CAREPARTNERS
Portland, ME

April 2000

        §       Background

MaineHealth is a non-profit integrated healthcare delivery system, whose organizations include hospitals, home care agencies, long-term care facilities, specialists, primary care practices, diagnostic centers, a reference laboratory and consumer learning centers.  MaineHealth has convened a twenty member Steering Committee whose members include representatives from each demonstration site, business, managed care, health care policy and advocate groups, state and local health officials, and physician groups to guide the planning phase of this project.

The MaineHealth effort builds upon important groundwork laid by a group of key stakeholders convened initially in 1997 by the Bingham Program, a philanthropic fun supports MaineHealth.

MaineHealth is designing a program that will establish an accessible system of care for uninsured persons in southern and Central Maine.  The program will provide quality accessible medical care to low income uninsured or underinsured persons; it will provide incentives for participants to utilize appropriate primary care and preventive healthcare services; it will ensure linkages to supportive and wrap around services available in the communities and it will control costs so as to sustain a financial viable system of care.

MaineHealth will work with private practice physicians, along with residency training programs, employed physicians and other providers in the community to provide services.  Key program design elements being analyzed include the provision of pharmacy benefit, case management, health education, and the development of a broad-based provider panel.  Through an extensive data tracking system we plan to measure changes inpatient healthy behaviors, as well as selected health status indicators.

Given the number of uninsured in the state, and what many term the current status of crisis in the healthcare system, the MaineHealth does intend to create a sustainable, quality-based system that provide access to healthcare and supportive services for a significant portion of low-income persons who cannot otherwise afford or obtain health care coverage.

MaineHealth will also utilize existing resources and work creatively with state and local leaders to address the needs of all uninsured.  For example, we intend to build the capacity to determine eligibility for public health care insurance programs (Medicaid, CHIP, Veterans benefits) for access program applicants; to link all persons who apply for the program to social and support services in the community; and finally to create a dialogue among business, healthcare, labor and others to address shared responsibility and arrive at a new solutions to assuring access to the uninsured.

Maine does not have traditional safety net programs funded by state or municipal taxes that are found in many other states.  Although this might be considered a drawback, we believe the lack of dedicated funding streams will allow us greater flexibility and control over the development of a financing plan for the MaineHealth program.  One of our primary goals is to secure broad based funding to support a system-wide initiative.  One possible source of new money for the access program is the state tobacco settlement; another is the creation of the Pine Tree Foundation, a foundation whose statutory missing is to increase access to healthcare.  The Foundation is being formed from the sale of Blue Cross Blue Shield of Maine to a for-profit entity, Anthem, Inc.  Other sources of funding to be explored include MaineHealth system itself, as well as public financing through legislative appropriations, taxes and fees.

Outreach Strategy

Outreach will begin as part of our research activities and the development of Community Advisory Committees.  Focus groups will be held with uninsured individuals and providers at each demonstration site in the first quarter of the project.  For consumers, the focus groups will identify existing access barriers, get feedback on proposed program components, and also identify means to successfully conduct outreach for program enrollment.  For providers, the focus groups will identify existing problems in providing uncompensated care, get feedback on proposed program components, and identify successful means to develop the provider network.

Community Advisory Committees will continue to be a primary outreach vehicle at the local level.  Membership will include organizations that have access to potential program participants, as well as providers, businesses, and other community leaders.

Delivery System

The delivery system will reflect the provider community in each of the three demonstration sites.  We anticipate broad based support from primary care, specialists, and hospitals; as well as developing comprehensive referral agreements with other community service organizations.  As stated, case management will be a key component of the delivery system; who will provide that service and where they will be located has not yet been decided.  We will be using Community Advisory Committees in each of the local sites to provide feedback on the proposed delivery system.  The Community Advisory committees will include consumers, providers, social and educational organizations, local businesses, government officials and other key stakeholders.

MaineHealth is currently looking at a variety of program design options, but many of the components expected to be included in our program term from what has been termed the network/referral model.  In this model, the access sites for the uninsured include all providers who agree to become part of the network/referral system of care.  Network/referral models build upon the tradition of providing free care to those in need, in private physician offices, clinic settings, and hospitals.  The model of care often adds administrative and benefit components to better meet the needs of patients and providers.  

Key features will likely include a comprehensive patient intake and eligibility verification, eligibility determination for public insurance programs, use of an assigned PCP for enrolled patients, a broad based and comprehensive provider network, case management, data systems to support utilization review, and pharmacy benefits.

MaineHealth realizes that it faces some significant challenges in the planning and implementation phases.  Areas that we are examining closely include the costs of providing prescription drug coverage and most effective means to do so; the financial impact of the program on participating providers; effective means of engaging physicians in the planning and implementation phases; and the desire to create a program which is responsive to the local environment while also being able to be implemented throughout the MaineHealth system.  To address these issues we plan to evaluate different finance mechanisms for both pharmacy and network services; as well as work closely with each demonstration site to identify role and responsibilities at the local versus system level.

The geographic region served by the MaineHealth system is extensive; it consists of ten counties of southern and central Maine, comprising a total population of approximately 950,000.  The MaineHealth Access Program will ultimately be implemented throughout the region, but it will be piloted initially in three counties; Cumberland, Lincoln, and Kennebec.  These counties represent very different geographic areas in Maine, including urban, suburban and rural areas.

We estimate that at least 15% of all Maine residents lack health insurance; this translates into approximately 142,000 uninsured persons in the region.  This estimate is based upon a study by the American Journal of Public Health (AJPH, January 1999, p. 36-42) which also states that proportionately more residents lack health insurance in Maine than in any other New England state.  A changing economic base, the large percent of businesses (96%) with fewer than 50 employees, and the rising cost of insurance have contributed to this problem.

As part of our planning design we are conducting a household telephone survey in the three demonstration counties to gauge the prevalence of uninsured, and to profile income, employment and healthcare utilization characteristics of the uninsured.  The household survey will provide us with county level data; data that we feel is critical to understanding the uninsured.  The results of the survey will be available in May, 2000.  We will also be conducting focus groups.

Phebe King M.P.A.
Assistant Director
CarePartners
241 Oxford Street
Portland, ME 04101
Phone:  207-842-7002
Fax:  207-541-7540
E-mail:  kingp@mmc.org