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Saturdays at Mercy Medical Center used to be perversely lucrative. The dialysis clinic across the street was closed on weekends.

That meant the downtown Baltimore hospital would see patients with failing kidneys who should have gone to the dialysis center. So Mercy admitted them, collecting as much as $30,000 for treatment that hundreds of dollars.

鈥淭hat鈥檚 how the system worked,鈥� said Mercy CEO Thomas Mullen. Instead of finding less expensive alternatives, he said, 鈥渙ur financial people were saying, 鈥榃e need to admit them.鈥欌��

Maryland鈥檚 ambitious hospital-payment overhaul, put in place in 2014, has changed such crass calculations, which are still business as usual for most of American health care. A modification of a long-standing state regulation that would be hard to replicate elsewhere, the system is nevertheless attracting national attention, analysts say.

As soon as Mercy started being penalized rather than rewarded for such avoidable admissions, it persuaded the dialysis facility to open on weekends, saving government insurance programs and other payers close to $1 million annually.

In the four years since Maryland implemented a statewide system of pushing hospitals to lower admissions, such savings are adding up to hundreds of millions of dollars for the taxpayers, employers and others who ultimately pay the bills, a .

Maryland essentially pays hospitals to keep people out of the hospital. Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

Like a giant health maintenance organization, the state caps hospitals鈥� revenue each year, letting them keep the difference if they reduce inpatient and outpatient treatment while maintaining care quality. Such 鈥済lobal budgets,鈥� which have attracted rare, bipartisan support during a time of rancor over health care, are supposed to make hospitals work harder to keep patients healthy outside their walls.

Maryland鈥檚 system, which evolved from a decades-old effort to oversee hospitals as if they were public utilities, regulates all hospital payments by every private and government insurer. That makes it radically different from piecemeal attempts to lasso health spending, such as creating accountable care organizations, which seek savings among smaller groups of patients.

From the program鈥檚 launch in 2014 through 2016, per capita hospital spending by all insurers grew by less than 2 percent a year in Maryland. That鈥檚 below the economic growth rate, from the state鈥檚 hospital regulator and the federal Department of Health and Human Services.

Keeping hospital spending below economic growth 鈥� defined four years ago as 3.58 percent annually 鈥� is a key goal for the program and something that rarely happened.

Counting The Savings

The state plan saved the Medicare program for seniors and the disabled about half a billion dollars over three years and achieved 鈥渟ubstantial reductions in hospitalization and especially improvements in quality of care,鈥� said a Medicare spokesman.

In the three years measured so far, he added, 鈥渢he state has already exceeded the required performance for the full five years of the model.鈥�

As high costs for hospital care have been growing more slowly nationwide, Maryland hospital costs over that period rose even less.

鈥淚t looks like it has very strong results,鈥� said John McDonough, a Harvard health policy professor who helped craft the federal Affordable Care Act.

What Maryland is doing, he said, 鈥渋s pretty bold and it鈥檚 pretty thoughtfully done and has generated a huge amount of interest around the country.鈥�

Comprehensive results through 2016 are the most recent available from Maryland and HHS, although savings continued last year, Maryland officials said. Independent researchers found mixed results for savings in the earlier years of Maryland鈥檚 system.

Maryland鈥檚 global budgets saved Medicare $293 million 鈥� 1.8 percent of total Medicare spending 鈥� in 2014 and 2015, research firm RTI International .

A separate paper from a team led by Eric Roberts at the University of Pittsburgh found that Maryland鈥檚 program in those years for reducing hospital use.

The system鈥檚 advocates say several years of results are needed to show it鈥檚 working.

鈥淭hese are not fake savings,鈥� said Joseph Antos, an economist at the conservative-leaning American Enterprise Institute who sits on Maryland鈥檚 hospital-payment commission. 鈥淚t didn鈥檛 happen instantaneously. It鈥檚 taken this number of years to achieve the kinds of savings that you see鈥� for 2016 and beyond.

Even boosters such as Joshua Sharfstein, the former Maryland health secretary who got approval for global budgets from the Obama administration, say the system is far from perfect or finalized.

鈥淭here is a range of responses. Some hospitals have been able to do more than others,鈥� said Sharfstein, now an associate dean at the Johns Hopkins Bloomberg School of Public Health in Baltimore. 鈥淐hange in health care is notoriously slow.鈥�

Hospitals have lagged in delivering primary, preventive care to people with chronic conditions such as asthma, diabetes and heart failure, especially in low-income neighborhoods.

Maryland鈥檚 system does little to control soaring costs of drugs or nursing home care, doctors鈥� office treatments and other care not connected to hospitals, although policymakers are working on proposals to do both.

Even so, 鈥渨hat Maryland has done is just so far ahead of many of these other models鈥� to try to control costs, said Dan D鈥橭razio, a management consultant who has worked with hospitals across the country. One Maryland hospital CEO told him: 鈥淭his has fundamentally changed how we wake up and do business every day,鈥� D鈥橭razio said.

Seeing A Difference

At Mercy, described by policymakers as more aggressive than many hospitals in watching costs, about a third of the patients now leave the hospital with medications in hand, said Dr. Wilma Rowe, the hospital鈥檚 chief medical officer. That bypasses the tendency for patients to skip a follow-up pharmacy visit and risk landing back in the emergency room.

A statewide data network notifies Mercy and other hospitals when one of their patients ends up in an emergency room somewhere else. That helps coordinate care.

Greater Baltimore Medical Center, north of the city, has hired dozens of primary care doctors to track around 1,000 people with diabetes聽鈥� staying in touch, advising on diets and keeping them on insulin so they avoid the hospital.

Often clinicians visit elderly patients鈥� homes to prevent what might turn into an ambulance call and admission, said the hospital鈥檚 CEO, Dr. John Chessare.

Before global budgets, 鈥淚鈥檇 look at the waiting room in the [emergency department], and if it wasn鈥檛 full I鈥檇 get scared,鈥� he said.

Now he worries it might be full of people who could be better treated elsewhere 鈥� including Gilchrist, a GBMC affiliate delivering hospice care for those at the end of life.

These days, he said, 鈥渨e consider it a defect if someone with chronic disease dies in the hospital.鈥�