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If Camden, New Jersey, becomes the first American = community=20 to lower its medical costs, it will have a murder to thank. At = nine-fifty on a=20 February night in 2001, a twenty-two-year-old black man was shot while = driving=20 his Ford Taurus station wagon through a neighborhood on the edge of the = Rutgers=20 University campus. The victim lay motionless in the street beside the = open door=20 on the driver=92s side, as if the car had ejected him. A neighborhood = couple, a=20 physical therapist and a volunteer firefighter, approached to see if = they could=20 help, but police waved them back.
=93He=92s not going to make it,=94 an officer reportedly told the = physical=20 therapist. =93He=92s pretty much dead.=94 She called a physician, = Jeffrey Brenner, who=20 lived a few doors up the street, and he ran to the scene with a = stethoscope and=20 a pocket ventilation mask. After some discussion, the police let him = enter the=20 crime scene and attend to the victim. Witnesses told the local newspaper = that he=20 was the first person to lay hands on the man.
=93He was slightly overweight, turned on his side,=94 Brenner = recalls. There was=20 glass everywhere. Although the victim had been shot several times and = many=20 minutes had passed, his body felt warm. Brenner checked his neck for a = carotid=20 pulse. The man was alive. Brenner began the chest compressions and = rescue=20 breathing that should have been started long before. But the young man, = who=20 turned out to be a Rutgers student, died soon afterward.
The incident became a local scandal. The student=92s injuries may not = have been=20 survivable, but the police couldn=92t have known that. After the = ambulance came,=20 Brenner confronted one of the officers to ask why they hadn=92t tried to = rescue=20 him.
=93We didn=92t want to dislodge the bullet,=94 he recalls the = policeman saying. It=20 was a ridiculous answer, a brushoff, and Brenner couldn=92t let it go. =
He was thirty-one years old at the time, a skinny, thick-bearded, = soft-spoken=20 family physician who had grown up in a bedroom suburb of Philadelphia. = As a=20 medical student at Robert Wood Johnson Medical School, in Piscataway, he = had=20 planned to become a neuroscientist. But he volunteered once a week in a = free=20 primary-care clinic for poor immigrants, and he found the work there = more=20 challenging than anything he was doing in the laboratory. The guy = studying=20 neuronal stem cells soon became the guy studying Spanish and training to = become=20 one of the few family physicians in his class. Once he completed his = residency,=20 in 1998, he joined the staff of a family-medicine practice in Camden. It = was in=20 a cheaply constructed, boxlike, one-story building on a desolate street = of bars,=20 car-repair shops, and empty lots. But he was young and eager to = recapture the=20 sense of purpose he=92d felt volunteering at the clinic during medical = school.
Few people shared his sense of possibility. Camden was in civic free = fall, on=20 its way to becoming one of the poorest, most crime-ridden cities in the = nation.=20 The local school system had gone into receivership. Corruption and = mismanagement=20 soon prompted a state takeover of the entire city. Just getting the = sewage=20 system to work could be a problem. The neglect of this anonymous = shooting victim=20 on Brenner=92s street was another instance of a city that had given up, = and=20 Brenner was tired of wondering why it had to be that way.
Around that time, a police reform commission was created, and Brenner = was=20 asked to serve as one of its two citizen members. He agreed and, to his=20 surprise, became completely absorbed. The experts they called in = explained the=20 basic principles of effective community policing. He learned about = George=20 Kelling and James Q. Wilson=92s =93broken-windows=94 theory, which = argued that minor,=20 visible neighborhood disorder breeds major crime. He learned about the = former=20 New York City police commissioner William Bratton and the Compstat = approach to=20 policing that he had championed in the nineties, which centered on = mapping crime=20 and focussing resources on the hot spots. The reform panel pushed the = Camden=20 Police Department to create computerized crime maps, and to change = police beats=20 and shifts to focus on the worst areas and times.
When the police wouldn=92t make the crime maps, Brenner made his own. = He=20 persuaded Camden=92s three main hospitals to let him have access to = their medical=20 billing records. He transferred the reams of data files onto a desktop = computer,=20 spent weeks figuring out how to pull the chaos of information into a = searchable=20 database, and then started tabulating the emergency-room visits of = victims of=20 serious assault. He created maps showing where the crime victims lived. = He=20 pushed for policies that would let the Camden police chief assign shifts = based=20 on the crime statistics=97only to find himself in a showdown with the = police=20 unions.
=93He has no clue,=94 the president of the city police superiors=92 = union said to=20 the Philadelphia Inquirer. =93I just think that his comments = about what=20 kind of schedule we should be on, how we should be deployed, are = laughable.=94=20
The unions kept the provisions out of the contract. The reform = commission=20 disbanded; Brenner withdrew from the cause, beaten. But he continued to = dig into=20 the database on his computer, now mostly out of idle interest.
Besides looking at assault patterns, he began studying patterns in = the way=20 patients flowed into and out of Camden=92s hospitals. =93I=92d just sit = there and play=20 with the data for hours,=94 he says, and the more he played the more he = found. For=20 instance, he ran the data on the locations where ambulances picked up = patients=20 with fall injuries, and discovered that a single building in central = Camden sent=20 more people to the hospital with serious falls=97fifty-seven elderly in = two=20 years=97than any other in the city, resulting in almost three million = dollars in=20 health-care bills. =93It was just this amazing window into the = health-care=20 delivery system,=94 he says.
So he took what he learned from police reform and tried a Compstat = approach=20 to the city=92s health-care performance=97a Healthstat, so to speak. He = made=20 block-by-block maps of the city, color-coded by the hospital costs of = its=20 residents, and looked for the hot spots. The two most expensive city = blocks were=20 in north Camden, one that had a large nursing home called Abigail House = and one=20 that had a low-income housing tower called Northgate II. He found that = between=20 January of 2002 and June of 2008 some nine hundred people in the two = buildings=20 accounted for more than four thousand hospital visits and about two = hundred=20 million dollars in health-care bills. One patient had three hundred and=20 twenty-four admissions in five years. The most expensive patient cost = insurers=20 $3.5 million.
Brenner wasn=92t all that interested in costs; he was more interested = in=20 helping people who received bad health care. But in his experience the = people=20 with the highest medical costs=97the people cycling in and out of the=20 hospital=97were usually the people receiving the worst care. = =93Emergency-room=20 visits and hospital admissions should be considered failures of the = health-care=20 system until proven otherwise,=94 he told me=97failures of prevention = and of timely,=20 effective care.
If he could find the people whose use of medical care was highest, he = figured, he could do something to help them. If he helped them, he would = also be=20 lowering their health-care costs. And, if the stats approach to crime = was right,=20 targeting those with the highest health-care costs would help lower the = entire=20 city=92s health-care costs. His calculations revealed that just one per = cent of=20 the hundred thousand people who made use of Camden=92s medical = facilities=20 accounted for thirty per cent of its costs. That=92s only a thousand = people=97about=20 half the size of a typical family physician=92s panel of patients.
Things, of course, got complicated. It would have taken months to get = the=20 approvals needed to pull names out of the data and approach people, and = he was=20 impatient to get started. So, in the spring of 2007, he held a meeting = with a=20 few social workers and emergency-room doctors from hospitals around the = city. He=20 showed them the cost statistics and use patterns of the most expensive = one per=20 cent. =93These are the people I want to help you with,=94 he said. He = asked for=20 assistance reaching them. =93Introduce me to your worst-of-the-worst = patients,=94 he=20 said.
They did. Then he got permission to look up the patients=92 data to = confirm=20 where they were on his cost map. =93For all the stupid, expensive,=20 predictive-modelling software that the big venders sell,=94 he says, = =93you just ask=20 the doctors, =91Who are your most difficult patients?,=92 and they can = identify=20 them.=94
The first person they found for him was a man in his mid-forties whom = I=92ll=20 call Frank Hendricks. Hendricks had severe congestive heart failure, = chronic=20 asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of = smoking=20 and alcohol abuse. He weighed five hundred and sixty pounds. In the = previous=20 three years, he had spent as much time in hospitals as out. When Brenner = met=20 him, he was in intensive care with a tracheotomy and a feeding tube, = having=20 developed septic shock from a gallbladder infection.
Brenner visited him daily. =93I just basically sat in his room like I = was a=20 third-year med student, hanging out with him for an hour, hour and a = half every=20 day, trying to figure out what makes the guy tick,=94 he recalled. He = learned that=20 Hendricks used to be an auto detailer and a cook. He had a longtime = girlfriend=20 and two children, now grown. A toxic combination of poor health, Johnnie = Walker=20 Red, and, it emerged, cocaine addiction had left him unreliably = employed,=20 uninsured, and living in a welfare motel. He had no consistent set of = doctors,=20 and almost no prospects for turning his situation around.
After several months, he had recovered enough to be discharged. But, = out in=20 the world, his life was simply another hospitalization waiting to = happen. By=20 then, however, Brenner had figured out a few things he could do to help. = Some of=20 it was simple doctor stuff. He made sure he followed Hendricks closely = enough to=20 recognize when serious problems were emerging. He double-checked that = the plans=20 and prescriptions the specialists had made for Hendricks=92s many = problems=20 actually fit together=97and, when they didn=92t, he got on the phone to = sort things=20 out. He teamed up with a nurse practitioner who could make home visits = to check=20 blood-sugar levels and blood pressure, teach Hendricks about what he = could do to=20 stay healthy, and make sure he was getting his medications.
A lot of what Brenner had to do, though, went beyond the usual doctor = stuff.=20 Brenner got a social worker to help Hendricks apply for disability = insurance, so=20 that he could leave the chaos of welfare motels, and have access to a = consistent=20 set of physicians. The team also pushed him to find sources of stability = and=20 value in his life. They got him to return to Alcoholics Anonymous, and, = when=20 Brenner found out that he was a devout Christian, he urged him to return = to=20 church. He told Hendricks that he needed to cook his own food once in a = while,=20 so he could get back in the habit of doing it. The main thing he was up = against=20 was Hendricks=92s hopelessness. He=92d given up. =93Can you imagine = being in the=20 hospital that long, what that does to you?=94 Brenner asked.
I spoke to Hendricks recently. He has gone without alcohol for a = year,=20 cocaine for two years, and smoking for three years. He lives with his = girlfriend=20 in a safer neighborhood, goes to church, and weathers family crises. He = cooks=20 his own meals now. His diabetes and congestive heart failure are under = much=20 better control. He=92s lost two hundred and twenty pounds, which means, = among=20 other things, that if he falls he can pick himself up, rather than = having to=20 call for an ambulance.
=93The fun thing about this work is that you can be there when the = light switch=20 goes on for a patient,=94 Brenner told me. =93It doesn=92t happen at the = pace we want.=20 But you can see it happen.=94
With Hendricks, there was no miraculous turnaround. =93Working with = him didn=92t=20 feel any different from working with any patient on smoking, bad diet, = not=20 exercising=97working on any particular rut someone has gotten into,=94 = Brenner said.=20 =93People are people, and they get into situations they don=92t = necessarily plan on.=20 My philosophy about primary care is that the only person who has changed = anyone=92s life is their mother. The reason is that she cares about = them, and she=20 says the same simple thing over and over and over.=94 So he tries to = care, and to=20 say a few simple things over and over and over.
I asked Hendricks what he made of Brenner when they first met.
=93He struck me as odd,=94 Hendricks said. =93His appearance was not = what I=20 expected of a young, clean-cut doctor.=94 There was that beard. There = was his=20 manner, too. =93His whole premise was =91I=92m here for you. I=92m not = here to be a part=20 of the medical system. I=92m here to get you back on your feet.=92 = =94
An ordinary cold can still be a major setback for Hendricks. He told = me that=20 he=92d been in the hospital four times this past summer. But the stays = were a few=20 days at most, and he=92s had no more cataclysmic, weeks-long I.C.U. = stays.
Was this kind of success replicable? As word went out about = Brenner=92s=20 interest in patients like Hendricks, he received more referrals. Camden = doctors=20 were delighted to have someone help with their =93worst of the worst.=94 = He took on=20 half a dozen patients, then two dozen, then more. It became increasingly = difficult to do this work alongside his regular medical practice. The = clinic was=20 already under financial strain, and received nothing for assisting these = patients. If it were up to him, he=92d recruit a whole staff of = primary-care=20 doctors and nurses and social workers, based right in the neighborhoods = where=20 the costliest patients lived. With the tens of millions of dollars in = hospital=20 bills they could save, he=92d pay the staff double to serve as = Camden=92s =E9lite=20 medical force and to rescue the city=92s health-care system.
But that=92s not how the health-insurance system is built. So he = applied for=20 small grants from philanthropies like the Robert Wood Johnson Foundation = and the=20 Merck Foundation. The money allowed him to ramp up his data system and = hire a=20 few people, like the nurse practitioner and the social worker who had = helped him=20 with Hendricks. He had some desk space at Cooper Hospital, and he turned = it over=20 to what he named the Camden Coalition of Healthcare Providers. He spoke = to=20 people who had been doing similar work, studied =93medical home=94 = programs for the=20 chronically ill in Seattle, San Francisco, and Pennsylvania, and adopted = some of=20 their lessons. By late 2010, his team had provided care for more than = three=20 hundred people on his =93super-utilizer=94 map.
I spent a day with Kathy Jackson, the nurse practitioner, and Jessica = Cordero, a medical assistant, to see what they did. The Camden Coalition = doesn=92t=20 have enough money for a clinic where they can see patients. They rely=20 exclusively on home visits and phone calls.
Over the phone, they inquire about emerging health issues, check for=20 insurance or housing problems, ask about unfilled prescriptions. All the = patients get the team=92s urgent-call number, which is covered by = someone who can=20 help them through a health crisis. Usually, the issue can be resolved on = the=20 spot=97it=92s a headache or a cough or the like=97but sometimes it = requires an=20 unplanned home visit, to perform an examination, order some tests, = provide a=20 prescription. Only occasionally does it require an emergency room.
Patients wouldn=92t make the call in the first place if the person = picking up=20 weren=92t someone like Jackson or Brenner=97someone they already knew = and trusted.=20 Even so, patients can disappear for days or weeks at a time. = =93High-utilizer work=20 is about building relationships with people who are in crisis,=94 = Brenner said.=20 =93The ones you build a relationship with, you can change behavior. Half = we can=20 build a relationship with. Half we can=92t.=94
One patient I spent time with illustrated the challenges. If you were = a=20 doctor meeting him in your office, you would quickly figure out that his = major=20 problems were moderate developmental deficits and out-of-control = hypertension=20 and diabetes. His blood pressure and blood sugars were so high that, at = the age=20 of thirty-nine, he was already developing blindness and advanced kidney = disease.=20 Unless something changed, he was perhaps six months away from complete = kidney=20 failure.
You might decide to increase his insulin dose and change his = blood-pressure=20 medicine. But you wouldn=92t grasp what the real problem was until you = walked up=20 the cracked concrete steps of the two-story brownstone where he lives = with his=20 mother, waited for him to shove aside the old newspapers and unopened = mail=20 blocking the door, noticed Cordero=92s shake of the head warning you not = to take=20 the rumpled seat he=92s offering because of the ant trail running across = it, and=20 took in the stack of dead computer monitors, the barking mutt chained to = an=20 inner doorway, and the rotten fruit on a newspaper-covered tabletop. = According=20 to a state evaluation, he was capable of handling his medications, and, = besides,=20 he lived with his mother, who could help. But one look made it clear = that they=20 were both incapable.
Jackson asked him whether he was taking his blood-pressure pills each = day.=20 Yes, he said. Could he show her the pill bottles? As it turned out, he = hadn=92t=20 taken any pills since she=92d last visited, the week before. His = finger-stick=20 blood sugar was twice the normal level. He needed a better living = situation. The=20 state had turned him down for placement in supervised housing, pointing = to his=20 test scores. But after months of paperwork=97during which he steadily = worsened,=20 passing in and out of hospitals=97the team was finally able to get him = into=20 housing where his medications could be dispensed on a schedule. He had = made an=20 overnight visit the previous weekend to test the place out.
=93I liked it,=94 he said. He moved in the next week. And, with that, = he got a=20 chance to avert dialysis=97and its tens of thousands of dollars in = annual costs=97at=20 least for a while.
Not everyone lets the team members into his or her life. One of their = patients is a young woman of no fixed address, with asthma and a = crack-cocaine=20 habit. The crack causes severe asthma attacks and puts her in the = hospital over=20 and over again. The team members have managed occasionally to track her = down in=20 emergency rooms or recognize her on street corners. All they can do is = give her=20 their number, and offer their help if she ever wanted it. She = hasn=92t.
Work like this has proved all-consuming. In May, 2009, Brenner closed = his=20 regular medical practice to focus on the program full time. It remains = unclear=20 how the program will make ends meet. But he and his team appear to be = having a=20 major impact. The Camden Coalition has been able to measure its = long-term effect=20 on its first thirty-six super-utilizers. They averaged sixty-two = hospital and=20 E.R. visits per month before joining the program and thirty-seven visits = after=97a=20 forty-per-cent reduction. Their hospital bills averaged $1.2 million per = month=20 before and just over half a million after=97a fifty-six-per-cent = reduction.
These results don=92t take into account Brenner=92s personnel costs, = or the costs=20 of the medications the patients are now taking as prescribed, or the = fact that=20 some of the patients might have improved on their own (or died, reducing = their=20 costs permanently). The net savings are undoubtedly lower, but they = remain,=20 almost certainly, revolutionary. Brenner and his team are out there on = the=20 boulevards of Camden demonstrating the possibilities of a strange new = approach=20 to health care: to look for the most expensive patients in the system = and then=20 direct resources and brainpower toward helping them.
Jeff Brenner has not been the only one to recognize = the=20 possibilities in focussing on the hot spots of medicine. One Friday = afternoon, I=20 drove to an industrial park on the outskirts of Boston, where a rapidly = growing=20 data-analysis company called Verisk Health occupies a floor of a = nondescript=20 office complex. It supplies =93medical intelligence=94 to organizations = that pay for=20 health benefits=97self-insured businesses, many public employers, even = the=20 government of Abu Dhabi.
Privacy laws prevent U.S. employers from looking at the details of = their=20 employees=92 medical spending. So they hand their health-care payment = data over to=20 companies that analyze the patterns and tell them how to reduce their=20 health-insurance spending. Mostly, these companies give financial advice = on=20 changing benefits=97telling them, say, to increase employee co-payments = for=20 brand-name drugs or emergency-room visits. But even employers who cut = benefits=20 find that their costs continue to outpace their earnings. Verisk, whose = clients=20 pay health-care bills for fifteen million patients, is among the data = companies=20 that are trying a more sophisticated approach.
Besides the usual statisticians and economists, Verisk recruited = doctors to=20 dive into the data. I met one of them, Nathan Gunn, who was thirty-six = years=20 old, had completed his medical training at the University of California, = San=20 Francisco, and was practicing as an internist part time. The rest of his = time he=20 worked as Verisk=92s head of research. Mostly, he was in meetings or at = his desk=20 poring through =93data runs=94 from clients. He insisted that it was = every bit as=20 absorbing as seeing sick patients=97sometimes more so. Every data run = tells a=20 different human story, he said.
At his computer, he pulled up a data set for me, scrubbed of = identifying=20 information, from a client that manages health-care benefits for some = two=20 hundred and fifty employers=97school districts, a large church = association, a bus=20 company, and the like. They had a hundred thousand =93covered lives=94 = in all.=20 Payouts for those people rose eight per cent a year, at least three = times as=20 fast as the employers=92 earnings. This wasn=92t good, but the numbers = seemed pretty=20 dry and abstract so far. Then he narrowed the list to the top five per = cent of=20 spenders=97just five thousand people accounted for almost sixty per cent = of the=20 spending=97and he began parsing further.
=93Take two ten-year-old boys with asthma,=94 he said. =93From a = disease=20 standpoint, they=92re exactly the same cost, right? Wrong. Imagine one = of those=20 kids never fills his inhalers and has been in urgent care with asthma = attacks=20 three times over the last year, probably because Mom and Dad aren=92t = really on=20 top of it.=94 That=92s the sort of patient Gunn uses his company=92s=20 medical-intelligence software program to zero in on=97a patient who is = sick and=20 getting inadequate care. =93That=92s really the sweet spot for = preventive care,=94=20 Gunn said.
He pulled up patients with known coronary-artery disease. There were = nine=20 hundred and twenty-one, he said, reading off the screen. He clicked a = few more=20 times and raised his eyebrows. One in seven of them had not had a full = office=20 visit with a physician in more than a year. =93You can do something = about that,=94=20 he said.
=93Let=92s do the E.R.-visit game,=94 he went on. =93This is a fun = one.=94 He sorted=20 the patients by number of visits, much as Jeff Brenner had done for = Camden. In=20 this employed population, the No. 1 patient was a twenty-five-year-old = woman. In=20 the past ten months, she=92d had twenty-nine E.R. visits, fifty-one = doctor=92s=20 office visits, and a hospital admission.
=93I can actually drill into these claims,=94 he said, squinting at = the screen.=20 =93All these claims here are migraine, migraine, migraine, migraine, = headache,=20 headache, headache.=94 For a twenty-five-year-old with her profile, he = said,=20 medical payments for the previous ten months would be expected to total=20 twenty-eight hundred dollars. Her actual payments came to more than = fifty-two=20 thousand dollars=97for =93headaches.=94
Was she a drug seeker? He pulled up her prescription profile, looking = for=20 narcotic prescriptions. Instead, he found prescriptions for insulin (she = was=20 apparently diabetic) and imipramine, an anti-migraine treatment. Gunn = was struck=20 by how faithfully she filled her prescriptions. She hadn=92t missed a = single=20 renewal=97=93which is actually interesting,=94 he said. That=92s not = what you usually=20 find at the extreme of the cost curve.
The story now became clear to him. She suffered from terrible = migraines. She=20 took her medicine, but it wasn=92t working. When the headaches got bad, = she=92d go=20 to the emergency room or to urgent care. The doctors would do CT and MRI = scans,=20 satisfy themselves that she didn=92t have a brain tumor or an aneurysm, = give her a=20 narcotic injection to stop the headache temporarily, maybe renew her = imipramine=20 prescription, and send her home, only to have her return a couple of = weeks later=20 and see whoever the next doctor on duty was. She wasn=92t getting what = she needed=20 for adequate migraine care=97a primary physician taking her in hand, = trying=20 different medications in a systematic way, and figuring out how to = better keep=20 her headaches at bay.
As he sorts through such stories, Gunn usually finds larger patterns, = too. He=20 told me about an analysis he had recently done for a big = information-technology=20 company on the East Coast. It provided health benefits to seven thousand = employees and family members, and had forty million dollars in = =93spend.=94 The firm=20 had already raised the employees=92 insurance co-payments considerably, = hoping to=20 give employees a reason to think twice about unnecessary medical visits, = tests,=20 and procedures=97make them have some =93skin in the game,=94 as they = say. Indeed,=20 almost every category of costly medical care went down: doctor visits,=20 emergency-room and hospital visits, drug prescriptions. Yet employee = health=20 costs continued to rise=97climbing almost ten per cent each year. The = company was=20 baffled.
Gunn=92s team took a look at the hot spots. The outliers, it turned = out, were=20 predominantly early retirees. Most had multiple chronic conditions=97in=20 particular, coronary-artery disease, asthma, and complex mental illness. = One had=20 badly worsening heart disease and diabetes, and medical bills over two = years in=20 excess of eighty thousand dollars. The man, dealing with higher = co-payments on a=20 fixed income, had cut back to filling only half his medication = prescriptions for=20 his high cholesterol and diabetes. He made few doctor visits. He avoided = the=20 E.R.=97until a heart attack necessitated emergency surgery and left him = disabled=20 with chronic heart failure.
The higher co-payments had backfired, Gunn said. While medical costs = for most=20 employees flattened out, those for early retirees jumped seventeen per = cent. The=20 sickest patients became much more expensive because they put off care = and=20 prevention until it was too late.
The critical flaw in our health-care system that people like Gunn and = Brenner=20 are finding is that it was never designed for the kind of patients who = incur the=20 highest costs. Medicine=92s primary mechanism of service is the doctor = visit and=20 the E.R. visit. (Americans make more than a billion such visits each = year,=20 according to the Centers for Disease Control.) For a thirty-year-old = with a=20 fever, a twenty-minute visit to the doctor=92s office may be just the = thing. For a=20 pedestrian hit by a minivan, there=92s nowhere better than an emergency = room. But=20 these institutions are vastly inadequate for people with complex = problems: the=20 forty-year-old with drug and alcohol addiction; the eighty-four-year-old = with=20 advanced Alzheimer=92s disease and a pneumonia; the sixty-year-old with = heart=20 failure, obesity, gout, a bad memory for his eleven medications, and = half a=20 dozen specialists recommending different tests and procedures. It=92s = like=20 arriving at a major construction project with nothing but a screwdriver = and a=20 crane.
Outsiders tend to be the first to recognize the inadequacies of our = social=20 institutions. But, precisely because they are outsiders, they are = usually in a=20 poor position to fix them. Gunn, though a doctor, mostly works for = people who do=20 not run health systems=97employers and insurers. So he counsels them = about ways to=20 tinker with the existing system. He tells them how to change co-payments = and=20 deductibles so they at least aren=92t making their cost problems worse. = He=20 identifies doctors and hospitals that seem to be providing particularly=20 ineffective care for high-needs patients, and encourages clients to = shift=20 contracts. And he often suggests that clients hire case-management = companies=97a=20 fast-growing industry with telephone banks of nurses offering high-cost = patients=20 advice in the hope of making up for the deficiencies of the system.
The strategy works, sort of. Verisk reports that most of its clients = can slow=20 the rate at which their health costs rise, at least to some extent. But = few have=20 seen decreases, and it=92s not obvious that the improvements can be = sustained.=20 Brenner, by contrast, is reinventing medicine from the inside. But he = does not=20 run a health-care system, and had to give up his practice to sustain his = work.=20 He is an outsider on the inside. So you might wonder whether medical=20 hot-spotting can really succeed on a scale that would help large = populations.=20 Yet there are signs that it can.
A recent Medicare demonstration program, given substantial additional = resources under the new health-care-reform law, offers medical = institutions an=20 extra monthly payment to finance the co=F6rdination of care for their = most=20 chronically expensive beneficiaries. If total costs fall more than five = per cent=20 compared with those of a matched set of control patients, the program = allows=20 institutions to keep part of the savings. If costs fail to decline, the=20 institutions have to return the monthly payments.
Several hospitals took the deal when the program was offered, in = 2006. One=20 was the Massachusetts General Hospital, in Boston. It asked a general = internist=20 named Tim Ferris to design the effort. The hospital had twenty-six = hundred=20 chronically high-cost patients, who together accounted for sixty million = dollars=20 in annual Medicare spending. They were in nineteen primary-care = practices, and=20 Ferris and his team made sure that each had a nurse whose sole job was = to=20 improve the co=F6rdination of care for these patients. The doctors saw = the=20 patients as usual. In between, the nurses saw them for longer visits, = made=20 surveillance phone calls, and, in consultation with the doctors, tried = to=20 recognize and address problems before they resulted in a hospital = visit.
Three years later, hospital stays and trips to the emergency room = have=20 dropped more than fifteen per cent. The hospital hit its five-per-cent=20 cost-reduction target. And the team is just getting the hang of what it = can=20 do.
Recently, I visited an even more radically = redesigned=20 physician practice, in Atlantic City. Cross the bridge into town = (Atlantic City=20 is on an island, I learned), ignore the Trump Plaza and Caesars casinos = looming=20 ahead of you, drive a few blocks along the Monopoly-board streets (the = game took=20 its street names from here), turn onto Tennessee Avenue, and enter the = doctors=92=20 office building that=92s across the street from the ninety-nine-cent = store and the=20 city=92s long-shuttered supermarket. On the second floor, just past the=20 occupational-health clinic, you will find the Special Care Center. The = reception=20 area, with its rustic taupe upholstery and tasteful lighting, looks like = any=20 other doctors=92 office. But it houses an experiment started in 2007 by = the=20 health-benefit programs of the casino workers=92 union and of a = hospital,=20 AtlantiCare Medical Center, the city=92s two largest pools of = employees.
Both are self-insured=97they are large enough to pay for their = workers=92 health=20 care directly=97and both have been hammered by the exploding costs. Yes, = even=20 hospitals are having a hard time paying their employees=92 medical = bills. As for=20 the union, its contracts are frequently for workers=92 total = compensation=97wages=20 plus benefits. It gets a fixed pot. Year after year, the low-wage = busboys, hotel=20 cleaners, and kitchen staff voted against sacrificing their health = benefits. As=20 a result, they have gone without a wage increase for years. Out of = desperation,=20 the union=92s health fund and the hospital decided to try something new. = They got=20 a young Harvard internist named Rushika Fernandopulle to run a clinic=20 exclusively for workers with exceptionally high medical expenses.
Fernandopulle, who was born in Sri Lanka and raised in Baltimore, = doesn=92t=20 seem like a radical when you meet him. He=92s short and round-faced, = smiles a lot,=20 and displays two cute rabbit teeth as he tells you how ridiculous the=20 health-care system is and how he plans to change it all. Jeff Brenner = was on his=20 advisory board, along with others who have pioneered the concept of = intensive=20 outpatient care for complex high-needs patients. The hospital provided = the floor=20 space. Fernandopulle created a point system to identify employees likely = to have=20 high recurrent costs, and they were offered the chance to join the new=20 clinic.
The Special Care Center reinvented the idea of a primary-care clinic = in=20 almost every way. The union=92s and the hospital=92s health funds agreed = to switch=20 from paying the doctors for every individual office visit and treatment = to=20 paying a flat monthly fee for each patient. That cut the huge expense = that most=20 clinics incur from billing paperwork. The patients were given unlimited = access=20 to the clinic without charges=97no co-payments, no insurance bills. = This,=20 Fernandopulle explained, would force doctors on staff to focus on = service, in=20 order to retain their patients and the fees they would bring.
The payment scheme also allowed him to design the clinic around the = things=20 that sick, expensive patients most need and value, rather than the ones = that pay=20 the best. He adopted an open-access scheduling system to guarantee = same-day=20 appointments for the acutely ill. He customized an electronic = information system=20 that tracks whether patients are meeting their goals. And he staffed the = clinic=20 with people who would help them do it. One nurse practitioner, for = instance, was=20 responsible for trying to get every smoker to quit.
I got a glimpse of how unusual the clinic is when I sat in on the = staff=20 meeting it holds each morning to review the medical issues of the = patients on=20 the appointment books. There was, for starters, the very existence of = the=20 meeting. I had never seen this kind of daily huddle at a doctor=92s = office, with=20 clinicians popping open their laptops and pulling up their patient lists = together. Then there was the particular mixture of people who squeezed = around=20 the conference table. As in many primary-care offices, the staff had two = physicians and two nurse practitioners. But a full-time social worker = and the=20 front-desk receptionist joined in for the patient review, too. And, = outnumbering=20 them all, there were eight full-time =93health coaches.=94
Fernandopulle created the position. Each health coach works with = patients=97in=20 person, by phone, by e-mail=97to help them manage their health. = Fernandopulle got=20 the idea from the promotoras, community health workers, whom he = had seen=20 on a medical mission in the Dominican Republic. The coaches work with = the=20 doctors but see their patients far more frequently than the doctors do, = at least=20 once every two weeks. Their most important attribute, Fernandopulle = explained,=20 is a knack for connecting with sick people, and understanding their=20 difficulties. Most of the coaches come from their patients=92 = communities and=20 speak their languages. Many have experience with chronic illness in = their own=20 families. (One was himself a patient in the clinic.) Few had clinical=20 experience. I asked each of the coaches what he or she had done before = working=20 in the Special Care Center. One worked the register at a Dunkin=92 = Donuts. Another=20 was a Sears retail manager. A third was an administrative assistant at a = casino.=20
=93We recruit for attitude and train for skill,=94 Fernandopulle = said. =93We don=92t=20 recruit from health care. This kind of care requires a very different = mind-set=20 from usual care. For example, what is the answer for a patient who walks = up to=20 the front desk with a question? The answer is =91Yes.=92 =91Can I see a = doctor?=92=20 =91Yes.=92 =91Can I get help making my ultrasound appointment?=92 = =91Yes.=92 Health care=20 trains people to say no to patients.=94 He told me that he=92d had to = replace half=20 of the clinic=92s initial hires=97including a doctor=97because they = didn=92t grasp the=20 focus on patient service.
In forty-five minutes, the staff did a rapid run-through of = everyone=92s=20 patients. They reviewed the requests that patients had made by e-mail or = telephone, the plans for the ones who had appointments that day. Staff = members=20 made sure that all patients who made a sick visit the day before got a = follow-up=20 call within twenty-four hours, that every test ordered was reviewed, = that every=20 unexpected problem was addressed.
Most patients required no more than a ten-second mention. Mr. Green = didn=92t=20 turn up for his cardiac testing or return calls about it. =93I know = where his wife=20 works. I=92ll track her down,=94 the receptionist said. Ms. Blue is = pregnant and on=20 a high-blood-pressure medication that=92s unsafe in pregnancy. =93I=92ll = change her=20 prescription right now,=94 her doctor said, and keyed it in. A handful = of patients=20 required longer discussion. One forty-five-year-old heart-disease = patient had=20 just had blood tests that showed worsening kidney failure. The team = decided to=20 repeat the blood tests that morning, organize a kidney ultrasound in the = afternoon if the tests confirmed the finding, and have him seen in the = office at=20 the end of the day.
A staff member read out the hospital census. Of the clinic=92s twelve = hundred=20 chronically ill patients, just one was in the hospital, and she was = being=20 discharged. The clinic=92s patients had gone four days without a single = E.R.=20 visit. On hearing this news, staffers cheered and broke into = applause.
Afterward, I met a patient, Vibha Gandhi. She was fifty-seven years = old and=20 had joined the clinic after suffering a third heart attack. She and her = husband,=20 Bharat, are Indian immigrants. He cleans casino bathrooms for thirteen = dollars=20 an hour on the night shift. Vibha has long had poor health, with = diabetes,=20 obesity, and congestive heart failure, but things got much worse in the = summer=20 of 2009. A heart attack landed her in intensive care, and her = coronary-artery=20 disease proved so advanced as to be inoperable. She arrived in a = wheelchair for=20 her first clinic visit. She could not walk more than a few steps without = losing=20 her breath and getting a viselike chest pain. The next step for such = patients is=20 often a heart transplant.
A year and a half later, she is out of her wheelchair. She attends = the=20 clinic=92s Tuesday yoga classes. With the help of a walker, she can go a = quarter=20 mile without stopping. Although her condition is still fragile=97she = takes a=20 purseful of medications, and a bout of the flu would send her back to an = intensive-care unit=97her daily life is far better than she once = imagined.
=93I didn=92t think I would live this long,=94 Vibha said through = Bharat, who=20 translated her Gujarati for me. =93I didn=92t want to live.=94
I asked her what had made her better. The couple credited exercise, = dietary=20 changes, medication adjustments, and strict monitoring of her diabetes. =
But surely she had been encouraged to do these things after her first = two=20 heart attacks. What made the difference this time?
=93Jayshree,=94 Vibha said, naming the health coach from Dunkin=92 = Donuts, who also=20 speaks Gujarati.
=93Jayshree pushes her, and she listens to her only and not to me,=94 = Bharat=20 said.
=93Why do you listen to Jayshree?=94 I asked Vibha.
=93Because she talks like my mother,=94 she said.
Fernandopulle carefully tracks the statistics of = those twelve=20 hundred patients. After twelve months in the program, he found, their=20 emergency-room visits and hospital admissions were reduced by more than = forty=20 per cent. Surgical procedures were down by a quarter. The patients were = also=20 markedly healthier. Among five hundred and three patients with high = blood=20 pressure, only two were in poor control. Patients with high cholesterol = had, on=20 average, a fifty-point drop in their levels. A stunning sixty-three per = cent of=20 smokers with heart and lung disease quit smoking. In surveys, service = and=20 quality ratings were high.
But was the program saving money? The team, after all, was more = expensive=20 than typical primary care. And certain costs shot up. Because patients = took=20 their medications more consistently, drug costs were higher. The doctors = ordered=20 more mammograms and diagnostic tests, and caught and treated more = cancers and=20 other conditions. There=92s also the statistical phenomenon known as = =93regression=20 to the mean=94: the super-high-cost patients may have been on their way = to getting=20 better (and less costly) on their own.
So the union=92s health fund enlisted an independent economist to = evaluate the=20 clinic=92s one-year results. According to the data, these workers made = up a third=20 of the local union=92s costliest ten per cent of members. To determine = if the=20 clinic was really making a difference, the economist compared their = costs over=20 twelve months with those of a similar group of Las Vegas casino workers. = The=20 results, he cautioned, are still preliminary. The sample was small. One = patient=20 requiring a heart transplant could wipe away any savings overnight. = Nonetheless,=20 compared with the Las Vegas workers, the Atlantic City workers in=20 Fernandopulle=92s program experienced a twenty-five-per-cent drop in = costs.
And this was just the start. The program, Fernandopulle told me, is = still=20 discovering new tricks. His team just recently figured out, for = instance, that=20 one reason some patients call 911 for problems the clinic would handle = better is=20 that they don=92t have the clinic=92s twenty-four-hour call number at = hand when they=20 need it. The health coaches told the patients to program it into their=20 cell-phone speed dial, but many didn=92t know how to do that. So the = health=20 coaches began doing it for them, and the number of 911 calls fell. = High-cost=20 habits are sticky; staff members are still learning the subtleties of = unsticking=20 them.
Their most difficult obstacle, however, has been the waywardness not = of=20 patients but of doctors=97the doctors whom the patients see outside the = clinic.=20 Jeff Brenner=92s Camden patients are usually uninsured or on welfare; = their=20 doctors were happy to have someone else deal with them. The Atlantic = City casino=20 workers and hospital staff, on the other hand, had the best-paying = insurance in=20 town. Some doctors weren=92t about to let that business slip away.
Fernandopulle told me about a woman who had seen a cardiologist for = chest=20 pain two decades ago, when she was in her twenties. It was the result of = a=20 temporary, inflammatory condition, but he continued to have her see him = for an=20 examination and an electrocardiogram every three months, and a cardiac=20 ultrasound every year. The results were always normal. After the clinic = doctors=20 advised her to stop, the cardiologist called her at home to say that her = health=20 was at risk if she didn=92t keep seeing him. She went back.
The clinic encountered similar troubles with some of the doctors who = saw its=20 hospitalized patients. One group of hospital-based internists was = excellent, and=20 co=F6rdinated its care plans with the clinic. But the others refused, = resulting in=20 longer stays and higher costs (and a fee for every visit, while the = better group=20 happened to be the only salaried one). When Fernandopulle arranged to = direct the=20 patients to the preferred doctors, the others retaliated, trolling the = emergency=20 department and persuading the patients to choose them instead.
=93 =91Rogues,=92 we call them,=94 Fernandopulle said. He and his = colleagues tried=20 warning the patients about the rogue doctors and contacting the E.R. = staff to=20 make sure they knew which doctors were preferred. =93One time, we = literally pinned=20 a note to a patient, like he was Paddington Bear,=94 he said. They=92ve = ended up=20 going to the hospital, and changing the doctors themselves when they = have to. As=20 the saying goes, one man=92s cost is another man=92s income.
The AtlantiCare hospital system is in a curious position in all this. = Can it=20 really make sense for a hospital to invest in a program, like the = Special Care=20 Center, that aims at reducing hospitalizations, even if its employees = are=20 included? I asked David Tilton, the president and C.E.O. of the system, = why he=20 was doing it. He had several answers. Some were of the=20 it=92s-the-right-thing-to-do variety. But I was interested in the = hard-nosed=20 reasons. The Atlantic City economy, he said, could not sustain his = health=20 system=92s perpetually rising costs. His hospital either fought the = pressure to=20 control costs and went down with the local economy or learned how to = benefit=20 from cost control.
And there are ways to benefit. At a minimum, a successful = hospital=20 could attract patients from competitors, cushioning it against a future = in which=20 people need hospitals less. Two decades ago, for instance, Denmark had = more than=20 a hundred and fifty hospitals for its five million people. The country = then made=20 changes to strengthen the quality and availability of outpatient = primary-care=20 services (including payments to encourage physicians to provide e-mail = access,=20 off-hours consultation, and nurse managers for complex care). Today, the = number=20 of hospitals has shrunk to seventy-one. Within five years, fewer than = forty are=20 expected to be required. A smart hospital might position itself to be = one of the=20 last ones standing.
Could anything that dramatic happen here? An important idea is = getting its=20 test run in America: the creation of intensive outpatient care to target = hot=20 spots, and thereby reduce over-all health-care costs. But, if it works,=20 hospitals will lose revenue and some will have to close. Medical = companies and=20 specialists profiting from the excess of scans and procedures will get = squeezed.=20 This will provoke retaliation, counter-campaigns, intense lobbying for=20 Washington to obstruct reform.
The stats-and-stethoscope upstarts are nonetheless making their dash. = Rushika=20 Fernandopulle has set up a version of his Special Care program in = Seattle, for=20 Boeing workers, and is developing one in Las Vegas, for casino workers. = Nathan=20 Gunn and Verisk Health have landed new contracts during the past year = with=20 companies providing health benefits to more than four million employees = and=20 family members. Tim Ferris has obtained federal approval to spread his = program=20 for Medicare patients to two other hospitals in the Partners Healthcare = System,=20 in Boston (including my own). Jeff Brenner, meanwhile, is seeking to = lower=20 health-care costs for all of Camden, by getting its primary-care = physicians to=20 extend the hot-spot strategy citywide. We=92ve been looking to = Washington to find=20 out how health-care reform will happen. But people like these are its = real=20 leaders.
During my visit to Camden, I attended a meeting = that Brenner=20 and several community groups had organized with residents of Northgate = II, the=20 building with the highest hospital billing in the city. He wanted to run = an idea=20 by them. The meeting took place in the building=92s ground-floor lounge. = There was=20 juice in Styrofoam cups and potato chips on little red plastic plates. A = pastor=20 with the Camden Bible Tabernacle started things off with a prayer. = Brenner let=20 one of the other coalition members do the talking.
How much money, he asked, did the residents think had been spent on=20 emergency-room and hospital visits in the past five years for the people = in this=20 one building? They had no idea. He wrote out the numbers on an easel = pad, but=20 they were imponderable abstractions. The residents=92 eyes widened only = when he=20 said that the payments, even accounting for unpaid bills, added up to = almost=20 sixty thousand dollars per person. He asked how many of them believed = that they=20 had received sixty thousand dollars=92 worth of health care. That was = when the=20 stories came out: the doctors who wouldn=92t give anyone on Medicaid an = office=20 appointment; the ten-hour emergency-room waits for ten minutes with an=20 intern.
Brenner was proposing to open a doctor=92s office right in their = building,=20 which would reduce their need for hospital visits. If it delivered = better care=20 and saved money, the doctor=92s office would receive part of the money = that it=20 saved Medicare and Medicaid, and would be able to add = services=97services that the=20 residents could help choose. With enough savings, they could have = same-day=20 doctor visits, nurse practitioners at night, a social worker, a = psychologist.=20 When Brenner=92s scenario was described, residents murmured approval, = but the=20 mention of a social worker brought questions.
=93Is she going to be all up in my business?=94 a woman asked. =93I = don=92t know if I=20 like that. I=92m not sure I want a social worker hanging around here.=94 =
This doctor=92s office, people were slowly realizing, would be = involved in=20 their lives=97a medical professional would be after them about their = smoking,=20 drinking, diet, medications. That was O.K. if the person were Dr. = Brenner. They=20 knew him. They believed that he cared about them. Acceptance, however, = would=20 clearly depend upon execution; it wasn=92t guaranteed. There was similar = ambivalence in the neighborhoods that Compstat strategists targeted for=20 additional=97and potentially intrusive=97policing.
Yet the stakes in health-care hot-spotting are enormous, and go far = beyond=20 health care. A recent report on more than a decade of education-reform = spending=20 in Massachusetts detailed a story found in every state. Massachusetts = sent=20 nearly a billion dollars to school districts to finance smaller class = sizes and=20 better teachers=92 pay, yet every dollar ended up being diverted to = covering=20 rising health-care costs. For each dollar added to school budgets, the = costs of=20 maintaining teacher health benefits took a dollar and forty cents.
Every country in the world is battling the rising cost of health = care. No=20 community anywhere has demonstrably lowered its health-care costs (not = just=20 slowed their rate of increase) by improving medical services. They=92ve = lowered=20 costs only by cutting or rationing them. To many people, the problem of=20 health-care costs is best encapsulated in a basic third-grade lesson: = you can=92t=20 have it all. You want higher wages, lower taxes, less debt? Then cut = health-care=20 services.
People like Jeff Brenner are saying that we can have it = all=97teachers=20 and health care. To be sure, uncertainties remain. Their small, = localized=20 successes have not yet been replicated in large populations. Up to a = fourth of=20 their patients face problems of a kind they have avoided tackling so = far:=20 catastrophic conditions. These are the patients who are in the top one = per cent=20 of costs because they were in a car crash that resulted in a hundred = thousand=20 dollars in surgery and intensive-care expenses, or had a cancer = requiring seven=20 thousand dollars a week for chemo and radiation. There=92s nothing much = to be done=20 for those patients, you=92d think. Yet they are also victims of poor and = disjointed service. Improving the value of the services=97rewarding = better results=20 per dollar spent=97could lead to dramatic innovations in catastrophic = care,=20 too.
The new health-reform law=97Obamacare=97is betting big on the = Brenners of the=20 world. It says that we can afford to subsidize insurance for millions, = remove=20 the ability of private and public insurers to cut high-cost patients = from their=20 rolls, and improve the quality of care. The law authorizes new = forms of=20 Medicare and Medicaid payment to encourage the development of =93medical = homes=94=20 and =93accountable care organizations=94=97doctors=92 offices and = medical systems that=20 get financial benefits for being more accessible to patients, better = organized,=20 and accountable for reducing the over-all costs of care. Backers believe = that,=20 given this support, innovators like Brenner will transform health care=20 everywhere.
Critics say that it=92s a pipe dream=97more money down the = health-care sinkhole.=20 They could turn out to be right, Brenner told me; a well-organized = opposition=20 could scuttle efforts like his. =93In the next few years, we=92re going = to have=20 absolutely irrefutable evidence that there are ways to reduce = health-care costs,=20 and they are =91high touch=92 and they are at the level of care,=94 he = said. =93We are=20 going to know that, hands down, this is possible.=94 From that point = onward, he=20 said, =93it=92s a political problem.=94 The struggle will be to survive = the=20 obstruction of lobbies, and the partisan tendency to view success as = victory for=20 the other side.
Already, these forces of resistance have become Brenner=92s prime = concern. He=20 needs state legislative approval to bring his program to Medicaid = patients at=20 Northgate II and across Camden. He needs federal approval to qualify as = an=20 accountable care organization for the city=92s Medicare patients. In = Camden, he=20 has built support across a range of groups, from the state Chamber of = Commerce=20 to local hospitals to activist organizations. But for months=97even as = rising=20 health costs and shrinking state aid have forced the city to contemplate = further=20 school cuts and the layoff of almost half of its police=97he has been = stalled.=20 With divided branches at both the state and the federal level, = =93government just=20 gets paralyzed,=94 he says.
In the meantime, though, he=92s forging ahead. In December, he = introduced an=20 expanded computer database that lets Camden doctors view laboratory = results,=20 radiology reports, emergency-room visits, and discharge summaries for = their=20 patients from all the hospitals in town=97and could show cost patterns, = too. The=20 absence of this sort of information is a daily impediment to the care of = patients in Boston, where I practice. Right now, we=92re nowhere close = to having=20 such data. But this, I=92m sure, will change. For in places like Camden, = New=20 Jersey, one of the poorest cities in America, there are people showing = the way.=20 ♦