How Maine Used Its Clout to Press for Higher-Value Health Care

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, recounts how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

What does a heavyweight look like in the fight for high-value health care? Take a look at how the state of Maine has used its muscle as the administrator of health plans for 34,000 employees, retirees and their families. It is an especially noteworthy story since the health care reform bills before Congress include a number of provisions to encourage the use of quality measures and value-based purchasing.
 
Maine’s State Employee Health Commission, responding to a call from the state legislature to contain health care expenses, developed a new health-benefits plan in 2006. No ordinary plan, its goals included engaging employees and retirees in the health care process, improving quality of care and encouraging providers to publicly report their performance information.

The upshot has been a value-based purchasing strategy based on public reports developed by the employer-led Maine Health Management Coalition, which works closely with the Robert Wood Johnson Foundation’s Aligning Forces for Quality grantee, Quality Counts, and the state government’s quality-improvement initiative, called the Maine Quality Forum.

The coalition scores hospitals on nationally recognized measures for patient satisfaction, patient safety and quality of clinical care for heart attacks, heart failure, pneumonia and surgical site infections. It grades primary-care practices on the use of office systems such as patient registries and the quality of care given for diabetes and heart disease. (For the quality measures in pediatric practices, it swaps in asthma care and immunizations.) The coalition assigns an overall rating in each of the categories and awards providers blue ribbons based on their performance.

Employers are free to use the rankings as they see fit in designing their own plans, and some of the largest employers in the state do, from Bath Iron Works to L.L. Bean. But it was when the State Employee Health Commission got involved that things ramped into high gear.

In 2007, the value-based purchasing strategy of the state health plan started ranking doctors and hospitals in tiers, based on how many blue ribbons they had earned. Services from preferred providers were exempted from annual deductibles, and co-payments for inpatient admissions and outpatient surgeries started being waived.

This represented a sharp new direction for employees, so the executive director of Maine’s Division of Employee Health and Benefits travelled the state like a circuit rider, stopping at 60 different locations to educate employees about the new plan. That employee-engagement effort has paid off. While a formal evaluation is underway, recent claims data indicate a 5-percent shift from non-preferred to preferred hospitals for outpatient services. There is also anecdotal evidence that it has grabbed everyone’s attention. For example, when the state notified employees of the change by letter, the Web site’s traffic jumped from 1,000 visits a month to a peak of more than 1,500 a day.

Hospitals and doctors are paying attention—and taking action. Less than three years after the 2006 state health plan started to take effect, the number of preferred hospitals had doubled from 14 of the eligible 36 to 28. And among physicians, the number of three–blue ribbon practices increased by 20 percent.

And now Quality Counts is stepping in with an aggressive program to drive those numbers higher by working with several physician-hospital organizations and networks on a quality-improvement initiative for physicians. The Maine Medical Center Physician-Hospital Organization, for one, began offering low-cost, Internet-based registries, care managers and other support to help practices manage patients with chronic diseases.

How much impact did it have? Ted Rooney, the project director for Aligning Forces for Quality in Maine, offers this assessment: “When the state of Maine started to tier primary-care practices in 2007 based on quality, it put the whole system on steroids.”