Maine’s largest health insurer has teamed up with Eastern Maine Healthcare Systems under a new venture aimed at keeping patients healthier while reducing costs.
The deal involves Anthem Blue Cross and Blue Shield in Maine, EMHS, and an EMHS-led coalition of hospitals and physician practices across the state already working to improve the value of health care.
EMHS and its partners have agreed to avoid any cost increase for services they deliver to 40,000 Anthem policyholders. That’s no small promise in the field of American health care, where even the most ambitious reform efforts aspire to curb the escalation of costs rather than actually produce savings.
In making that pledge, EMHS has put potentially millions of dollars at stake.
“We’re committed to this, but it’s not without a lot of anxiety,” said Michelle Hood, president and CEO of EMHS. “Holding ourselves accountable to this will be a real test of our organizational willpower.”
The goal is to make patients healthier and happier by rewarding doctors and nurses for keeping them well rather than for ordering more visits and procedures. The entities have formed an “accountable care organization,” a cornerstone of the federal health reform law that many hope will rein in health care costs. Under an accountable care organization, alliances of health providers take responsibility for a specific population of patients, and they get paid based on both the cost and the quality of care they deliver.
The Anthem deal involves 15 hospitals and 405 primary care providers from 114 practices throughout Maine, which operate under the name EMHS Beacon Health.
Dan Corcoran, president of Anthem Blue Cross and Blue Shield in Maine, said the new arrangement marks a significant step forward for the insurer. The accountable care organization builds on Anthem’s existing program to improve health care and control costs, which includes about 75 percent of the primary care physicians in Maine, he said.
“This is, in my opinion, real ownership on their part to improve quality and to lower costs,” Corcoran said of EMHS.
The health providers will work with Anthem under the accountable care organization to encourage patients to get preventive care and manage chronic illnesses, which eat up three-quarters of all health care dollars and represent the leading causes of death and disability in the U.S. Critical to their success will be teams of health professionals who help patients make appointments, manage medications and follow through on doctors’ orders, such as nurse care coordinators, social workers and health coaches.
The organizations will track the health of the 40,000 Anthem policyholders, checking to see if, for example, diabetes patients get regular eye exams and heart attack survivors take recommended beta blockers.
If the hospitals and doctors reduce costs while providing high-quality care, they can share in the savings. Likewise, if they fail to cut costs or miss certain quality targets, they get pinched financially.
EMHS has already felt the sting of an accountable care organization arrangement. Three years ago, it was among 32 organizations nationally chosen by Medicare, the government health insurance program for seniors, to pioneer the model.
In 2013, that “ pioneer accountable care organization” failed to meet its spending target, leading to a nearly $3 million penalty for EMHS. The accountable care organization managed to save money during the first year, however, and its patients give it high marks, according to EMHS. Its nurse care coordination program also received accreditation from a prominent national quality organization.
The health system has extended similar coverage to employees on its health plan.
EMHS is managing an older population under its Medicare accountable care organization. With Anthem, the group of patients is younger, at an average age of 37. Younger people may benefit more from preventive care, but in Maine, they also face some of the same chronic illnesses as their older counterparts, Hood said.
Other Maine health systems also have formed accountable care organizations, some with government programs such as Medicare and others by teaming with private health insurers. Anthem already has an accountable care organization with MaineHealth, the parent to Maine Medical Center in Portland, but that arrangement covers fewer people. The new deal marks the largest commercial accountable care organization to date in the state, according to Anthem and EMHS.
The term “accountable care organization” remains in flux, with providers and payers negotiating widely warying arrangements under the same banner.
Some fear that accountable care organizations — by requiring hospitals to band together, further consolidating their already considerable market power — will free health providers to hike prices. Many of the arrangements have failed to live up to their promise — only 19 of the 32 pioneer accountable care organization groups originally chosen by Medicare remain in the program, including EMHS. Navigating the program’s rules has proved difficult for some hospitals, even those deemed most well-equipped to meet the challenge.
Others doubt that accountable care organizations, despite all the work they require, will save enough money to make them worthwhile.
But Dr. Michael Ross, a pediatrician with Eastern Maine Medical Center in Bangor, says working under an accountable care organization allows him to better care for his patients. With the help of a nurse care manager, he ensures patients take their medications and stay well after they leave his exam room, rather than relying solely on time-crunched office visits, he said.
“It’s the type of expanded care that as a provider I couldn’t have dreamed about three or four years ago,” he said. “This is care I’ve wanted to provide since I was a graduate from medical school. Now 10 years later, I can begin to do this.”
Both Anthem and EMHS will collect and analyze data on quality, costs and the services patients use, which both say will allow them to identify opportunities to improve care and keep costs affordable.