Thursday, December 12, 2013
By ARTHUR BATSON III
PORTLAND – The Portland Press Herald published an editorial Sept. 10 titled "Maine health law better for insurers than patients." The editorial blasted Maine's health care reform law, Public Law 90, while pointing to Arkansas as a model for its work in addressing root health care cost drivers.
The editorial described Arkansas' attempt to shift from a fee-for-service payment model; to center care on primary care physicians, who play the role of "quarterback" in care management; and to hold providers responsible for the quality of the services they provide.
These are all things happening today in Maine, thanks to PL 90.
One provision of PL 90 enabled the creation of MaineSense, the nation's first health insurance association captive: a member-owned insurance company that does not offer policies to the public.
MaineSense was created by employers tired of paying the tab for an expensive and inefficient health care system with no ability to guarantee quality and value for their employees.
The Institute of Medicine issued a report that cites more than $750 billion of waste in health care spending, or 30 cents of every dollar. Sadly for employers and employees who want good health and quality health care, paying for such an inefficient system has meant less coverage and higher costs.
So what are these MaineSense members doing to take control? They formed the Maine Wellness Association to leverage the combined buying power of many Maine employers and partnered with Martin's Point to develop an insurance program that offers them a voice.
They brought the pragmatism and problem-solving skills they employ daily as employers to bear on their health care. This is a model first applied to workers' compensation costs in Maine, to great success.
MaineSense requires that all employees designate a primary care physician. They, too, agree that primary care doctors should act as the quarterback in care management. They have shifted away from the fee-for-service payment structure and are aligning the incentives between patients and doctors.
Primary care physicians are paid on a "partial capitation" model -- a set monthly fee for each patient -- while also earning bonuses based on quality measures such as patient satisfaction and how well they direct and manage the overall care of their patients.
The program integrates advocates to help ensure that members get the right care at the right time, whether that it is at home or at a center of excellence in Boston or beyond. MaineSense emphasizes health and wellness and encourages high-value services and informed decisions.
The program seeks to provide the highest-quality care for employees -- even if that means using out-of-state medical facilities that are recognized as centers of excellence.
Health care services in Maine vary widely in quality and cost. MaineSense aims to inform consumers about these variations and to empower them to make high-value choices resulting in better care and lower cost.
The members of MaineSense recognize that what they are attempting to do is going to take time and effort. The employers participate in a monthly call to discuss program issues and offer feedback. Working groups meet frequently to solve problems and address challenges.
In the end, everyone in the program recognizes that they are part of the solution. Health care challenges will not solve themselves, and employers and employees as payers and patients have as much stake in the system's improving as anyone.
MaineSense focuses on better health for employees and more efficiency and value in the health care system. With time, the right approaches and everyone working together, the results can be healthier, happier Mainers and sustainable costs.
Despite the criticism of PL 90, here is an example of one provision in the law that has allowed competition, ingenuity and intelligence to begin to change the system. With an abundance of common sense and the leverage MaineSense members share as the payers of the bills, everyone in the program recognizes they can be part of the solution.
Arthur Batson III is chief financial officer at Lucas Tree Experts and chairman of the board of MaineSense.