During one six-month period of time over the past two years, Buddy Pietila, a Nobleboro man with advanced liver disease, was hospitalized 13 times.

The care he received saved his life, but the fact that Buddy needed to be hospitalized so often is a pretty strong indication that the medical system was not working for him. Because Buddy is insured through MaineCare and because MaineCare only pays for a fraction of the cost of hospital services, the hospitals were losing money.

It was a lose-lose situation, one that plays out hundreds, maybe thousands, of times in hospitals across the country every day.

Then Buddy met Tory Gamage, a member of the MaineHealth Community Care Team.

Tory talked to Buddy about taking his medications and she also arranged for emergency medical responders to come to his house to take blood samples through the Lincoln County Paramedicine Program.

Buddy can't drive himself, so having somebody come to him made the difference between having his blood tested on a regular basis and not having it tested at all.

By identifying the problems that were causing Buddy to need hospital care and working with him to overcome obstacles, Tory helped the health care system work for Buddy. At the same time, she saved the system a lot of money.

The tools she used were simple communication and persistence.

"She doesn't preach or anything. She has a way of putting it across the right way," said Buddy. "She talks a language that I can understand."

While Buddy is not cured - he is now waiting for a liver transplant -his story is now much more hopeful thanks to a more proactive approach to his medical care. His narrative is also an example of how a new way of coordinating care, called accountable care, can make medicine not only less expensive but also better.

A key component of that first part - making health care less expensive - is changing the way health care is paid for.

Instead of paying for health care through a fee-for-service model (the current system) that pays doctors and hospitals for providing services to people when they are sick, accountable care would pay hospitals and physicians to keep them well.

The new system would work like this: health care systems - hospitals and physicians - would be paid a lump sum to provide care for a population. If the health care system could keep most of that population healthy and out of the hospital, while also achieving certain quality goals, they could keep part of the money that they didn't spend.
The health care system could then invest that money in programs that have been proven to keep people healthy - an exercise program for overweight children or paramedicine services to help older people stay in their homes longer and more safely. In theory at least, the population would keep getting healthier.

And while this may sound theoretical, accountable care is already here.

The federal government has begun to build aspects of accountable care into Medicare and Medicaid (MaineCare in Maine), which insure a large proportion of the population in Maine and most of the patients in Lincoln County, which has a larger population of older people.

Private insurance companies have also adopted aspects of the new system by paying providers based on the quality of their service, instead of just the number of services.

As part of the MaineHealth system, Lincoln County Healthcare is part of a MaineHealth Accountable Care Organization that includes more than 1,300 physicians and provides care to more than 46,000 Medicare patients.

Those patients that are part of Accountable Care Organizations keep the same doctor and most probably notice very little, if any, difference.

As health care systems in Maine and across the country move toward accountable care, the biggest change most patients will notice will be a greater focus on preventative care. For some, that change will be manifested in relationships with people like Tory Gamage, who will serve as problem solvers, finding ways to keep people healthier and out of the hospital.

For others, particularly people who are on many different medications, the change may be a new relationship with a pharmacist who will help them understand how and when to take their medications.

This new type of medical care is designed to intervene earlier, before a patient has a medical crisis that lands them in the hospital or the emergency department, and it will depend on different types of providers who understand their patients as people, not just as medical problems.

By working with people to change habits and help them live healthier lives, we hope and we believe we can make health care work better for everybody.

Mark Fourre, MD, is an emergency physician and Chief Medical Officer of Lincoln County Healthcare, the parent company of Miles Memorial Hospital and St. Andrews Hospital. He also serves on Lincoln County Healthcare's Board of Trustees. Prior to joining Lincoln County Healthcare, Dr. Fourre was attending faculty at Maine Medical Center, where he developed the Emergency Medicine Residency Program and served as Residency Director.