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Time for Toto to Pull the Curtain Away from Patient-Centered Medical Homes

Patient-Centered Medical Homes in statewide populations have unstoppable momentum and major constituencies in support of them, so valid analysis of their outcomes is probably as futile as it will be unwelcome.  However, the math speaks for itself, at least in the mother of all statewide medical homes, North Carolina Medicaid’s Community Care Access Model.

I write this after having analyzed the actual data from this project’s outcomes report, rather than the stated conclusion of the report, a conclusion that continues to be cited in support of the many states considering or implementing medical home models for their Medicaid populations.

The conclusion makes North Carolina looks like a huge win for PCMH:   $300-million in reported savings.  However, readers should have (but largely didn’t) observe a number of curiosities about the data in support of that conclusion:

(1)    Every element of resource use declined.  People have to be getting their care from somewhere, but inpatient, ER, outpatient, physician, drug, and other expenses somehow all declined vs. trend.

(2)    The decline in physician practice expense is especially counterintuitive:  Why are the doctors so supportive if they are working harder but making less money?

(3)    Even though somehow savings were shown in physician expense, per capita doctor visits did indeed increase.   More concerning was that specialist visits –which are supposed to decline in a PCMH model – also increased.

(4)    Inpatient expense fell 47%.  This was achieved despite the fact that all the AHRQ’s “Ambulatory Care –Sensitive Conditions”  total to about 20% of admissions in most populations.

(5)    The evaluators (William M. Mercer) are on record as saying that “choice [emphasis mine] of trend has a large impact on estimates of financial savings.”  Perhaps it is possible that Mercer, having given themselves this latitude, “chose” a trend that would make the study look good.

Those observations merely suggest that the study was done wrong.    But one other “finding” invalidates the entire study:  the 54% reduction in spending on babies under one year of age, accounting for the majority of the entire $300-milllion in spending.   (Any nontrivial savings whatsoever in this category should have raised eyebrows since PCMH is mostly about managing chronically ill patients.)   The components of spending in that category include physician expense, which should rise since doctors get paid more to be more accessible, and drug expense, which should rise for the same reason.  This means that the entire 54% savings across the category must be concentrated in neonatal expense.   Since neonatal expense is about half of total spending in the age category, it would have to decline by a mathematically impossible 100%+ in order for the category to average a 54% reduction.

But perhaps the neonatal savings came close to 100%.  To determine that, let’s do something the investigators didn’t do:  Look at the actual data.  Neonatal admissions and days of care, by state, are freely available at   http://hcupnet.ahrq.gov/HCUPnet.jsp.   It turns out that the percentage of neonatal admissions and days fell only 1%, from 27.5% in the baseline to 26.5% in the last year studied—a decline two orders of magnitude less than was required to make Mercer’s math work.  (The argument that neonatal utilization would have risen absent a PCMH program is also invalid – South Carolina enjoyed a relative decline in neonatal utilization as well over that same period, without a medical home.)

Therefore, without even needing to “challenge the data,” but rather just looking that the data that the consultants presented, as well as other public sources of data, one must conclude that the study is fatally flawed.

What do proponents of this study say in defense?   In a private conversation with one of the major proponents of a PCMH model (whose company benefits greatly from adoption of electronic health records), the response was that he “believed” the Mercer outcomes.  Math, however, is not a belief system.  It’s as proof system, and every assumption about the savings from widespread implementation of statewide medical homes in the Medicaid population has just been proven wrong.

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HealthyTJAl LewisMargalit Gur-ArieAl LewisSteve Wilkins Recent comment authors
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HealthyTJ
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HealthyTJ

I understand your gripes about this particular study. However, there is a bigger picture here. This is a good piece to look at to think about the underlying issues more clearly- and the real possibilities and limits of Accountable Care Organizations that intent to create a more integrated care format http://healthpolicyandreform.nejm.org/?p=13937&query=home.

Al Lewis
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thanks for letting me have the last word. Not sure what more I can add. I looked at quite a number of DRGs (and the DRGs in total) and would suggest that anyone else do the same. There were none with significant numbers of admissions (I didn’t look at low-frequency ones) where the savings in Medicaid admissions (vs. usual care as represented by the rest of the state’s admissions) even approached the claimed “average” of 47% better. I looked the hardest at the DRGs most likely to show savings. First, the neonates due to the very high claimed savings. Next,… Read more »

Brad F
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Brad F

Al
No sarcasm here, you strike me as a pretty sharp guy, but based on your assertions, I would expect that with your above work in this domain, a fuller look at the data was in the cards–at least as inpatient expenses go. I wont be searching HCUP–your post, your task:)

Needless to say. asthma wont cut it for me alone, and to validate your conclusions, I need to see more. i did not think I was asking for air-speed velocity of an unladen swallow, but that is just me.

Anyway, you can certainly have the last word.
cordially
Brad

PS–?

Al Lewis
Guest

Well, the ones I looked at in depth were the ones most likely to decrease (but for the most part, didn’t decrease even by double-digits when adjusted for usual care changes, let alone 47%). In particular, asthma is the most instructive since (1) NC made such a big deal of their asthma program and (2) asthma admissions are possibly the most avoidable common admission among common diagnoses. Using the state population in 2001 (the middle year of the baseline) and 2006 (study year endpoint), and separating out the Medicaid and the non-Medicaid populations, I then went to the HCUP database… Read more »

Brad F
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Brad F

Al
Would you be so kind as to list the top 5 (or 10) DRGs that WERE reduced, if not ambi sensitve designated.

It might be semantics (“ambi sensitive”), but it is possible that through systemic changes in NC program, reductions were real, perhaps not accounted for by providers alone, and a greater look at what is being done, by whom, and at what cost (ROI) is necessary?

There is a reason inpat costs went down IF they bucked secular trends. If so, that occurrence deserves consideration.

Thanks
Brad
Brad

Al Lewis
Guest

Yes, thank you for pointing that out. I would call that omission a major oversight, sort of like the 1831 Bible that left the word “not” out of its commandment on adultery. John, if you have an pencil and eraser rhandy, would it to be late to insert the words “statewide Medicaid” before Patient-Centered Medical Homes? Two other observations I failed to address. First, coordinated care, which might bring down overall costs, does not bring down the cost of preventive care, any more than insulating your house brings down the cost of insulation. The most successfuly, most widely studied (by… Read more »

JCS MD
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JCS MD

“… I have no problem with those PCMH results you’ve described in group health plans. Those settings lend themselves to PCMH success and I wish hem the best of luck.”

The title of your post certainly doesn’t support that statement.

Al Lewis
Guest

This is my favorite comment so far…:) My policy (so it doesn’t look like i am pitching a product) is if I blog on something, to give away the report to anyone except close competitors and (in this case) the state of NC, which having spent $500,000 can probably afford $500 more. So even close competitors can have it but they need to pay for it. It is at dismgmt.com. This vignette is featured in Case Studies in Invalid Outcomes, which is available for the asking. I might also recommend (but you gotta pay for it) its theoretical companion volume,… Read more »

Margalit Gur-Arie
Guest

Is the entire report available anywhere for me to read, or is its just for “internal use”?

Al Lewis
Guest

The neonatal data link (to the federal governement’s data, not my data).is in the article. Neonatal days and admissions declined only marginally — that’s what the data says. Mercer didn’t look at this database or else looked at it, realized they couldn’t refute it, and didn’t bring it up. Either way is substandard. (To be fair, there was a noticeable mix change between the ultra-preemies and the other preemies, so that perhaps the cost reduction exceeded the 1% utilization reduction, but remember, they need a 100% reduction to make their conclusion valid.) The ACSC list also comes from AHRQ and… Read more »

Mark Spohr
Guest

I now have a better understanding of your assertion that it is impossible to reduce inpatient (expenses) by 47% when only 20% of admissions are sensitive to ambulatory care”. You don’t seem to be accounting for the fact that you are comparing inpatient expenses ($) to admissions (a patient count). Inpatient care is expensive compared to ambulatory care so even a small reduction in the number of admissions and severity of admitted patients can lead to large savings (even 47%). I also don’t understand your assertion that only 20% of admissions are sensitive to ambulatory care… could you explain? I… Read more »

Al Lewis
Guest

thank you to many of you for keeping an open mind and drawing their own conclusiions from the data and, as one person pointed out, the incentives of the evaluators.. I will try to address the other comments but I don’t expect to change many minds. As Upton Sinclair once said, “It is impossible to prove something to someone whose salay depends on believing the opposite.” (1) It isn’t the expenses incurred by physicians that are declining. it is the expense of paying physicians. In other words, according to Mercver they are making less now than they would have. that’s… Read more »

Steve Wilkins
Guest

Al,

I understand that you do results benchmarking and ROI plausibility testing for Disease Management Vendors. Presumably it’s possible to do something similar for the larger patient centered medical home initiatives.

I’d love to see how findings from primary care-redesign initiatives like those at Geisinger, Group Health and BCBS of Michigan stack up against yours and vice versa!

lynn
Guest
lynn

It may be simple, perhaps PCMH are avoiding the complexly ill and are managing care of a more “normal” population of pregnant women and children. Without knowing the nature of the NC Medicaid enrollees it’s hard to tell.

JCS MD
Guest
JCS MD

I always welcome the chance to get a little learnin’ about PCMH, disease management, case management, care coordination, cost and quality initiatives, and the like. I read the author’s post, did a preliminary data search, and re-read the author’s post. Lessons learned: The author’s post certainly does not carry the weight of such an antagonistic title. Whether it’s the structure, the conclusions without support, the lack of data source citation (excepting the neonatal comparison), or the lack of author disclosure/conflict of interest, this post surely has a lot of its own ‘curiosities’. Before supporting or refuting the authors assertions, I’d… Read more »