Friday, December 6, 2013
By John Richardson firstname.lastname@example.org
When state employees or their family members have to go to a hospital in Portland, their health insurer wants them to go to Mercy.
The State Employee Health Commission doesn't just recommend the hospital, it waives the co-pays of $50 to $100 per day if the patient goes to Mercy. They can still choose to go to nearby Maine Medical Center, but it'll cost them.
For five years, the commission has used industry quality data and financial incentives to improve care and reduce long-term costs to the state's insurance plan, as well as drive quality improvements across the health care market. The hopital ratings are based on a variety of criteria, from patient safety and clinical care to the percentage of former patients who say they would recommend the hospital to a friend.
The rating system will soon take a key step forward by including prices in its ranking standards. Starting in August, Maine's 36 acute care hospitals will have to maintain both high quality care and low prices if they want to remain on the preferred list.
Mercy is one of only five hospitals statewide that have been on the preferred list for five straight years. The other four are Mid Coast Hospital in Brunswick, Miles Memorial Hospital in Damariscotta, Mayo Regional Hospital in Dover and Eastern Maine Medical Center in Bangor.
"Never having slipped from the preferred hospital list in five years is a significant accomplishment," said Frank Johnson, executive director of the Maine State Employee Health Commission.
Hospitals such as Mercy and Mid Coast consider the designation an important badge of approval.
"With quality and safety, it's not a want anymore, it's a must-have," said Scott Rusk, Mercy's vice president of medical administration. "You have to choose what you want to be good at and not overstep that."
Maine Medical Center, the state's largest hospital, dropped from preferred status last fall due to a lower score on compliance with a checklist of cardiac care procedures. It has since raised its scores and is expected to return to the preferred list when the commission updates the rankings in August.
"We're meeting the standard today in all areas where we had fallen short," said Doug Salvador, Maine Medical Center's associate chief medical officer and patient safety officer.
The Maine Employee Health Commission provides coverage to 34,000 state employees and family members statewide, including about 3,800 people in the Portland area. Its tiered health insurance benefits are partly the result of the quality efforts of the Maine Heath Management Coalition, which posts quality rankings of Maine hospitals and physicians on a website.
The commission uses the data to reduce the number of expensive, avoidable problems such as infections, complications and re-admissions. But it also has helped raise quality of care for all Maine patients, according to Johnson.
"Individually and collectively, hospital performance has improved during the last five years we've had this in place," he said.
When Maine General in Augusta fell off the preferred list last year, the hospital knew it had to get back into the commission's good graces. A large portion of the hospital's patient base is covered by the state employee insurance plan.
"The loss of the preferred hospital status was something they experienced before. They didn't feel it was something they could afford to do again," Johnson said.
Maine General came forward with a five-year plan to develop a lower-cost, accountable care model and in return the commission agreed to waive co-pays at the hospital as if it was on the preferred list.
It's not clear if the rating has had a measurable impact on the two primary hospitals in Portland, where state employees are part of a much larger, more diverse market.
Maine Medical Center has received calls from patients asking about the state's preferred list, said Salvador, the hospital's quality chief.
Salvador said he tried to reassure them that the hospital is performing at a high level. Despite the rating on cardiac care protocols, he said, heart attack patients coming to Maine Medical Center are less likely to die than if they go to nearly any other hospital in the state.
"There's no perfect thermometer you can apply to a hospital that says high quality or low quality," said Salvador.
At the same time, he said, the growing transparency and use of quality data is driving real improvements in quality at Maine Medical Center and other hospitals. And hospitals are taking it seriously.
"The consequences of not being on the (preferred) list is going to grow," he said.
Rusk, at Mercy, said large private employers also are now focusing more on quality data to contain health insurance costs. The addition of costs into the state's rating system will make it even trickier for hospitals to maintain high quality.
"It's something you have to balance very carefully," he said.
Johnson, the commission director, admits the rating system isn't perfect.
The quality ratings are based on a limited number of performance measures that are publicly reported by hospitals.
There is no comparable data to compare obstetrics and gynecology, for example, so it's possible a hospital that is not on the preferred list provides higher quality of ob-gyn care than a preferred hospital. Cost comparisons will be based on the average price for a variety of services, not on the prices for the specific procedure that a patient may need.
"It's based on what information we have," Johnson said. "If hospitals are performing well in those categories, we hope it extends to others as well."
Staff Writer John Richardson can be contacted at 791-6324 or at: