board makes educational
policy. One-third of the nine-member school board is elected each year in a special school-
district election held in Middleboro. Each year, the school board submits a recommended
budget for consideration by the Middleboro City Council. The city council approves the
school budget before it is submitted, as part of the town’s total budget, for voter approval.
All employees of the Middleboro School Department—except the school superintendent
Dr. Sam Drucker—are unionized. Abby O’Hara is currently the chair of the school board,
a position she has held for the past ten years. The new $28.5 million high school located
in Middleboro opened last year after being considered by the city council for about eight
years. The town is heavily involved in high school sports. Middleboro Memorial Stadium
is a landmark in regional high school football.

Jasper is the site of numerous elementary schools, a regional middle school (5–8),
and a high school (9–12). A state-supported junior college is scheduled to open. A five-
member elected school board that is independent of the town governs the Jasper Regional
Educational Cooperative. Each year, this school board submits a recommended budget
directly to the voters. Once approved, the funds are collected by the Town of Jasper
from local taxes. The Jasper Regional Education Cooperative has expressed interest in
working with the state to develop a regional vocational high school to complement the
new Hillsboro County Junior College.

State University (SU) in University Town is the land-grant university within the
state. It has a nursing, public health, and allied health school connected to its relatively
large liberal arts and agricultural schools. Its 39,000 students make SU the largest public
university in the state. A private liberal arts college of 1,000 students is also located in
Capital City. SU maintains a small branch campus in Capital City as well.

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AN: 1839062 ; Seidel, Lee F., Lewis, James B..; The Middleboro Casebook: Healthcare Strategy and Operations, Second Edition
Account: lifelong

T h e M i d d l e b o r o C a s e b o o k4

Church membership remains strong in Hillsboro County. Aside from their religious
influence, churches sponsor many of the youth sports leagues and are the site of many
social gatherings.

Local chapters of Rotary International meet monthly in Middleboro and Jasper.
AARP—formerly called the American Association of Retired Persons—maintains a chapter
in Middleboro. The local chapter of American Red Cross, located in Middleboro, sponsors
monthly blood drives throughout the county.

When statistics are adjusted for demographic characteristics, crime rates in the
county are 10 percent below the national averages for non–metropolitan areas.

poliTicAl chArAcTeriSTicS
Middleboro and its surrounding communities are politically conservative. Unlike other
areas in the state, the same political party has dominated Middleboro for the past 45
years, except in presidential elections. Its politicians have gained statewide political power
by consistently being reelected to office. The city is especially proud that the area’s rep-
resentative to the US Congress, James Giles, is a Middleboro native who retains his law
practice in town.

Middleboro is governed by a six-member city council whose members are elected
every two years. By tradition, the council member who receives the largest number of
popular votes is appointed by the council to serve as mayor. Although the office’s powers
are mostly ceremonial, the mayor has the ability to influence decisions by presiding
over council meetings and by making appointments to boards and commissions. Keith
Edwards, a local retailer, has held the position of mayor for 17 years. Other members of
the Middleboro City Council are Frederick Washburn, Diana Story, David Alley, Patricia
Hood, and Michael York. The city’s largest department is the school department, and the
second largest is public works. York is the council member who has lead responsibilities
for all healthcare-related issues and programs.

The City of Middleboro has recently begun legal action to block the licensing of
three group homes for the developmentally disabled population. Middleboro Community
Mental Health Center currently owns and operates Justin Place, a four-bed group home in
Middleboro. Group Homes Inc., a national corporation, has a contract with the state to
own and operate these homes. According to Mayor Edwards, the Hillsboro County Health
Department has failed to take into consideration the serious implications these homes will
create for Middleboro. Mayor Edwards recommends that the application for licensure
be turned down on grounds related to negative community impact. Stephanie Jervis-
Washburn, the executive director of Middleboro Community Mental Health Center, has
also questioned the need for additional group homes, although at the same time indicating
that her organization would be willing to assess the need for such services and possibly
develop them should a need be identified.

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C a s e 1 : T h e C o m m u n i t y 5

Middleboro is the county seat for Hillsboro County. Three county commissioners
elected by the population at large govern Hillsboro County. While the county level of
government is not a powerful political subdivision in this region, it does control the
court system, the penal system, and the registry of motor vehicles; it also provides some
human service programs. Hillsboro County owns and operates a nursing home located in
Middleboro. It is a major county employer in Middleboro. The current Hillsboro County
Commissioners are Janet Ruseski, Bill Nelligan, and Mary Harrison.

Jasper is governed by a 12-member town council and a mayor. All are elected for
four-year terms. William Hines is the mayor, a position he has held for the past nine
years. The town council employs a professional city manager, Susan Giles-Harrison. The
Jasper Industrial Development Authority (JIDA)—authorized by the voters 15 years
ago—is a subunit of the town council and has the authority to issue bonds to support
industrial development in Jasper. State law allows a municipal government to use tax-
increment financing for purposes of economic development. Giles-Harrison also serves
as the executive director of JIDA. Two years ago, JIDA formed a special committee to
consider the feasibility of a hospital located on its property that was to be owned and
operated by the town. This committee is chaired by Sharon Lee, who is the spouse of a
Jasper physician, a member of the town council, and a former consultant for a national
consulting firm that specializes in healthcare. Other members of this committee include
Mayor Hines and town councilor Ed Hicks. Giles-Harrison provides staff support for
the committee.

Under a program supported by the federal Department of Homeland Security,
the mayors of all the communities located in Hillsboro County and their fire and police
officials have created a task force to estimate surge capacity in an emergency or mass
casualty situation. Officials from the two Middleboro hospitals—MIDCARE and Webster
Health System—have attended task force meetings. The task force continues to update
its estimate of potential evacuation or triage locations and beds that could be used. The
Office of the Governor supports this project by funding a countywide assessment of surge
capacity conducted by State University.

Initial findings and results from the surge capacity study indicate the following:

◆ At least 385 hotel or motel rooms are available in Hillsboro County.

◆ Public schools are able to hold 4,500 citizens, although none has provisions
for emergencies.

◆ The disaster plans for both hospitals have not been coordinated. Each has its
own plan and has estimated that it can accommodate at least 150 percent to
180 percent of its inpatient capacity for one week.

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T h e M i d d l e b o r o C a s e b o o k6

◆ No countywide, centralized communication system or command-and-control
system exists that is able to direct resources and responses in the face of a
significant disaster.

A more comprehensive assessment and plan is expected in six months.
Since 2009, Hillsboro County has sponsored a Community Emergency Response

Team program to educate residents about disaster preparedness for hazards that may arise
such as fires, floods, and weather-related disasters. Classes are held three times a year;
to date, approximately 120 residents have completed training. Program instructors have
been drawn from local police and fire departments, both local hospitals, and the Hillsboro
County Health Department.

For the past five years, the state legislature has attempted to make the state a right-
to-work state. Although the bill was not passed, it did secure 52 percent approval in the
state senate last year. The current governor has indicated that, if the legislation passes in
both houses, he would veto it. His political opponents have indicated their support for
the right-to-work legislation.

economic chArAcTeriSTicS
Middleboro’s tax profile reflects the conservative nature of the community. Increases in
property taxes have just barely kept pace with inflation. The state has both a graduated
income tax and a sales tax. By state law, any incorporated city is allowed to add a 0.5
percent local sales tax to the state sales tax. The Middleboro City Council has repeatedly
rejected all proposals to do this.

Middleboro is the site of important wholesale and retail trade in Hillsboro County.
Its major industries include manufacturing, finance, and service. Jasper is also establishing
itself as a manufacturing center. Agriculture, which once dominated, now accounts for
20 percent of income and 16 percent of all employment in the county. Manufacturing
accounts for 32 percent of income and 30 percent of employment. Per capita income is
5 percent below the national average. Fourteen percent of the county’s population falls
below the federal poverty standard. In Capital City, 18 percent of the population is under
the federal poverty level.

Local banks estimate that approximately 8 percent of the single homes in the
county have outstanding mortgages greater than the homes’ current market value. The
regional foreclosure rate is 1 percent greater than the national rate.

Three of Middleboro’s manufacturing companies employ nearly 15 percent of the
community’s workforce, down 7 percent from five years ago:

1. Carlstead Rayon, a privately controlled textile corporation, employs 5.1
percent of the workforce.

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C a s e 1 : T h e C o m m u n i t y 7

2. River Industries, a division of National Auto Technology, manufactures
rubber products for automobiles. For the past three years, it has reduced its
workforce by 9 percent but still accounts for 4.5 percent of the workforce.

3. Master Tractor, formerly a division of United Agricultural Supply, was
recently sold to a Japanese firm, which indicated that some parts for tractors
will be imported from offshore and South American suppliers. A leader in
the market for small tractors, Master Tractor employs 4.6 percent of the
workforce.

The manufacturing plants of Carlstead Rayon, River Industries, and Master Tractor
are all adjacent to Middleboro’s rail service.

Following are employment opportunities in Jasper:

◆ Blue Bear Ale is a popular, locally owned, statewide microbrewery. Its sites are
located in Middleboro and Mifflenville. The company plans to open a new
site in Jasper in 2017.

◆ U.S. Parts, a division of a national corporation that manufactures components
for large air conditioning units, relocated to Jasper three years ago. Today, it
employs 2.2 percent of Jasper’s workforce.

◆ National Yearbooks, a corporation headquartered in a major western city,
established a modern printing and manufacturing plant in Jasper last year,
using resources provided by JIDA. The company specializes in manufacturing
yearbooks for colleges and high schools. Although currently it employs only
81 workers, it estimates that employment will increase 10 percent for each of
the next ten years as it reduces its existing regional manufacturing sites and
concentrates its entire North American manufacturing at the Jasper plant.
National Yearbooks is not unionized and offers a full range of health insurance
options to its full-time workers.

◆ Office Pro, a retail and wholesale provider of office supplies and office
furniture, operates its regional warehouse in the Jasper Industrial Park, located
on the western boundary of Jasper.

Agriculture and construction companies in the rest of Hillsboro County are
primarily small, family-owned businesses. Chicken Farms, Inc., located in Harris City, is a
national corporation that specializes in raising chickens for fast-food restaurants. It recently
began to acquire family farms in the area and has announced plans to locate a processing
plant somewhere in the county.

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T h e M i d d l e b o r o C a s e b o o k8

Countywide, housing construction permits have steadily declined over the past
seven years. The housing stock is considered old—except in Jasper—by both national and
state standards. The recent real-estate exception is the area between Jasper and Capital City.

Hillsboro County has one state-chartered commercial bank—Middleboro Trust
Company—that has offices in Middleboro, Mifflenville, Statesville, Harris City, and Jasper.
The county also has four small savings-and-loans (S&L) institutions, which were started
principally to provide capital to the agricultural sector. To avoid insolvency 12 years ago,
the Merchants Bank of Capital City acquired the Carterville Bank (S&L). Harry Carter,
Carterville Bank’s president, was a prominent politician at that time and was subsequently
convicted of investor fraud.

Major capital financing is available through Middleboro Trust Company, a
correspondent bank of a major national financial institution, or through a commercial bank
located in Capital City. Bankers’ Cooperative, a multistate commercial bank headquartered
in another state, has recently announced plans to expand into Jasper.

mediA reSourceS
The major newspaper in the county is the Middleboro Sentinel. It has a daily as well as a
Sunday edition, and it maintains a comprehensive website. Its circulation is 22,000 for the
daily edition and 8,200 for the Sunday edition. Three years ago, National News Stands,
Inc., a national owner and operator of local newspapers, acquired the Middleboro Sentinel.
Jack Donnelly has been its editor for 16 years. In Jasper, The Capital City News reaches
approximately 25 percent of all households in town. Its rates are similar to those of the
Middleboro Sentinel.

Middleboro has three local radio stations—AM-75, AM-1220, and FM-89.7—
that cover local news and current events. TV Channel 32 is an independent station located
in Middleboro. It provides network and independent programs. Affiliates of national
television networks are located in Capital City, and their broadcast reaches most residents
in the county. Cable TV and high-speed Internet from national and local providers are
available throughout the county as well.

medicAl reSourceS

hillSboro heAlTh

This tax-exempt, Medicare-certified home health agency provides a broad range of home-
based services throughout the county. Two years ago, the agency was formed after a merger
and expanded its mission and focus. It established a Medicare-certified hospice service
and curtailed a number of community health programs. It uses funds provided by the

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C a s e 1 : T h e C o m m u n i t y 9

towns and cities in the area, Hillsboro County, and United Way to support indigent care
associated with Medicare-certified services. It transferred maternal and child health pro-
grams, funded by a grant from the state’s Department of Health and Human Services, to
voluntary health agencies. Martha Washington is Hillsboro Health’s CEO, and Janet Myer
is president of its board of directors.

phySiciAn cAre ServiceS, inc.

Physician Care Services (PCS), Inc. is a private, tax-paying corporation that owns and
operates two urgent care/occupational health centers—one located in Mifflenville and
the other in Jasper. PCS employs physicians and other professionals to provide walk-in
ambulatory care, a full range of diagnostic services, and an occupational health program.
Currently, PCS is considering opening a third center in the Jasper Industrial Park. Dr.
Stephen Tobias is the president/CEO and medical director of PCS.

middleboro communiTy menTAl heAlTh cenTer

In 1964, Middleboro Community Mental Health Center (MCMHC) was established as
a tax-exempt 501(c)(3) corporation; it is one of two such designated centers in Hillsboro
County. MCMHC provides a range of services and programs, including adult, child and
family, emergency, and education. In addition, it owns and operates a central office called
Gardner Place as well as a four-bed group home called Justin Place; both facilities are
located in northwest Middleboro. Stephanie Jervis-Washburn serves as MCMHC’s exec-
utive director.

webSTer heAlTh SySTem

Webster Health System owns and operates a fully accredited, tax-exempt, 85-bed osteo-
pathic hospital located in Middleboro adjacent to the interstate highway. Named after its
founder Dr. Edward W. Webster, this system was founded as Webster Hospital in 1930.
Currently, the hospital has an active medical staff and makes use of many other physicians
with consulting privileges from Osteopathic Medical Center (OMC) in Capital City. Ten
years ago, Webster Hospital changed its name to Webster Health System and became an
affiliate corporation of Osteopathic Hospitals of America, Inc. (OHA). Under this affili-
ation, OMC and OHA support the management of the system, provide joint-purchasing
and supply-chain opportunities, and provide capital. In return, OMC and OHA have
an exclusive contract to receive all medically appropriate referrals. Since executing the
agreement, Webster Health System has established Quick Med, a walk-in ambulatory
care clinic adjacent to its emergency department; recruited physicians; and expanded all

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T h e M i d d l e b o r o C a s e b o o k1 0

services related to birthing. The system and members of its medical staff jointly own Web-
ster Health, Inc., a tax-paying corporation, to support joint ventures. In 2015, the system
appointed Steve Swisher as president and CEO.

midcAre, inc.

Middleboro Medical Center, or MIDCARE, is a health system established on January
1, 2015, to “meet the needs of Hillsboro County.” The system grew out of Middleboro
Community Hospital, a fully licensed, tax-exempt acute care hospital founded in 1890
on the north side of Middleboro. Most of MIDCARE’s current beds are located in wings
originally constructed in 1962 and 1966 with the assistance of federal Hill-Burton funds;
these wings have now been modernized. In 2014, this modernization involved converting
a significant number of semiprivate rooms into private rooms and updating the birth-
ing facilities. MIDCARE provides a full range of diagnostic, outpatient, therapeutic, and
emergency medical services, including a cancer center. Adjacent to the hospital is the Mid-
dleboro Medical Office Building; ample parking is available for both facilities. Although
licensed for 272 beds, the hospital had to reduce its inpatient capacity to lower costs and
adjust to new hospital utilization patterns.

In 2015, the system signed a ten-year agreement to become an affiliate member
of Treeline Health Systems, Inc. Under this affiliation, MIDCARE pays dues to be part
of Treeline; in return, Treeline provides medical oversight and direction for MIDCARE’s
cancer center, access to its national supply chain management system, and technical
assistance and support for MIDCARE’s clinical data systems. In addition, both parties
agreed to develop a clinical residency program for primary care practitioners. In 2012,
a physician–hospital organization was created to facilitate the development of joint and
other collaborative ventures involving the medical staff. James Higgens is the president of
MIDCARE.

medicAl ASSociATeS

Medical Associates is a multispecialty physician group with offices in downtown Middle-
boro and in Jasper. Founded in 1951, it is a tax-paying private corporation organized as a
professional partnership. Physicians in the group provide specialty and subspecialty care on
an ambulatory basis, and in the Jasper location, they also offer ambulatory surgical services.
All of its physicians are board certified and maintain active medical staff privileges at area
hospitals. Over the past three years, to facilitate the expansion of its primary services, the
group has added more physicians in its Jasper office as well as advanced registered nurse
practitioners in both locations. In 2017, it introduced Medical Associates Express, a 24/7

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C a s e 1 : T h e C o m m u n i t y 1 1

walk-in clinic, to its Jasper office. The group contracts with Wythe Laboratories in Capital
City for all medical tests and with Radiology Partners for all diagnostic images. Cynthia
Worley is the executive manager at Medical Associates.

JASper gArdenS

Jasper Gardens is a private, tax-paying, 110-bed long-term care facility located in Jasper. It
qualifies for Medicare, Medicaid, all private insurance plans, and self-pay. Its owners—Jef-
ferson Partners, LLC of Capital City—recently announced plans to expand its inpatient
and outpatient rehabilitation services. Also, Jefferson Partners recently submitted to the
Town of Jasper an application to build an 88-bed assisted living facility as well as 50 adult
single-family homes on the same campus as Jasper Gardens. At the news conference, Jef-
ferson Partners indicated that this “continuing care retirement community” will be oper-
ational within three years. Jayne Winters is the licensed administrator of Jasper Gardens.

hillSboro counTy heAlTh depArTmenT

Located in Middleboro, this department is responsible for the distribution of state health
agency funds to local health agencies, immunizations, environmental health, the long-term
care facility Manorhaven, and the implementation of county health priorities using county
tax revenues. Using a statewide data system, the department gathers vital and mortality
statistics and provides the data to the state as part of its annual report to the Hillsboro
County Commissioners. John Snow is the director of the health department, and Dr.
Doris Felix is the current chair of the Hillsboro County Board of Health, which oversees
the department. The board comprises 12 members, each of whom is appointed for an
overlapping five-year term by the Hillsboro County Commissioners. Other professionals
the department employs include registered nurses, public health assistants, and experts in
public health.

oTher heAlTh ServiceS

Aside from Medical Associates, many small, single-specialty and solo medical practices
operate out of Hillsboro County.

The Carter Home—located north of Middleboro and Jasper near Mifflenville—is
a tax-paying, 110-bed long-term care facility that qualifies for both Medicare (as a skilled
nursing facility) and Medicaid (as an intermediate care facility). Jack H. Carter has been
president of the Carter Home Corporation, Inc. for the past 20 years and is currently the
administrator of the Carter Home. Recently, the corporation opened Carter Village, an
assisted living facility comprising 50 two-bedroom apartments with a congregate meal

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T h e M i d d l e b o r o C a s e b o o k1 2

facility, 24-hour access to nursing services, access to physical and occupational therapists,
and van service to shopping areas in Middleboro.

Manorhaven—located in Middleboro—is a 110-bed long-term care facility that
is owned and operated by Hillsboro County. It also operates a limited adult day care
program for residents of Middleboro. Services at the facility qualify for both Medicare
and Medicaid reimbursement. Jennifer Jones has been Manorhaven’s administrator for
the past eight years.

Rock Creek—located north of Mifflenville near Harris City—is a private, 126-bed
nursing home and 84-bed assisted living facility. It qualifies for Medicaid insurance, but it
serves no Medicare patients. Five years ago, a statewide proprietary chain purchased Rock
Creek. Its current administrator is John Lipman.

Senior Living of Mifflenville—located between Middleboro and Mifflenville—
is an assisted living facility that offers two types of living arrangements. In the 45-unit
assisted living facility, residents rent a private, one- or two-bedroom apartment with a
small kitchen. Amenities include congregate meals, transportation services, and a full
recreational program. In the adult home, 125 residents are provided either private or semi-
private room accommodation. A 24-hour nursing staff provides supervision. Senior Living
of Mifflenville opened four years ago and is owned and operated by a national corporation.
Its adult home is not a licensed nursing home.

Sockalexis Center—located in Jasper—has the contract to provide behavioral
health and counseling services to the Jasper schools and is moving aggressively into the
corporate substance abuse and employee assistance program market. The center is staffed
by four doctorally trained clinical psychologists, three master’s-level social workers, and
three substance abuse counselors.

Greenwood Group—located just east of Jasper—is a provider of substance abuse
therapy known for its “upscale” setting. It is staffed by psychiatrists, clinical psychologists,
a social worker, substance abuse counselors, and health-and-wellness personnel. The
organization has targeted commercially insured clients.

Royman Oaks, LLC, offers employment counseling and job placement for clients
with a history of behavioral disorders.

Grosvenor Arms—located in Jasper—is a seven-bed adult group home. Its staff
includes residential counselors, a clinical psychologist, a social worker, and a marriage-
and-family therapist.

A state-supported, 154-bed inpatient psychiatric institution is located nearly 150
miles northeast of Middleboro.

Churches throughout Hillsboro County coordinate and provide Meals on Wheels,
a program that delivers hot lunches to homebound elderly and disabled populations.

In Middleboro, the Fire Department provides emergency services staffed with
emergency medical technicians (EMTs). In Jasper, the Fire Department uses paramedics
to provide emergency services. Other communities rely on volunteer firefighters and

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C a s e 1 : T h e C o m m u n i t y 1 3

emergency responders, some of whom require basic EMT certification. This year, the
county launched a countywide 911 emergency dispatch system.

Statewide Blue Cross and Blue Shield is headquartered in Capital City, along with
the state chapters of the following organizations:

◆ AARP

◆ Alzheimer’s Association

◆ American Cancer Society

◆ American Diabetes Association

◆ American Heart Association

◆ American Lung Association

◆ Brain Injury Association of America

◆ Epilepsy Foundation

◆ Mental Health America (formerly National Mental Health Association)

◆ Muscular Dystrophy Association

◆ Planned Parenthood Federation of America

◆ United Cerebral Palsy

The statewide Alzheimer’s Association has publicly expressed its priority to estab-
lish a membership office in Middleboro and throughout Hillsboro County.

The state has two medical schools. One is public and located on the eastern
boundary, and the other one is private with an osteopathic focus and located on the
northern boundary. Both are located in major cities and are more than 250 miles away
from Capital City. Over the past 30 years, the hospitals in Capital City have become
major referral centers for the community hospitals located within a 100- to 150-mile
geographic circle. Capital City General Hospital and Osteopathic Medical Center—the
two largest hospitals in the city—maintain teaching affiliations with the two medical
schools in the state.

In Hillsboro County, there are this many healthcare professionals per 100,000
people:

◆ 42.0 dentists, most of whom are independent practitioners with private
offices;

◆ 20.3 veterinarians;

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T h e M i d d l e b o r o C a s e b o o k1 4

◆ 811.4 registered nurses; and

◆ 27.0 physicians.

Six licensed mortuaries work in the county—four in Middleboro and two in Jasper.

STATe regulATionS

The state continues to maintain a certificate-of-need (CON) law for all acute and spe-
cialty hospitals and long-term care facilities that receive Medicaid and/or Medicare. Home
health agencies were exempted from the law 12 years ago. Also specifically excluded from
the law are private physician offices, clinics, and dispensaries for employees and health
maintenance organizations. The thresholds for application of CON are $4 million for
major medical equipment, $10 million for new construction, any transfer of ownership,
and any increase in the number of licensed bed size equal to or greater than 15 beds or 20
percent of the facility (whichever is less). CON proposals are evaluated on the basis of the
proposal’s ability to better address the needs of the service area, immediate and long-term
financial viability, cost control, and quality-of-care implications.

CON applications are forwarded to the State Commissioner of Health and Welfare
and then analyzed by the State Bureau of Healthcare Services. The state’s CON Board
renders the final decision. The governor, following the recommendation of the state
legislature, appoints the seven-member board. Jack Carter, the only local representative on
this board, owns a nursing home in Hillsboro County. Working with a committee in the
state legislature, the governor will be issuing recommendations on whether CON should
be reauthorized, changed, or allowed to lapse as a state statute.

communiTy concernS And iSSueS
Local political leaders have long recognized that Middleboro is economically stagnant.
They have discussed the need to build a major industrial park adjacent to the interstate
highway. Local business leaders, however, have resisted this venture, arguing that the funds
designated for an industrial park be invested instead in improving the central business dis-
trict to bolster the city’s existing retail trade business. As a result of these competing views,
Middleboro has not invested in either development.

The entire city has been affected by the national downturn in the traditional
industrial and manufacturing sector. The current unemployment rate in Hillsboro County
is 3.4 percentage points higher than the state’s overall rate. Most of this unemployment is
in the Middleboro area.

Twenty-five years ago, a flood hit Middleboro, heavily damaging Carlstead Rayon’s
plant. While some of this damage has been repaired, the corporation did not return to full

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C a s e 1 : T h e C o m m u n i t y 1 5

production. It elected to use the insurance settlement to open a new production facility in
another state with a right-to-work law and to switch some of its production to an overseas
location. In an emergency settlement one month before Carlstead Rayon was about to
completely close its Middleboro plant, it agreed to maintain a scaled-down manufacturing
operation—as long as the city waived in perpetuity all of the company’s real estate taxes
and the state provided it with industrial-development bonds for capital acquisition.

Although this settlement did save a significant number of jobs, local and state
political leaders continue to be criticized for the terms of the agreement. Earlier this year,
the Middleboro Sentinel ran a series of stories on the environmental hazards caused by
Carlstead Rayon’s questionable handling of waste materials through the years. Finally,
about one month ago, the Hillsboro County Health Department requested a Health
Consultation of the Carlstead site by the Agency for Toxic Substances and Disease
Registry of the US Department of Health and Human Services, Public Health Service.
The consultation report is due to be released within the next two months, and the expected
conclusion is that portions of Carlstead will be designated as hazardous waste sites and thus
subject to remediation requirements.

Meanwhile, the company has recently informed the city that it wants a 25 percent
reduction in the price it pays for water. The Middleboro City Council has repeatedly asked
all tax-exempt healthcare providers to make a payment in lieu of taxes to cover municipal
services costs. Last year, Steven Local ran for city council with one campaign promise: He
would convince nonprofit hospitals and other healthcare “free riders” to “pay their fair
share” or face consequences from the city, including court action. He lost the election by
21 votes but vowed to return next year with an even stronger campaign. For the past five
years, Hillsboro County has received an annual payment of $28,000 under the federal
Payment in Lieu of Taxes program (Public Law 113–79).

For the past five years, Middleboro politics has been dominated by three issues: (1)
the increases in property taxes, (2) the cost of schools, and (3) the use of funds included in
Medicaid to pay for abortions. Planned Parenthood continues to attract demonstrations
and protests. Generally, economic development issues do not characterize the local political
campaigns.

Over the past three years, major industrial development has occurred in Jasper.
U.S. Parts arrived in town, and today the company occupies almost 60 percent of the
Jasper Industrial Park, a campus established five years ago. National Yearbooks is expected
to fill the remaining capacity in the Jasper Industrial Park within five years. Plans are
also underway to expand the park or to construct another one next to the new interstate
highway between Jasper and Capital City. City officials in Middleboro are still being
criticized for letting Jasper “beat out” Middleboro in attracting these major employers.

In 18 months, the state will open a moderate-security prison as part of the plan
to develop regional prison facilities. The prison will have a capacity of 600 inmates and
will be located 30 miles south and west of Jasper. It is expected to become another major

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T h e M i d d l e b o r o C a s e b o o k1 6

employer in town. Seven years ago, Floyd Donovan, a state senator from Jasper, began the
community’s effort to secure the prison for Jasper.

Issues involving growth continue to dominate the politics in Jasper. While the
entire community seems very satisfied with the success of JIDA, many are dissatisfied
with the impact the developments have had on municipal services and the local education
system. Responsible Growth, a four-year-old group comprising 100 Jasper residents who
voice community concerns, succeeded in electing two of its members—Jennifer Kip and
Alan Simpson—to the Jasper Town Council. Both expressed concern that Jasper was too
quickly becoming a bedroom community to Capital City.

It is common knowledge that Kip and Simpson have approached the governor
about opening a hospital in Jasper. “Residents in Jasper need access to a hospital, especially
an emergency room,” Kip stated. “Too many of our residents have to travel too many miles
when they most need these types of services.” The governor has recommended the two
work with the State Commissioner of Health and Welfare to determine whether a small
hospital in Jasper is a viable venture. The governor has promised his support to ensure
the residents “of this growing community have access to the type of health services they
need and can support.” Kip and Simpson have told the press they will ask the Jasper Town
Council to authorize the hiring of a consulting firm to study this issue.

National Development Corp. has recently presented to the Jasper Planning Board
a proposal to construct an 800-unit subdivision of moderately priced housing on land
adjacent to the new interstate highway. The proposal holds the developer responsible for
all infrastructures.

new inTerSTATe highwAy

Three years ago, Representative Giles announced with the governor that a new four-lane
interstate highway would be built from Jasper to Capital City and University Town. This
road would shorten the travel distance from downtown Jasper to downtown Capital
City (currently, 32 miles) to 16 miles and from Jasper to University Town (currently,
93 miles) to 70 miles. Representative Giles acknowledged that this project would inject
numerous new jobs into the local economy and would provide Jasper with the transpor-
tation link it has needed for 15 years. The road from Jasper to Capital City should be
completed in the next 12 months, while the road from Jasper to University Town will
be finished in 18 months.

Over the past three years, the south of Jasper and land between Jasper and Capital
City have experienced significant attention and a number of development proposals. For
example, the Jasper Town Council, including Kip and Simpson, recently approved the
zoning application for a major shopping mall complex, which will be located adjacent
to the new highway and at the edge of Jasper—approximately six miles from downtown
Jasper and ten miles from the boundary of Capital City and Capital County.

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C a s e 1 : T h e C o m m u n i t y 1 7

When contacted by Mayor Edwards of Middleboro, Representative Giles indi-
cated that the new interstate is unlikely to be extended from Jasper to Middleboro.
Long-term plans have this new highway intersecting the existing east–west highway in
University Town. Representative Giles did say, however, that he would ask the governor
whether state funds exist to upgrade the existing road between Jasper and Middleboro
to a limited-access highway.

Under recent federal legislation, the State Department of Transportation issued
a feasibility study for a commuter rail link between Jasper and Capital City. The study
indicates that such a rail system may be feasible if Jasper continues to grow at its current
rate over the next five to seven years.

Tables 1.5 through 1.12 show the health insurance profile, hospital data, and
mortality rates in Hillsboro County.

counTywide grievAnceS

Citizens Against Abortions is a small but vocal political force in Jasper. On three occa-
sions, the group has picketed in front of the offices of physicians known to have per-
formed abortions at hospitals in either Middleboro or Capital City and a Planned
Parenthood clinic. TV Action 12, the largest TV station in Capital City, broadcasted on
the evening news two of these demonstrations in Jasper. This group has announced plans
to picket area hospitals. The Middleboro Sentinel has estimated that this organization has
35 to 40 members.

Leaders from other communities in Hillsboro County—Harris City, Boalsburg,
Minortown, and Carterville—have begun to meet monthly to discuss common concerns.
The group recently issued a statement directed at the Hillsboro County Commissioners.
The statement indicated that too many county resources are being devoted to develop the
southern part at the expense of the northern, smaller communities.

Philanthropy has declined in the county. As a condition of receiving funds from
United Way, a nonprofit agency must forgo any independent fund-raising, although it can
accept individual gifts. The rate of giving throughout the county has declined 30 percent,
and the amount disbursed by United Way has also shrunk by 16 percent. Even though
all large industries and many small employers in the county cooperate with United Way,
measures suggest that philanthropy has significantly decreased over the past ten years.

Five years ago, a state law was passed prohibiting health insurers doing business in
the state from excluding people from coverage because of their preexisting conditions. This
action was taken independently of the same provisions in the federal Affordable Care Act
(ACA). In addition, debate about a small-group health insurance reform bill is ongoing in
the statehouse. If passed, the law will allow small employers—those with fewer than ten
employees—to participate in health insurance purchasing pools, which offer more coverage

On the web at
ache.org/books/
Middleboro2

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T h e M i d d l e b o r o C a s e b o o k1 8

options at a lower rate than available from the employers’ previous arrangements. The state
decided not to participate in the insurance exchange originally stipulated by the ACA.

All employers in the state are required to obtain workers’ compensation insurance.
Currently, employees injured on the job are free to choose which healthcare provider
would treat them. A new workers’ comp law has been recently enacted, however. In
18 months, the responsibility for choosing the medical provider to care for an injured
worker will be, by law, the employer’s—not the employee’s. This legislation also changes
the workers’ comp appeal process. Appeals will continue to flow through the circuit
court and the State Supreme Court, and employees will still have 30 days from the
time of the injury to initiate an appeal. However, questions reviewed under the new
appeals process will pertain to law only and will not permit a jury trial. The old process
permitted reviews of law and fact as well as a jury trial. In addition, the new law will
increase competition for workers’ comp business among healthcare providers. Most
residents and observers feel that the changes amount to a tightening up of the workers’
comp system, at the expense of employees. By all indications, the new law and its yet-
to-be-seen impacts will be watched carefully. For example, a recent article in The Capital
City News reported that a study by the Teamsters and Service Workers Unions found
that, under the current system, the state’s rejection rate of workers’ comp claims was
extremely high and had been rising for at least the past four years. According to the
study, rejected claims are not paid by the state but by the employees’ regular health
insurance plans, which often include deductibles and copayments. The unions identified
the shift of insurance coverage from the state workers’ comp system to the employees
and employers as a major way of increasing health insurance expenses.

At a recent annual meeting, the State Medical Society endorsed statewide tort
reform, similar to the reform adopted in Texas in 2003. The group recommends limiting
awards for noneconomic damages to $750,000. Policy action committees have been
established in each county to work with state representatives to implement this revision
to the tort system.

Capital City Medical Center has purchased a five-year land option in Jasper (near
the new interstate) and indicated that it is considering constructing a medical office with
select ancillary services for its physicians. The medical center is expected to announce a
formal plan in 18 to 24 months.

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C a s e 1 : T h e C o m m u n i t y 1 9

City/Town 1994 1999 2004 2009 2014 20

Jasper 31,560 39,871 42,657 46,902 49,247 51,230

Middleboro 45,460 45,861 46,995 47,364 47,590 48,502

Statesville 11,788 11,750 11,790 12,750 14,350 14,780

Harris City 12,009 12,203 12,953 12,951 12,904 12,8

Mifflenville 10,325 10,623 10,945 10,952 11,240 11,253

Carterville 2,356 2,367 2,145 2,378 2,066 2,198

Minortown 2,160 2,163 2,190 2,056 2,103 2,005

Boalsburg 1,790 1,885 1,893 1,891 1,935 1,965

Total 117,448 126,723 131,568 137,244 141,435 144,768

Outside Hillsboro

County

Capital City 110,450 120,450 155,340 160,230 163,440 177,560

University Town 78,990 81,044 81,370 83,560 84,500 85,840

Table 1.1
Hillsboro
County
Population

On the web at
ache.org/books/
Middleboro2

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T h e M i d d l e b o r o C a s e b o o k2 0

City/Town Population White Black Other

Jasper

2019 51,230 47,162 1,534 2,534

2014 49,247 46,879 1,367 1,001

Middleboro

2019 48,502 35,440 9,095 3,967

2014 47,590 34,891 9,234 3,465

Statesville

2019 14,780 14,371 42 367

2014 14,350 14,078 16 256

Harris City

2019 12,835 12,130 145 560

2014 12,904 12,256 130 518

Mifflenville

2019 11,253 10,859 314 80

2014 11,240 10,855 301 84

Carterville

2019 2,198 2,104 16 78

2014 2,066 1,958 7 101

Minortown

2019 2,005 1,989 9 7

2014 2,103 2,099 0 4

Boalsburg

2019 1,965 1,942 14 9

2014 1,935 1,924 6 5

Total

2019 144,768 125,997 11,169 7,602

2014 141,435 124,940 11,061 5,434

Table 1.2
Hillsboro

County
Population by

Race

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C a s e 1 : T h e C o m m u n i t y 2 1

Ages

City/Town Total Under 5 5−14 15−24 25−44 45−64 65−74 75+

Jasper 51,230 3,942 7,647 7,533 15,726 11,487 3,083 1,812

Male 25,796 2,010 3,910 3,810 7,977 5,740 1,537 812

Female 25,434 1,932 3,737 3,723 7,749 5,747 1,546 1,000

Middleboro 48,502 3,203 7,060 6,725 13,904 10,661 3,522 3,427

Male 24,341 1,625 3,610 3,456 7,052 5,320 1,745 1,533

Female 24,161 1,578 3,450 3,269 6,852 5,341 1,777 1,894

Statesville 14,780 1,022 2,151 1,920 4,516 3,282 903 986

Male 7,287 521 1,107 996 2,273 1,651 441 298

Female 7,493 501 1,044 924 2,243 1,631 462 688

Harris City 12,835 805 1,868 1,780 3,629 2,850 848 1,055

Male 6,429 407 943 900 1,827 1,428 413 511

Female 6,406 398 925 880 1,802 1,422 435 544

Mifflenville 11,253 712 1,448 1,259 3,655 2,499 743 937

Male 5,617 362 730 643 1,837 1,239 358 448

Female 5,636 350 718 616 1,818 1,260 385 489

Carterville 2,198 102 320 305 655 488 156 172

Male 1,064 52 162 156 320 238 70 66

Female 1,134 50 158 149 335 250 86 106

Minortown 2,005 109 292 278 497 445 163 221

Male 1,011 55 152 140 266 222 77 99

Female 994 54 140 138 231 223 86 122

Boalsburg 1,964 114 286 272 586 436 143 128

Male 958 60 140 133 292 210 68 55

Female 1,007 54 146 139 294 226 75 73

Total 144,768 10,009 21,072 20,072 43,168 32,148 9,561 8,738

Male 72,503 5,092 10,754 10,234 21,844 16,048 4,709 3,822

Female 72,265 4,917 10,318 9,838 21,324 16,100 4,852 4,916

Table 1.3
Hillsboro
County Age
Profile by Sex

On the web at
ache.org/books/
Middleboro2

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T h e M i d d l e b o r o C a s e b o o k2 2

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seidel_lewis_layout_all.indd 22 1/23/17 11:27 PM

C a s e 1 : T h e C o m m u n i t y 2 3

Percentage of Coverage

Not
Covered

Any Time
During

the Year

Covered by
Employment-

Based
Insurance

Covered
by Self-

Employment
Insurance

Covered
by

Medicaid

Covered
by

Medicare

Covered by
Medicare

and Medicaid

All Residents 14.1 47.8 6.0 21.0 17.0 3.1

Employer Size,
Workers Aged
18−64

Fewer than 25
Employees

26.8 34.7 14.6 1.0 0.2 0.2

25−99 Employees 23.5 64.3 7.4 1.5 0.1 0.0

100−499
Employees

14.9 76.6 4.7 1.5 0.2 0.3

500−999
Employees

13.6 78.8 0.0 0.7 0.2 0.3

1,000+ Employees 0.0 0.0 0.0 0.0 0.0 0.0

Household
Income

Less than
$25,000

28.3 13.9 8.2 43.50 8.1 0.00

$25,000−$49,999 22.8 35.4 23.6 12.20 7.9 0.00

$50,000−$74,999 13.2 66.3 30.5 0.00 7.5 0.00

$75,000 or More 9.3 72.4 39.4 0.00 5.7 0.00

Note: Percentages may exceed 100%, depending on changes during the year of study and multiple coverage.

Table 1.5
Hillsboro
County Health
Insurance
Profile

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T h e M i d d l e b o r o C a s e b o o k2 4

Fee-for-Service Managed Care

Employer
Deductible

($)

Coinsurance

(%)

Deductible

($)

Coinsurance
per MD Visit

(%)

Carlstead Rayon 3,200 80/20

PPO 6,400 80/20

HMO 4,000 70/30

HD 12,900 70/30

River Industries

LD 2,500 70/30

HD 12,900 60/40

Master Tractor

PPO 7,500 60/40

HMO 7,500 70/30

HD 12,900 60/40

U.S. Parts

PPO 7,500 60/40
HMO 7,500 70/30

National Yearbooks

PPO 1,000 70/30

HMO 800 80/20

HD 10,500 70/30

POS 400 80/20

Office Pro 2,500 60/40

Chicken Farms, Inc. 12,900 50/50 300 85/15

Middleboro Trust
Company

PPO 2,000 70/30

HMO 1,500 80/20

HD 12,900 60/40

Notes: (1) Deductibles shown are for family coverage. (2) State law mandates mental health cover-
age in any insurance plan with more than 25 participants. The plan must include 30 hours coverage
for outpatient visits and 20 days for inpatient. (3) HD: high deductible; HMO: health maintenance
organization; LD: low deductible; POS: point of service; PPO: preferred provider organization

Table 1.6
Health

Insurance
Benefits
of Major

Employers
in Hillsboro

County

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C a s e 1 : T h e C o m m u n i t y 2 5

Coverage 1994 1999 2004 2009 2014 2019

No Insurance 12.5 12.9 14.5 19.1 19.3 15.5

Medicaid 12.7 15.1 15.2 16.3 19.2 19.7

Any Private Plan 63.6 59.6 58.4 56.3 55.1 49.3

Medicare 14.3 13.7 14.1 14.9 15.0 16.1

Military Healthcare 2.0 2.5 2.8 2.4 2.4 2.6

Note: Numbers are a percentage of total. Total insured and totals may exceed 100% due to multiple
coverages.

Table 1.7
Hillsboro
County
Estimated
Health
Insurance
Coverage

Patient Days

City/Town Population
Hospital

Discharges Total
Webster Health
System (WHS) MIDCARE Other

Jasper

2019 51,230 4,771 25,859 4,668 12,000 9,191

2014 49,247 5,352 24,084 3,013 17,100 3,971

2009 46,902 4,878 22,926 3,078 17,664 2,184

2004 42,657 4,795 24,453 3,105 19,825 1,523

Middleboro

2019 48,502 6,023 32,343 5,037 27,002 304

2014 47,590 6,201 35,346 7,076 27,830 440

2009 47,364 6,394 33,889 4,850 28,185 854

2004 46,995 7,364 43,448 4,445 38,143 860

Statesville

2019 14,780 1,528 8,918 2,490 6,356 72

2014 14,350 1,530 7,191 3,020 4,056 115

2009 12,750 1,469 7,938 3,175 4,673 90

2004 11,790 1,455 8,293 3,375 4,846 72

Harris City

2019 12,835 1,581 8,468 6,590 1,720 158

2014 12,904 1,730 8,996 6,743 2,020 233

2009 12,951 1,756 12,117 9,866 2,006 245

2004 12,953 1,886 12,447 7,856 4,360 231

Mifflenville

2019 11,253 1,324 7,378 2,291 4,938 149

2014 11,240 1,456 7,280 2,839 4,288 153

2009 10,952 1,687 8,939 3,320 5,475 144

2004 10,945 1,795 10,411 2,003 8,230 178

continued

Table 1.8
Hillsboro

County Hospital
Discharges and

Patient Days

On the web at
ache.org/books/
Middleboro2

seidel_lewis_layout_all.indd 25 1/23/17 11:27 PM

T h e M i d d l e b o r o C a s e b o o k2 6

Patient Days
City/Town Population
Hospital
Discharges Total
Webster Health
System (WHS) MIDCARE Other
Carterville

2019 2,198 275 1,442 390 1,000 52

2014 2,066 194 1,716 596 1,077 43

2009 2,378 338 1,891 702 1,177 12

2004 2,145 332 2,095 723 1,283 89

Minortown

2019 2,005 194 1,127 94 1,001 32

2014 2,103 420 2,408 601 1,796 11

2009 2,056 317 1,963 508 1,448 7

2004 2,190 382 2,446 468 1,962 16

Boalsburg

2019 1,965 229 1,326 528 798 0

2014 1,935 220 1,217 681 513 23

2009 1,891 236 1,395 747 608 40

2004 1,893 254 1,547 707 761 79

Hillsboro
County
Totals

2019 144,768 15,925 86,861 20,288 56,815 9,758

2014 141,435 17,103 88,238 24,569 58,680 4,989

2009 137,244 17,075 91,058 26,246 61,236 3,576

2004 131,568 18,263 105,140 22,682 79,410 3,048

Noncounty
Residents

2019 26 126 71 55

2014 32 176 86 90

2009 24 128 45 83

2004 21 124 44 80

Total

2019 86,987 20,359 56,870 9,758

2014 88,414 24,655 58,770 4,989

2009 91,186 26,291 61,319 3,576

2004 105,264 22,726 79,490 3,048

continued
Table 1.8
Hillsboro
County Hospital
Discharges and

Patient Days

(continued)

On the web at
ache.org/books/
Middleboro2

seidel_lewis_layout_all.indd 26 1/23/17 11:27 PM

C a s e 1 : T h e C o m m u n i t y 2 7

2019 Hospital Discharges by Town and Hospital

City/Town Total Discharges WHS MIDCARE Other

Jasper 4,771 802 2,202 1,767

Middleboro 6,023 967 5,000 56

Statesville 1,528 450 1,064 14

Harris City 1,581 1,228 325 28

Mifflenville 1,324 503 801 20

Carterville 275 71 195 9

Minortown 194 20 170 4

Boalsburg 229 94 135 0

Total Discharges 15,925 4,135 9,892 1,898

Table 1.8
Hillsboro
County Hospital
Discharges and
Patient Days
(continued)

On the web at
ache.org/books/
Middleboro2

Specialty Total MIDCARE WHS Other

Family Practice 41 5 27 9

Middleboro 9 0 9 0

Jasper 14 0 6 8

Harris City 3 0 3 0

Statesville 3 1 1 1

Mifflenville 6 1 5 0

Carterville 2 1 1 0

Minortown 2 1 1 0

Boalsburg 2 1 1 0

Internal Medicine 47 33 2 12

Middleboro 12 10 2 0

Jasper 22 10 0 12

Harris City 2 2 0 0

Statesville 2 2 0 0

Mifflenville 4 4 0 0

Carterville 2 2 0 0

Minortown 2 2 0 0

Boalsburg 1 1 0 0

Pediatrics 28 16 4 8

Middleboro 14 10 4 0

Jasper 14 6 0 8

continued

Table 1.9
Hillsboro

County
Physicians

by Specialty,
City/Town,

and Hospital
Affiliation

seidel_lewis_layout_all.indd 27 1/23/17 11:27 PM

T h e M i d d l e b o r o C a s e b o o k2 8

Specialty Total MIDCARE WHS Other

Allergy
Immunology

5 3 0 2

Middleboro 2 2 0 0

Jasper 3 1 0 2

Cardiology 8 5 1 2

Middleboro 5 5 0 0

Jasper 3 0 1 2

Gastroenterology 6 6 0 0

Middleboro 4 4 0 0

Jasper 2 2 0 0

Psychiatry 8 8 0 0

Middleboro 6 6 0 0

Jasper 2 2 0 0

Other Medical* 17 12 3 2

Middleboro 15 10 3 2

Jasper 2 2 0 0

Orthopedic 13 8 3 2

Middleboro 11 8 3 0

Jasper 2 0 0 2

General Surgery 18 12 4 2

Middleboro 14 10 4 0

Jasper 4 2 0 2

OB/GYN 22 12 8 2

Middleboro 14 8 6 0

Jasper 8 4 2 2

Other Surgical** 17 16 1 0

Middleboro 17 16 1 0

Jasper 0 0 0 0

continued
Table 1.9
Hillsboro
County
Physicians
by Specialty,
City/Town,

and Hospital
Affiliation

(continued)

seidel_lewis_layout_all.indd 28 1/23/17 11:27 PM

C a s e 1 : T h e C o m m u n i t y 2 9

Specialty Total MIDCARE WHS Other

Hospital-Based 61 43 18 0

Emergency 20 12 8 0

Anesthesiology 14 10 4 0

Radiology 16 13 3 0

Pathology 11 8 3 0

Total 291 179 71 41

Notes: (1) Table includes only physicians who have active medical staff privileges or are employed by an accred-
ited hospital. (2) * includes dermatology, pulmonology, endocrinology, otolaryngology, pulmonary medicine,
ear/nose/throat, oncology, and hematology; ** includes vascular surgery, bariatric surgery, ophthalmology,
plastic surgery, thoracic surgery, urology, and neurosurgery; (3) WHS is Webster Health System, and Other is a
hospital not located in Hillsboro County.

Table 1.9
Hillsboro
County
Physicians
by Specialty,
City/Town,
and Hospital
Affiliation
(continued)

Coverage 1989 1994 1999 2004 2009 2014 2019

Live Births 1,282 1,746 1,945 2,205 2,678 2,935 2,254

Deaths
(Except Fetal)

833 890 967 1,085 1,210 1,236 1,193

Infant Deaths 16 13 21 14 14 17 15

Neonatal Deaths* 10 12 13 10 8 6 7

Postneonatal
Deaths**

6 1 8 4 6 11 8

Maternal Deaths 2 1 1 2 1 2 3

Out-of-Wedlock
Births

140 167 175 216 299 355 256

Marriages 1,053 977 923 901 1,051 981 995

Note: * fewer than 28 days after birth; ** within 28−365 days of birth.

Table 1.10
Hillsboro
County Vital
Statistics

On the web at
ache.org/books/
Middleboro2

seidel_lewis_layout_all.indd 29 1/23/17 11:27 PM

T h e M i d d l e b o r o C a s e b o o k3 0

Cause of Death
ICD-10
Codes 1989 1994 1999 2004 2009 2014 2019

Diseases of the
Heart

I00−I09,
I11, I13,
120−151

302 325 361 390 418 401 367

Malignant
Neoplasms

C00−C97 212 221 234 240 245 256 262

Chronic Lower
Respiratory
Diseases

J40−J47 32 32 34 34 36 40 60

All Accidents V01−X59,
Y85−Y86

44 45 49 59 70 64 62

Cerebrovascular
Diseases

I60−I69 57 60 67 73 86 93 78

Alzheimer’s
Disease

G30 0 10 16 20 26 34 38

Diabetes Mellitus E10−E14 25 22 30 30 33 33 32

Influenza and
Pneumonia

J09−J18 31 27 31 40 34 30 37

Nephritis,
Nephrotic Syn-
drome, and
Nephrosis

N00−
N07,
N17−N19,
N25−N27

16 23 20 18 21 22 20

Intentional
Self-Harm

U03,
X60−X84,
Y87.0

14 21 18 20 26 24 17

Total Deaths from
Leading Causes

733 786 860 924 995 997 973

All Deaths 833 890 967 1,085 1,210 1,236 1,193

Table 1.11
Hillsboro

County Resident
Deaths by

Cause of Death

seidel_lewis_layout_all.indd 30 1/23/17 11:27 PM

C a s e 1 : T h e C o m m u n i t y 3 1

Age Group

Cause of Death Total Under 1 1−4 5−14 15−24 25−44 45−64 65−75 75+

Diseases of the
Heart

2019 367 1 0 0 3 18 62 120 163

2014 401 2 0 0 2 14 58 124 201

2009 418 0 0 0 0 11 50 139 218

2004 390 0 0 0 0 9 40 120 221

Malignant
Neoplasms

2019 262 2 0 2 3 20 34 67 134

2014 256 1 0 1 1 24 38 79 112

2009 245 0 0 2 4 19 24 75 121

2004 240 0 0 0 0 14 31 77 118

Chronic Lower
Respiratory
Diseases

2019 60 0 0 0 0 0 15 20 25

2014 40 0 0 0 0 0 13 13 14

2009 36 0 0 0 0 0 11 9 16

2004 34 0 0 0 0 0 12 8 14

All Accidents

2019 62 3 5 10 10 5 7 9 13

2014 64 5 2 9 8 6 7 8 19

2009 70 3 4 4 18 15 12 5 9

2004 59 5 1 2 13 16 8 3 11

Cerebrovascular
Diseases

2019 78 0 0 0 0 2 12 28 36

2014 93 0 0 0 1 3 10 26 53

2009 86 0 0 0 0 2 14 23 47

2004 73 0 0 0 0 5 17 16 35

Alzheimer’s
Disease

2019 38 0 0 0 0 0 0 12 26

2014 34 0 0 0 0 0 2 3 29

2009 26 0 0 0 0 0 1 0 25

2004 20 0 0 0 0 0 1 2 17

Diabetes Mellitus

2019 32 0 0 0 0 0 3 14 15

2014 33 0 0 0 0 0 5 12 16

2009 33 0 0 0 0 2 10 12 9

2004 30 0 0 0 0 1 12 12 5

continued

Table 1.12
Hillsboro

County Causes
of Resident

Death by Age
Group

seidel_lewis_layout_all.indd 31 1/23/17 11:27 PM

372
295
295
875
291
291

T h e M i d d l e b o r o C a s e b o o k3 2

Age Group
Cause of Death Total Under 1 1−4 5−14 15−24 25−44 45−64 65−75 75+
Influenza and
Pneumonia

2019 37 1 1 0 0 0 2 14 19

2014 30 1 0 0 0 0 1 12 16

2009 34 1 2 0 0 0 2 8 21

2004 40 0 1 0 0 4 4 9 22

Nephritis,
Nephrotic
Syndrome, and
Nephrosis

2019 20 0 1 0 1 3 3 4 8

2014 22 0 1 0 1 2 4 5 9

2009 21 0 0 1 2 4 6 2 6

2004 18 0 1 3 3 1 2 2 6

Intentional
Self-Harm

2019 17 0 0 1 6 2 3 2 3

2014 24 0 0 0 2 2 9 5 6

2009 26 0 0 4 6 6 4 2 4

2004 20 0 0 3 2 3 6 4 2

Septicemia

2019 16 1 2 0 0 0 3 1 9

2014 14 1 0 0 0 0 2 2 9

2009 13 0 0 0 0 0 1 4 8

2004 14 1 0 0 0 0 3 3 7

Chronic Liver
Disease and
Cirrhosis

2019 16 0 0 0 0 0 5 5 6

2014 12 0 0 0 0 0 3 5 4

2009 18 0 0 0 0 0 6 5 7

2004 13 0 0 0 0 1 4 4 4

Total from Listed
Causes

2019 1,005 8 9 13 23 50 149 296 457

2014 1,023 10 3 10 15 51 152 294 488

2009 1,026 4 6 11 30 59 141 284 491

2004 951 6 3 8 18 54 140 260 462

Table 1.12
Hillsboro
County Causes
of Resident

Death by
Age Group

(continued)

seidel_lewis_layout_all.indd 32 1/23/17 11:27 PM

Case Analysis

Read Case 1, The Community, in The Middleboro Casebook, pp. 1-32, study graphs at end of case.

In three to five pages address the questions below in sections A and B in an APA formatted paper, double-spaced, 1-inch margins.

1. The Community

A. Demographic and Population Analysis

We need an analysis of the population changes and characteristics in Hillsboro County. Please address each of the following questions and provide appropriate quantitative justification to support your conclusions and recommendations

1. Over the past five and ten years, which of the communities located in Hillsboro County have grown faster than the overall rate of population increase in Hillsboro County? Over the last five and ten years, which of the communities in Hillsboro County have grown slower than the overall rate of population growth in Hillsboro County?

2. What should we expect the population to be as of 2025 for all towns located in Hillsboro County?

3. To what degree does the age profile of Hillsboro County resemble the overall age profile demographic of the United States? Which towns in the county are the “oldest” and the “youngest?”

4. Assess the implications of your findings related to the delivery of health services in the county.

B. Hillsboro County Health Analysis

Using the available data, indicate the top ten health challenges facing residents in this county. Use the state of New Hampshire or your state for purposes of reference. Note that Capital City is not in Hillsboro County. For Hillsboro County list your findings in priority order with explanations and rationale. What are the implications of your findings on the organized health services in the county?

1. Visit cdc.gov’s Prevention Status Reports for NH or your state of residence.

https://www.cdc.gov/psr/overview.html

2. View your reference state’s PSR:

https://wwwn.cdc.gov/psr/

3. Are any of the top ten health challenges facing residents in Hillsboro County preventable? Are they hereditary? Are they due to environmental factors? Are they attributable to other social determinants of health? Is Hillsboro County similar or unique than your reference state? How so? Why might that be the case?

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