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Advancing Health Care Reform in Maine: Why, What, & How?. Aging Advocacy Summit November 2012 Lisa M. Letourneau MD, MPH. Objectives. Identify factors contributing to the urgent case for transforming US health care system Introduce key components of Maine’s emerging model for change

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Advancing health care reform in maine why what how
Advancing Health Care Reform in Maine:Why, What, & How?

Aging Advocacy Summit

November 2012

Lisa M. Letourneau MD, MPH


  • Identify factors contributing to the urgent case for transforming US health care system

  • Introduce key components of Maine’s emerging model for change

    • Patient Centered Medical Home (PCMH)

    • Community Care Teams (CCTs)

    • Accountable Care Organizations (ACOs)

  • Describe the role of consumers in supporting , driving this change

Who we are
: Who We Are

  • Independent, multi-stakeholder alliance in Maine working to transform health and healthcare by leading, collaborating, and aligning improvement efforts

  • Only organization working to improve quality of care for all Maine people

  • Members include consumers, doctors, nurses, hospitals, health systems, payers, employers, government, policy makers, and others working to improve health and healthcare

What we do
: What We Do

  • Align health care quality improvement efforts

  • Engage consumers meaningfully in improving health and health care

  • Establish sustainable system of quality improvement support for providers

  • Improve integration of behavioral and physical healthcare

Major programs
: Major Programs

  • Aligning Forces for Quality

  • Maine Patient Centered Medical Home Pilot

  • Improving Behavioral Health Integration

  • Transforming Care at the Bedside

  • QC Learning Community

  • QC Annual Conference (“Best Practice College”)


Vision for a transformed health care system
Vision for a Transformed Health Care System

Healthy, productive, connected people & families

…receiving healthcare from a highly functioning “accountable care organization”

… supported by a robust & well-supported system of primary care providers

What we want from our health care
What We Want from Our Health Care

  • Relationship with our providers that crosses settings, time, & place

  • Caring, compassionate interactions

  • Coordination & integration of care across providers

  • Ability to access care 24/7 – when & where we need it

  • Time, time, time…

But what do we get
But What Do We Get?

The 15 minute visit!

Why follow the money
Why? Follow the Money!

  • What we want:

  • Relationship, time with our providers

  • Caring, compassionate interactions

  • Coordination & integration of care

  • Ability to access care 24/7

  • What we pay for:

  • Visits

  • Tests

  • Procedures

  • Procedures

  • Procedures

The stalemate that blocks change
The Stalemate That Blocks Change

Employers & payers unwilling to pay for desired services unless providers demonstrate value AND show potential to save money

Providers unable to transform practice without viable & sustainable payment for desired services


Community leadership for change
Community Leadership for Change

Maine Quality Counts

DHA’s Maine Quality Forum

Maine Health Management Coalition



The medical home acos models for change
The Medical Home & ACOs: Models for Change!

Employers & payers pay for desired services if providers can demonstrate value AND reduce spending

= Payment Reform

Providers change practice, create value with viable & sustainable payment for desired services

= Delivery System Change


Defining medical home
Defining Medical Home

“A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.”

American Academy Pediatrics

Maine pcmh pilot core expectations for practices
Maine PCMH Pilot “Core Expectations” for Practices

  • Demonstrated physician leadership for improvement

  • Team-based approach

  • Population risk-stratification and management

  • Practice-integrated care management

  • Same-day access to care

  • Behavioral-physical health integration

  • Inclusion of patients & families

  • Connection to community / local HMP

  • Commitment to reducing avoidable spending & waste

  • Integration of health IT

Community care teams
Community Care Teams

  • Multi-disciplinary, community-based, practice-integrated care teams

  • Build on successful models (NC, VT, NJ)

  • Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes

  • Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits)


Maine PCMH Pilot Community Care Teams




  • Community Care Team


Outpatient Services


Care Mgt


Food Systems

High-need Individual

PCMH Practice

Med Mgt


  • Community Resources



Hospital Services

Behav. Health & Sub Abuse


Physical Therapy



Faith Community

Maine s medical home movement
Maine’s Medical Home Movement

~ 540 Maine Primary Care Practices

~130+ MaineCare HH Practices?

100+ NCQA PCMH Recognized Practices



  • Payers:

  • Medicare

  • Medicaid

  • Commercial (Anthem, Aetna, HPHC)

  • Self-insured employers


26 Maine PCMH Pilot Practices



50PilotPhase 2 Practices


So what about acos
So…What About ACOs?

“Accountable Care Organizations (ACOs) will constitute groups of providers - physicians, other clinicians, hospitals or other providers - that together provide care and share accountability for the cost and quality of care for a population of patients”

T. Lake et al, “Lessons from the Field: Making Accountable Care Organizations Real “, NIHCR Research Brief, Jan 2011


Acos in maine what s happening
ACOs in Maine – What’s Happening?

  • Employer-Provider ACO Pilots

    • Maine Health Management Coalition leadership

    • MaineGeneral-SEHC, EMMC, other pilots

  • Medicare – multiple ACO options

    • Pioneer ACO – EMHS

    • Shared Savings programs – MH, CMMC, MePCA

  • Medicaid: Value-Based Purchasing strategy

    • Seeking “Accountable Communities” proposals



Engaging consumers partnering with patients
Engaging Consumers, Partnering with Patients

  • Untapped “force” for improving health care

  • Need to shift from provider-centered to patient-centered approaches (think banking!)

  • Need patients to better understand their role

    • To improve their health, and

    • To change health care system

  • Changing patient role requires changing culture of US health care


Patient Engagement

  • What We Say:

  • We want patients to take active role in making decisions about their health

  • We want patients to ask questions

  • We want patients to express values & preferences

  • What We know:

  • Patients – even well educated, are reluctant to ask questions

  • Patients are fearful of challenging provider recommendations

  • Many patients feel physicians are authoritarian (vs. “authoritative”)

“Better Health. Better ME!”

Consumer Engagement Campaign

  • Take Charge of Your Health:

  • Step ONE: VISIT your Primary Care Provider

  • Step TWO: ASK Questions

  • Step THREE: KNOW your numbers

  • Step FOUR: FIND and use community resources and programs to support health


ABIM “Choosing Wisely” Campaign

  • Physician-led effort to identify opportunities to improve care and decrease use of wasteful services

  • Have created lists: “5 Things Physicians & Patients Should Question”

  • Appeals to professionalism

  • Promotes partnership with patients

  • Have engaged multiple specialty physician groups


Managed care all over again

‘Old-School’ Managed Care

Focus on reducing costs

Global capitation

PCP at full financial risk

PCP as gatekeeper

Very limited information and tools

vs. PCMH + ACOs

Focus on demonstrating value

New care management fees (plus performance payments?)

Limited financial risk to PCP

Primary care team coordinates care & supports patient needs across “med neighborhood”

Improved information and tools (EMR, registries)

Managed Care All Over Again?


Change is hard
Change is Hard

  • Hard to repair the plane in flight

  • Hard to practice while practicing!

  • People fear change (loss) - any change

Qc 2013 save the date aligning maine s forces to achieve the triple aim of improvement
QC 2013 – Save the Date! Aligning Maine’s Forces To Achieve the Triple Aim of Improvement

  • Wed, Apr 3, 2013

  • Augusta Civic Center

  • Dr. Donald Berwick

  • Join us!


Contact info questions
Contact Info / Questions

  • Lisa Letourneau MD, MPH


  • 207.415.4043

  • Maine Quality Counts


  • Maine PCMH Pilot


      (See “Programs”  PCMH)