When politicians complain about the Affordable Care Act, they usually focus on areas where they think it went too far.

But for the sake of small, rural hospitals in Maine, they really ought to be looking at the places where it didn’t go nearly far enough.

The sweeping 2010 law greatly expanded who can get health insurance, but made only tentative steps toward reforming how providers are compensated for care.

Now that a new Republican Congress and president have promised to overhaul the health care system, they should focus on speeding up the transition toward a system that controls costs by keeping people healthy instead of one that goes bankrupt by waiting for them to get sick.

Maine’s rural hospitals have been at the forefront of changes in the health care economy.

Surgery is becoming increasingly specialized and dependent on expensive technology. Small hospitals can’t afford to replicate the range of services that regional medical centers offer.

But the local hospitals are still vital pieces in the health delivery system, serving as centers for primary care, rehabilitation and outpatient services like physical therapy. Unfortunately, that doesn’t pay the bills.

Maine has several ongoing experiments with Medicare Accountable Care Organizations, in which a group of providers are paid a lump sum to care for a group of patients. If the patients meet certain health benchmarks, the ACO would share the savings, if any, creating an incentive for keeping people healthy.

But most people are not in an ACO, and small hospitals are still being compensated as if they were still in the business of inpatient surgery.

“We don’t yet get paid for keeping people healthy,” Marie Vienneau, CEO of Mayo Regional Hospital in Dover-Foxcroft, recently told the Maine Sunday Telegram. “We don’t get paid for it, but we still do it because we know it’s the right thing to do.”

It’s one of the toughest problems in American health. “The right thing to do” is usually the simplest and least costly thing to do and what’s best for the patient, but it’s not what gets the financial reward. For instance, Medicare will pay to amputate the leg of a person with diabetes, but generally won’t cover routine foot care, which might have prevented an infection that has serious consequences.

It’s easy to put a value on the use of an operating room, equipment and staff time, but much more difficult to put a price tag on preventing something from happening.

That’s the challenge for would-be reformers. Health care costs are growing faster than inflation, and competition among insurers won’t change that. A system that focuses on wellness would reduce the need for expensive interventions, but it won’t happen if we penalize the institutions that deliver that kind of care.


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