Draining the Primary Care Medical Home Swamp

All three primary care home demonstrations have failed as noted by Kip Sullivan in a recent thehealthcareblog. Kip Sullivan is a voice of reason in an insane policy period. This is only one of many appropriately critical pieces that make sense.

In another sad twist of fate, a major reason for the failure was the promotion by medical associations - including family medicine. Even more important in reading his works, is the discrimination specific to those smaller, where needed, caring for the most complex, and most ignored. Family Medicine has long had the best track record for all of these areas.

Sullivan and Soumerai have noted that these innovations and regulations have taken on a life of their own.  Pay for performance: a dangerous health policy fad that won't die

Others such as Casalino who have noted the value of small practices in some areas such as preventing admissions, have at least implicated that the policies are clearly running over those smaller, independent, rural, and delivering care where needed. 

The evidence is there regarding the failure of disruptive innovations failing across all areas other than disruption, but sadly the cherry picking continues to present the best possible appearance while ignoring the consequences that are quite obvious.

Cherry Picking Gone Wild

Most of us are familiar with the best strategy in health care - cherry pick the best patients, plans, locations, practices, etc. This is essentially the only way to increase costs and outcomes while decreasing complexity and likely improving satisfactions. So far only telehealth involving homebound elderly and plans to help coordinate death qualify as capable of this in significant and relevant ways.

Cherry picking occurs all the time in large systems and large primary care. Locations can be changed, plans can be changed, or patients can be moved. Cherry picking does not work in rural practice. You cannot exclude patients, plans, or services without consequences. You are also among the most likely to have cherry picking work against you. This actually applies across locations that are urban and less concentrated. This is three times the population impacted compared the rural population and 4 to 5 times the rural population left behind (not all rural populations do poorly).

Cherry picking is rampant in health policy research. Researchers can cherry pick data sources, variables within the sources, types of analysis, comparisons, journals, and limitations. Steadily and slowly the rigor and relevance have been lost. Some of these aspects were explored in The Tyranny of Health Care Research.

As Sullivan points out in the following works, the various innovations are the result of looking at the data and situations a certain way while ignoring the likely consequences of little change in outcomes, higher costs of delivery, and disruptions to those who deliver care.

Darmouth, Orsag, CMS, and others are not the only ones to blame.

The trail that leads to the failure of PCMH also points to a major source of the problem - AAFP. Read the strikes below and how CMS was influenced by AAFP and other primary care entities. As Sullivan noted "In fairness to CMS, the dual defects I'm discussing – multiple components vaguely defined, and lack of evidence supporting the components separately or as a package – were not created by CMS."

They were put together by the following:
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Physicians (ACP)
American Osteopathic Association (AOA)

Even worse, the innovations, digitalizations, regulations, and certifications all hit family medicine hardest. Half of us are in small practices (recent survey of exam takers). We have to pay 30 - 80% more for each of these disruptive changes (Health Affairs articles), and suffer from the most rapid changes, and suffer from the usual disruptions because we are predominantly small and medium and not largest (Mold, Annals FM).

Strike 1 quote from Sullivan

 "Demonstration sites were associated with significant increases in total Medicare expenditures during Year 3 relative to comparison sites and cumulatively when care management fee payments were excluded from the analysis (p<.01). When the fees were included, total Medicare expenditures were significantly higher in demonstration sites (p <.05) … [B]eneficiary surveys identified few significant differences in outcomes for demonstration and comparison FQHC patients." (p. xxii) The report also noted that PCMH staff experienced severe stress. "[C]linicians and staff reported significant reductions in overall professional satisfaction and corresponding increases in stress, burnout, chaos, and likelihood of leaving their practices," noted the report. (p. 124)

Strike 2 quote

Here's how they put it: "Medicare expenditures for the MAPCP Demonstration beneficiaries were … nearly $171 million more than the non-PCMH comparison beneficiaries" (after taking into account CMS's payments to the PCMHs) (p. ES8), and "there were no consistent impacts by the MAPCP Demonstration on quality of care, access to care, utilization, or expenditures within or across states…." (p. ES12) RTI reported the same results for Medicaid. RTI did not attempt to assess staff morale, but the report did note, "Many practices across the MAPCP Demonstration states found it challenging to fund extended hours and to find staff to work the hours." (ES6)
Strike 3
Mathematica concluded the CPCI had no impact on Medicare spending and had a "minimal" impact on the tiny handful of quality measures CMS used. "After including care management fees, Medicare expenditures increased by $6 PBPM [per beneficiary per month] more for CPC practices than for comparison practices," the report stated. "The difference was not statistically significant." (p. xviii) Moreover, the report found that the CPCI "had minimal effects on the limited claims-based quality-of-care process and outcome measures examined" and "had little impact on beneficiaries' experience of care." (p. xviii) Mathematica reported that the burdens associated with "transforming" clinics into PCMHs had no impact, good or bad, on burnout among PCMH staff.  However, they did note that "some … care managers felt overwhelmed" (p. xxxii) and that "[R]espondents reported that participation throughout the CPC initiative was burdensome…. In addition…, several respondents reported that they had overall change fatigue." (p. 135)

Now you can examine the reports that gain publication. These are the ones that cherry pick the few areas with a small but significant difference - enough to allow promotion. These are magnified in the postings of the consultants and corporations who hope to further increase their health care dollars - at our expense.

More appropriate to is to consider the changes as meaningless and disruptive. Those far away do not see this. Those in touch (Sullivan) or involved (Mold, others) do so major issues. Even worse is that so much is unstudied and unsupported - but widely implemented.

More from Sullivan:

I have asked you to look at CMS's "change package" because it illustrates at a glance why the PCMH has failed. The two most fundamental reasons are: The "definition" of the PCMH consists of multiple elements, nearly all of which are unsupported by evidence; and most of the elements are so vaguely defined they are impossible to operationalize. It's that combination of

  • (a) multiple elements unsupported by evidence and 
  • (b) multiple elements that elude clear definition that renders the PCMH concept so useless.

In fairness to CMS, the dual defects I'm discussing – multiple components vaguely defined, and lack of evidence supporting the components separately or as a package – were not created by CMS. They were invented by the four primary care groups who propelled the PCMH from esoteric idea to stardom in 2007 with the publication of a document entitled "Joint Principles of the Patient-Centered Medical Home". (AAFP, AAP, ACP, AOA)

This has been promoted by AAFP at their site at  https://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf

Other works by Sullivan help track the development of these esoteric designs based on assumption and a desire to "tinker" around. 

Open Letter to President Obama About His JAMA Paper   is a series tracking the origins of the ACA and the flawed assumptions. "Just because you're leaving office doesn't mean you must sit on the sidelines and watch the ACA take a slow nose dive. If you set aside some time after you leave office to immerse yourself in health policy, and if you give high priority to finding the truth and low priority to making the ACA look good, you will conclude as I have that the ACA has little cost containment in it. You'll conclude, as I have, that Peter Orszag, Zeke Emanuel, Jeanne Lambrew and the other advisors who told you "accountable care organizations" and other pay-for-performance fads could cut costs were merely regurgitating groupthink developed over the last half-century by the managed care movement."

And more recently Sullivan reviews  Curb Your Enthusiasm    
 Lawton Burns and Mark Pauly, economists at the Wharton School, just published an article that should be required reading for all policy makers and health services researchers. The article,  entitled "Transformation of the health care industry: Curb your enthusiasm," appears in the latest edition of the Milbank Quarterly.
Burns and Pauly undertook an enormous task and executed it well. They first sought to explain the assumptions underlying Managed Care (MC) 2.0 – the proposals promoted by the managed care movement in the wake of the HMO backlash of the late 1990s. Then they evaluated the probability that the MC 2.0 proposals will work as advertised. To do that, they looked at the relevant research and then at the social conditions that are impeding the implementation of those proposals. That's a lot to bite off.

This is an unusually valuable article because of its scope, organization, and documentation. I will summarize it first, then discuss it in more detail. I'll close with a discussion of my one serious criticism of this excellent paper: The authors, having made it clear they think the current "value-based" approach to cost containment is doomed, profess to see no solutions to rising health care costs.

My take is that it took 13 years from 1965 to 1978 for those most organized to beat Medicare and Medicaid into pumping more cash into them with less remaining for most Americans. It only took about 5 years in the 1990s for managed care reforms to be taken down - and the academic and managed care arms joined together for micromanagement and other assumptions. end of Sullivan quote

True Reforms Are Defeated More Rapidly or Before They Begin

The 2010 reforms were defeated as they were considered - cognitive vs procedural, equity in payments instead of major differences for those practicing in higher concentrations vs lower, universal in at least primary care, and substantial elimination of insurance.

As I have noted before, this human population experimentation violates numerous ethical and moral principles. Harm has been done, consent has not been given, there was little attempt to consider benefit to risk or even if the experiments would work, much less the consequences.

People, practices, practitioners, and physicians are dying - by design    And just possibly in each of these areas - they are the ones that we most need to be alive.


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