I
park on Jackson Street downtown and
walk into work each morning, often
passing a few people still holding a
bottle or can of the previous night’s poison. Sometimes they mumble something
unintelligible as I pass, me typically hurrying and them occasionally stumbling, but
usually there is no exchange at all: no nod
of the head, no smile, not even a glance. But
once I pass through the revolving door of
University Hospital they cannot avoid me. The mumbling man’s
schizophrenia unfolds. The stumbler’s toxicology screen reveals
his vices. Still, I can’t help but feel that most of my neighborhood
patients are not either of these—stumbler or mumbler—but
rather simply “uncontrolled.”
Dr. Jeffrey Brenner who practices in Camden, New Jersey,
which is one of the most violent cities in the country, started
noticing something similar more than a decade ago. Analyzing
a database of Camden’s three main hospitals’ medical records,
he tracked where each person admitted to the local hospital
had come from. What he found was telling. There were several
“hot spots” as they later came to be known, areas of extremely
high medical care utilization. In fact, a nursing home and public
housing facility (two buildings and roughly nine hundred people)
had supplied more than four thousand hospital visits between
2002 and 2008, costing the city more than 200 million dollars!
The most expensive single patient had cost insurers more than
three and a half millions dollars.
So, Brenner started treating them. He called and even went to
their homes. He assigned people to make sure that medications
got taken so that patients he worked with would never be on
their own. His staff even helped people find new living situations
if the current one was unhealthy. And it worked: by 2009 his
top thirty-six “high utilizers” had reduced their hospital bills by
56%. What’s more is that the results are replicable. Massachusetts
General Hospital participated in a program in 2006, in which
Medicare offered increased funding for care coordination and
profit sharing if hospitals could demonstrate a five percent cost
reduction among their chronically admitted population. Not only
did they meet that goal, they reduced overall ER visits by 15%.
There is no secret as to what the future of medicine is. It’s
efficient care. Within recent months The New England Journal
stated that the over-arching issue of the next decade is cost control. Almost in the same breath, a few weeks ago, they stated that
increased patient access to health records, increased coordination
of care, and preventive medicine are the keys to cost control.
The future of medicine is doing whatever it takes to keep people
healthy rather than just curing them when illness arrives. In Dr.
Brenner’s case it required an entire team of nurses and social
workers and endless hours spent trying to educate his patients.
It required great sacrifice and very little credit when he began.
He did all this initially without increased incentives, receiving
no extra compensation for his early work.
But he has shown that there is unequivocally a problem and
that he has a good solution.
Camden is not alone. Louisville’s own Dosker Manor is responsible for over nine hundred EMS calls annually, which alone
costs the city millions. I have spoken with residents and they
have minimal access to health care. They wait sixteen and twenty
hours in the emergency room when things go awry because most
of their problems are not immediately life and death but rather
matters of chronically uncontrolled disease states. Few of them
have primary care physicians due to decreased transportation
options or simply not understanding the importance of maintenance of things like hypertension or diabetes. Certainly most
of their residents understand almost nothing of their disease
states and therefore have very little impetus to seek treatment
until their condition warrants admission—an unhealthy and
dangerous practice. Though I am working to get numbers, it
takes very little to recognize that of their eight hundred residents
there are