🔒Health care crossroads: Rising costs coupled with need to be affordable

When Lois Skillings talks about the future of health care in Maine, she likes to use the phrase “collaboration, not competition.”

A registered nurse by training, Skillings, president and CEO of Mid Coast Hospital since 2011, succeeded Herb Paris, the long-time CEO who guided the merger of Brunswick and Bath community hospitals. The merger created Mid Coast, which opened its new hospital in 2001.

The merger was unusual in Maine — more often, larger hospitals have purchased smaller institutions in their region — and the only comparable example is MaineGeneral, which last year opened a regional hospital in Augusta, consolidating operations with Waterville.

But Skillings believes more collaboration, whether actual mergers or less formal arrangements, is the only way hospitals can continue to be the health care leaders in their regions.

In fact, during an interview in her office, she went further.

“I really believe that hospitals have to totally redefine their roles if they want to remain relevant,” she says.

That prediction comes after an eventful two decades for Maine's hospitals. Among the major events affecting their business model was the sale in 2000 of the state's largest health insurer, Maine Blue Cross Blue Shield, to Anthem and its conversion to a for-profit subsidiary.

In 2003, Gov. John Baldacci convinced the Legislature to expand the state's Medicaid program, MaineCare, a move that has resonated ever since. And the 2010 passage of the Affordable Care Act (ACA) posed what may be the greatest challenge yet to hospitals' ability to change and adapt.

A tremendous amount of money has flowed into the system; health care is now one of the state's largest economic sectors, but, according to Skillings, that's part of the problem.

Maine has long endured higher-than-average health care costs in a nation that already has the world's highest health care costs, she says. Mid Coast is in that sense an experiment to determine whether a more cooperative approach can help bring costs in line — an experiment that has had successes, Skillings says.

“Though Maine as a whole is 20% above the national average, we are 25% below the costs of our peer hospitals,” she says. “In fact, we may have the lowest costs of any hospital in Maine, period.”

But cost is only one factor in the transformation of health care Skillings says needs to occur. Mid Coast embraces the “Triple Aim” goals put forward by the Institute for Healthcare Improvement in Cambridge, Mass.

Skillings describes the three goals as, “Get healthier, improve the health care experience and reduce per capita costs.”

The first may in fact be the most important. Mainers, and Americans, need to face up to the reality that “we're really not very healthy in comparison to where we could be,” she says.

Reported record rates of childhood obesity, continuing even through to seniors of the current generation, are one sign that public health has taken a wrong turn. The better news, she says, is that efforts to change course may be working.

Mid Coast, along with other hospital organizations, including Maine Health in Portland, is going directly into elementary schools, targeting its efforts at kindergarten through second grade. “This is when kids are beginning to form lifelong habits,” she says. “At this point, change is possible.”

Mid Coast bases its approach on the “Let's Go,” program, a national curriculum that covers the basics of young children's lives. Its “5-2-1-0” components are easy to comprehend and remember: Eat five servings of fruits and vegetables daily, limit screen time (TV and electronic devices) to two hours a day, spend a least an hour daily in physical activity and drink no carbonated soft drinks.

If that seems to describe exactly what most teen-agers have not been doing over the last generation, that's exactly the point, Skillings says. The contemporary diet, high in fats and sweeteners, low in whole foods, and the culture of electronic recreation rather than “go out and play,” is at the heart of an emerging health crisis.

It isn't just about children, either: “We need to understand that each of us is responsible for our own health, for the food we eat, the exercise we do, and the other choices we make.”

If it sounds as if Skillings doesn't think Maine hospitals have been doing their jobs, that's not the case. Maine, along with Vermont and New Hampshire, has long been a leader in better results for patients. “We have phenomenal health outcomes” by national standards, but it's not enough just to treat acute illness, she says. Hospitals have to go much deeper.

One example of the new focus is a renewed emphasis on primary care, “where most of health care does, or should, take place,” she says.

Like most Maine hospitals, Mid Coast has a primary care practice, and it's recently been reorganizing the way it delivers care, as has Martin's Point, another major primary care provider in Brunswick and throughout Maine.

Mid Coast has participated in the Patient Centered Medical Home program introduced by Dirigo Health, and now the Accountable Care Organization (ACO) initiative of the ACA.

The central focus is changing the emphasis on one-on-one encounters between providers and patients into a team approach, with collaboration by physicians, physicians' assistants, nurse practitioners, nurses and social workers. “Rather than waiting for patients to make an appointment and come in, we look for those we haven't, and what they may need that they're not finding,” she says.

Inquiring into life circumstances, particularly for those living alone, is an important part of the outreach Skillings says all health care organizations need to take seriously.

One way of highlighting the new approach was Mid Coast's planning process called “2020 Vision” that attempted to forecast how health care might function in the Midcoast region going forward. “We listened to thousands of people — our patients, community groups, senior centers, and civic leaders,” Skillings says.

The effort was, in part, an attempt to get ready for the vast changes that the ACA promises to make, a transformation that Skillings says is now underway.

The new focus on preventive health and personal responsibility is one reason why Maine hospitals, Mid Coast definitely included, support expanding Medicaid in line with the ACA's provisions, a step Maine has yet to take. “Everyone needs to be involved in the system, to have access, to know where they can get help,” Skillings says. “There can't be any exceptions.”

Hospitals, and all providers, must take a hard look at what they do well, and where others might be able to do better, she says. “We've stopped doing some of the procedures where we have low volumes,” she says. “We don't do bariatric, vascular or thoracic surgery any more. Those can be done better elsewhere.”

Rather than worrying about the changes ahead, Skillings says this is an exciting time to be involved in health care. “Every day I learn things,” she says. “Every day we talk about how to do things better.”

One of the simplest, but most dramatic ways to imagine the transformation is one she credits to Mid Coast's CFO, Robert McCue.

“We were talking about the 'H' sign you see everywhere that directs you to the nearest hospital,” she says. “Bob says, 'We've got to change that. When people see it, we want them to think it stands for 'health,' not 'hospital.' ”

Twenty years from now, she says, is a reasonable time to imagine that happening.

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