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The Healthcare Blog - Mon, 08/15/2016 - 16:30
Part of a series on primary care challenges and their solutions.
I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.
The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.
The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.
Today I went back to Barton’s chart and looked at his interaction screen.
With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.
The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.
The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.
After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.
There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.
On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.
I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?
So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.
It reminds me of the story I heard as a child about the boy who cried wolf…
Categories: OIG Advisory Opinions
The Healthcare Blog - Mon, 08/15/2016 - 12:37
This has been a very sad weekend for me personally, the wider health care community and for anyone who knew Jess Jacobs, who died on Saturday. She was only 29 years old, and was smart, funny, enthusiastic, and brave well beyond her years. She suffered from two very rare diseases, but was also working to push health policy forward at ONC, FDA and Aetna, and she really knew her stuff. Jess was a marvel and a rarity in more ways than one. She was #UnicornJess. (That link will take you to the twitter memorial on Sunday night, but also check out remembrances from Ted Eytan & Carly Medosch). I’m ashamed that I never thought to offer this to her while it was happening, but now I’m going to run several of her pieces from her site about her “care” experience on THCB in the coming days, starting with this one from 2015. (Hospital X is I believe Georgetown Univ Med Center but she went through every hospital in DC and there were no good ones. She wouldn’t name them beause she expected to be back, but that’s not an issue now). And while my thoughts are with Jess family and friends, I’m going to redouble my efforts to change what passes for care in today’s system–Matthew Holt
I’ve now spent two consecutive Memorial Day weekends at Hospital X with intractable vomiting. Last year I checked myself in. This year, I took the scenic route via three weeks of hard time at Hospital A followed by a transfer to Hospital X. When the nurse blindsided me with the transfer order to Hospital X after COB on a Friday night, I assumed it was a clerical error. The plan that’d been laid out by my primary hospitalist team was to transfer me to a hospital which specializes in CVS. When my (new) weekend hospitalist had run by for +/- 90 seconds Friday morning, he’d said I’d be transferred Monday as planned.
But here I was, 8 hours later, hysterically crying over the prospect of being sent back to the hell which is Hospital X. I finally got nursing to call the hospitalist so I could plead with him to change the order. I let him know that Hospital X’s ‘care’ is better characterized as psychological and physical torture. I firmly believe I am better off facedown in a ditch, drowning in an inch of muddy water, than under the care of Hospital X. The hospitalist attempted to contain his exasperation while insisting that ditches are a far worse fate than Hospital X and I am lucky he had managed to secure a transfer to a new cyclic vomiting specialist there. I’ve now been admitted for 8 days at Hospital X and haven’t seen anyone from the GI department, let alone a CVS specialist. I have, however, been told by hospital police that they would cuff me and take me to jail for taking photos of them ransacking my belongings following a syncopal episode. This egregious treatment doesn’t surprise me – indeed, last month I wrote Hospital X a letter of complaint, copied below, which shared how their lack humanity has broken my spirit.
Dear Dr. X-
Thank you for your willingness to contact me, the patient in question, regarding my experience with Hospital X. Apologies for the lapse in time, your email disappeared to the bottom of my inbox whenI was readmitted to Hospital A with a central line infection. My choice to return to the facility which gave me the infection, instead of coming to Hospital X, is a good indication of the disdain with which I hold your hospital with.
When Dr. Y visited me during a two-week stay in July, I thought Hospital X had hit rock bottom. During this stay my roommate’s bloody vomit sat clogged in the sink for three days before someone came to plunge it. Sanitary conditions pale in comparison to the forced separation from my friend and advocate who is a Medical Student with your facility. While I fully understand the need to keep relationships between students and patients professional to protect patient privacy/health and their education… Over the years my friend has come to know my health likely better than I do… and long ago I legally gave them permission to access my medical information [so any professional/educational distance is null].
However, that isn’t the stay which brings me to tears when I answer people asking ‘What is the worst healthcare experience of your life?’ – that honor belongs to the 48 hours I spent housed in an on-call room last November.
November’s stay made me appreciate my cellphone in ways that you should not have to appreciate your phone while inpatient at a hospital. Here my phone wasn’t my connection to the outside world – it was how I connected the dots within. It enabled me to contact five of my physicians, all of whom are attending physicians at your institution, when my resident was unable to do so. When the resident insinuated I had not established care with hematology, I was able to call the hematology department and connect my hematologist to the resident in under 15 minutes. At the time of admission, I had given this resident a typed list of my specialists which included the same contact information I used successfully; as such I find it difficult to believe the resident attempted to verify I was an existing patient.
When the nurses couldn’t hear the physical bells my roommate and I were given, I resorted to calling the nursing station on my cellphone (Ironically, courtesy of the speaker in the wall of our on-call room, we heard nurse requests from all the other patients on the floor). My roommate did not have a cellphone and I ended up relaying her requests by calling the nurses station each time my roommate rang her physical bell. As such, I didn’t sleep the entire time we were in this closet.
However, these communications issues are simply annoyances in comparison to the emotional torture of a fellow human experiencing unrelenting pain.
My roommate, admitted for a Sickle Cell crisis, cried hysterically for over 12 hours while her pain remained unmanaged. During this time I called and emailed the patient advocate several times on my roommate’s behalf and ‘rang’ the nurse countless times. Eventually my roommate’s attending came to see her. Unfortunately her physician was “Dr. Feelgood.” I had the misfortune of being this physician’s patient in July. I nicknamed him “Dr. Feelgood” for stopping my pain regimen (developed by a pain specialist) and insisting yoga (contraindicated with my joint condition) would magically fix all my problems. True to form, Dr. Feelgood insisted my roommate’s issues related to positive thinking and refused to revert to a pain regimen that had apparently worked before. I’m not a physician and have no idea what pain medications this girl should have been on. But as a human I know that “Tears = Bad” and anyone that cries for twelve hours while begging someone, anyone, to call their physician of record isn’t faking it. She didn’t stop crying until a doctor with some humanity sedated her following shift change. The complete disregard for her pain stripped her of her dignity and brought me to tears.
I’ve experienced many horrible things during my healthcare journey. I have experienced pain – I broke my femur in a remote location and spent hours in transit before receiving pain medication. I have experienced makeshift environments – last September I spent 27 hours in a hallway waiting for a bed to open while being treated for a pulmonary embolism. But this experience of complete powerlessness in the face of another’s pain is, bar none, the most profoundly heartbreaking experience of my life.
During this situation, I contacted the patient advocate several times via email/phone and complained in person post discharge. While I am appreciative of Dr. Y for bringing these issues to your attention and find your immediate response very encouraging, it saddens me that as a simple patient my voice wasn’t heard.
Wishing you all the best,
Here is their response:
Thanks to my forced transfer to this facility, I’ve found that nothing’s improved. I was slated for discharge earlier today, only to be remanded over dangerously offkilter labs caught when the attending went to signoff on my discharge. These electrolyte imbalances did not become dangerous overnight and might have been treated when I passed out earlier this week. But no. Instead they looked for an illicit cause to my syncope, sending police in to toss my room during my post syncopal phase in which I shake. When the police came in I photographed their aggression. The officers immediately threatened to handcuff me and throw me in jail if I didn’t delete the photos while they watched. Obviously I acquiesced instead of finding out whether you go to real jail or hospital jail when you get arrested by hospital rent-a-cops.
Either way, the facility is now unwilling to return my central line supplies. This is a bit of a policy change from when I was admitted – the admitting charge nurse had given back my unlabeled pills with the understanding that I wouldn’t take them while admitted. Now I’m being told that, while I have an active prescription from one of their own attendings and can show that I/my insurance paid for these items, the facility will not return the items because my infusion pharmacy didn’t label each saline flush, heparin lock, and zofran vial with my name. Additionally, I must petition to have my medical record amended to strike their incorrect suspicion that I illicitly obtained/administered IV morphine to myself while admitted.
But this was only the beginning of ‘Big Brother.’ Since I’ve now passed out twice, I have the pleasure of a Sitter. A Sitter is someone who sits in your room and watches you, presumably so you don’t attempt to get out of bed on your own and fall. Previous Sitters have let me know they’ve found the task of watching me easy/boring/ridiculous since I know who/where I am and play by the posted ‘Call! Don’t Fall!’ rules. This admission is no different. The two falls I’ve had I called nursing, told them I thought I was about to pass out, and, fell to the floor despite nursing having their hands on me at the time.
However, I can’t blame the facility for trying to avoid another fall – as previously explained by a friendly CNA: “We’d rather have you die than fall. There’s less paperwork.” But with less paperwork comes unintended consequences for the patient – both physical and emotional. Physically I’m losing muscle mass and stability as my only exercise is the 8 or so feet between my bed and the toilet. Otherwise I’m stuck in an alarmed bed 24/7 which is so sensitive, it goes off if I roll over incorrectly.
Emotionally, well, there’s a loss of dignity that comes with someone watching you pee or, perhaps worse, visit with friends and family. Of course, this isn’t an ever vigilant eye, that would require a living wage or technology implementation. Since we’re on the 1980’s technology/(presumably) minimum wage package, sometimes the Sitter is asleep. Or visiting loudly with other employees passing in the hall at 4AM. Or singing a little song at 2AM. Or decides to snack on foods that makes you queasy. (Side Note: Mine’s currently sitting 5 feet away eating bacon. She’s also 8 months pregnant so I really hope I don’t fall on her watch. This is a workers comp lawsuit just waiting to happen.)
When I told the charge nurse the Sitter singing/talking/eating at all hours was becoming the last straw, the Sitter took it personally. I tried to reassure her that she wasn’t the only reason I hadn’t slept in days. No, her disregard is just one of many items on the list – 3AM blood draws, 5AM vitals, 7AM physician visits – disrupting the painsomnia and nausea that have become all-encompassing since switching to oral meds. Why is Hospital X so committed to the oral med ‘attempt/vomit/repeat’ plan? Because the second I can hold something down, they can discharge. Not exactly the holistic care experience advertised on the website.
While I hate to say it, it seems my emotionally-charged-knee-jerk “I would be better off in a ditch than at Hospital X!” prophecy rings true. And, while my brain isn’t quite working (indeed, much of this post was written prior to my semi-forced admission back to Hospital X), eventually it will return and I’ll report Hospital X to the various licensing/quality bodies for the absurdity.
The sad thing is… I know my experience is not unique within the community of patients suffering from chronic disease. Everyday patients are harmed by the one-size fits all approach to medicine which makes no room for those with ill-defined syndromes and default to patient blaming. And these real problems can’t be solved with hospital wide technology updates or private rooms. While there’s a huge focus on prevention and population health (as there should be), we need to be careful we don’t forget the 1% of unicorns who make up 20% of healthcare spending. And, while there’s obviously no easy answer, there is an answer. We (yes, we as in me and you), as the people who’ve fallen in love with Mars Curiosity’s delightful personality, can figure out how to deliver care that’s individually appropriate on Earth. We can. I believe it.
Jess Jacobs, who died Sat Aug 14, 2016, was a former official at ONC & FDA, and was recently working at Aetna
Categories: OIG Advisory Opinions
The Healthcare Blog - Mon, 08/15/2016 - 08:52
Two and a half years ago, John Halmaka posted an entry with this title – and I recall that it was a good summary of the state of the industry. While I didn’t agree with all of his suggestions, I enjoyed the review and it offered a good set of guiding principles. Since I was Acting National Coordinator for about the same duration as Vindell will serve, (Fall of 2013 – after Farzad Mostashari departed, and before Karen DeSalvo arrived) I’ll offer some thoughts from one who has been in his position.
- Certification. The health IT certification program is the core of ONC’s responsibility to the nation. While some have called for the eradication or reduction of the certification program, I would argue that this would be akin to scaling back Dodd-Frank. Yeh – crazy. As a product of ONC’s certification program, we now have health IT systems that do what their developers claim they do. Before this program existed, creative health IT salespeople would assure customers that systems had functionality that simply didn’t exist, or was nonfunctional. The program, like certification programs in other industries (telecommunications, transportation, etc.) is in place to assure the purchasers of products that these products do what developers claim. Is the certification program perfect? No. Of course not. The program needs to iterate with the evolution of the industry and the standards that are evolving. Revisions to the certification program must therefore continue, so that the certification requirements don’t point to obsolete standards. A focused “2015R2” certification regulation would therefore be an appropriate component of ONC’s fall work – so that something can be “shovel ready” for a new administration for ~ February release – with final rule in ~ April/May of 2017.
- The 2017 Spend Plan. The 2017 federal budget appears to be on track to pass @ some point soon – and ONC’s appropriation for 2017 is looking like it will land at a steady ~ $60M ($65M if the extra $5M for narcotic abuse prevention lands). The National Coordinator defines the “spend plan” for how the organization allocates this money – and the plan needs to be developed and executed at the beginning of the fiscal year: October, 2016. The new National Coordinator is therefore making decisions now about how the funds will be spent over the next 12 months. Office Directors are preparing proposed budgets for the year: new FTEs, new projects that they want to launch. Every year, it’s the same – just as it is in any large organization – proposals are submitted and the proposals represent 2x-3x the $$ available. Tough calls need to be made. The NC makes these calls. It’s hard to do this when you don’t know who your successor will be in January – or what their preferences will be. When I was in this position in October, 2012, I worked closely with the Office Directors and the ONC Chief Operating Offer (Lisa Lewis), to identify the components of the organization’s work that were essential, and which were not. We delayed decisions on about $2M to give Karen some flexibility to fund programs that were important to her. As I mentioned in my response to Politico’s request for comments on the next phase of ONC’s path, my view is that it’s time to wind down ONC’s grants and health IT evangelism activity. Perhaps it’s just my personality coming through here – as I am a well-known introvert, with little interest in quadrant 1 of the sizzle-substance 2 x 2 matrix (kudos to Janhavi for its invention), but I am concerned that it’s not government’s role to convince the public of the value/need for health IT. If health IT has value (and I believe it does) then this value will be tangible and self-evident to the public. If not, then no annual conference, blog post, or challenge grant will change this fact – or anyone’s perception of it. ONC’s annual meeting – an event that costs several hundred thousand dollars and attracts the same participants every year – adds rather little to the nation’s progress toward improved health through the strategic use of health IT. Kill the conference. Kill the health IT flag-waving. There’s already plenty of that to go around, and the taxpayer need not pay for it.
- Focus on quality. No – not quality measures. Quality of health, quality of care, quality of decisions. Do these need to be measured? Of course they do – and with the growth of value based payment in federal programs upon us, measurement of quality is imperative. But we have conflated the concepts of quality and measurement. As many know, I’ve long been concerned that the way that we use clinical quality measures in health care is fundamentally flawed. Indeed, it was my concern about these flaws that led me to join ONC in the first place: as the CMIO at Allscripts, I was responsible for helping our EHR development teams meet the requirements of Stage 1 of the EHR incentive programs (“meaningful use”) and it became clear that the accuracy of quality measure reporting would be terrible across the industry. Why was this? Because the 2011 certification criteria and Stage 1 meaningful use requirements were too vague about the data that would be used to measure quality. For example, a quality measure might express that patients with “severe congestive heart failure” would be expected to be on a certain class of medications. But there was no clarity for how “severe” was to be assessed, and many EHRs didn’t even formally capture ejection fraction, which would be an imperative component of an assessment of the severity of one’s CHF. For Stage 2/2012 certification, we changed all of this, and while most readers don’t know or care about the details, these quiet changes represent the first important step toward improved quality measurement: the data elements that are required for quality measures are explicitly identified in the certification regulation, and no measures are required that exceed the scope of these data elements. Read the last sentence again if you need to – as it’s very important and this guiding principle remains ignored by NQF, by many commercial health plan quality measures, and by many state Medicaid programs that are trying to implement quality programs.Simply put: it’s impossible to report on data that was never captured. A “quality measure” that assumes the presence of information in an IT system that is not present will be an invalid quality measure. Period. I thought / hoped we solved this problem in 2012. Unfortunately, we did not. Quality measures are still proposed without consideration for the data that EHRs have captured. It’s now easy to know what the EHR can capture (what it can capture and what it has captured may of course differ). Start with the NLM’s Data Element Catalog (Jesse James won the naming competition). If the concept that you want to measure isn’t in here, then re-design your measure, because the EHRs don’t capture the data in a uniform manner. If it is there, then the likelihood is high (but not certain) that the data can be captured, queried, and transmitted.Recall that I said our method of measuring quality is flawed. Why is it flawed? Because all of our focus is on quality measures rather than quality improvement, and improvement is a product of measurement and decision support. Let’s parse this statement, beginning with the difference between measures and measurement. A measure is an explicit logical statement about care delivery and its alignment with a very specific expectation. For example, there is some evidence that individuals with diabetes will live longer if their blood sugar is well controlled, so there is a quality measure for this: IF (individual has diabetes) AND (blood sugar is well controlled) THEN (quality measure satisfied). Each of the logical expressions can be defined explicitly. This measure can then be applied to thousands of care providers and their “scores” on the quality of care they presumably offer can be compared. But what if blood sugar control isn’t so important? What if there becomes a better way to measure individuals’ optimal health? Measuring care quality in this way is like having a speedometer in your car that measures 10, 15,25, 37 and 55 miles-per-hour and nothing in between. It’s a seat of measures -hard-coded into the system rather than measurement: a fluid, adaptable system that enables us to see how we are doing and therefore to enable us to adjust our work dynamically if necessary. How do we adjust? With clinical decision support (CDS)! As you will read in the chapter I wrote in Eta Berner’s just-published book on CDS, the federal government has done a great deal of work to build CDS capability in health IT systems, and to align it with quality measurement. We’re not there yet – but we are well on the way. Keep this on the front burner, and the path to the triple aim will be shorter and much less bumpy.
- As my friend Jerry Osheroff always says – focus on the most important things: TMIT. Are we helping improve the health of people? That’s most important. Don’t lose sight of it. Karen DeSalvo taught me many things when I was her deputy – but the one I’ve internalized the most was something that she taught me very early in her time at HHS: we need shift our conversation from how to improve “health care” to how we improve health.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sun, 08/14/2016 - 16:41
By now most people have heard of the new mobile phone game, Pokemon-Go. Pokemon-Go uses cellphone GPS data to identify when you are in the mobile game and allow Pokémon characters to “magically appear” in areas around you (through your phone screen). As you move around, different types of Pokémon will appear for you to catch. The idea is to encourage players to travel around their geographic location in order to catch Pokémon. This game provides a glimpse into an approaching next wave of personal wellness and patient engagement applications that will likely incorporate augmented reality into the mainstream consciousness and imagination.
Augmented reality games provide a twist on geocaching. I have gone on geocaching trips with my kids and generally enjoyed the pleasure of getting eaten alive by mosquitos while looking under every rock in a quarter mile for a box filled with a couple of dirty action figures. I did this voluntarily as it was one of the many ways to increase physical activity and get my kids engaged.
Augmented reality games, such as Pokémon-go have showed innovation for the virtual world and mobile computing. These type of games have the ability to be a better option for the future of computing over virtual reality. If instances of augmented reality games utilize gaming to create interest, a game could be created to encourage physical movement to complete tasks. As time progresses we may see a rush to capitalize on augmented reality now that an application has shown how it can be integrated into our daily lives.
The potential implications in health care and medicine of these mobile phone games can provide a number of new avenues for keeping people healthy using augmented reality techniques.
Organizations can apply these techniques to make augmented reality games more customer-centric and engaging by:
Adding augmented reality games to activate patients to keep ‘step counters’ up
This game model for making achievements while playing a mobile game creates a new model to help drive activity of people who are sedentary. I have already recognized the short term sea change of activity in my children playing augmented reality games on their mobile phones. Although being fully immersed in virtual reality poses a small threat that may remove people from reality and create a fear in society of living without augmentation. We have a need to keep physically moving but games have traditionally kept us stationary. Currently, I try do it by walking to work, about a 1.5 mile walk while listening to audio books on my phone. I’d be happy to find new ways, maybe games, more tuned to adult wellness and interests, to spend more time outdoors. If I am engaged in an augmented reality experience, I could spend time in foreign cities when travelling and enjoy exploring the location.
Providing augmented reality for patient wayfinding and resource optimization
It may not be the most exciting healthcare application but wayfinding is still a big challenge in hospitals. New technologies such as blue tooth beacons and wi-fi tracking allow patients to navigate through a large complex space like a hospital. By adding augmented reality we can both help patients be active in their care and also better understand how their care is working. A clever developer can make being in a hospital feel more like a game to encourage behaviors that can lead to shorter lengths of stay.
For children and patients, adding creative experiences to a hospital visit may help to reduce the anxiety, discomfort, and boredom during a long hospital experience.
For physicians and administrators, an augmented reality view of the hospital can help to identify issues that need resolution such as viewing through a mobile phone where locations with high infections rates are, rooms with higher or lower utilization, and other facility related information.
Providing patients with education, treatment, and adherence support
Having the ability to pair the intelligence of mobile computing with the images on the screen can help provide information to patients in an entertaining and useful way. A number of patient advocacy groups have designed such games that show how medication compliance impacts risk in diseases. Using a detailed game to show the actual body with a ‘look inside’ view can be impactful in helping to communicate the risks of patient behaviors in adherence and high risks.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sun, 08/14/2016 - 12:13
In the first article in this three-part series I reviewed the findings in CMS’s latest report on one of its “medical home” experiments – the second-year evaluation of the Multi-Payer Advanced Primary Care (MAPCP) Demonstration.We saw that the “patient-centered medical homes” (PCMHs) in that demo have failed to cut costs or improve quality during the first two years of the demo. We also saw that the sloppy definition of “medical home” put the author of the report, RTI International, in a bind: They did not identify a single feature of PCMHs to treat as an independent variable, and were forced to offer an impressionistic, on-the-one-hand-on-the-other-hand account of what the PCMHs are doing.
In the second article of this series I examined the report’s explanation for why the PCMHs have so far been unable to outperform non-PCMHs despite receiving substantial subsidies from CMS and other sources that non-PCMHs don’t get. The report seems to say that insufficient subsidies explains the PCMHs’ failure. I noted, however, that the report contains no evidence indicating how much more money PCMHs might need.
At the end of my second article I characterized the problem presented by the report as a conundrum. On the one hand, PCMH staff and many other observers feel PCMHs are severely underfunded, but on the other hand no one can say by how much or which PCMH services need more money.
So what do we do? Do we just pick a number out of thin air and say that’s how much more money PCMHs need, and pour that money down the PCMH black hole along with the other subsidies PCMHs receive now? That appears to be CMS’s position judging from its endorsement of yet another “medical home” program (CPC+ as an “alternative payment model” in its proposed MACRA rule despite the fact that all three of CMS’s “home” demos are failing.
Salvaging what we can
Throwing more money down the PCMH black hole is not a good idea. I recommend that CMS allow PCMHs to focus, and that CMS do so by radically sharpening and cutting down the definition of “PCMH” so that the concept refers to a uniform set of medical and social services provided to a subset of the chronically ill. 
Once CMS has clearly defined what services it wants “homes” to provide, it can then determine what the extra services cost and make adequate payment for them. It would help if, in addition to paying adequately for the extra services, CMS would let doctors and patients decide when the extra services should be provided rather than stick its nose into the doctor-patient relationship with pay-for-box-clicking schemes. Paying adequately for additional services and eliminating pay-for-clicks schemes would increase the physician “flexibility” that CMS claims it seeks to promote with PCMHs. Eliminating pay-for-clicks schemes would also lower physician overhead and reduce physician burn-out.
Please note the beautiful simplicity of my solution. By treating the problem first as a lack-of-focus problem, we solve the underfunding problem. Moreover, because doctors would now be paid for specific services rather than a fee per attributed patient, we would solve the sloppy attribution problem (see my comment on that problem here . CMS would not have to guess which patients “belong” to which doctors. Doctors would decide which patients they are treating, not CMS.
Compelling evidence CMS’s “homes” aren’t focused
Common sense and a growing body of research supports my insufficient-focus diagnosis and my recommended solution – more focus. The most compelling evidence of insufficient focus by the MAPCP PCMHs is their inability to lower costs or improve quality for what RTI calls “special populations.”
That is the oddest outcome of the MAPCP demo to date. Improving the quality and lowering the cost of care for the chronically ill is the primary goal of the MAPCP demo. As CMS puts it on its MAPCP website , “The care management fee is intended to cover care coordination, improved access, patient education and other services to support chronically ill patients.” (My italics) And yet, according to the second-year evaluation, “MAPCP Demonstration states did not develop unique interventions tailored to special populations….” (p. 2-46) 
It should come as no surprise, therefore, that, with the exception of one state, PCMHs were unable to lower costs or improve quality for those populations compared with non-PCMHs (see Tables 2-12 and 2-14 of the Year Two evaluation). The limited exception was Vermont. In that state PCMHs lowered spending on all five “special population” groups but, oddly, were unable to improve quality for them. In fact, Vermont PCMHs drove up ER visits and hospital admissions for patients with multiple chronic illnesses (see Table 2-15 pp. 2-50/2-51).
On the other hand, a growing body of research supports the conclusion that extra services targeted at the chronically ill improves health and, once in a blue moon, lowers total spending even after taking into account the cost of the extra services. Examples of such research include research on programs that monitor heart failure patients , find houses for the homeless , and deliver primary and specialist services to very sick children ) and adults.
Drastically shrinking the scope of “homes” and defining their services more concretely and uniformly would not only ensure better use of the unknown quantities of money going into “homes,” but would discourage the evidence-free conversation we’ve been having about them and encourage a more evidence-based conversation. Both outcomes would be achievable because analysts could finally publish honest-to-God research – research that examines concrete independent variables rather than warm and fuzzy phrases like “whole-person focus.” With independent variables specified, we could eventually determine why some “homes” fail and some succeed.
Vermont’s success might be an illusion
RTI’s inability to explain why Vermont was the only state in which PCMHs achieved gross savings compared with non-PCMHs illustrates the problem. Why was Vermont the only state in which that happened? Why did every major category of medical spending by Vermont PCMHs drop? Why were Vermont PCMHs unable to improve quality if they were so good at cutting costs? Because of the flabby definition of “PCMH,” no one knows. We can only offer hypotheses. Here are mine.
According to Table 2-9 of the Year Two report, Vermont PCMHs cut every one of the 11 categories of expenditures, with two minor exceptions: “Home health” and “other facilities” (spending in these categories rose a small, non-significant amount). All other categories, including primary care, fell. Something is fishy here. As Al Lewis observed in a comment on THCB about another report which claimed across-the-board savings for Vermont PCMHs, “Every component of cost can’t decline – something has to increase in order to save money elsewhere.”
Three explanations come to mind:
(1) The Medicare beneficiaries attributed to Vermont PCMHs were healthier than the beneficiaries assigned to non-PCMHs;
(2) “leakage” was greater among Vermont non-PCMHs than PCMHs, which artificially raised non-PCMH costs; and
(3) PCMH patients received services that were paid for “off the books,” and those services either substituted directly for medical services or improved the health of PCMH patients enough that they needed fewer medical services.
I’ll explore each hypothesis briefly.
Healthier patients. RTI states that patients assigned to Vermont “homes” were “three percent less costly” than the “average Medicare FFS beneficiary.” (p. 5-7) This may be a consequence of the convoluted plurality-of-claims method RTI used to “attribute” patients to PCMH and non-PCMH clinics.  That method assigns more “loyal” patients to PCMHs, and loyalty may be correlated with health. RTI also informs us that “Medicare expenditures are not risk adjusted” but instead are subjected to “entropy-balanced weighting.” (p. 1-19) The combination of healthier patients and failure to adjust accurately for health differences might explain the apparent ability of Vermont PCMHs to lower CMS’s gross (claims only) costs.
More “leakage.” RTI’s plurality-of-claims method might have resulted in more “leakage” for non-PCMHs.  By giving PCMH’s Vermont’s least transient and most loyal patients and, conversely, handing the non-PCMHs a pool of less loyal and more transient patients, RTI might have guaranteed that the non-PCMH attributees (yikes, what a word!) would seek more care outside the clinic to which they were attributed. For example, if non-PCMHs were assigned more snowbirds who sought treatment in the Sunbelt, non-PCMHs would have been dinged for those treatment costs, but there would have been nothing the non-PCMHs could have done to control those costs.
Enron book-keeping. Finally, as I have noted already, RTI has not reported CMS’s net savings in Vermont – savings as measured by claims minus the “care coordination fees” CMS paid to PCMHs. Those savings might well be negative. But CMS’s payments are not the only subsidies that must be subtracted from the savings Vermont PCMHs allegedly achieved. PCMHs in Vermont, as in the other states, received numerous other payments and in-kind contributions which RTI did not measure. Non-PCMHs received none of those subsidies, measured or unmeasured. It seems likely that some of the subsidies PCMHs received funded services which either took the place of or reduced the need for medical services, thereby allowing expenditures on traditional medical services to drop. It is possible more money was spent on Vermont PCMH patients than non-PCMH patients when all subsidies are included.
The most important fact about Vermont’s apparent success is that neither RTI nor anyone else can explain it because the variables are so numerous and so poorly defined. RTI did not even try. I understand.
More focus, less mumbo jumbo
In this three-part series, I have discussed three defects in RTI’s report on Year Two of the MAPCP demo:
(1) RTI’s inability to say anything concrete about what “homes” are doing that run-of-the-mill clinics don’t do and, conversely, RTI’s heavy reliance on impressionistic commentary;
(2) RTI’s inability to describe the independent variables they plan to investigate, and, most importantly,
(3) RTI’s inability to explain the failure of MAPCP homes to work as advertised and, in Vermont’s case, to explain why PCMHs in that state appear to be successful in lowering gross costs but unsuccessful in improving quality.
All these problems can be traced back to the condescending mumbo jumbo that PCMH advocates use to describe PCMHs – “patient-centered,” “whole-person focus,” “meaningful use,” “coordination across the medical neighborhood,” etc. An entity defined by such happy talk cannot possibly focus, and researchers who investigate such an entity can’t possibly define concrete, measurable factors that might explain the entity’s successes and failures.
“Medical home” proponents claim they are motivated by a desire to pour more resources into primary care and expand the primary care work force. The “home” fad is doing the reverse. It is sucking resources out of the primary care sector and contributing to burn-out among primary care doctors, which is already at epidemic levels. It should be clear now even to CMS, the American Academy of Family Physicians, and others who have exhibited such blind faith in “homes” that improving primary care requires pouring more resources into primary care, not “homes.”
Ideally, CMS and the insurance industry will do that by raising reimbursement rates for primary care physicians. That seems unlikely to happen in the near future. The next best solution would be to redefine the “medical home” so that it adds to rather than depletes resources available to primary care doctors. The way to do that is to define the “medical home” as a clinic that provides specific, uniformly defined services for a subset of the sick, and to pay that clinic adequately for those services.
 An example of such a service set would be all those offered by the Diabetes Prevention Program http://care.diabetesjournals.org/content/25/12/2165, or all goods and services (medical and social) that would contribute to the recovery of opioid addicts. The only criterion CMS should use in determining what services PCMHs should offer would be benefit to the patient. If CMS were to adopt a cost-containment criterion as well, few services would be approved. Whether the maudlin “medical home” label should be retained and bestowed on clinics that provide these sets of services is not an issue I need to address here.
 RTI reports two “exceptions” to their statement that PCMH programs did not focus on “special populations.” New York focused on rural residents by default (the PCMHs were all in rural areas of the state); Vermont’s Support and Services at Home program, which began in 2011, served 3,000 elderly people in subsidized housing by the end of 2013.
 The plurality-of-claims method RTI chose required RTI to examine CMS claims filed over a “look back period” (one to two years, depending on the state) and then assign patients to PCMHs and control clinics for the “performance” period based on which clinic filed the most claims for that patient in the look back period. For a discussion of RTI’s attribution method for each state, see Appendix B https://downloads.cms.gov/files/cmmi/mapcp-secondevalrpt-technicalappendix.pdf .
 Attributing patients was apparently a messy process in all eight states. According to RTI, “All eight states reported challenges with health information technology … and the quality and timeliness of data, which was associated with challenges with patient attribution.” (p. 2-7)
Categories: OIG Advisory Opinions