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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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9 replies »

  1. 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.

  2. 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? Or Jim Purcell?

    I guess you have no obligation to readers to share who these folks are, but those of us working in the field of health care quality improvement would really like to know where people are coming from who are commenting on things they so clearly don’t understand, misrepresent and mislead.

  3. 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. Here are a few questions for you. If this is such a great program, why did both Mercer and Milliman decide to rather transparently make up savings figures instead of telling the truth? (Have them sue me if that statement is inaccurate.) Why did Milliman change their story 180 degrees rather than defend it?

    Why was there no reduction in North Carolina Medicaid (relative to other states or relative to commercial payers) in ambulatory care sensitive medical events or asthma or diabetes events, even though the whole point of the programs was to reduce those admissions — at great expense to taxpayers? Why did North Carolina continually, year after year, blow way through its Medicaid budget if they were saving the hundreds of millions of dollars annually that those firms claimed? Why were North Carolina’s costs/Medicaid member so much higher than surrounding states?

    You are welcome to criticize my style. I do make it clear that I don’t suffer fools lightly. At the same time, I don’t mind criticism at all, since criticism usually reflects badly on the person criticizing me, as in your criticism. It tends to frustrate my critics that my work is accurate. The very fact that you rambled at length but failed to identify one single flaw in my work makes my point better than I could have made it myself.

    Oh, yes, the last guy who tried to criticize my work right here in THCB? https://thehealthcareblog.com/blog/2014/02/21/in-defense-of-corporate-wellness-programs/

    He ended up losing one of his biggest accounts because I helpfully pointed out that all his own savings figures were made up, as the Pittsburgh newspaper reported. http://www.post-gazette.com/business/healthcare-business/2015/03/03/Worker-wellness-plans-called-into-question-but-others-defend-it/stories/201503030025

  4. 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 Chernew that found the state’s Medicaid costs were cut by 9 percent since CCNC started their program in 2008.

    http://www.northcarolinahealthnews.org/2015/08/21/report-medicaid-care-management-program-saved-millions/ )

    Currently some 46 states have adopted PCMH or other accountable care model for their Medicaid and CHIP programs. Serious health researchers have published numerous studies on the potential benefits of the PCMH model and have identified specific features that can improve access to care for underserved populations, reduce hospitalization and ER use, and improve quality and patient satisfaction. Key studies also point to some PCMH networks failing to cut costs and reduce utilization of hospital and emergency services—especially in early experiments with the model. What a surprise! With the very definition of PCMH still evolving (new standards were created in 2014), Medicaid expanding in some states and not in others; and a continuing shortage of doctors willing to care for Medicaid patients, mixed results are expected.

    http://content.healthaffairs.org/content/34/7/1105.full

    Mostly though, people interested in meeting the quality, cost and outcome goals of a high-functioning health care system view the “failures” as learning opportunities. The movement to fix the dysfunctional health care system that has existed in this country for so long will not follow a straight, upward course as payers and providers experiment with new care innovations.

    I’m not sure why THCB chooses to regularly feature Lewis’s posts but these screeds are one reason I turn elsewhere for reliable, thoughtful health care insight. They aren’t interesting, they are unnecessarily mean-spirited (“I revel in that kind of criticism. I was hoping she would accuse me of having small hands,” he says of PCPCC’s Ms. Nielsen), and don’t add anything to the ongoing movement to reform and rehabilitate our ailing health care system.

  5. 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…

  6. 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.

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

  8. 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.

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