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May 2011

Analytics and health care

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.

Solitude and Leadership

I recently came across an essay entitled "Solitude and Leadership" by William Deresiewicz, which has been named a finalist for a National Magazine Award in the category Essays and Criticism (winners will be announced next week). The article, published in the Spring 2010 issue of American Scholar, is the transcript of a lecture the author gave at West Point in October 2009. I thought I'd mention a few of the points Deresiewicz - who taught English at Yale until 2008 - makes about leadership:

  • Although a large part of the American elite ("the people in charge of government, business, academia, and all our major institutions - senators, judges, CEOs, college presidents, and so forth") comes from Ivy League institutions or West Point, Deresiewicz had difficulty viewing his students as leaders, and he argues that exceptional achievement does not equate leadership. ("Great heart surgeons or great novelists or great shortstops may be terrific at what they do, but that doesn't mean they're leaders.")
  • He discusses the number of extracurricular activities that high school students must have on their resume to be viable candidates to the top colleges (hint: six is not enough), and describes the students who do get admitted as "great kids who had been trained to be world-class hoop jumpers" or, in the words of a student herself, "excellent sheep". It seems that universities' goal has become to "educat[e] people who make a big name for themselves in the world, people with impressive titles, people the university can brag about." This, of course, has little to do with leadership.
  • Here comes the best part of the article - the discussion of Heart of Darkness, the novel by Joseph Conrad - set "in the Belgian Congo three generations before Vietnam" - which inspired the movie Apocalypse Now by Francis Ford Coppola. More specifically, Deresiewicz discusses the bureaucracy angle to the story. Make sure you read the quote of Conrad's novel that starts with "He was commonplace in complexion" and later the paragraph by Deresiewicz that begins with "That's really the great mystery about bureaucracies. Why is it so often that the best people are stuck in the middle and the people who are running things - the leaders - are the mediocrities?"
  • I also enjoyed learning more about the career path of General David Petraeus, who apparently annoyed his supervisor when he "develop[ed] the strategy he would later formulate in the Counterinsurgency Field Manual" because he "was way ahead of the leadership" and was assigned what was regarded as a dead-end job. "But he stuck to his guns, and ultimately he was vindicated." 
  • I loved the part about researchers at Stanford who have shown students, contrary to what they believe, do not actually multitask effectively. I completely agree - I am a big proponent of doing only one task at a time, and also taking breaks from technology (especially cell phones and email) for increased focus. "[Researchers] found that in every case the high multitaskers scored worse. They were worse at distinguishing between relevant and irrelevant information and ignoring the latter... they were worse at... "mental filing"... their minds were more disorganized. And they were even worse at the very thing that defines multitasking itself: switching between tasks."
  • Deresiewicz then completes the lecture by elaborating on his original point of introspection, the sort of independent thinking made possible by solitude, which is necessary now to, later, "find the strength and wisdom to challenge an unwise order or question a wrongheaded policy" - in the same way, I think, that you want to have made a plan for action in the face of emergencies before they arise, Deresiewicz urges West Point plebes to consider dilemmas now "so you will have the strength to deal with them when they arise."

"Solitude and Leadership" was an outstanding read. It is in competition for the National Magazine Award with several other excellent magazine articles such as "The Hot Spotters" by Atul Gawande in the New Yorker, so it is difficult to guess the lecture's odds of winning, but we would all benefit from reading it - and examine what we can do to help students become future leaders.