In Maine, struggling for affordability, access
Many years ago, there was a saying in American politics to describe an important bellwether state: "As Maine goes, so goes the nation." Today the state is still an important indicator, especially in healthcare.
From urban teaching hospitals and critical access facilities to rural family clinics, as well as naturopaths and concierge primary care, outdoor enthusiasts and vegans, obese Medicaid beneficiaries and uninsured lobsterman who smoke a pack a day -- Maine's healthcare system and its patient populations run the gamut.
Like health organizations in other parts of the country, Maine's providers and insurers are facing the same demand for more affordability, more access, higher quality and better experiences, at home, in the hospital, or at retail clinics.
There is a sometimes fractious debate, however, among Maine's leading healthcare organizations about how to get to that future -- and how to measure affordability and quality in the first place.
Pre-Affordable Care Act, Maine had the fifth-highest per capita healthcare costs in the nation, $8,521, according to the Kaiser Family Foundation's most recent data, from 2009.
That's more than 25 percent higher than the national average at the same time that Maine's per capita income is about 10 percent below the nation's average income -- a juxtaposition that Dan Corcoran, president of Anthem Blue Cross and Blue Shield of Maine, thinks should stay fresh in the mind when state policymakers, taxpayers and patients think about the delivery system.
It's possible Maine has an oversupply of hospitals and not enough community-based and primary care options, Corcoran argued at a recent panel hosted by the Maine Health Management Coalition.
"We have 1.3 million residents and 39 hospitals. In New Hampshire, they have the same population and only 26 hospitals," he said. "Maine is much bigger in land size, but that only explains some of it. It might suggest that we don't have the ideal rationalized infrastructure to serve the state well."
As Maine's three major hospital systems think about moving to value-based payments for Medicare and how to best use their multi-million IT investments, Corcoran thinks they need to embrace primary care and prevention, via models such as the patient-centered medical home, rather than saving the existing incentives for hospitals as the center of healthcare.
"I believe in global risk arrangements," said Corcoran, whose company, a part of WellPoint, is Maine's largest insurer. "We will preserve revenue in flow while hospital systems focus on cost-reductions."
Maine's provider leaders, though, take issue with the assertion that the state's hospital care is expensive and inefficient, considering that Maine has the second-highest proportion of residents over the age of 65, slightly higher than average disease incidents and a struggling Medicaid program that in the last decade was often late in reimbursement.
"We need to be in agreement more on what drives the cost of healthcare in Maine. I'm not confident that the coalition is in agreement," said William Caron, president of MaineHealth, the state's largest healthcare system, referring to the Maine Health Management Coalition, a stakeholder organization that includes payers, providers and employers. "There is a focus on price, which I think is misdirected and is going to be derisive."
The focus, Caron said, should be on "economic development and growth," so residents can move up the income latter and the state can grow its tax base to fund services like infrastructure and education, both which some fear are being crowded out by healthcare spending. "I see more opportunity to adjust the denominator rather than the numerator," Caron said.
Caron, an accountant by training who helped launch the MaineHealth system from the flagship, 600-bed Maine Medical Center in Portland in 1997, concedes that hospital-heavy health systems like MaineHealth have to evolve to meet the needs of patients, with technology and community-based care.
"We're spending an awful lot of time these days trying to figure out where the best place to deliver care is," Caron said. "We're going to have to make more decisions about where care is delivered. "
Part of the challenge -- and also the opportunity -- is using telemedicine and community-based care to give patients a better experience, not just reduce costs. Combined, Medicare and Medicaid beneficiaries account for 60 percent of healthcare spending in Maine.
"What incentives do they have to agree to fewer services?" Caron asked.
