Maine Medical Center and Anthem BCBS Prepare to Launch ACO

One of Maine’s largest hospital systems has teamed up with the state’s biggest private health insurer in an effort to improve patients’ health while lowering costs.

MaineHealth, parent organization of Portland’s Maine Medical Center, has partnered with Anthem Blue Cross and Blue Shield in Maine to launch an “accountable care organization,” a new model designed to move away from the existing health care system that pays providers based on the number of patients they see and the amount of services and procedures they order. The hope is that tying health care payments to how well doctors, nurses and other providers work together to improve patients’ health will help patients and rein in expenses.

“We really think this is a step in the right direction in terms of moving from paying for volume to paying for value,” said Colin McHugh, regional vice president of provider engagement and contracting for Anthem. “This really will be felt by individuals and employer groups.”

Maine already has a few other accountable care organizations — two health groups announced plans for such organizations in 2012 and Brewer-based Eastern Maine Healthcare Systems became one of the first health networks in the country to pursue the model in 2011. MaineHealth also operates another model that serves patients covered by Medicare, but its deal with Anthem marks the first commercial accountable care organization in Maine.

The Anthem accountable care organization would mirror MaineHealth’s Medicare model, folding in Anthem customers and the same group of more than 1,000 physicians, largely primary care doctors, said Andrea Patstone, vice president of strategic initiatives for MaineHealth.

Health systems across the country are experimenting with the model, which was formalized under the recent federal health reform law. Unlike the managed care model of the 1990s, accountable care organizations do not restrict which doctors or hospitals a patient may visit. Individuals also may opt out of sharing their health information with an accountable care organization.

The model ties insurance reimbursements to how well health providers keep patients healthy while stemming costs. Under the MaineHealth-Anthem partnership, MaineHealth would get a cut of any savings it realizes, provided the system meets health care quality benchmarks. Those benchmarks typically include measures such as patient satisfaction and preventive health screenings.

Anthem customers would benefit from any savings in the form of lower premiums, McHugh said.

If MaineHealth fails to meet savings and quality goals, it would owe some money back, Patstone said.

While it’s a new approach, MaineHealth’s accountable care organization with Anthem is still rooted in the existing “fee for service” model in health care in which hospitals and doctors are paid for each procedure and visit. But the endeavor will be key to transitioning MaineHealth to a new health care landscape in which payments will be based less on volume and more on patients’ overall health, Patstone said.

The arrangement will lead to more personal care and allow providers to better spot gaps in patients’ treatment, she said.

“Patients, given their age or their health conditions, need different things,” she said. “Somebody who is in their mid-20s needs a different kind of care than somebody who is in their late 60s. What these arrangements allow us to do is combine information, with patients’ permission, from the insurance side and the health system side to do a much better job at identifying and segmenting our patients according to what they need.”

For example, a doctor could more easily spot when a diabetic patient is overdue on routine testing and reach out to ensure the patient gets it, she said. A primary care doctor will know more readily if a patient was recently discharged from the hospital, leading to better follow-up care that could prevent a costly and avoidable readmission, Patstone said.

The arrangement with Anthem involves about 3 percent of MaineHealth’s annual net patient revenue, or about $45 million. Between 50,000 and 60,000 individuals are eligible to participate in the accountable care organization, which will be phased in over this year.

Both Anthem and MaineHealth expect each of their organizations to increasingly shift toward the model in coming years.

Accountable care organizations are just one effort emerging in the national push to reduce health care costs while improving quality, said Mitchell Stein, policy director for the advocacy group Consumers for Affordable Health Care. While the the goals of the models are laudable, the cost savings they promise remains unproven in these early stages, he said.

Protections also must be put in place to ensure that accountable care organizations aren’t saving money by denying patients needed care, and quality measures must be publicly reported, Stein said.

“By taking responsibility for keeping people healthy instead of treating them when they are sick, ACOs have the potential to be a positive force on our health care system,” he said. “However, the ACO model is still unproven and has inherent risks … The patients being treated under these umbrellas have a need to know exactly what reimbursements and incentives their providers are receiving.”

Anthem modeled its arrangement with MaineHealth after an accountable care organization the insurer formed with New Hampshire’s Dartmouth-Hitchcock Medical Center, McHugh said. Since its launch in October 2010, that ACO has led to savings of more than 3 percent in patient costs, an 18 percent drop in avoidable emergency room visits, and a 13 percent decrease in inpatient hospital days, according to Anthem.

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Med City News
May 6th, 2013