In my last post I attempted to list the things I found especially resonant last year in media, entertainment, art and journalism. I say “attempted” because I didn’t keep track of this stuff very well during 2010. In lieu of keeping track, I retroactively scoured my bookmarks in places like delicious, Instapaper and Evernote, and as a result I probably favored things I consumed toward the end of the year and forgot things I encountered in January and February.
In the spirit of trying to do better in 2011, I’ll mention over my next two posts a couple of articles I’ve read recently that are bound to make my greatest hits list at the end of the year.
In the first, Dr. Atul Gawande who writes perhaps better than anyone about healthcare had a recent piece in the New Yorker about the burden of addressing “super-utilizers,” or the most expensive patients. He examines some pioneering new initiatives which show, counter-intuitively, that hospitals can significantly lower costs by giving even more attention to these neediest patients.
He follows a doctor named Jeff Brenner in Camden, NJ who was inspired by the way urban police departments study crime statistics – clustering crimes block by block into hot spots, then targeting law enforcement to get the biggest bang for the buck. He applied a similar strategy to zero in on healthcare hotspots and found, for example that:
…a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city, resulting in almost three million dollars in health-care bills.
And in one low-income housing tower:
…between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.
Armed with this information, Dr. Brenner reaches out to numerous doctors in several hospitals and offers to take on their “worst-of-the-worst” patients, and with the help of his small staff he starts to give these patients the highest degree of personal attention he can. He sees some patients every day. He nags social workers on behalf of patients and escorts them to AA meetings. With this kind of care, these patients who used to visit the emergency room half a dozen times a year, racking up tens of thousands of dollars in bills (paid for by taxpayers), suddenly don’t need the hospital at all. Daily maintenance costs much less.
Gawande visits a company called Verisk Health that specializes in “medical intelligence” for organizations that pay for health insurance. A doctor analyst named Nathan Gunn drills into patient claims and shows Gawande a typical example of the kind of patient who stands out:
All these claims here are migraine, migraine, migraine, migraine, headache, headache, headache.” For a twenty-five-year-old with her profile, he said, medical payments for the previous ten months would be expected to total twenty-eight hundred dollars. Her actual payments came to more than fifty-two thousand dollars—for “headaches.”
Was she a drug seeker? He pulled up her prescription profile, looking for narcotic prescriptions. Instead, he found prescriptions for insulin (she was apparently diabetic) and imipramine, an anti-migraine treatment. Gunn was struck by how faithfully she filled her prescriptions. She hadn’t missed a single renewal—“which is actually interesting,” he said. That’s not what you usually find at the extreme of the cost curve.
The story now became clear to him. She suffered from terrible migraines. She took her medicine, but it wasn’t working. When the headaches got bad, she’d go to the emergency room or to urgent care. The doctors would do CT and MRI scans, satisfy themselves that she didn’t have a brain tumor or an aneurysm, give her a narcotic injection to stop the headache temporarily, maybe renew her imipramine prescription, and send her home, only to have her return a couple of weeks later and see whoever the next doctor on duty was. She wasn’t getting what she needed for adequate migraine care—a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her headaches at bay.
A typical strategy companies employ to lower their healthcare costs is to require employees to pay higher premiums. Employees respond by decreasing the frequency of their doctor visits. Unfortunately, even the sickest employees put off visiting the doctor, which winds up generating higher costs in the end. Dr. Gunn and Verisk Health use this kind of information to persuade companies that better, more-focused care is a more effective strategy than higher premiums.
Finally, Gawande spends time at a clinic in Atlantic City run by a doctor named Rushika Fernandopulle who invented a role he calls “health coach” and hired eight of them to work on his staff – outnumbering his doctors, nurses and nurse practitioners. His approach is a more formalized version of what Dr. Brenner is doing, where each staff member is tasked with meeting very specific goals. One nurse practitioner for example is in charge of getting all the patients to quit smoking.
Gawande is not a political writer, and this isn’t a political article. It’s a delight to read a piece on healthcare that is completely devoid of demagoguery. It’s almost unfortunate that Gawande notes in passing at one point that the Affordable Care Act (I refuse to call it “Obamacare”) makes some money available for the kinds of pilot projects highlighted in the article, and Dr. Fernandopulle’s clinic has made use of that money. I say unfortunate because the mere mention of the healthcare bill will be read as endorsement, and for some readers this will cast a dark shadow across the whole article.
My own feeling is that conservatives who decry the healthcare bill because of its failure to address costs should perhaps appreciate the way the bill encourages private sector solutions, and the way it requires many super-utilizer patients to be insured and thereby help pay for the kind of high-touch ongoing care that keeps them healthier and ultimately saves taxpayers money.