Improving patient care and quality, and ultimately reducing the cost of care

Eastern Maine Health System (EMHS) is a not-for-profit, nationally recognized, integrated health delivery system headquartered in Brewer, Maine. The EMHS family includes eight hospitals, numerous medical practices and clinics, long-term care facilities, home health and hospice, and ground and air emergency transport. Whether located in Maine’s urban centers or in the state’s more rural areas, EMHS’ inclusive statewide network of care is tailored to community and patients to ensure Maine people have the care they need close to home. EMHS is 1 of only 32 organizations across the United States invited to become a Pioneer Accountable Care Organization (ACO) through the Centers for Medicare and Medicaid Services (CMS).


As a top-performing Pioneer ACO, EMHS has a proven record of quality outcomes, cost reduction, and highly engaged patients. According to EMHS President and CEO M. Michelle Hood, FACHE, “The five-year demonstration project is designed to improve the coordination, efficiency, effectiveness, quality, and cost of healthcare.”


Initially, Beacon Health focused on Medicare patients of primary care providers in three EMHS hospitals, and it continues to expand the scope of the network. This expansion has increased the span of its care to roughly 24,000 lives in 2013 from an initial patient population of slightly more than 8,000.


In 2012, the project’s first year, Geisinger Health Plan experts provided population health services to EMHS to support patients under the EMHS Beacon Health, Pioneer ACO. 


Current State Assessment


Geisinger’s case management team worked closely with Beacon Health to assess its current infrastructure, build consensus with the leadership team, and set a course for implementing a comprehensive approach to population health management, beginning by developing an effective recruiting strategy to hire the most qualified nurses for the patient population. The initial assessment covered roughly 10 areas, ranging from leadership and governance to practice redesign readiness to IT optimization.

“Geisinger has earned national recognition for its success with innovative approaches to improve the quality of patient care. EMHS is well positioned to work with Geisinger to replicate its highly successful model.”

—M. Michelle Hood, FACHE, President and CEO of EMHS

Data Management and Analytics


Significant workaround data analytics began as data became available to Geisinger’s actuarial and clinical informatics teams. The teams assimilated, cleaned, and audited population-related data files, including claims and provider data. They subsequently performed the actuarial and clinical informatics analyses, including benchmarking, that allowed Geisinger and Beacon Health to identify the key drivers of medical costs and intervention priorities.


Case Management


Case management strategy was developed to ensure appropriate focus on the care of the most complex patients while supporting a high level of nurse care coordination competency for the entire patient population. A thorough assessment of the nurse care coordinator staff led to developing an effective recruiting strategy to hire the most qualified nurses for the patient population. Geisinger Health Plan personnel conducted numerous in-person training sessions for Beacon Health nurse care coordinators along with offering web-based programs and a two-day education program focused on complex case and chronic disease management. Specific care coordination workflows, documentation tools, and risk stratification approaches were implemented. Weekly management meetings were conducted between Geisinger and EMHS clinical leadership that focused on issues such as population management, governance and leadership structure, staff development, data needs to drive outcomes, and tailoring of workflows, among others.


As our strategic relationship continues, work will include primary care redesign, an enhanced medical home model, and a continued effort around hospital-based transitions of care. Additional clinical services are being established.




Many factors contributed to the success of EMHS Beacon Health population health improvement results. This includes an expansion of internal care coordination capabilities (initially developed under the Bangor Beacon Community grant), collaboration with Geisinger Health Plan experts, and access to Geisinger models to improve care and reduce costs.


According to a report issued by CMS, costs for the more than 669,000 beneficiaries aligned with the Pioneer ACOs grew by only 0.3 percent in 2012, whereas costs for similar beneficiaries grew by 0.8 percent in the same period. Thirteen of the 32 Pioneer ACOs produced shared savings with CMS, generating a gross savings of $87.6 million in 2012. Pioneer ACOs earned more than $76 million by providing coordinated quality care.1  Two Pioneer ACOs had shared losses totaling about $4.0 million. Program savings were driven, in part, by reductions that Pioneer ACOs generated in hospital admissions and readmissions.


EMHS Beacon Health delivered significant savings of 5% across 8,118 beneficiaries. The savings translated to $499 per beneficiary per year. Beacon Health retained half the savings; CMS retained the other half.


In comparison, Partners Healthcare, founded by Brigham and Women’s Hospital and Massachusetts General Hospital, saved $14.4 million (or 3%) across 52,000 beneficiaries. This amounts to about $277 per beneficiary per year.





1 $87.6MM in savings over 669,000 beneficiaries are calculated as $130 per beneficiary. 

2 Partners press release dated 7/16/2013.  See www.partners.org/about/media-center/articles/pioneer-aco-year-1-results.aspx

Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

fuvb ekfhve v

Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.