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PCMH Fails Natural Experiment

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Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

In Vermont, the making-up-data-to-disguise-failure story was similar, following the implementation of a statewide medical home model.  Even though there was no change in relevant hospital event rates (ambulatory care-sensitive medical admissions), the PCMH model was initially alleged to save $120,000,000, or a whopping $600/eligible person.  Had this figure been real instead of completely fabricated, Vermont could have financed its long-planned move to single-payer simply by projecting that savings to the entire population.  Embarrassingly, the state was so taken with the faulty analysis that they didn’t back off their single-payer plan for a year after the savings were shown to be made up.

These two results are supported by the findings from Oregon Medicaid’s healthcare “lottery” program. Oregon Medicaid was not a “natural experiment” in PCMH’s, but rather in whether increased access to care made a difference in outcomes.  It turned out going from no insurance to insurance offering free primary care had no effect on physical health after two years.  The Law of Diminishing Returns would imply that adding even more primary care would therefore also have no effect.  We’re not counting that as a natural experiment, but rather as inferential support for the two natural experiments.

The response of the PCMH lobby to these natural proofs?  Forced to defend the indefensible against an onslaught of both fifth-grade arithmetic and actual events proving the fifth grade arithmetic accurate, the head of the PCMH special interest group, Marci Nielsen, simply made ad hominem attacks on me.  (These attacks were not html and hence not linkable.  Rather there is a healthcare policy email group to which industry thought leaders–and apparently the occasional lobbyist–are invited to participate.)

Lest I give the impression these childish displays of churlishness bother me, quite the opposite.  I’m bummed the thread isn’t linkable. In the immortal words of the great philosopher George W. Bush, bring ’em on.  The fact that these people can’t actually construct a coherent argument demonstrates the vacuity of their position.  Literally, one of Ms. Nielsen’s arguments was: “That’s the pot calling the kettle black.”

I revel in that kind of criticism. I was hoping she would accuse me of having small hands.

Flint: The Most Recent Natural Experiment

There are no redeeming features in the Flint debacle, but creating a “natural experiment” in the PCP-patient relationship – the underlying linchpin of the PCMH model — is as close as it gets.

Roughly 50 primary care physicians practice in and around Flint.  Only one figured out the obvious: their patients were all drinking poisoned water. That means 49 of them – 98% — had so little connection to their patients’ day-to-day lives that they didn’t make their patients aware of the obvious and substantial harm visible to the naked eye. All these doctors had to do was look at the water and then get it tested.  But only one did.

Yet the entire PCMH model is based on the implicit assumption that primary care physicians should be the stars in the healthcare firmament.  That hypothesis was given a simple natural experiment – helping patients avoid or at least identify obvious harms — and totally flunked.

Presumably some of those doctors in Flint had PCMH-levelrelationships (even if not a formal PCMH) with some of their patients.  It didn’t help.  What we learned in Flint is that the idea of “building a relationship” with a doctor by getting a checkup may be like building a relationship with your Amway rep by purchasing Artistry®LuXury Eye Cream.

This is not to denigrate the role of the PCP at all. That is people’s first line of care, especially for people who have enough health problems to merit regular visits, as well as for patients with acute needs.  However, the two ideas that:(1) sending more people to the doctor builds relationships and relationships matter a lot; and that (2) PCPs somehow get it right/save money both fail these three natural experiments. No natural experiment has ever shown the opposite.

So — just like in wellness where it turns out the way to save money is not to spend more of it on prevention –it’s time to reconsider the entire PCMH assumption that spending more money on PCPs saves money somewhere else.  In other words, it’s time to re-think the entire PCMH concept.

And, just for the record, my hands are fine.

Al Lewis is the co-founder of Quizzify and the author of Why Nobody Believes the Numbers.

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Steve WilliamsAl LewisNaomi FreundlichwhynobodybelievRobert Parker MD, MBA, FACP Recent comment authors
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John Irvine
Member

I have watched with increasing concern that the blog you host is so full of misstatements of fact, ridiculous opinions and other fatuous comments that I am left with no other option than to unsubscribe. I am not clear the provenance of you or your cohort of bloggers, but what appeared to be a promising discussion board has turned into absurdity. The latest post by Al Lewis is so full ridiculous views that it wouldn’t pass any reasonability test. And why don’t authors identify who they are and what organization or political affiliation they represent? Who is Al Lewis anyway?… Read more »

John Irvine
Member

Whoever this person is may accept my million-dollar reward offer for showing the opposite of what I say about wellness. Further, if they get Milliman to take me up on the million-dollar reward offer, they can have $50,000. While the reward is for wellness, I would happily extend it to Milliman and Mercer. http://theysaidwhat.net/2015/08/06/show-wellness-isnt-an-epic-fail-and-collect-a-1-million-reward/ So here is their chance to get rich simply by showing they believe what they say instead of just bloviating due to their distaste for facts.

Jim Purcell is the former CEO of Blue Cross of Rhode Island.

John Irvine
Member

Thank you for your comment, Ms. Freundlich. I found it interesting that you chose to criticize me for being perfectly okay with an ad hominem attack from a PCMH lobbyist, rather than criticize the lobbyist for being so innumerate that she used kindergarten language because she was unable to attack my position on its merits. As are you, I might add. It’s not enough just to quote another study. You need to find the flaws in my own work, but you’d be wasting your time, since it is unassailable, being totally based on transparent and readily available federal government data.… Read more »

John Irvine
Member

Al Lewis likes to be provocative and sound alarms about conspiracies that are often of his own making. Describing the entire patient-centered medical home concept as “a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy” is a perfect example. In fact, in this piece Lewis focuses on just three state Medicaid PCMH efforts and references his own “gotcha” research on Community Care North Carolina to tar the entire field. (And he never mentions the study the North Carolina Office of the State Auditor commissioned from Harvard health policy professor Michael… Read more »

whynobodybeliev
Member

Thanks for all your comments everyone. I don’t have anything to add–you all said stuff better than I did. But I always like to acknowledge my appreciation nonetheless. Plus I’m on my phone and for writing long messages the keyboard is too small for my hands…

Robert Parker MD, MBA, FACP
Member

Al, thanks again. I have experience with a number of Medicaid population segments and their PCMHs. The variations are enormous across beneficiaries and service providers. But to the degree the beneficiaries vote with their feet, the EDs keep getting busier with low complexity while many PCMHs double and triple book their schedules in an effort to stay busy. Failure of the ‘natural experiments’ should not dissuade further experimentation. But integrity of reporting is always a necessary first step.

Tom Emerick
Member
Tom Emerick

Al, I could but agree more. Thanks for this post. One reason PCMH’s fail is poor referrals to specialists.

Perry
Member
Perry

Per AAFP the cost of PCMH is estimated at $100,000 per FTE physician. In this same article, they regale the successes of the PCMH, notwithstanding the fact that studies have shown cost containment and decreased ER visits are also possible with good small primary care practices. Here is the link:
http://www.aafp.org/news/practice-professional-issues/20151021pcmhstudy.html
As a member of AAFP, it is incredible to me that this organization continues to support the PCMH so vehemently.

LeoHolmMD
Member
LeoHolmMD

Not that you need more ammo, but:
http://annals.org/article.aspx?articleid=1402441
http://annals.org/article.aspx?articleid=2491915
Soon, the cheerleaders will be the only ones left in the stadium.