Reforming Dirigo to success

Much has been written and said the past year about the Dirigo Health Plan. This is entirely appropriate as the health of our people and our economy are both dependent on resolving the health-care crisis.

Currently 135,000 Maine residents are without health insurance. Cost shifting is harming our business climate and costing us jobs. Small businesses need health insurance to attract and retain employees.

Dirigo addresses the three challenges of health care: access, quality and cost. It incorporates some novel concepts and shifts the paradigm from sick care to prevention.

Databases will provide doctors with costs and outcomes of care for different procedures, so that they may select the most cost effective treatment for a patient. Electronic Medical Records (EMR) will eliminate duplicative tests, imaging, and costly lab work. Wellness incentives will be offered to encourage healthier lifestyles in an attempt to reduce the incidence of preventable diseases.

Dirigo has already started to enroll members. Benefits are due to start on Jan. 1, 2005. Dirigo will continue to expand until all Maine residents and businesses have access to affordable health insurance by 2009. Subsidies will be available to individuals and households with incomes under 300 percent of the federal poverty level.

Dirigo is a public-private collaboration. A one-time pool of $52 million provides Dirigo with startup funding, along with grants from the private sector. Anthem, a private insurer, submitted a bid that was accepted by the state to provide a certain amount of coverage in exchange for that pool of money.

Permanent funding for Dirigo will be provided by a tax levied on the savings incurred by the insurance companies (the dividend of early access, improved lifestyles, and early intervention when a medical condition arises), Medicaid funds, and premiums.

Dirigo has great promise but it still has many obstacles to overcome if it is going to be anything more than a flash in the pan. These obstacles fall into two categories.

In the first category are the concerns of the hospital administrators, doctors, nurses, technicians, support staff, maintenance staff, and the citizens of the local communities that worry about what this change will mean to the quality of local healthcare.

In the second category are the problems of enrolling enough people and small businesses to give Dirigo wings, implementing complex treatment concepts, finding additional measures to contain cost growth, and getting enough people to participate in the wellness aspect of Dirigo so that the savings needed to make Dirigo self-sufficient are realized.

Some of the obstacles in the second category are probably going to prove insurmountable if those in the first are not resolved. Below are what I believe are the major concerns in the first category and what can be done to address them.

. Mandated Regionalization: This is a bad idea for three reasons.

1. Let’s put the patient first. Stress complicates medical conditions. Long drives, unfamiliar surroundings, and being far from family and friends add to stress. This is likely to slow recovery (increasing cost) or may even tip the scales to a more unfavorable outcome.

2. Regionalization will result in many programs being shifted from smaller hospitals that were operating them more efficiently to regional hubs, effectively rewarding poor performance and adding to cost.

3. One of the most attractive features that a community can have when trying to attract new enterprises, is local access to quality healthcare. Therefore the large communities with total healthcare services would attract the lion’s share of new businesses, starving the more modest and rural areas of desperately needed growth.

Regional facilitators, not overseers with czar powers, should coordinate cost saving measures between the units within each region, issuing quarterly reports and recommendations, but leaving the final decision with each local hospital as to whether or not to implement any recommendations.

. Medicaid and Medicare Reimbursement: These federal programs reimburse providers only 30 cents for each dollar of care. This creates a huge strain on hospital budgets. Maine has the lowest rate or reimbursement in the country. We need to pressure our federally elected officials to fund these programs at a fair rate.

. Lost Jobs: There should be no net local loss of jobs in the process. The objective of Dirigo is to provide increased care to people on the wellness side, thereby reducing the demand on the sick care side of healthcare. Retraining should be offered when necessary for workers to switch “teams.” Nurse staffing must be kept at a patient ratio that ensures quality healthcare.

. Cost of EMR Systems for Doctors: These systems are necessary for doctors to access the EMR database. The state should acquire these units in a process similar to the student laptops. Buying in bulk should bring down the cost per unit and training cost. Then the state should find ways to offset the doctors’ cost within three years.

. Tort Reform: Dirigo contains a provision requiring the superintendent of insurance to submit a report on this to the Legislature by Jan. 1, 2005. Tort reform can be enacted that will protect the right of patients that have been harmed by incompetence or negligence, and at the same time protect our quality doctors from costly, frivolous litigation. Health insurance without quality doctors is no benefit.

Reforming health care is a mammoth undertaking. Only through everyone coming together and bringing forth the best of ourselves will we be able to muster the good will and mental resources needed to ensure Dirigo’s success.

We have an opportunity to do a really good thing. Let’s not let it slip away.

Peter P. Misluk Jr. is the Democratic state Senate candidate for Waldo County, District 23.