This is the second in a series of conversations I had with some open-minded colleagues who also deeply want to seen meaningful change in the U.S. healthcare system. The person I primarily responded to mentioned a chapter in Pursuing the Triple Aim. Here is what I wrote back to him:
I was reminded how I was not super impressed with the Pursuing the Triple Aim book. Certainly, there are some good points in it, but each chapter also reads like a sales job from large healthcare systems. Rarely are these programs put to the test of peer review in the traditional medical literature. And sometimes when they are, they appear in some journals, which, in my opinion publishes too much stuff from commercial interests, such as Optum, or whoever
Let’s take a look at some of the primary care programs and their claims more closely. In no particular order:
The Nuka system
This is one of the more transparent programs in the sense that their leaders have publicly spoken about their innovations, and their results have been published in the standard medical literature. Their leaders have talked about lots of aspects of the program: patients renamed customer-owners, inventing mini-pharmacy dispensaries for rural villages, using lots of tribal workforce for all job descriptions, and so on. Let’s look at two publications about Nuka that appeared in the mainstream medical literature.
One was a time series analysis of medical record data that looked at time periods from transition to the new system, to PCMH implementation, to early PCMH adoption, to post PCMH implementation. In this study, they found a decrease in hospitalizations for unintentional injury or poisoning, and asthma. The heart failure hospitalizations were about the same. Hypertension admissions increased. The study was silent on conditions such as coronary artery disease, MIs, diabetes, DKA, etc. I assume this means there was no significant difference. It would have been easy enough to measure, but I acknowledge I’m speculating about this.
Notice that none of these positive outcomes have anything to do with OMT or other frameworks for Syndrome X care (blood pressure, diabetes, obesity, coronary artery disease, strokes, and so on). So, what explains the decrease in poisonings and asthma? They don’t talk about any specific asthma management plan. In a similar article that also mentioned a decrease in emergency visits for asthma and unintentional injuries, they included a qualitative component. In this section, they talk about improved access to primary care as the primary driver. One of the quotes was I think emergency department visits have gone way down because it’s so much easier to see their primary care clinician. They also mentioned getting nurses out of the specific disease management function (diabetes nurse, asthma nurse, etc.), and better support for primary care by the leadership.
I wish they would have drilled down the poisoning/injury numbers more. It should have been easy to count the number of lacerations, contusions, sprains, strains, and extremity fractures before and after full PCMH implementation. In other words, were injuries and poisonings down more because community health workers counseled young men to drink less and be safer, and the young men changed their behavior? Or did the total number of incidents not change much, but the custom-owners knew that their primary care center could see them reasonably fast, and they didn’t have to go to the ER. My guess is the latter, but it’s just a guess.
HealthPartners
Harvard Business School reported on HealthPartners diabetes management program in 2003 and calculated it only saved $75 per patient. The numbers you included in your email were from 2011, but I can’t find any information in the literature to support this. The problem with the HealthPartners report in Triple Aim is there is not enough detail to support the claims. It’s left to the reader to trust the numbers. I’ll talk about this more at the end.
Independent Health
In the same HBS report, they calculated that a diabetes program in the Independent Health Association “failed to find proof of substantial short-term medical cost savings attributable to the program.”
IDEAL program
IDEAL was a state-wide program in Minnesota where the Department of Health and HealthPartners collaborated in traditional QI efforts. They showed a decrease in the average A1c and LDL cholesterol levels, but did not calculate costs.
Iora Health/ChenMed/and so on
These reports are hard to parse out because they are so emmeshed in the Medicare Advantage coding game that has been highly profitable to insurance companies and private equity. I’m in the camp that believes that more of the savings/profits in Medicare Advantage have come from coding games than actual improvements in care (I think the Gillfilan/Berwick posts about this issue are more believable than the opposing pieces). But given this complication, let’s press on and see what we can find.
Harvard Business Review has reported several times about Iora Health. Let’s look at one published in 2017. It states, “For example, an unpublished Iora study found that inpatient hospital admissions among a cohort of 1,176 Iora Medicare enrollees over an 18-month period decreased by 50%, emergency department visits decreased by 20%, and the total medical spend declined by 12% — this despite the cohort being sicker than average Medicare patients.” OK, it’s unpublished, but it could be true. I’m sure their primary audience was investors, so allow me a bit of scepticism here. Another big question in my mind is the statement the “cohort being sicker than average Medicare patients.” It’s really difficult to tell if this is real or a reflection of aggressive coding within the Medicare Advantage game. Let’s keep moving.
In another HBR report on Iora, there is a section that talks up the health coaches (they take the patients shopping, for example), which is in line with OMT thinking, so I won’t repeat those critiques here. Further down is a statement that is just silly, “Under its capitation system, Iora makes money only if its patients stay healthy and thus require fewer tests and procedures.” More tests are ordered when a patient is under an aggressive screen-and-treat system vs. leaving well people alone.
Further down is where it gets meatier. The report states, “Iora saved money by contracting specialists as consultants to the primary care practice—essentially inviting cardiologists, nephrologists, and others to join the gig economy. When Fernandopulle asked the head of endocrinology at a top hospital what percentage of endocrine clinic patients could be managed by a primary care physician with a little expert advice by phone or e-mail, the answer was an astonishing 80%. A formal study of e-consultations by PCPs across 10 specialty areas, including neurology, rheumatology, dermatology, and nephrology, confirmed that on average, primary care physicians were able to address problems in those areas for 60% of patients.” Now we’re talking.
For context, just in case you didn’t already know, the corridor from Washington DC to Boston is the great sucking black hole of despair for family medicine. It is the most over-specialized part of the country with the fewest family physicians who are generally highly disrespected. This is where 3 of 4 Iora pilot sites were, the other being Las Vegas, which I assume is also not the most family medicine-friendly part of the country. (And of the groups were unions, which could have had very generous benefits that needed paring). Dr. Fernandopulle was probably a combination of lucky and smart that he was in Boston and focused his early efforts on that region. This result sounds exactly like one of the classic Starfield conclusions that 50% of visits to ologists are really primary care.
Savings that are generated from decreasing visits to ologists makes sense to me. The lowest hanging fruit in this domain is simply to reduce the number of touches to ologist care that add no value to the patient’s journey. The higher-hanging fruit is the difference in the cultures of the ologies and family medicine that also lead to more patient-centric and less aggressive testing and treating, but this is still accomplished if a patient is steered towards primary care as the easiest and most convenient place to access care.
I won’t list all the other articles about Iora here, but other themes are switching more prescriptions to generic, developing its own IT system, and again, the coaches and reducing ologist visits. I’ll just say here that I accept that the coaches are part of its success, but not in the way the typical article suggests. Hosting cooking classes is not the trick, it’s being quickly accessible if the patient has a concern. The coaches serve to increase access and act as information filters for the doctors.
In the interest of watching my word count, I’ll just say that the reports on ChenMed and the others sound very similar to me as Iora Health, so I’ll not comment about them in more detail. I’ll make one more quick semantic comment though. All of these articles say something like, “Iora works by keeping people healthy,” which isn’t true. People with heart failure aren’t healthy, their heart doesn’t pump well. People with diabetes aren’t healthy, their ability to regulate blood sugars is broken. A better way of thinking about this is that the doctors/teams help people live as well as possible given the cards they were dealt. But they’re patients are not perfectly “healthy.”
Wrap Up
The problem with all of these reports by mostly commercial entities is that they do not provide enough transparency and detail to really prove their case. For example, no report says this, “Before we started with working with some union, they were spending $X on blood pressure, diabetes, and cholesterol medicines; related tests (blood work, stress tests, etc.); ER visits total and disease-specific to syndrome X situations (chest pain, MI, stroke, etc.); hospital visits total and disease-specific; and other related big ticket items such as heart caths and such. We then spent $Y on more drugs, tests, coaches/dieticians/counselors, primary care, and so on over the next blah-blah years. At that point in the same population (understanding that all U.S. populations are mobile), we spent $Z on roughly the same list as $X. Therefore, the net spend or savings was whatever.”
Within this framework, there are still some spend traps to watch out for. A group could claim that their intervention results in lower A1c levels and lower costs per diabetic. Was the before/after group the same size (and likely horribly expensively managed, like a multi-ology model) or did the coaches go out and screen a bunch of people who felt fine, found more cases of diabetes, most of them controlled on just metformin, and thereby making the dollars and outcome results per diabetic look better?
Another trap would be something like a report not using established methods for reporting cost-effectiveness results, like taking the newly detected diabetics, and projecting future costs based on an overall average spend on diabetics, not a newly diagnosed patient with very mild disease. Another trap would be cherry-picking populations that have fewer minorities, low-income patients, and patients with significant mental illness or substance abuse challenges. And of course, throw in social determinant challenges (and no, no one has invented a way to correct for these, and mathematically, I don’t think it will ever happen). Another trap would be to take a group of insured patients in a region who likely are representative of their region, show that some intervention lowered the total spend, but did not disclose that this group had an exorbitant spend before, and now have a spend that is the same as other groups (In other words, there was plenty of fat to cut out, but nothing more fundamental about care delivery changed compared to other local options).
What about the Medicare Advantage population? Similar situation here, with slightly different accounting. For example, if Iora or whoever claims 15% overall decrease in total spend, was it that pre-Iora the total spend was $400 PMPM, then they did their thing, then the spend was $340 PMPM (not adding inflation in this example)? Or did Iora get in there, add lots of HCC codes, which then led to a new predicted spend of $500 PMPM, and they accomplished $425 which they claimed was a 15% reduction, when in fact it was an increase in the total spend? Again, I can’t find any report that divulges this level of detail. And if there is a report that looks like this example, I’d still like to see the detail I listed in the earlier example.
I suspect that some of the things Iora did are substantive, real, and reduced stupid healthcare expenses. One report said their doctors/teams take care of about 400-500 Medicare patients, vs. other approaches in the HMO era where they’d assign a family doc 800 or so patients. Remember that the fundamental Barbara Starfield, MD finding that geographic places with more family physicians (not internists, by the way) enjoy better health outcomes and lower costs. In the managed care era, no one ever tried to experimentally replicate this observational finding by merely loading up an area with family physicians and see what happens. In my view, if these ratios are true, then this is kind of what Iora did.
Good for them, and Nuka. All I ask is that we develop a deeper understanding of WHY total cost reductions happened. Except for patients with severe cases of common chronic diseases, it had nothing to do with wellness interventions, prevention, screening, or treating chronic diseases. It has everything to do with making access to primary care be the easiest way for a patient to access the system (side thought: I wonder if there are billboards on the highways in Iora cities that say, “The wait time to be seen at Iora Clinic is 10 minutes.” The ERs seem to think it drives business to them.). It has everything to do with specifically limiting access to ologists. It has everything to do with applying the unique culture of high-value family medicine to complex patient situations, where the unique medical decision making of family medicine becomes the “right” way to deliver care.
I very much appreciate the members of this group who know that we need more primary care in this country to achieve better outcomes at a lower cost. But if you keep prioritizing and incentivizing the wrong features and work functions of family medicine, you’ll continue to just make it worse.
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