Maine Communities' Successful Uninsured Program Emphasizes Care Management Over Emergency Departments

May 3, 2006

For many hospitals, charity care, however generous, consists primarily of treating people in the emergency department. It's sort of an endless cycle, says Deborah A. Deatrick, vice president of community health for MaineHealth, headquartered in Portland, Maine. "There's no care management, no pharmacy service. They come in, they go out. We knew we needed to go beyond that." The January 2006 issue of HFMA's Executive Insights newsletter describes how they did.

One approach that has been widely adopted in community-based efforts to provide care for the uninsured is Project Access, in which clinicians provide pro bono services to a specific number of patients annually. CarePartners, the program model developed, sponsored, and launched by MaineHealth in June 2001, is similar to Project Access but with some important differences.

No Dropouts

Project Access is typically based in a county medical society, making it more physician-centric than CarePartners, which is more hospital-centric. In addition to physician visits, hospital services (inpatient, outpatient, and home care) are provided to CarePartners enrollees in three counties at seven hospitals, including four system members who serve as hosts and three hospitals unaffiliated with the MaineHealth System.

Unlike many Project Access programs, CarePartners provides both pharmacy benefits and care managers, both of which are paid for by the four host hospitals. With help from a handful of foundations, including the Robert Wood Johnson Foundation, the system also supports central functions such as information systems and relationships with Anthem Blue Cross and Blue Shield, the pro bono third-party administrator.

Enrollees are assigned to a primary care physician and must get specialty referrals from that physician. In four and a half years of operation, no member of the volunteer provider network -- physician or hospital -- has dropped out. "That's because we haven't asked them to take on an unreasonable burden," says Deatrick. By agreement, participation by each primary care physician is limited to 10 patients at any one time and by each specialist to 20 visits per year. "In two areas, the network actually includes all the providers in the community, which has been a real strength of the program," says Deatrick.

Another strength is that CarePartners set its income eligibility levels to match the charity care guidelines of the hospitals, in order to discourage unfavorable selection into either CarePartners or the charity care programs. The program recertifies eligibility every six months, at which point enrollees must document their current income and employment status. Over the first three and a half years of operation, the average length of enrollment was 11 months.

Enrollee Profile

Currently, CarePartners has 1,000 enrollees. Three-quarters are employed, most part-time by small, private employers, and almost as many had insurance in the year before they enrolled. The average enrollee has two to four chronic medical conditions, making the program's care management component critical. "These are people who use an enormous number of medications, have lots of medication compliance issues, and have huge access problems," according to Deatrick. "They shouldn't be using the ED; it's a poor use of system resources. They need regular care from a primary care physician. The cost benefit potential of the program is far greater with these individuals."

CarePartners providers submit dummy invoices for all transactions, allowing administrators to track the value of donated services. From June 2001 to June 2005, these totaled $12,351,060, of which three-fourths was donated by hospitals and one-fourth by community clinicians, including $1.8 million by primary care physicians. The program also tracks pharmacy costs, ED utilization, and per-member-per-month costs, all of which registered significant reductions.

A Double Whammy

All of that could be cause for congratulations, unless you consider that CarePartners had expected to be out of business by now. In 2004, Maine approved a state initiative called Dirigo (meaning "I Lead," the state motto) Choice, which is designed to provide health care for uninsured persons whose income is too high for Medicaid. It was supposed to cover 31,000 people by the end of the first year; instead, it has just 7,500 enrollees. One reason: Many eligible people can't afford the premium, copays, and deductibles.

"So whereas we thought a year or so ago that CarePartners would be folding up its tents and moving on, it's quite the reverse," says Deatrick ruefully. "We've had to cap enrollment in all three sites and we have long waiting lists. Not only hasn't Dirigo taken care of the problem -- and premium increases effective Jan. 1, 2006, will make it even less affordable -- but also our state Medicaid program has rolled back eligibility thresholds. So we got a double whammy." The situation is most precarious in rural areas, Deatrick explains, where there is too little capacity to support a voluntary provider network program like CarePartners.

For now, CarePartners will go on as it has, serving the participating hospitals as an adjunct to their other charity care. Because the program gives all providers an individualized annual report on the value of their donated services, says Deatrick, "we think it allows them to provide that care in a more useful manner."