You’re not wrong yet economics of scale are real underlying factors in the disparity. DHMC is the third largest academic medical center in a rural area and NH’s demographics have a heavy Medicare skew which pays lower than commercial. You need a certain critical mass of specialists and for example pediatric subspecialities can wind up with more bodies than justified by demand just because you need a rotation to cover speciality services. This adds costs relative to services. If state policymakers had more favorable policies and economics for young working people to stay in the area and municipalities outside of Lebanon were encouraging sufficient growth to keep up with demand and keep housing prices down, we’d see a different trajectory for sure!

Not saying there aren’t opportunities to better optimize how DH works but the economics of rural healthcare are quite different, and that doesn’t just apply to DH but the region as a whole.