A Watershed Year: What 2015 Holds for the Patient Centered Medical Home (PCMH)

The savvy Jeff Levin-Scherz, who blogs over at Managing Healthcare Costs has responded to the Disease Management Care Blog's snarky "Prattling Pinheads of Pessimism" post on the topic of the Patient Centered Medical Home (PCMH). 

He's not a nattering nabob of negativity or a prattling pessimistic pinhead, says he.  He'd like to be thought of as a skeptic seeking substantiation.   The DMCB wholeheartedly approves of the agreeable alliterative appellation.

2015 may well turn out to be the watershed decision year for the PCMH:

If there's no published peer-reviewed proof that it reduces health care costs, nabobs, pinheads, skeptics and policymakers will need to decide if no evidence of an impact on costs is the same as evidence of no impact on costs.

If the answer is no, THEN we'll then have to decide if the traditional "X causes Y" mathematical approaches to derive proof (such as a comparison of averages using standard power calculations and/or impact on expected or observeed trend) are equal to the task in a very "statistically noisy" environment involving complicated human beings.

If that answer is no, THEN we'll have to decide if reasonable and informed assessments of potential cost reductions, used by countless other businesses every day in other sectors of the economy, are good enough,

If that answer is no, THEN we'll have to decide if there is face value to the PCMH. This involves a contrast of any patient benefit versus its incremental cost.  If the benefit is worth the cost.....

THEN we may have to decide if consumers are willing to pay for it, or if health care costs will need to be cut elsewhere to pay for it.

Stay tuned!

Additional Ingredients for ACO Success: Communication Training, Support Tools and Culture

Pity the hospital CEOs, EVPs and Chairs and their "Accountable Care Organizations" (ACOs). They've lined up the doctors, invested in an electronic record, hired some care management nurses and signed the risk contracts.

And then Matthew Press and colleagues come along with this AJMC article on Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives.

Their message? You may have what's necessary, but it's not sufficient. Organization and incentives are not enough.

What's also needed are:

1. Training: physicians need education on coordination, collaboration communication and teamwork.  The education should be an organizational priority and typically involve course work, observation and feedback with continuous evaluation.  This cannot be accomplished in a one day workshop.  An example of what it might take can be found here.

2. Support tools: since efficient information transfer must to be built into ACOs' workflows, informal "situation" or "personality" dependent communication between docs and nurses need to be transformed.  An example of the kind of framework that Kaiser instituted can be found here.  While you're at it, think about HIPAA-compliant texting, wiki-enabled EHR records and patient activity streams.

3. Culture: if front line staff are going to support the delivery of high quality and optimum cost care, the organization will need to protect time for care coordination activities, multi-disciplinary meetings, forums to share best practices and incentives that recognize collaborative behaviors.

Looks like the work has only just begun.

The Relationship Between Discharging Patients From the Hospital Too Early and the Likelihood of a 30 Day Readmission: Treat, Street and Repeat.

I'm baaaaack!

When persons are admitted to a hospital, insurers' payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blog's physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  That's why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But that's all theoretical.  What's the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospital's "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  That's the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  That's the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears there's an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."

Of "Antifragile" and Accountable Care Organizations (ACOs)

Emboldened by yesterday's economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns it's attention to a magnificent new word:

"Antifragile."

That's the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandora's ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCB's antifragile infatuations, recall AHERF's spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but it'll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health system's antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......