Maine has a new Accountable Care Organization, and it's the largest commercial ACO in the state. Anthem insurance and Eastern Maine Health Systems Beacon Health say the goal is to lower costs and improve healthcare for about 40,000 Anthem members. While there are some potential financial risks for providers, EMHS and Anthem say patients have everything to gain.
It's the Affordable Care Act that created Accountable Care Organizations, or ACOs. The idea behind them is to tie health care reimbursements to overall patient quality, versus itemized procedures or services. Doctors and hospitals band together to coordinate patient care, and they're rewarded financially when that care is of high quality, and efficient.
This ACO between EMHS Beacon Health and Anthem includes 15 hospitals and 400 primary care providers across 67 Maine cities and towns. EMHS's Vice President of Network Development Mike Donahue says his organization has committed to hold the cost for health services flat while improving outcomes.
"Essentially this is a one-year arrangement that we hope to transition into a multi-year arrangement," Donahue says.
For its part, Anthem will provide some money upfront to providers to invest in improving care - things like hiring nurse care coordinators to call patients in between visits to make sure they're taking medications and meeting their health goals.
Anthem already does this under its Enhanced Personal Care Program for about half of the primary care providers in the state. The addition of the EMHS ACO brings that number to about 75 percent. Spokesman Rory Sheehan says Anthem also shares data with physicians.
"This helps them identify gaps in care, and whether a patient is taking the medication they're supposed to be taking," Sheehan says. So basically, in a way, we're able to help complete the full picture for physicians with some of the data we have available to us."
Accountable Care Organizations aren't new to EMHS. They established a pioneer ACO in 2012 for Medicare patients. Since that time, emergency room visits are down about 3 percent and hospital admissions are down 21 percent. At the same time, primary care visits increased nearly 24 percent.
But while improving care, EMHS didn't meet all of its cost requirements, and received a penalty of about $3 million. Mike Donahue says, as a result of that experience - and a younger patient population in this ACO, he expects a different outcome. "For this particular population, we can be as successful, and even more successful, with our care coordination," he says.
One other challenge with ACOs is there's a time lag between when a provider gives care to a patient, and when the reimbursements arrive - at least a year. Donahue says it shows how important it is for health care to transition away from the traditional fee-for-service model.
"You know, if you're the payor, you have to see, 'OK, this is successful, therefore I'm willing to upfront more," he says.
Despite the financial risks for health care systems, EMHS Director of Care Coordination Tori Gaetani says patients have only to gain from ACOs. "And hopefully what their gain is is a better outcome in their health care and their experience with their health care providers."
