Affordable health care

Mainers this year will spend approximately $5 billion on health care, plenty to provide every citizen with a comprehensive health plan. But more than 10 percent of residents – 160,000 people – have no insurance, another large percentage have insurance in name only – $5,000 deductible, high co-pays – businesses, seeing annual increases of 25 or 30 percent in health costs, are saying they can no longer afford the benefit, the state still hasn’t decided how it will pay its rising Medicaid share and just about everyone is bracing for new higher prices, especially for prescription drugs.

State government has reacted to this largely by stretching federal-state programs or offering discounted rates to the most vulnerable. This is a reasonable response but not a sustainable one. To understand why, consider that the major source of revenue for creating or maintaining health programs is new cigarette taxes, 27 cents under Gov. Angus King’s budget and 50 cents in an ambitious and laudable plan by Speaker Michael Saxl. There’s nothing wrong with requiring smokers to pay their share of health care or using price increases as disincentives for smoking, but the limit on this funding strategy is obvious. The price of health care goes up substantially every year; taxes on cigarettes cannot.

In the absence of major reform from Washington, two recent proposals suggest that Maine has an opportunity and good reason to step back and figure out more efficient ways of extending crucial health services without spending more money on them.

The first comes from Senate President Pro Tem Rick Bennett, who recently persuaded Heinz Family Philanthropies to study the demographics, economics and needs of the population qualified for Maine’s Prescription Drugs for the Elderly program and develop a model program based on its findings. Heinz did similar good work in Massachusetts last year, described by Teresa Heinz, chairman of the philanthropy, as a plan to enable Massachusetts to “untangle a dilemma that has left legislators in other states tied in knots: creating a prescription drug plan for all senior citizens, regardless of income, that is voluntary, comprehensive, includes catastrophic coverage, but it affordable.”

The Maine study by the Heinz foundation will take perhaps another month to complete. It promises to be an extensive examination, one that could well point to answers in other areas of health care. Before this state approves any of the half-dozen significant health care reforms currently before the Legislature, it should review the results of this work. Maine spends about $15 million a year on its Drugs for the Elderly program; if it can do it more effectively, it will reach more people. If it can apply lessons in increasing effectiveness system wide, it can save millions while covering the uninsured.

The governor’s Blue Ribbon commission on health care last year estimated that $1.1 billion of the nearly $5 billion spent in 1999 was lost to duplication, needless administration and general bureaucracy. Chopping even one-fourth of that amount would make a huge difference in the ability of Maine to obtain more affordable health care. That’s what an idea by Dr. Erik Steele proposes to do through a plan the Legislature could pass this session.

Dr. Steele, administrator for emergency services at Eastern Maine Medical Center and a columnist for the Bangor Daily News, proposes a Maine Institute of Health Care and Quality and Cost Control, which would serve as a nonpartisan source for identifying “cost-effective practices identified in good medical studies and work to make them the usual practice in Maine.” An example of savings: studies show that patients who twist an ankle and have certain symptoms do not need an X-ray to determine whether the ankle is fractured. But doctors often take an X-ray anyway because, in the event of a misdiagnosis, they want to be able to defend themselves in a lawsuit.

The examination procedure described by Dr. Steele is known as the Ottawa Ankle Rules and there is, similarly, the Ottawa Knee Rules. If they were in place to legally protect doctors who followed them, Maine could save considerably on X-rays without compromising care. According to Dr. Steele, there are dozens of possible procedures that could be performed as well but less expensively to save hundreds of millions of dollars annually. They would have to be carefully examined, of course, and shown to be effective before being approved, but they could dramatically reduce the cost of care.

Maine would not be alone in doing this. States nationwide are considering ways to allow doctors to maintain effective practices while keeping care affordable. The five health plans that cover almost everyone in Minnesota announced Monday that they are supporting standard treatment and prevention procedures for 50 common ailments from lower-back pain to bladder infection to improve quality and hold down costs.

And more could be done. University of Pittsburgh researchers recently identified low-risk patients with community-acquired pneumonia (CAP) who often are hospitalized but do not need to be. The work contributed to new guidelines from the Infectious Diseases Society of America, which notes that hospital treatment for CAP is more than 20 times higher than outpatient treatment. But unless an outside institute in Maine reviews and encourages this less-expensive but equally effective care, practices will not change here and the cost of treating this illness will not decrease.

If the kind of inefficiency is present anywhere near the levels identified by the governor’s commission, the study initiated by Sen. Bennett should begin to expose them and the institute proposed by Dr. Steele should dismantle them. These aren’t a substitute for expanded health coverage; they are a way Maine may be able to afford that coverage.