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AUGUSTA

MaineGeneral to overhaul payment method

Hospital wants preferred status again for treating state employees

By Betty Adams badams@centralmaine.com
Staff Writer

AUGUSTA -- While MaineGeneral Medical Center continues planning its new regional hospital, it's also working on a new payment model that would collect only one fee from the state employees' health insurance plan.

"What we're hoping to do over time is to get away from the fee-for-service arrangement and move to a global payment arrangement where we would pay one fee for enrollees in the MaineGeneral service area," said Frank Johnson, executive director of the state Division of Employee Health and Benefits.

In the Greater Augusta and Waterville areas, some 10,000 people, including dependents, are enrolled in the state employee insurance plan, Johnson said.

Johnson said MaineGeneral receives an average of $22 million to $24 million annually from the plan for hospital services.

Work to implement the new payment system -- part of MaineGeneral's plan to become an "accountable care organization" -- is a work in progress.

MaineGeneral Executive Vice President Dr. Barbara Crowley, defined "accountable care organization" as one that is "accountable for both quality and cost for a patient population."

A steering committee involving the Maine Healthcare Management Coalition -- an umbrella group that ranks hospitals -- meets today to begin work.

"We think that the big advantages for our membership will be access to a very well-coordinated care system," Johnson said. "For those who have chronic illness, we believe the system will be more responsive to their needs. For those without chronic illness, there will be more time and energy for preventive care, as well as a host of other services, including behavioral health services and health education."

The proposal to set up the "accountable care organization" status came after MaineGeneral Medical Center realized it was losing its status as a preferred provider for state employees for the second time in about 18 months. Preferred status means copays and deductibles are waived for those insured under the state plan.

The hospital -- which has inpatient services in Augusta and at Thayer in Waterville -- failed to meet two criteria in the latest round of preferred-provider ratings. While safety and quality measures were satisfactory or better, the results were below the average for U.S. hospitals in the areas of patient ratings and patient recommendations.

The scores -- provided by MaineGeneral -- are based on patients' responses to questions between April 2008 and March 2009:

* MaineGeneral's patient rating was 60. Maine hospitals averaged 70; U.S. hospitals averaged 65.

* MaineGeneral's patient recommendation rating was 65. Maine hospitals averaged 75; U.S. hospitals averaged 68.

Under an agreement with the State Employee Health Commission, MaineGeneral would retain preferred status for benefit purposes for those enrolled in the state employee plan.

The program also is designed to improve access to primary care and primary care services and standardizing referrals to physicians.

"MaineGeneral made a pretty compelling case saying it can't invest in additional primary care services in an environment where we're losing revenue," Johnson said. "In the long term, it will provide (enrollees) better overall services and care."

Crowley said the program would start with the people insured by through the state employees' program who see the hospital's primary care physicians.

"We're committing to a five-year proposal to bend the cost curve," Crowley said. "It's a big deal. Our intention is to move from the current system that pays you for volume. We want to provide for higher quality, more coordinated care and the right care."

She said the hospital will add 16 primary-care providers with a goal of being immediately available to patients: "If you call today, you can be seen today."

Currently, the hospital has 27 primary-care practices with 96 doctors and serves 88 communities. She said many times people go to the emergency room because they can't reach their primary care provider.

"We could end up being a leader in national payment reform," she said. "I'm pretty excited about this. We have an opportunity to do something about care and costs."

Betty Adams -- 621-5631

badams@centralmaine.com