NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

It’s not quite time to publish the obituary for by far the most extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it. The HMO-friendly GOP controls the statehouse, a blistering audit on Medicaid management has just been released (with plans for a CCNC-specific audit in the works), and the state’s most influential media outlet has ”vindicated” those who were excoriated for daring to question it, such as me, to name one random person who has frankly obsessed with it.  (This might explain why I never get invited to parties.)

By way of background, the state’s Medicaid agency initiated what might loosely have been termed an enhanced-access model almost 15 years ago, and have subsequently expanded their experiment into a full-fledged patient-centered medical home, which currently covers many disabled members, the large majority of the non-disabled adults, and most of the children.

This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR. Here is the influential and literate Disease Management Care Blog on the subject:

It’s impossible it seems to read anything about the Patient Centered Medical Home (PCMH) and not run into Community Care of North Carolina (CCNC) as the ‘The PCMH Saves Money’ poster child. No power point presentation on the topic is complete without its mention, no Meeting Agenda is full if it’s not there, if you’re going to testify on the PCMH’s benefits before Congress, you should bring it up , the Commonwealth Fund is working hard to replicate it and it’s even embedded in Medical Home Wikipedia.

Further, North Carolina and states that wanted to adopt this model were given an unprecedented 9-to-1 federal match, reflecting the Obama Administration’s admiration for its success.

Meanwhile, the overall North Carolina Medicaid budgets were frequently exceeded, by considerable margins – $1.4-billion in the last three years alone. But few people made the connection between that unanticipated extra spending and CCNC, because CCNC hired gold-plated consultants — first  Mercer and later Milliman – to demonstrate dramatic savings from the PCMH itself.

Mercer’s findings were obviously impossible because they showed the majority of savings from CCNC to be in the 0-to-1-year-old category, which, as luck would have it, wasn’t even eligible for CCNC.  (And in any event, admissions in that age group turned out not to have declined.)  Fortunately for Mercer, Milliman is bearing most of the scrutiny now, being the more recent of the two studies.  Their results were also obviously impossible, showing up to $250,000,000 in annual admissions savings despite the state spending only $114,000,000 in the year prior to the study and despite the fact that there was no decline in admissions.

Both studies (and a third, from TREO, that showed such massive savings that even CCNC rarely cites it any more) were invalidated almost immediately.  Their inconsistencies, omissions of data sources, impossibilities and unanswered questions led unaffiliated North Carolinian outcomes experts to describe these reports in the lay media with phrases like “fatally flawed,” “professionally embarrassing,” and “would be laughed off the stage”.

The subsequent CCNC and Milliman defense strategy, invented by the tobacco industry and perfected by the fossil fuel interests, has been to “sow doubt” and emphasize tangents so that journalists need to write “he said-she said” stories and follow up on irrelevancies.    For instance, possibly uniquely in any report on any population health intervention, the Milliman consultants forgot to mention the baseline year in their study.  They have attempted to turn that lemon into lemonade by ”accusing” me of assuming that 2006 was the baseline, because the published table showing results started with 2007. (Not that it matters―the admission rate has been flat for a decade.)

Meanwhile, CCNC and Milliman haven’t actually answered the questions that get to the heart of whether they misled people for so long on purpose or simply out of ignorance.  Perhaps posting the questions here will prompt a response, but more likely the pair of them will just continue to make accusations without addressing the questions below.  The questions are pretty much unanswerable, so I’m not holding out much hope that their posting will address them:

1. Why did Milliman feel that the Agency for Health Research and Quality’s (AHRQ) Medicaid admissions data, considered the gold standard by health services researchers, which showed precisely the opposite of their conclusions (no change in children’s hospital admissions) not be worthy of mention in his extensive report, even if only to say why it was wrong? Couldn’t this omission be construed as an attempt to mislead legislators into believing that no such data existed?

2. Why did Milliman also feel that the MACPAC Report to Congress showing North Carolina’s per capita Medicaid costs to be substantially higher than the average for the surrounding states in the two beneficiary categories in which the medical home model predominated was similarly not worthy of mention, even though one could easily conclude from this report that the medical home had driven the state’s Medicaid costs much higher? Couldn’t this also be construed as an attempt to mislead legislators who may not be aware of this data into believing that this data does not exist?

3. Why did Milliman also feel that it was not worthy of mention that the particular diagnosis categories specifically targeted by CCNC for admissions reduction, such as asthma and diabetes, showed no reduction in admissions relative to other states? Did Milliman not feel it to be relevant that a program targeted, at great expense, at reducing chronic disease admissions did not in fact reduce chronic disease admissions?

4. Why, with almost the entire children’s Medicaid population in the medical home, thus giving North Carolina the luxury of comparison to a “natural control” consisting of the two other states (South Carolina and Tennessee) that also reported statewide children’s admissions and costs to AHRQ, did Milliman elect not to mention that those states’ children’s Medicaid admissions rates were essentially identical to North Carolina’s even absent any large medical home investment on their part? Couldn’t that also be construed as an attempt to make legislators believe that no such comparative data existed, because if they found out about it, they would wonder why North Carolina’s performance was so mediocre?

5. What makes Community Care of North Carolina uniquely able to generate massive savings through its medical home model when all the other unaffiliated medical literature shows either no effect or is inconclusive? Since Milliman finds so much more savings that all other researchers, shouldn’t the report have indicated that as a study limitation? Otherwise, couldn’t legislators be misled into believing these models of care are widely believed to dramatically reduce costs?

Milliman’s lead consultant also suffers from a major memory lapse:  He says now that his $250 million savings estimate was based on cost categories other than admissions, since there were no reductions in admissions according to AHRQ. (And admissions could have fallen to zero without accounting for even half of that $250 million.).  However, before making that statement, the consultant would have been well-advised to re-read page 3 of his original report, which says (boldface mine):

“This medical home model…has a cost, as members receive more primary care services and prescription drugs. Also the medical home model has direct costs… It is assumed that these costs would be more than offset by reduced costs for emergency room visits, inpatient hospital admissions and other [unspecified] services.”

The Milliman report therefore states precisely the opposite of what Milliman is saying now: admissions would have accounted for more than 100%of the $250,000,000 net savings. (ER visits showed no change.)

This is not just about North Carolina.  As noted above, PCMH adherents embraced CCNC on its way up to the point where PCMH and CCNC are joined at the hip.  So what does the PCMH movement do about these folks on the way down? In Medicaid – the category where improved access should make the greatest difference — adoption has slowed to a crawl even with the 9-to-1 match.  Further, one of the pillars of the PCMH is prevention, which may not save money. At the very least, PCMH adherents, to quote the immortal words of the great philosopher Ricky Ricardo, will have a lot of ‘splaining to do.

Al Lewis, president of the Disease Management Purchasing Consortium, is author of the critically acclaimed 2012 humorous look at the innumeracy of health plans, consultants and vendors, Why Nobody Believes the Numbers.

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14 Responses for “Community Care of North Carolina’s Last Chance: To Fool the Legislature Rather than Answer the Questions”

  1. Bill Springer says:

    In any type of scholarly research, whether in health care or other scientific branches, there is a methodology to follow around providing a proper context in which to interpret the findings of the work. As you clearly illustrate, Mercer and Milliman went to unusual lengths to deviate from this normal practice. Whether as a result of sloppy work without proper peer review and criticism before publication, or other less honorable motivations, these shortcomings and the reality tests which their work flunked force one to pretty much completely refute its credibility. Thanks for caling them out on their shoddy and quite possible intentionally biased work, Al.

  2. Al Lewis says:

    Yes, to your point, we can all argue over data, what it means, how to interpret etc. That’s one of the things that makes this blog and health services research fun and exciting, and one reason I like to read John Goodman’s postings even if I don’t always agree with them. But Milliman simply decided to ignore the data and instead make up their own. In the immortal words of the great philosopher Patrick Moynihan, everyone is entitled to their own opinions, but not to their own facts.

    • Peter1 says:

      The new all Republican legislature and governor would like to see Medicaid disbanded, as is mental health. Right now they have created paperwork nitpick hell so as to frustrate providers and clients to not use the program. But they did vote for a tax deduction that included rich law firms.

      You need to get your minds around the new Taliban mind set in NC state government. Unemployment underfunding (due in large part to previous Democrats) is being “solved” by cutting benefits (almost in half) and reducing weeks of collection. They’ve also decided not to expand Medicaid even though the feds are paying for most of it.

      • Jean says:

        Peter1 the nitpick paperwork hell was started long before the Republicans took over. Im an independent provider and have been subjected to it for years trust me I know what I am talking about. Im also a registered Independent that tends to vote Democrat and can not tell you how happy this is being done. Its about time

        • Peter1 says:

          Jean, we also are registered independents and view Democrats in NC not much different than Republicans. In fact Democrats have no principles they can point to which they adhere to. But the present McCory/Art Pope/Republican majority think slash and burn is good public policy for everyone, yet it only serves their business/donor base.

          Exactly what are you happy about that is being done?

          • Jean says:

            that DMA and CCNC are being audited and being made accountable finally. Im speaking about this particular article.

  3. Lynn in SC says:

    Living and working in SC, I was always puzzled by how NC could do so well when our incidence and utilization data were so similar. Now I know. NC was “cheating.” Why did NC hire Mercer, then Milliman, then TREO when NC has a Institute of Medicine, research and policy institute for such efforts?

  4. Tom says:

    I work in state government and I am also glad to see the rise of accountability. It has been frustrating to me to see Medicaid waiver after waiver in this time of economic decline, justified on the basis of how NC performs so much better than other states.

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  7. Jean says:

    Peer reviewed journal aritcle showing CCNC’s impact on readmissions:
    http://content.healthaffairs.org/content/32/8/1407.full?ijkey=10uuiQ3x26Q.s&keytype=ref&siteid=healthaff

    Can someone point to a peer reviewed journal article that shows CCNC has no impact? An online post for the Am. Jn. of Managed Care may not cut it…nor does a reference to the conservative leaning Carolina Journal (both of these referenced many times when criticizing CCNC).

  8. Al Lewis says:

    All peer-reviewed articles are not the same. Mine, by the way, was peer-reviewed and printed and was not just online. The consultant, Milliman, admitted lying by changing their position 180 degrees. Is that enough for you? How about the fact that their original concluson was impossible two different ways?

    Have you read my book? It has all the data. It’s all publicly availably and easily validated.

    And I have offered them a $50,000 bet that an unaffiliated panel of biostatistians will side with me. Math isn’t he said-she said, by the way. My numbers add up and theirs don’t. Case closed.

    Also, those Milliman people are lying again — it will be the subject of my best THCB post later this week. (Actually they were part of a committee that endorsed admitted liars — didn’t actually lie themselves this time.) Forward this to them and have them sue me for saying that if you like. I could use the PR.

    thanks for the opportunty to restate my case in no uncertain terms.

  9. Jean says:

    I didn’t ask about Milliman and you didn’t provide any references. Case closed?

  10. Al Lewis says:

    the questions that CCNC and their lackeys from Milliman refuse to answer are right there.

    I’m going to suggest that you use your own powers of reasoning to address this issue since ther are no more “references.” $260MM in savings is greater than $114MM in cost, for example, making it impossible for them to have done what they said.

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