Faced with increasingly worrisome economic challenges, four North Country hospitals said Monday they have signed an agreement to work together to try and find ways to "improve quality, increase efficiencies and lower cost of health care delivery in the region." The hospitals said their problems range from growing healthcare costs to Medicaid payments that don't always cover services provided to the poor. And, the situation has been getting worse, said Russell Keene, the CEO at Androscoggin Valley Hospital in Berlin.