The Maine
Experience
In Pursuit of Value-Based
Purchasing
August 4, 2009
Background





Self-insured POS plan of 34,000 (with additional
6,800 Medicare retirees)
Largest employer-sponsored plan in Maine
Governed by State Employee Health
Commission, twenty-two member
labor/management organization
Slightly older working population
Higher incidence of chronic illness
The Path to Value-Based
Purchasing


Founding member of Maine Health Management
Coalition – multi-stakeholder organization of
employers, hospitals, health plans, and
physician groups
External factors
 Institute
of Medicine reports
 Juran Institute report for MBGH
 NEJM study findings on treatment of chronic illness
 Dartmouth Atlas
Commission Adopts Value-Based
Purchasing Strategy
Growth in plan expenses is unsustainable
 Resisted traditional cost shifting tactics in
favor of value equation (quality, utilization,
efficiency) – trying to change behavior
 Gaps in care and unwarranted variation
cannot be adequately addressed without
changes in benefits and reimbursement

Phase I – TDES (1/1/05)




Telephonic Diabetes Education & Support
program
Improve participation in self-management
program and improve adherence to prescribed
treatment
Partnership with TPA (Anthem) and non-profit
Medical Care Development
Adapted traditional education and selfmanagement model to telephonic pilot
TDES Basic Design
1st and 12th sessions require face-to-face
encounter with nurse educator for pre/post
assessment & biometric measures
 Intervening 10 sessions are conducted via
telephone at convenient times
 Plan waives Rx copays for diabetic
medications and supplies for duration of
member’s participation

Results of TDES Pilot



Participants received recommended care
evidenced by: physician visits, foot exams,
retinal eye exams, HbA1c levels
Members participating in TDES had statistically
significant improvement in adherence to oral
diabetes medications
Compared to randomly selected control group
TDES participants had an adjusted average cost
$1,300 less than control group over 12-month
follow-up
Phase II – Hospital Tiering (7/1/06)
Goals & Objectives





Encourage public disclosure of provider
performance
Establish attainable performance benchmarks to
be incrementally adjusted
Drive quality improvement
Give members tools to make informed decisions
Provide incentives to shape decision-making
Hospital Tiering Basic Design






Completion of Leapfrog safe practices survey
Performance on Maine Health Management Coalition
medication survey indicating “has made good progress
to implement recommended safe practices”
Met or exceeded national average on CMS clinical core
measures
Services billed by “preferred hospital” exempt from
annual deductible
All hospitals remain in the network
Over 60 sessions conducted statewide to inform
members
What Happened?




Only 14 of 36 acute care hospitals met the
criteria for preferred hospital
Members voiced concern to local hospital
officials for failing to meet criteria
By 1/1/07 all Maine hospitals had completed the
Leapfrog safe practices survey and the MHMC
medication safety survey
Number of preferred hospitals jumped to 25 by
1/1/07
The Next Phase of Hospital Tiering




Providers became more engaged in process
Agreement to use MHMC as “trusted” source of
measures and reporting
State aligned with MHMC hospital ratings – blue
ribbon designations (7/1/07)
Financial incentives for members become more
meaningful (10/1/08)
What Do We Know About Hospital
Tiering?





Design was quite benign and non-threatening but it
produced results
Incremental approach helped ensure members were not
disenchanted
Focus on quality and safety insulated initiative from
provider complaints
Anecdotally, hospital QI staff and pharmacists told us the
initiative helped secure resources
In first year there was 5% shift in outpatient services
from non-preferred to preferred hospitals
What Have We Learned?
There is strong evidence to support that
initial objectives have been met
 Individually and collectively hospital quality
performance has improved – at least for
dimensions of care we measure
 Incentives do have some impact on both
provider and enrollee behavior

What Do We Need To Know?




Is there a link between higher-performing
hospitals and efficiency?
How do we design incentives to produce desired
results?
Can we adapt this model to specific high-volume
or high-risk procedures?
How do we demonstrate the continued
effectiveness of this strategy?
Phase III – Primary Care Physician
(PCP) Tiering
Maine Health Management Coalition’s
Pathways to Excellence (PTE) developed
metrics to measure management of
patients with chronic conditions
 Measures office systems, treatment of
diabetes, treatment of heart disease,
treatment of pediatric asthma and results
of childhood immunizations

How Does PCP Tiering Work?
Preferred practices must be awarded two
or three blue ribbons
 Office visit copays to preferred practices
are waived
 Services billed by preferred practices not
subject to deductible

Developments in PCP Tiering
From 2007 to 2008 35% increase in the
number of practices with 3 blue ribbons
and 20% increase in number of practices
with 2 blue ribbons
 By 2009 over 50% of the better than 400
primary care practices were preferred
 MHMC moving to national measures –
Bridges to Excellence and NCQA

Phase IV
Adapt TDES principle to asthma and
congestive heart failure (7/1/09)
 Centers of Excellence for bariatric surgery
(7/1/09)
 Health credit program (10/1/09)

Next Steps





Minimally invasive surgery
Introduction of efficiency measures (to include
utilization) for PCPs, specialists and hospitals
Shared decision-making for preference-sensitive
services
Regional medical tourism
Payment reform