A state the size of Vermont claiming savings of $120,000,000 through a patient-centered medical home (PCMH) program should raise eyebrows.
North Carolina made similar claims about its PCMH model, only to have the results so thoroughly debunked that consulting firm, Milliman, was forced to retract its key assertion.
I expect more from Vermont, if only because I’m a Democrat and Vermont has turned so “blue” that in 2008 John McCain received only 10,000 more votes than Calvin Coolidge garnered in 1924. However, it turns out red states don’t have a monopoly on invalid PCMH data.
A brief summary of the Vermont Blueprint for Health, as described in the enabling legislation, would be: “a program for integrating a system of healthcare for patients, improving the health of the overall population…by promotion health maintenance, prevention, and care coordination and management.”
This is to be achieved by emphasizing the usual suspects — patient-centered medical homes and various support mechanisms for them. The idea is to achieve “a reduction in avoidable acute care (emergency visits and inpatient admissions).”
Growth in participation has been phenomenal. In 2009, only a few practices and a dozen employees were involved, so we can call that the baseline year. The report’s findings take us through 2012, by the end of which two-thirds of the state’s primary care practices (104) and population (423,000) were involved, along with 114 full-time employees.
The State’s Analysis
Through the end of 2012, the state — by using the classic fallacy (also embraced by the wellness industry) of comparing participants to non-participants — was able to show savings of $120,000,000 and a double-digit ROI.
I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.
That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”
Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!
But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”
In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.
It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?