To save money, doctors and insurance companies across the nation are dramatically changing the way they do business.
As a result, tens of thousands of Maine patients — Medicare, Medicaid and privately insured — are beginning to see a change in their relationship with their providers.
At the heart of it: Health care groups are putting greater emphasis on preventive medicine and paying more attention to patient safety and satisfaction. And the healthier and happier those doctors keep their patients, the greater their financial reward.
“We’re trying (to be) more proactive instead of reactive, health-focused rather than rescue-focused,” said Dr. Ned Claxton, medical director of Central Maine Healthcare‘s new accountable care organization and president of the medical staff.
Doctors currently earn money by the patient and the service provided. A 15-minute office visit, for example, nets doctors a certain amount. The more patients a doctor sees, the more money the doctor gets, regardless of whether those patients get healthier or sicker, are happy or unhappy with their care.
Health care reform’s Affordable Care Act requires Medicare this year to establish a shared-savings program with doctors to improve care and cut costs. Because healthy patients cost insurance less than sick ones, and preventive care costs less than crisis or chronic care, the idea was to give doctors an incentive to keep patients healthy by giving those doctors a piece of the savings.
Health care providers could participate by forming accountable care organizations, known as ACOs. Already, such networks of health care providers have formed and are responsible for groups of Medicare patients. Although patients can see doctors outside the network, the ACO’s bottom line is tied to the proven health and happiness of those patients, creating a significant incentive for doctors to collaborate with physicians in and outside the ACO, to closely monitor patients’ health and to make sure patients are satisfied with the care they get.
The happier and healthier patients are, the more money Medicare stands to save. The more money Medicare saves, the more money the ACO gets.
Medicare’s first 32 ACOs were approved around the country late last year and launched in 2012. Among them was an ACO run by the Eastern Maine Healthcare System in Bangor. It is serving 9,000 patients and is expected to add several thousand more by the end of the year.
This summer, the U.S. Department of Health and Human Services approved another 89 ACOs, giving it a total has a 154 organizations in voluntary ACO programs and related voluntary Medicare “shared savings” programs. This includes about 2.4 million Medicare enrollees, or 4.9 percent of all Medicare enrollees, officials say.
ACOs in Maine include one closely affiliated with Central Maine Healthcare in Lewiston, which is expected to serve 16,000 people in central and western Maine, and one by MaineHealth in Portland, which will include St. Mary’s Regional Medical Center in Lewiston and will serve about 35,000 people.
The state of Maine is looking at forming an ACO for MaineCare, the state’s Medicaid program. And several physician groups have formed or are working on forming ACOs agreeable to private insurance companies.
“The old way of paying for health care, which is based on how much volume we deliver, that’s not acceptable to taxpayers and it’s not acceptable to employers and, frankly, it shouldn’t be acceptable to us anymore, either, because that’s what’s gotten us into the national health care crisis that we have right now,” said Andrea Patstone, vice president for strategic initiatives at MaineHealth.
Opting out allowed
How will it work? That depends on the ACO and the insurer.
Medicare patients become part of an ACO if their primary doctor is a member of one. Although ACOs will be held accountable for the care of their Medicare patients, individuals can opt out of sharing their personal, identifiable health information, limiting their participation. They can change their minds at any time.
Medicare patients choose their doctors and can see physicians outside the ACO. Although an ACO gets more money by keeping patients healthy, patients do not have to follow their doctor’s advice, submit to ordered tests or undergo surgery, even if it’s recommended by their doctor.
The state is working on developing an ACO for MaineCare, so its patient rules are not yet set, but they are expected to be similar to Medicare.
The rules can differ when it comes to ACOs that work with private insurance. State and federal laws prohibit insurance companies from infringing on many patient rights, so they cannot, for example, penalize people for failing to follow their doctor’s orders. However, insurance companies can limit benefits or use incentives — such as lower co-pays or out-of-pocket payments — to encourage patients to do what is beneficial to the insurance company.
For example, all insurance programs can make patients pay more for a doctor who is outside their preferred physician network. That may turn into paying more to see a doctor outside an ACO.
But no matter who the insurer is, experts say, ACO patients should expect at least one major advantage over the current system: more time and attention from their health care providers.
“Currently, in health care, if people stay healthy, no one gets paid,” said Elizabeth Mitchell, CEO of the Maine Health Management Coalition, a Portland-based nonprofit group of employers, hospitals, insurers and doctors.
“So they’re trying to change the incentives to enable physicians to be paid for keeping people healthy,” Mitchell said. “ACOs, in theory, will do that.”
For some patients, that could mean getting a call from their doctor’s office telling them their electronic medical records have been flagged because their age, weight and family history puts them at risk of a heart attack, and asking if they’d be willing to take a cholesterol test and meet with a weight-loss professional.
For some, it could mean a longer appointment with the family doctor to talk about vaccinations, age-appropriate health screenings and exercise.
For others, it could mean being given an email address for their nurse practitioner, physician assistant or doctor, so some of their health questions could be answered more quickly.
But there are drawbacks.
When Eastern Maine Healthcare started its Medicare ACO in January, its staff had to read each patient 11 pages of Medicare-approved legalese to inform them of their rights. For patients, the paperwork raised far more questions than it answered.
“That was painful,” said M. Michelle Hood, president and CEO of Eastern Maine Healthcare Systems. The group has since talked to Medicare officials about trimming the required reading. “We learned some lessons . . . We’re adding additional patients in year two and hopefully, that’ll go a little bit more smoothly.”
Mitchell, at the Maine Health Coalition, said her members who purchase health insurance are concerned ACOs will create monopolies, since groups of doctors and hospitals must band together to form those networks. And once they have that monopoly, the fear is those medical providers will raise prices.
“As they become integrated entities, that is a real possibility,” Mitchell said. “The sort of irony, though, is care systems need to be integrated to coordinate the care for patients. There’s a need for clinical integration to improve care. There’s a concern about organizational integration.”
David Howes, president and CEO of Martin’s Point Healthcare, is a proponent of ACOs. His nonprofit, Portland-based health care organization runs nine health care centers in Maine and New Hampshire and provides health insurance plans to businesses and military members, as well as Medicare Advantage plans to those who are Medicare-eligible. It’s formed an ACO to cover military and Medicare Advantage members. It has developed an ACO relationship with one private insurance company and expects to develop a second. And it’s considering applying for Medicare ACO status.
But Howes sees “huge challenges” for ACOs, including the fact that health care now is designed to help people after they get sick, not before.
“We have a system that’s not being built to do this,” he said. “So we have very large numbers of specialty physicians and very extensive hospital systems that are really dedicated to rescue care. These are assets that are going to be distressed and that’s a big issue.”
He also believes it’s going to be difficult for doctors to get patients to listen to their advice about preventive care, the hallmark of ACOs.
“As a species, we really don’t want to believe these things can happen to us,” he said.
Despite the challenges, many doctors and hospital groups are betting ACOs will be “very popular.”
Martin’s Point has about 13,000 patients involved in ACOs. It expects that number to grow to 19,000 by the end of the year and to 24,000 if it becomes a Medicare ACO.
“Our vision, our dream, is that everyone who comes to us will be cared for in this way,” he said. “I think it’s the only way we’re going to get our arms around cost. And this improves the quality of people’s lives.”