On a page of the UMass Memorial Health Care website, the message is succinct and in bold type: "Plumley Village Health Services is permanently closed."

The small Worcester facility within the UMass Memorial system closed its doors on July 10. The two doctors employed there chose to leave the system.

It's one of several program closures in fewer than two years and will not be the last for the healthcare system, which is running a $22 million deficit in the third quarter of 2018.

Operating in the red, UMass Memorial Health Care CEO Dr. Eric Dickson says his team is looking to innovate and focus on Accountable Care Organizations, virtual healthcare and minimally invasive surgeries.

"If you look at who we are in Central Massachusetts in healthcare, this system has to survive," Dickson said. "In Central Massachusetts, it's us in terms of pediatric trauma, pediatric ICU, level 3 NICU and a long ride to Boston. And if you've got a life-threatening, time-sensitive illness, we have to be here for that."

UMass Memorial Health Care is not only the region's leading medical provider, it is also the largest employer in Central Massachusetts.

In a tight situation, it leaves Dickson and his team trying to figure out where to cut costs and services without impacting efficiency.

The most recent program closure announcement came last Wednesday, as UMass Memorial said it would end outpatient psychiatry as well as outpatient physical therapy services at the Hahnemann Campus and at Queen Street in January. Inpatient physical therapy and outpatient hand therapy services will not change.

Before that, the healthcare system has announced the end of endoscopy service at UMass Memorial Health Alliance - Clinton Hospital, the closure of the Plumley Village Health Services as well as the Burbank Urgent Care center in Fitchburg, the end of the pediatric unit at Health Alliance Hospital in Leominster and the closure of 13 psychiatric beds at UMass Memorial Medical Center.

"So, if you've got a small program like endoscopy in Clinton ... that's totally underutilized and you can absorb that volume at a program that's 10 miles away, then you have to do that," Dickson said. "You can't have unused capacity. Pediatrics is the same way up at Health Alliance. I've got room on the pediatrics floor here for kids that need to be admitted. I've got a higher level of care at the Medical Center. I can't maintain an inpatient pediatrics ward at a hospital that has one kid a day in a bed."

Dickson said a certain volume of patients is needed to maintain such programs.

"Plumley Village was the same thing. Two of the best doctors I've ever worked with were at Plumley Village," Dickson said. "Despite all of the consolidation and program closures we have made, we're still, three quarters into the year we've lost $22 million. It's not sustainable for a health care system."

While more program closures loom, Dickson said there have been no talks of closing an entire hospital.

"There's been certainly no decision to close any hospital and I think Clinton ... plays an absolutely vital role in terms of providing time-sensitive care," he said. "There's been no discussions whatsoever about closing down emergency services and acute care services there."

Dickson said he's not blind to the fact that the program closures bring hardships to some patients, especially those who do not have means of transportation.

"I'm not going to sit here and say, 'oh, it's OK, everybody can just drive to Health Alliance to get their endoscopy.' For some people, that is a hardship," he said. "But the worst hardship would be truly losing all services that we have and not having the service at all."

Ultimately, closing smaller services is the more attractive alternative.

"If it becomes an inconvenience for people to go to get things like an endoscopy 10 miles away, I'm sorry about that, but I'll trade that off versus closing a trauma center or closing a high acuity service any day of the week," Dickson said. "I know it's the best thing for the region."

Despite the closures, UMass Memorial is operating with the lowest amount of reserve out of any academic health science system in the state.

In getting rid of 13 psychiatric beds at the University Campus, the decision came down to a need for additional medical and surgical beds, as the hospital is the region's only Level 1 trauma center.

UMass Memorial is opening a new 120-bed psychiatric facility in Worcester to help treat patients. The facility is expected to open in January and cost between $18 and $22 million.

With that facility set to open, and beds at other centers, more than 250 inpatient psychiatric beds were expected to open in the region, able to provide room for patients who would have used the 13 beds that were closing at the University Campus, the hospital said.

The end of such services was not about saving a certain dollar amount, a UMass Memorial spokesman said. Rather, those closures were about "working more efficiently, maximizing resources and eliminating waste."

When considering UMass Memorial's deficit, some critics point to the large paychecks taken home by the system's administrators.

For all executive positions, the system's compensation committee performs a market survey.

"People that run two and a half billion dollar companies tend to have very high salaries, make very good livings. That's true for me, that's true for other people that do other jobs," Dickson said. "I can't get the quality of executives I need if I don't pay people what they would make at other health care systems doing a similar job."

A large contributor of the system's deficit, UMass Memorial says, was a significant loss in volume and reduced reimbursements from the Medicaid program.

"Though the organization still posted an operating loss, the important cost-saving initiatives we began implementing earlier this year to operate more efficiently are having an impact. We are making progress but still must do more," said Tony Berry, a spokesman for UMass Memorial.

Over the course of the third quarter, UMass Memorial saw 105 fewer Medicaid inpatient discharges compared to the same period last year.

For the nine months ending June 30, there were 709 fewer discharges than in the same nine months of 2017, a spokesman said. Of that, 282 were Medicaid-related.

And, the system has seen a Medicaid outpatient revenue drop of $10 million for the nine months that ended on June 30 compared to the prior year.

"In order for our hospitals to continue serving the people of Central Massachusetts in this increasingly challenging health care environment, we must respond to the demands of state policy makers and the public - and do what we can to improve quality while reducing operational costs," said Sergio Melgar, the system's chief financial officer. "We are working to consolidate services whenever possible and finding ways to work more efficiently and cost-effectively while maintaining the high-level of quality care our patients expect and deserve."

So, what does UMass Memorial turn to despite the deficit?

"What we're really trying to create is an army of problem solvers, an army of innovators," Dickson said. "Every time they find a way to reduce waste within the healthcare system, or in their work area, they're really saving jobs for other people."

Since fiscal 2014, UMass Memorial implemented more than 60,000 ideas submitted by its caregivers.

The system is also putting effort into its Accountable Care Organization.

In response to mandates within The Affordable Care Act, Centers for Medicare and Medicaid Service designed the Medicare Shared Savings Program to reward ACOs that improve both the quality and cost efficiency of health care.

"We're going transition the business model more toward value-based care and ACO care," Dickson said.

Last year, the UMass Memorial Accountable Care Organization realized nearly $23 million in total savings, the healthcare system said. The UMass Memorial ACO was ranked first in New England and 15th nationally out of 472 Medicare Shared Savings Program ACOs.

The UMass Memorial ACO consists of seven hospitals, four federally qualified health centers, 60 medical practices and 24 independent doctors. In the ACO, 456 providers are primary care physicians and 1,441 providers are specialists.

"This is a result of a diverse team, with many components, coming together with one goal in mind: Doing what is best for the patients in this ACO," said John Greenwood, the UMass Memorial ACO president. "The level of teamwork and coordination has been phenomenal...This gives us tremendous momentum and provides a roadmap to success for our renewed program over the next three years."

UMass Memorial also prides itself on minimally invasive surgeries, something Dickson wants to focus on.

For example, doctors at the Medical Center already perform living donor liver transplants laparoscopically.

Virtual medicine -- where doctors can interact with patients without the patient actually having to come into the office -- is also something UMass Memorial wants to concentrate on.

"I think that we'll interact with our patients more frequently, but they won't have to park their car and walk into a clinic," Dickson said.

More closures could befall UMass Memorial Health Care if Question 1, focused on nurse staffing ratios, passes in November.

Dickson said it would cost the system $40 million if passed as written.

"So, we would have to make $40 million in cuts on top of being $22 million in the red for three quarters of the year," he explained.

Dickson made an analogy: "There are things you can do at 5,000 feet you can't do at 500 feet. At 500 feet, you're landing or crashing. At 5,000 feet, you can turn, you can restart an engine, you can do other things."

"I think for UMass Memorial it's going to be a constant revision of our existing programs," Dickson said. "We're going to have to rebuild this airplane in flight."