Salisbury Selectman Brett Walker believes his town of 1,500 residents is being overcharged.

Five years after Salisbury signed on to an unusual agreement to share emergency medical services with Boscawen and Canterbury, Salisbury is footing nearly one-fifth of the bill despite sustaining only about 10% of the medical calls.

It’s an arrangement, Walker said at a contentious meeting between the three towns last month, that “needs to change.” Otherwise, Walker threatened, Salisbury will abandon the agreement entirely and search for medical services elsewhere.

If Salisbury makes true on its threat, its portion of the costs would fall to Boscawen and Canterbury – unless they can convince the county to chip in. In a partnership virtually without parallel in the state, the three towns – total population: 7,987 – currently contract emergency medical services from a non-profit called Penacook Rescue Squad. The towns will spend a total of $539,000 this year, with Boscawen paying $273,000, Canterbury $166,000, and Salisbury $100,000.

Were Salisbury to go out on its own, it would not be without recent precedent in the region. Last year, Allenstown backed out of a longstanding partnership with Pembroke in a decision that generated ill-will for leaders of both towns.

Driven by aging populations and barriers to routine healthcare, emergency medical calls have steadily increased over the years, overwhelming small towns that often have only one ambulance in operation at any given time.

During one 12-hour stretch last month, Penacook Rescue Squad responded to 10 calls – four occurred simultaneously. A day like that would have been unheard of when now-Chief Shawn Brechtel started as a volunteer EMT at Penacook Rescue more than 25 years ago. In 2000, the non-profit averaged slightly more than a call per day; by last year, it averaged more than three.

That mounting call volume – and a simultaneous rise in expenses – has led towns to re-examine how they envision providing emergency medical services going forward.

Municipalities essentially have four options: provide the services in-house, typically through the town fire department; contract services from a neighboring town; contract with an ambulance company, often associated with a hospital; or form some sort of inter-town compact, as Boscawen, Canterbury, and Salisbury have done.

Of the 27 municipalities in Merrimack County – 19 of which have a population under 5,000 people – just over half currently rely on their own fire department to provide EMS services. Of the remainder, five pay for services from another town, four rely on a hospital ambulance company, and four – the three Penacook Rescue towns, along with Northfield – use an inter-town agency, according to information provided by the New Hampshire Department of Safety.

For the smallest towns, particularly those with volunteer fire departments, running a 24-7 ambulance service in-house is typically financially untenable – or, at the very least, significantly more costly than other options. 

Penacook Rescue Squad, which started in Penacook before relocating to lower Boscawen in 1989, has for decades served as that other option for Boscawen and Canterbury. The organization, one of two nonprofits in the state that provide emergency medical services to multiple towns, began as a jack-of-all-trades volunteer rescue squad in 1955, during a period when ambulance services were non-existent. Over time, the organization evolved – from a rescue squad to an EMS provider, and from volunteer-run to employee-staffed.

Over the years, Salisbury, a conservative, independent-minded town that shuttered its police department in 2011, has vacillated between running a volunteer emergency medical services department on its own and contracting the services of Penacook Rescue. At the meeting last month, Fire Chief Bill MacDuffie said they had previously explored contracting from the Franklin or New London Fire Departments, instead. Both options would likely either cost more or increase response times, Penacook Rescue Chief Shawn Brechtel predicted.

Salisbury also owns an ambulance, unlike the other two towns, and has over the years experimented with running it. Staffing consistency has been a challenge.

“We do have options, and we want to make sure we do the best thing for our town,” said Walker, the Salisbury selectman.

 

​​​​​​How much should each town pay?

When the chairs of the select boards of Boscawen, Canterbury, and Salisbury signed a contract with Penacook Rescue in fall 2019, they agreed to a simple formula: costs would be divvied up on the basis of town population alone. Boscawen – population: 4,045 – pays 51% of the bill, Canterbury – population: 2,457 – pays 31%, and Salisbury – population: 1,485 – pays 19%.

But call volume does not track population. As of Aug. 1, Boscawen had received 72% of the calls this year, Canterbury had received 17%, and Salisbury had received 10%.

A major reason for the disparity is that Boscawen houses the Merrimack County complex. Of the calls Boscawen received during the first seven months of this year, 39% went to the county nursing home or jail. Subtract those calls and Boscawen is only experiencing a slightly higher call volume than its population would predict – 62% versus 51%.

The question is who should foot the bill for the calls to the county facilities. Salisbury selectmen argue that the issue is simple: the county facilities are in Boscawen and so they are Boscawen’s responsibility.

“I don’t think Salisbury should be paying for those, and I don’t think Canterbury should be paying for those,” Selectman Jim Hoyt said.

But Boscawen town leaders see the issue differently. The 500-some-odd residents of the nursing home and jail exist in a sort of gray area: for purposes of population tallies, they count toward the town, composing about 12% of Boscawen’s population; but they come from the 27 municipalities within the county, and the facilities they inhabit pay nothing in taxes.

“They provide us absolutely no income, but they do provide us with a lot of costs,” Boscawen Select Board Chair Lorrie Carey said. 

Carey believes the county itself should chip in to pay for Penacook Rescue. Leaders of the three towns agreed at last month’s meeting to together broach the topic with county administrators and are in the process of scheduling a meeting for later this month.

Merrimack County Administrator Ross Cunningham said in a brief interview that it was “too premature” to say whether the county would be willing to pay a portion of the three town’s emergency medical service costs.

However, Salisbury may have already upended the plan. In a vaguely worded email sent last week, the smallest of the three towns appeared to renege on its offer to participate in the request to the county.

“Last night during the Selectmen’s meeting they decided to work directly with the Penacook Rescue Squad’s Board of Directors and are opting out of any future joint meetings with Boscawen and Canterbury,” Salisbury Town Administrator April Rollins wrote last Thursday to Boscawen’s town administrator in an email obtained via a right-to-know request.

Hoyt, the Salisbury selectman, was tight-lipped when asked about the board’s reversal and the town’s plans going forward.

“We tried having talks with all three towns, we weren’t really accomplishing anything,” he said. “Salisbury’s position is those aren’t really our towns and that’s up to them.”

Salisbury town leaders have reached out to Penacook Rescue on their own to schedule a one-on-one meeting. Hoyt declined to indicate last week how they will proceed.

Canterbury, for it’s part, has been mostly quiet. At the meeting last month, members of its select board expressed support for Penacook Rescue and for asking the county to contribute to its costs. They did not respond to an interview request.

 

​​​​​​Echoes of the Pembroke-Allenstown ‘divorce’ of 2023?

The jockeying between Boscawen, Canterbury, and Salisbury is hardly new territory for the capital region. 

Last spring, Allenstown shocked Pembroke when it announced it was pulling out of a similar inter-town ambulance company, called Tri-Town Ambulance Service. (The company had at first provided emergency medical services to Hooksett as well before that town brought those services in-house over a decade ago.)

Allenstown Fire Chief Eric Lambert said his town decided to transition to a traditional fire department-run emergency medical services model because Allenstown is growing, medical calls were being missed, and the model would ultimately be more cost-effective in the long term. 

Allenstown is reallocating about the same amount of money it spent on Tri-Town – approximately $300,000 – to the fire department, though it’s ambulances are not always staffed by paramedics, as they were via Tri-Town.

Pembroke’s town leaders, meanwhile, were caught totally off-guard when they received a letter from Allenstown selectmen announcing their design, Pembroke Select Board chair Karen Yeaton said in an interview.

“It was a complete surprise for us,” she said. “We had to start scrambling.”

(Allenstown Selectman Scott McDonald defended the manner in which his town notified Pembroke of its decision, saying that it was “according to the contract” in place at the time. He said the select board deliberated in non-public session prior to making a decision, because the move “would not be well-received” had it been discussed publicly first.)

Pembroke voters elected this spring to retain the same level of emergency medical services. Providing those services on their own caused the town’s bill to more than double, from $261,000 in 2022 to $659,000 this year, despite the fact the change went into effect midway through 2024. The cost will only increase more next year, Pembroke Town Administrator David Jodoin predicted.

“We had an inter-municipal agreement which you could say was the envy of a lot of communities,” Jodoin said. “We were really shocked when Allenstown” backed out.

Other towns “better think long and hard” before they make the same decision, Jodoin cautioned.

 

Where does Penacook Rescue go from here?

If Salisbury follows in Allenstown’s footsteps, a new cost-sharing agreement between Boscawen and Canterbury – and potentially the county – would need to be hashed out.

There are two major questions.

First: What should the cost ratio be based upon?

Whereas the 2019 agreement between the three towns set costs solely on the basis of population, one option proposed would take into account call volume, as well. (For comparison, Pembroke’s and Allenstown’s agreement was based solely on call volume and did not take population into account at all.)

An estimate that included Salisbury shows that this option – which would be a 65%-35% composite of population and call volume, respectively – would cause Boscawen’s costs to increase eight percentage points, and Canterbury’s and Salisbury’s to drop five and three percentage points, respectively.

The second – more existential – question: What should the future of Penacook Rescue be?

Amid increasing call volume, the organization will at some point need to start running a second ambulance, as well as find a new location to fit it.

“I wanted to come to the towns so they could plan for that in the future,” said Shawn Brechtel, the Penacook Rescue chief.

Under an option presented at last month’s meeting, Penacook Rescue would begin running a second ambulance 12 hours per day. The bulk of the additional expense would fall on Boscawen, which would pay $540,000, nearly double what it pays now. Canterbury’s and Salisbury’s costs would stay about steady.

“It is getting to the point where we really do need that second ambulance,” said Carey, the Boscawen select board chair. “If you don’t pay to have them there when you need them, they won’t be there. And I don’t want to be the person who says the reason why your family member died is because we short-changed ambulance services.”

But Carey also recognizes the additional expense of a second ambulance is something she can’t fathom passing on to taxpayers.

“The older folks are being taxed out of their homes; the younger folks can’t even purchase homes,” Carey said. “The reality is we need rescue service. How do we best do it?”

For Carey, the answer is “strength in numbers”.  But, for the Salisburys and Allenstowns of the world, the answer may be that what’s good for the goose is not good for the gander.

Jeremy Margolis can be contacted at jmargolis@cmonitor.com.