Health reform is spurring big, overdue changes within Maine hospitals. One broad change involves doing more to track and boost the health of entire populations, not just individual patients. That means more accountability for doctors, more preventive health options, more measuring of health outcomes, and greater efforts to keep patients out of hospitals, serving them instead in their homes or doctors’ offices.
Studies show the Affordable Care Act will both help and hurt different health care industries. Private insurers, for example, are likely to benefit from the individual mandate that everyone carry an insurance plan, but they will also face restrictions. There will no longer be lifetime or annual limits on benefits; they can’t deny people based on pre-existing conditions; and more than 80 percent of their premium dollars must be spent on medical care, instead of administration or profit.
For hospitals’ bottom lines, health care reform has its benefits, especially if Maine expands Medicaid to low-income residents. Hospitals must treat whomever walks into the emergency department, whether they have insurance or not. With fewer uninsured people, hospitals are projected to provide less in charity care. (In 2011, the state’s 39 hospitals provided free care totaling $196 million.) People with insurance are also more likely to seek medical help, benefiting hospitals.
At the same time, however, hospitals are essentially redesigning their revenue structure. They are transitioning to a system where they are paid based more on their quality of care and less on the number of services provided.
For Lincoln County HealthCare, the parent company of St. Andrews Hospital in Boothbay Harbor and Miles Memorial Hospital in Damariscotta, adapting from providing less medical care in its hospitals, to being more outpatient-delivery based, is a matter of law and financial necessity. Between 2003 and 2013, St. Andrews — which is closing its emergency department Oct. 1 — saw a 30 percent decrease in emergency room use. At Miles, it’s dropped 5 percent. At the same time, outpatient visits have risen steadily.
Mark Fourre, an emergency room doctor and chief medical officer of Lincoln County Healthcare, spoke this week about specific efforts to adapt to local and national forces. The company is part of the state’s largest hospital network, MaineHealth, for which Fourre is also senior medical director for clinical integration.
The irony is that often what’s beneficial for patients’ health and wallets isn’t good for business. Declining admissions and hospital stays is “a significant part of what the struggle financially for hospitals is,” Fourre said. At the same time it provides opportunities.
One opportunity has come in the form of the MaineHealth Accountable Care Organization. St. Andrews and Miles, along with other MaineHealth providers and the not-for-profit insurer Harvard Pilgrim Health Care, launched the ACO in January 2012. Propelled by the Medicare Shared Savings Program under the Affordable Care Act, the goal is to lower growth in health care costs, while meeting certain quality care standards.
Under the program, providers, hospitals and suppliers are eligible to receive payments for the shared savings if they meet the quality care goals. Preliminary results from the first 12 months show costs within the MaineHealth Accountable Care Organization fell more than 7 percent over the previous year.
Part of moving to a health care system based more on quality of care means hospitals must do much more to measure, report and improve upon that quality. And that means they need data.
Some of the biggest changes MaineHealth is undergoing stem from its co-founding of the Northern New England Accountable Care Collaborative, with Dartmouth-Hitchcock Health, Eastern Maine Healthcare Systems and Dartmouth College. The collaborative provides technology that allows the health systems to integrate and analyze clinical data, claims data, public health data and patient-reported data.
MaineHealth is starting to systematically track, for example, how well its physicians take care of diabetes patients, whether they screen people for depression, how well they screen people for high blood pressure and the rate at which their patients have to be readmitted soon after leaving the hospital, Fourre said. It can then compare its results with those of other providers, learn where the gaps are and improve care.
Some practices are already doing this. “What hasn’t happened until recently is there hasn’t been a systematic approach,” Fourre said. Also, the health system hasn’t been able to break down the performance numbers by physician. Doing so — and getting physicians to alter their practices — will require a culture change, he said.
Content-management technology can also help direct preventive care. For example, MaineHealth is developing systems to track and notify patients who haven’t had colon cancer screenings or mammograms and could benefit from them, Fourre said. Preventing disease also means educating more people about immunizations.
The overall vision must shift, he said. Hospitals and providers must focus on managing the health of entire populations, not just individuals.
Improving people’s wellness can’t be done without engaged, informed patients, however. One provision of the ACA, to expand Medicaid, has been opposed by Gov. Paul LePage and many legislative Republicans.
For Fourre, the question is less about whether everyone should have insurance — the “obvious answer,” he said, is that “we would all be better off” — and more about how to make sure patients are more accountable for their health. While privately insured individuals share in the cost of their insurance programs, and therefore tend to be more informed consumers, those on Medicare or Medicaid don’t have the same level of financial responsibility.
With the constant uproar about health care reform, people might think changes will happen quickly. The reality is they are more likely to be steady and persistent changes, Fourre said. The health care industry won’t be torn out and planted anew. It will build upon and adapt current practices. It will experience setbacks and improvements, both in quality of care and, hopefully, patients’ quality of life.