Stakeholders tackle big health care challenges: MHMC pushes a value-based approach in Maine

As one of the state's largest private employers, Bath Iron Works could be described as a rather large “canary in the coal mine” of Maine's health care system. Like other Maine employers, both large and small, it faces significant challenges as it tries to manage its health care costs in a more sustainable and meaningful way.

Owned by General Dynamics, the Bath shipyard is self insured and covers about 5,000 employees with an additional 7,000 covered dependents. Health care is the shipyard's single-most-expensive overhead cost, says Michelle Probert, BIW's manager of integrated health services. And the unshakeable reality of the extremely competitive shipbuilding markets that BIW competes in — typically against southern shipyards with lower wages and generally lower electricity and heating costs — is that overhead costs matter a lot when contract awards are often decided by differences of pennies on the dollar.

The stakes are high: If the shipyard does not diversify, lower its costs and win future work such as the $12 billion U.S. Coast Guard's Offshore Patrol Cutter Program that will be decided next year, it faces the loss of more than 1,000 jobs by the end of the decade due to a diminishing Navy workload.

Probert says the shipyard can't achieve its goals in a vacuum, which is why it's working closely with the Maine Health Management Coalition and other stakeholders to improve both the quality and cost of health care in the state.

“While we tip our hat to Maine's health care providers for the top-notch quality care they provide, the unfortunate truth is that Maine also ranks at the top of the country for having high health care costs,” she says. “In the meantime, our competition almost exclusively resides in states with lower-than-average health care costs for the U.S. — in some cases, substantially lower.”

“Businesses spend a lot of money on health care and I think the central question for them is, 'Are we getting value for our money in terms of health care services?'” says Andrew Webber, CEO of the Topsham-based Maine Health Management Coalition, a nonprofit whose 60-plus members include public and private employers, hospitals, health plans and doctors. “That's been a real question for a number of years and we haven't cracked the nut on it yet.”

Webber has spent 35 years in the health policy arena, much of it in Washington, D.C. Prior to becoming MHMC's CEO in September 2013, he had a 10-year stint as the president and CEO of the National Business Coalition on Health. What drew him to Maine, he says, is the united front taken by the coalition's stakeholders, including such major employers as BIW, L.L.Bean and The Jackson Laboratory, in measuring and reporting health care quality and cost with the shared goal of improving its value.

“The tension is not about the long-term vision, it's about how quickly we can get there,” he says. “All the parties are at the table — providers and payers. Both sides need to have some give and take. But the important thing that we shouldn't forget: We have them all at the table. Do you know how unusual that is? It's extremely unusual. They know each other. They respect each other. They are committed to getting there together and that allows for a possibility of getting to a shared vision.”

Bending the curve

Webber says the primary objective of employers is making sure their workers are healthy and productive. Wellness programs and emphasizing workplace safety are the most common strategies employers use to keep people out of the hospital, motivated and truly productive. Beyond that, he says, a surprising number are perplexed about what more they can do to drive higher quality health care for their workers and at lower cost.

Having business champions such as BIW, he says, helps the coalition's mission by showing ways that even small employers can begin to bend the value curve for both their business and workers.

Webber says MHMC offers a suite of services for its members to help them understand better their health care cost drivers, as well as identify ways to improve quality of care for their workers. With a new member, he says, MHMC asks the employer to contact its health plan carrier and ask if they would send the claim data file to the coalition and any other data the company might have, for example, absenteeism due to illness. With electronic medical records, that process has become much easier and more sophisticated.

The coalition uses that data to create both a “plan performance” report and a “benchmark” report comparing that business's claims experience with other employers in Maine. That information, in turn, helps employers formulate a targeted strategy to improve care for their employees and dependents while also lowering costs.

“The data informs the conversation you can have with providers,” Webber says. “It informs the goals you set. We want every employer to be able to understand the population they hope to manage. It really starts with that level of understanding.”

BIW, for example, uses multiple data sources to understand the risks of its populations and to develop health care strategies to address them, says Probert, including analyses that combine claims, health screening, health coaching, absence and productivity data, that helps inform the shipyard's overall strategy from year to year. MHMC helps the company “further drill down into these areas and provide a local context to our approach,” she says.

Using that data and with input from all four of its unions and its human resources staff, BIW's Joint Committee on Healthcare last fall identified the under-utilization of preventive and primary care services as its main priority for this year. It also meets regularly with Mid Coast Health Services, Martin's Point, St. Mary's Healthcare and other systems to make sure its health coaches and initiatives such as a diabetes prevention program are actually being used by BIW workers.

Starting at the end of 2014, BIW “co-located” its team of seven health care coaches and Fit for Life wellness program with its highest-volume primary care practices to encourage better coordination and usage.

Participation in health screenings, which is BIW's primary way to introduce employees to health coaching, increased almost 40% from 2013 to 2014, says Probert. For 2015, the shipyard set a goal of another 25% increase in employees screened. The Fit for Life program is on track to achieve a 250% increase in the number of spouses screened, from 200 in 2014 to a goal of 500 this year.  And after a single pilot Diabetes Prevention Program class in 2014, BIW now has 10 classes running with about 120 total participants.

Other stakeholders play a role, too

Dr. Mark Fourre, chief medical officer at Lincoln County Health, a member of the MaineHealth system, says providers embrace the transformation of Maine's health care system and are doing their share to advance it. In addition to his role at Lincoln County Health, Fourre also is president of Community Physicians of Maine and the Maine Medical Center Physician-Hospital Organization, a network of 1,300 physicians.

One MaineHealth initiative with an impressive track record going back several years, he says, is the AH! (Asthma Health) Program, which uses hospital-based educators to support providers in helping asthma patients manage their chronic illness better, including complying with medications and controlling environmental factors (such as household dust) that can aggravate symptoms. The program has dramatically reduced asthma-related emergency department visits for both children and adults, improved medication compliance and increased awareness among school nurses, community health workers and other providers about best practices for managing asthma.

“It's a wonderful program and it's quite mature,” Fourre says. “It delivers all the things you're looking for in the 'Triple Aim' goals of health care.”

Even more importantly, he says, MaineHealth is following a similar model of using data to shape strategies for improving the health of targeted population on several other fronts, resulting in measurable improvements. Other initiatives highlighted in its 2014 Health Index report include:

 • Decreasing preventable hospitalizations by focusing on high-quality community-based primary care to manage chronic illnesses such as diabetes, hypertension and angina.

 • Decreasing obesity by partnering with Harvard Pilgrim Health Care Foundation to expand the Let's Go program promoting healthy eating in schools and other child-care programs. Its two-year HOMEtowns program reached more than 300,000 people in seven rural counties in Maine, likewise promoting healthy eating and physical activity.

 • Decreasing tobacco use by providing bedside counseling at MaineHealth member hospitals to patients hospitalized with smoking-related illnesses, which resulted in increased referrals to the Maine Tobacco HelpLine. MaineHealth and its partners also expanded community programs to deter young people from smoking as well as smoking cessation programs.

Of the latter initiative, Fourre says as an emergency room physician he's learned that the “You should stop smoking” advice he might have given an emphysema patient a few years ago didn't go far enough. Now, recognizing that many smokers need help in quitting, he refers those patients to such programs and follows up with the primary care doctor to make sure there's additional support on that front as well.

Shifting to 'value-based insurance design'

Nancy Morris, MHMC's director of communications and member services, says MHMC was founded on the premise that in order to have a real impact on health care costs, you needed to align the care providers, the payers and patients in a health care system that makes sure everyone is getting “the right care at the right cost.” The challenge in trying to gauge the impact of coalition's work is that the various stakeholders are in “various degrees of change …[and] not everyone is doing it the same way.”

MHMC's publication since 2007 of data on quality outcomes, Morris says, has helped to greatly improve the quality of health care in Maine: In the 2014 National Healthcare Quality Report, Maine ranked fourth behind Minnesota, Massachusetts and Wisconsin in the “effectiveness, safety, timeliness, patient centeredness, care coordination, efficiency and adequacy of health system infrastructure.” Maine hospitals consistently are ranked the best in the nation for patient safety and quality of care.

The coalition's current focus involves what Morris describes as “most comprehensive effort in the country” to transform Maine's health care system into a “value-based insurance design” model. With other stakeholders in the Maine State Innovation Model initiative, MHMC is working to shift the incentives in the market away from a “fee-for-service” system based on high-volume, high-cost care to a health benefit design that provides incentives to consumers who opt for care that is both high quality and low cost. It also creates incentives for health care providers to choose lower-cost care options when a range of equally effective approaches to care are available for a given patient.

Morris says the goal is to build one standard health plan design, so that whether it's Anthem, Aetna, Cigna, Harvard Pilgrim or Community Health Options providing the coverage, an employer and its employees will “know the rules will be the same.”

“We need the benefits plan to help people pick what's right for them,” she says, adding that in some cases it would address “under-use of the right service” and in others “over-use of the wrong service.”

Kevin Lewis, CEO of the Lewiston-based Community Health Options, welcomes that change. The VBID model is at the core of his nonprofit health insurance cooperative's approach, reflected by its reduced out-of-pocket costs to make office visits, medications and equipment less costly and more likely to be used by its insured members with asthma, chronic obstructive pulmonary disease, diabetes and hypertension. It also is supporting tobacco treatment programs at no cost to members when prescribed and works with providers to ensure patients fully understand their treatment options, including available lower-cost options of equal or higher quality value.

“We're only just beginning in terms of what we can do with the model,” Lewis says. “It absolutely is the right way to go.”