Atul Gawande from The New Yorker won a National Magazine Award last week for his moving and thought-provoking piece on hospice care entitled "Letting Go". The article is available in its entirety here without subscription, and I highly encourage everyone to read it. (William Deresiewicz's "Solitude and Leadership", about which I wrote my previous post, was a finalist for the same award.)
Anyway, for today's post I want to write about another of Gawande's articles in The New Yorker, that one called "Hot Spotters". The subtitle is: "Can we lower medical costs by giving the neediest patients better care?" The beginning of the article focuses on the use of computerized crime maps "to change police beats and shifts to focus on the worst areas and times"; unfortunately, police in Camden did not want to implement any of the changes advocated by physician (and numbers buff) Jeffrey Brenner, who created and analyzed the maps based on hospital admissions when the police did not bother giving him their own statistics.
But his foray into hospital data provided Brenner with many unexpected and intriguing insights; for instance, "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." He located the two most expensive (in terms of hospital bills) city blocks; "One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million." This mattered because of Brenner's belief that "the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care."
Gawande then describes how Brenner asked physicians to introduce him to their "worst-of-the-worst" patients (those who keep getting admitted in the hospital again and again) and studied these patients to help identify ways to make them take their meds and reduce the likelihood of readmission. The work of Brenner and his staff (who rely on small grants to operate, because of the scarce funding) is already bearing fruit: "The Camden Coalition has been able to measure [the program's] long-term effect on its first thirty-six super-utilizers. They averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction."
The article then discusses a data-analysis company named Verisk Health, which uses medical-intelligence software to identify sick patients getting inadequate care. For instance, "[o]ne in seven [among patients with known coronary-artery disease] had not had a full office visit with a physician in more than a year." There is also an interesting paragraph about a twenty-five-year-old woman who had "twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission" over the past ten months for migraines. Another valuable part is about the way increasing copayments at a large company backfired in trying to keep costs under control because "[t]he sickest patients [who were early retirees] became much more expensive because they put off care and prevention until it was too late."
Gawande then discusses whether medical hot-spotting can truly succeed on a large scale, as it would require the support of true insiders of the medical profession; the examples he gives suggest it is possible: a Medicare demonstration program offering an extra payment to institutions that are able to decrease their costs and, more importantly (and described at length) a clinic in Atlantic City set up to help two large self-insured organizations deal with ballooning costs, and offering a revolutionary approach to health care.
(And the story of the Indian wife whose health took an amazing turn for the best thanks to the "health coach" assigned by the clinic, although the coach had no training in health care before she took the job, because she talks, in Gujarati, like the woman's mother! Heart-warming.) The issues the clinic encountered with outside doctors who stand to lose from a change in the health-care model also served as eye-openers.
An interesting tidbit that Gawande mentions in passing: "A recent report on more than a decade of education-reform spending in Massachusetts detailed a story found in every state. Massachusetts sent nearly a billion dollars to school districts to finance smaller class sizes and better teachers’ pay, yet every dollar ended up being diverted to covering rising health-care costs."
The full, ten-screen-pages-long article contains even more information about this innovative and promising way to reduce health-care costs. A must-read.