Bill Caron and MaineHealth: Better Care for Maine People through Partnerships
I bought my first stethoscope in 1992: a burgundy model from Littman Cardiology, purchased on the recommendation of my professor at the University of Vermont College of Medicine. Bill Caron became the treasurer and vice president of Maine Medical Center in Portland that same year. As a 21-year-old medical student, my comprehension of health was based largely on the systems of the human body; Caron understood health to be equally impacted by financial and administrative systems that connected patients and providers. Our paths had yet to cross, yet we were clearly on a parallel course.
A native of Dover, NH, Caron had always been comfortable with numbers. While an undergraduate at the College of the Holy Cross, he took an accounting course as a “filler” and immediately found himself intrigued. He jokes, “I never liked exotic math like trigonometry and advanced algebra,” instead preferring the practicality of finance. He rounded out his education with a master’s degree in accounting from Northeastern University.
Caron gained extensive experience in health care during his 17 years with the global accounting firm Ernst and Young. His early projects included feasibility studies for hospitals in rural areas such as Dover-Foxcroft and Caribou. Caron particularly enjoyed working with doctors. “I’m a little old-fashioned. I believe that physicians are special. They chose their careers for very specific reasons—99 percent of their decision to practice medicine is about caring for people.”
Shortly after he joined MMC, Caron began participating in meetings with interim MMC president Don McDowell and members of the Maine Medical Center Foundation to determine whether Southern Maine would benefit from a formalized network of health care institutions. In the mid 1990s there were more than 40 not-for-profit hospitals in the state. Each had its own board of directors, and each had the desire to serve its community. The system, while well intentioned, was fragmented and redundant. McDowell referred to it as a “health care unsystem.”
This situation was by no means unusual. Across the United States, hospitals and other medical organizations were recognizing similar inefficiencies. They were also recognizing the strength of having a collective voice. Through creating what became known as integrated delivery systems, they were more effectively able to negotiate with insurance companies regarding payments for care.
In Southern Maine, the interest in collaboration came about as a result of something perhaps more important—an idea that would become the vision for MaineHealth and its eventual tagline: “Working together so our communities are the healthiest in America.”
The not-for-profit MaineHealth system was born in 1997, with McDowell as its first president and Caron as vice president and treasurer. In addition to MMC, founding members included St. Andrews Hospital in Boothbay and Miles Memorial Hospital in Damariscotta.
Partnership was a critical aspect of the MaineHealth structure from its inception. In addition to physicians and hospital administrators, the MaineHealth board of trustees would come to include individuals like Sara Burns, CEO at Central Maine Power, and Sandy Matheson, executive director of the Maine State Retirement System. Through the years, MaineHealth has maintained a shared governance system of leadership, in which local institutions have their own boards, and are represented at the MaineHealth level as well. Says Caron, “Healthcare organizations come in all shapes and sizes. Strong local board leaders help us understand what is different in their community.”
Caron also gained understanding of the healthcare system through what he calls a “fairly major healthcare event.” Eighteen years ago Caron went for a routine dental cleaning, without realizing that he had a small abnormality in one of his heart valves. Patients with this type of abnormality are usually given antibiotics before procedures like dental cleaning, to protect against endocarditis, an infection of the heart that can occur when bacteria are released into the bloodstream. Caron developed endocarditis, requiring hospitalization at MMC. He remembers, “Things got complicated and I went through a lot of services–starting with a good, experienced primary care physician. I had cardiologists, nurses, a cardiac surgeon, and home care providers who gave me antibiotics. All of whom gave me world-class care, right here in Portland, Maine.”
Thanks to the care of his medical team, Caron fully recovered from what could have been a life-ending illness. “Very seldom does an administrative leader get to see the inside of how a hospital really works from a patient perspective. I saw where we could do a better job from a customer perspective, but when it came to clinical care it was just phenomenal.”
Caron became the CEO of MaineHealth in October 2000, and much has changed under his watch. MaineHealth is now the largest private employer in the state, with more than 16,000 employees. Its service area includes 11 of Maine’s southernmost counties and (as of January 2014), Carroll County in New Hampshire. With a network of nine hospitals, and related healthcare entities such as NorDx Laboratories, its combined revenues are nearly $2 billion a year.
In the spring of 2014, I meet with Caron to discuss the current state of MaineHealth and the healthcare system at large. MaineHealth is located in an outwardly unassuming edifice on Free Street in Portland. The former headquarters of Blue Cross/Blue Shield, the MaineHealth building was completely renovated in 2010, with the assistance of architect Patrick Costin. Light streams through a central atrium that has been carved through the middle of the space; Casco Bay is visible from the upper floor windows to the East. On the day I visit, a tugboat can be seen shepherding a tanker through Portland Harbor.
As a former medical advisor for the MaineHealth system, I recall the warren of offices spread out over several floors in multiple buildings on Congress Street (and elsewhere). The Free Street building bespeaks a cohesiveness brought about by consolidation. It also reflects the transformation that MaineHealth has undergone since 1997: something new and unexpected has emerged from more traditional beginnings.
Caron comments on this transformation. “We absolutely need and needed to reform the healthcare system,” he says. “We can no longer afford healthcare the way we were providing it in the 90s and early 2000s. The economics of our state are changing. The demographics of our state are changing. We need to look at how we provide care, where we provide care, and do it differently.”
Caron is well aware of the challenges inherent in change. MaineHealth has been criticized for its cost-saving measures, including layoffs, the transition of the St. Andrews emergency department to an urgent care center, and the downsizing of smaller hospitals like Miles. Caron describes a recent study that addressed the decreased utilization of inpatient surgical services in rural Maine facilities. Of 35 hospitals that have the capacity to provide inpatient surgeries, 23 have less than two surgeries a day, and 14 have less than one surgery a day.
The low number of surgeries impacts both the cost and quality of these services. “We need to create scale in administrative and clinical systems,” Caron says. “Hospitals are going to be something different than what they are today.”
One way of creating scale is to have a functioning electronic medical record (EMR) in place. EMRs are a critical means of communicating information between primary care practices, specialist offices, laboratories, hospitals, and other organizations that have a part to play in creating wellness. The EMR also allows providers to stay up to date on screening tests for their patients, and collect research data on the patient population as a whole.
MaineHealth has invested more than $200 million in the Epic EMR—much more than originally budgeted.
Caron admits that when the Epic system was launched in December 2012, “We were not fully prepared. We missed some key steps.” It took six months to untangle the problems that surfaced. MaineHealth has now completely revised the timeline and “re-forecast the cost,” so that every hospital in the system will be online by 2017. According to Caron, health care providers recognize the importance of an EMR that works throughout the MaineHealth system. “Providers tell me that an integrated platform is the future, and it offers the best care—it’s torture getting through it, but once we get through it, it will be worth it.”
MaineHealth has also invested heavily in a concept known as the “patient-centered medical home,” or PCMH. According to Maine Quality Counts, the PCMH is “an approach to providing primary care to people of all ages.” Not a physical structure, it is rather “a team of health professionals who work together to provide a central point for coordinating care.” These professionals may include specialists in areas such as mental health and nutrition.
Dr. Ann Skelton, chief of family medicine at MMC, is a believer in the PCMH. “The principles of the patient-centered medical home, including coordination of care, teamwork, enhanced access and whole-person orientation, have the potential to transform health care delivery into a system that provides more positive patient experiences and outcomes at a lower cost.” MaineHealth will remake all of its practices into the PCMH model, at a cost of $15 million over five years. They are three years into this plan.
The majority of Maine health care providers (and their patients) will be affected by this move toward the PCMH. It is estimated that more than 80 percent of our state’s physicians are now employed by hospitals and health care systems like MaineHealth, Eastern Maine Healthcare, and Central Maine Healthcare—all of which have aligned themselves with the PCMH model. As a family physician now employed by one of these systems, I have seen firsthand the benefit of offering a team-based approach to care. Although I still interact with patients as individuals—using my stethoscope to listen to hearts, one at a time—I know that I am a better doctor by virtue of working collaboratively in a more efficient way.
The PCMH model continues to evolve, as do the expectations that patients have for the system that provides their care. This evolution will take time. Says Caron, “I’ve got an 82-year-old mother. When a physician tells her to salute, she does. If we are going to address quality and cost issues in healthcare, we need an informed, active consumer. I don’t worry about the people under 40. They will tell us what they want for health care. The issue is that it’s going to take three to four generations until they are the primary consumers.”
MaineHealth is already finding success, and being recognized for its efforts. Using their own annual Health Index report and measurements done by others (such as the County Health Rankings), MaineHealth has seen an increase in childhood immunization rates, and a decline in deaths due to heart disease. They have also been named one of the top-performing integrated delivery system several years in a row. MaineHealth vice president of community health, Deb Deatrick, comments, “There’s still work to do, but together with our community partners, we’re primed to take it on.”
Deatrick has a lot of respect for the work that Caron has done for MaineHealth. “Bill is definitely a numbers guy. But to him, the important numbers are not just about operating margins. They’re indicators of the quality of care in our hospitals and the number of people we help get affordable health care. They’re also numbers that tell us we’re making a difference in big issues like child obesity or heart disease. It’s a passion for numbers like these that makes him a different kind of health system CEO.”
Caron himself has grown more realistic about the return on investment for healthcare dollars. “Investments in improving health are long-term investments. I used to think it was five to ten years. Deb would chuckle and say, ‘If we’re lucky.’”
When asked what he hopes his legacy will be, Caron is careful to use the word ‘we.’ The necessity of partnership is always top of mind. “We integrated healthcare in Maine over a 20-year period. We improved the health of those communities we served. We improved the quality of care and reduced the costs of the care we provided. That’s what I would hope we would be known for.”
Sitting across a broad white table from Bill Caron, I consider our different approaches to bringing health to the people of Maine. Mine begins with a stethoscope. His begins with a spreadsheet. We represent very different ways of looking at the medical system. Yet we are each, in our own way, “working together so our communities are the healthiest in America.”
For each of us, it is the relationships between people that are of paramount importance—and there is one relationship in particular that continues to be relevant to people’s wellness. Says Caron, “I get caught up as a leader about organizational relationships—about how hospitals should relate to one another, how administrators should relate to doctors—but I believe when you break it down, the most common element of the healthcare system is the physician-patient relationship. I say to people, ‘Keep your focus on that relationship and we won’t go wrong.’”