Rankings by the Maine Health Management Coalition bring consumer awareness to health care

Business owners routinely cite the cost of health care among the top issues plaguing their productivity, but often feel there's not much they can do about it.

Enter Maine Health Management Coalition, a Portland-based organization working to lower health care costs and improve quality. The coalition's 60-plus members include large employers like Bath Iron Works, MEMIC and Wright Express; unions; health care providers; and insurance companies, all willing to discuss ways to reform the health care system to make health costs manageable for businesses, while ensuring access to high-quality care.

The coalition is one of about 40 regional health improvement collaboratives in the country -- multi-stakeholder groups aiming to reform health care, according to Harold Miller, president and CEO of the Network of Regional Healthcare Improvement. The Maine Health Management Coalition "is one of the leaders nationally," he says, particularly when it comes to facilitating discussions among employers and health care providers on how hospitals and doctors are paid. "Purchasers and providers are sitting down at the table and talking, and that's not something that happens in most regions around the country," he says.

To help drive these conversations, Maine Health Management Coalition, through its foundation, has been collecting and publicly reporting quality data on all of the state's 39 hospitals and about half its physician practices. In April, it revamped its website, getbettermaine.org, which rates hospitals and practices on a number of factors, like heart attack care and surgical infections, giving them a low, good, better or best rating. In the next year, the website will also include cost information, says CEO Elizabeth Mitchell.

The Maine State Employee Health Commission for five years has been using the coalition's rankings to develop a preferred list of hospitals and providers. State employees who want to receive their insurance's full co-pay must go to one of these preferred providers, ensuring both the state and the employee get the best bang for their buck.

The coalition is also involved in a pilot program, now 18 months old, to develop what are known as patient-centered medical homes, which beef up the work done at a primary care level to better coordinate a person's care. A total of 26 primary care practices in Maine are participating and have agreed to better monitor their performance, offer more community health services and be more proactive in getting patients to seek preventative care. A handful of the coalition's large business members, and health insurers Aetna, Anthem Cigna and Harvard Pilgrim, agreed to help fund the pilot, and it was one of eight in the country to receive Medicare funding, to the tune of $20 million. In the past year, some of the communities where there are participating practices saw hospital visits drop 20%.

"Companies like Boeing are deciding to only create new jobs in regions where there's a medical home because the health care costs are lower and they end up getting better care," says Mitchell. "So it's economic development as well as health improvement, and that's really what we're after."

Mitchell, daughter of longtime legislator Libby Mitchell and a former state representative, worked on health care reform in England. Since becoming CEO of the Maine Health Management Coalition three years ago, the organization has grown from a one-person operation to a full-time staff of six, plus seven consultants. Combined, the coalition and the foundation have an annual $1.5 million budget, and are funded through member dues and grants, respectively.

Mainebiz recently sat down with Elizabeth Mitchell to discuss the coalition's work in the face of national health care reform, and how businesses can be proactive in managing their health care costs. An edited transcript follows.

Mainebiz: The Maine Health Management Coalition has been around nearly 18 years, but we haven't heard a lot about it.

Elizabeth Mitchell: It's been a well-kept secret, and I think that has worked, because we're really trying to work with the different stakeholders to fix the system, and that hasn't required a very high-profile presence. I think with health care reform nationally, and the increasing urgency to do something about health care costs, it's taken on a much higher profile, and our work has been hopefully impactful and gotten noticed.

With health care reform a major topic now, is the coalition doing more to raise its public profile or engage with the business community?

Both. We know that the strength of the coalition is through its members, so the more members we have, the better. We have had several members join in the last couple of years, some large businesses, and we always welcome more, because we really think it is through the aligned efforts of the purchasers working with the providers that we're actually going to see change. And we've also revamped our public reporting site, where we rank hospitals and physicians, and that has gotten a lot more attention because it's much more user friendly. We went from getting maybe 50 hits a week to 2,000 a week, and that's generating a lot more demand for information.

As you mentioned, health care costs are hard on businesses. What does the coalition do to help businesses address them?

The coalition has several approaches. They are all market based, they are done through purchasing and incentives and transparency. We think the foundation to a functional market is transparent information, so you should know if the health care you buy is of good quality and where you can get good-quality care. We think you have the right to know as a patient because it will affect your health and safety, but also as a business because you're paying for that care. And we also know it varies dramatically. There was a study from the Maine Quality Forum about two or three years ago that showed huge variations [in the quality of care]. So it's not all equal, and we think people need to know that.

So, publicly reporting on performance of doctors and hospitals is one of our foundational roles, and we think that that will contribute to a.) improved performance. We know that it does; publicly reporting has been shown to really drive up the quality of care. And, b.) to help purchasers actually buy good care. It's called value-based purchasing, and you pay for outcomes, and you make sure that there's information around that, and you actually reward the higher performance.

And then helping purchasers, so the employers -- Hannaford, and L.L.Bean and the state of Maine -- understand how their current system actually impacts the health care system. Currently there are very perverse incentives. [As a provider] the more you do, the more you get paid, whether it's helpful, whether it's high quality, whether it's harmful, you get paid, and actually with infections and readmissions and errors, you actually get paid twice. ... So how can we make sure that the way that the large employers are paying the bill is actually creating the incentives to allow the doctors to do the right thing?

One of the other things we do that our members find very important is we have a database, so employers can actually compare the value that they're getting for health care dollars with their peers. So, for instance, Jackson Labs joined the coalition and became a data member and got to see that actually they were spending about 50% more for hospital costs than the state average among coalition members, which allowed them to have very important conversations with their local providers -- why is this, what can we do differently, how do we address costs while still preserving quality? And they've actually done something very innovative, which is they created a direct contract with a single hospital who has very high-quality marks and was willing to do something very innovative.

What can employers do to improve the value of the health care they pay for?

There are several steps. First of all, you have to know what it is. So, again, going back to measuring, and reporting on performance is step one -- you have to have that information. We've been doing that for about seven years. Then there's a lot more innovative strategies that employers are using now who are members of the coalition. Several of them are tiering, so you [the employee] get a higher level of coverage if you go to a provider who has demonstrated good quality. You can still have a choice, but if you want your full health care benefits, the incentive is to see one of the higher-quality providers. And that really has an impact, not only on patient awareness and choice, but also on the heath care system and the providers who are striving to get good marks to be included on a preferred network. And more and more of our employer members are choosing to tier based on quality and safety.

Also there are some changes to benefit design that several of our member are using. So, if you want your employers to stay healthy, then they need to have a primary care provider. Several of our members are taking steps to change their benefit plan so, for instance, their employees have to choose a primary care provider, and they have incentive to use a primary care provider instead of the hospital or the emergency room.

And then the really heavy lift, but what our members have stepped up to try to do, is to change the payment systems, and say, "We will reward and pay for quality and value and outcomes." And that will take a lot of different forms. It may be paying for primary care services that currently aren't reimbursed but we know help people stay healthy. One example is to have a care manager in a primary care office where they make sure people don't end up in the hospital unnecessarily, that they're on their medications [and] that they're tracking their progress.

That's something a business might not think to do, negotiate with a health care provider.

I think historically that has definitely been the case. I think what's so important about this forum is that they realize they can actually make a big difference, and they may get their increase every year from the insurance company or from their providers, but they can say, "Wait a minute, what are we paying for, how can we do this differently, and what do you need, doctors, to actually provide care differently?" It's remarkable how much the doctors want to see changes as well. They know the system needs to improve, but they're trapped in this current payment system that means they have to see a patient every 15 minutes even if that's not enough time to give the right care.

Has there been pushback from the health care community on these quality rankings?

Yes. The good news is that they take the quality rankings seriously, and they should, because they have been developed through very a comprehensive, multi-stakeholder process. What we report on our website has been vetted by clinicians, hospital executives, patients and businesses over a very long process. We typically have 30-40 doctors at all the meetings where we choose the measures, so the measures have a certain level of credibility... A lot of the physician community has bought into this process.

It is not without controversy. When people fail to make the preferred list, or fail to get a good score, there's often a lot of concern about that, that maybe it wasn't fair, maybe the methodology is wrong, and what happens to access if employers are designing networks and there's not a hospital in your region that scores well, will that hurt people and the care they need?

Overall, though, the consensus, at least among our members, seems to be that, while there are challenges, it's more important that people know how to find good-quality care and that they are supported in seeking good-quality care, and frankly that the providers who are giving good-quality care get recognized and rewarded... Most insurance companies in Maine actually pay additional money to those who score well on our site.

What's the best way for businesses to prepare for or participate in health care changes?

I think recognizing the role that businesses can play in changing the system is the first step. That's sort of the sleeping giant of the system, because incentives created by businesses can really drive how the system unfolds. So really becoming aware of how the current payment system is impacting how care is delivered, how high quality it is, are your employees getting right care at right time in right setting -- they can really play a role in that...

I hear from businesses all the time, and there are so many missed opportunities in investments and jobs because of what they're paying for health care. There are decisions made not to open businesses in Maine because health care costs are so high. There are businesses that compete nationally who have to compensate for having higher medical costs in Maine. It is really hurting the economy among private employers and public employers. ... The more employers there are that recognize and accept that, and then accept their role in improvement, I think the better off we'll be.

Federal reform may or may not help us. It's really almost beside the point. We have a community in Maine where we have got to get costs down and quality up, and we can do this together through a market, through collaboration. Maybe the federal legislation will help us, and that would be great, but we have to do it regardless.