By Al Lewis

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.