MEDICAL REPORT THE HOT SPOTTERS Can we lower medical costs by giving the neediest patients better care? BY ATUL GAWANDE f Camden, New Jersey, becomes the ken family physician who had grown up Bratton and the Compstat approach to Ifirst American community to lower its in a bedroom suburb of Philadelphia. As policing that he had championed in the medical costs, it will have a murder to a medical student at Robert Wood John- nineties, which centered on mapping thank. At nine-fifty on a February night son Medical School, in Piscataway, he crime and focussing resources on the hot in 2001, a twenty-two-year-old black had planned to become a neuroscientist. spots. The reform panel pushed the Cam- man was shot while driving his Ford Tau- But he volunteered once a week in a free den Police Department to create comput- rus station wagon through a neighbor- primary-care clinic for poor immigrants, erized crime maps, and to change police hood on the edge of the Rutgers Univer- and he found the work there more chal- beats and shifts to focus on the worst areas sity campus. The victim lay motionless in lenging than anything he was doing in the and times. the street beside the open door on the laboratory. The guy studying neuronal When the police wouldn’t make the driver’s side, as if the car had ejected him. stem cells soon became the guy studying crime maps, Brenner made his own. He A neighborhood couple, a physical thera- Spanish and training to become one of persuaded Camden’s three main hospitals pist and a volunteer firefighter, ap- the few family physicians in his class. to let him have access to their medical bill- proached to see if they could help, but po- Once he completed his residency, in ing records. He transferred the reams of lice waved them back. 1998, he joined the staff of a family-med- data files onto a desktop computer, spent “He’s not going to make it,” an officer icine practice in Camden. It was in a weeks figuring out how to pull the chaos reportedly told the physical therapist. cheaply constructed, boxlike, one-story of information into a searchable database, “He’s pretty much dead.” She called a building on a desolate street of bars, car- and then started tabulating the emer- physician, Jeffrey Brenner, who lived a repair shops, and empty lots. But he was gency-room visits of victims of serious as- few doors up the street, and he ran to the young and eager to recapture the sense of sault. He created maps showing where the scene with a stethoscope and a pocket purpose he’d felt volunteering at the clinic crime victims lived. He pushed for poli- ventilation mask. After some discussion, during medical school. cies that would let the Camden police the police let him enter the crime scene Few people shared his sense of possi- chief assign shifts based on the crime sta- and attend to the victim. Witnesses told bility. Camden was in civic free fall, on its tistics—only to find himself in a show- the local newspaper that he was the first way to becoming one of the poorest, most down with the police unions. person to lay hands on the man. crime-ridden cities in the nation. The “He has no clue,” the president of the “He was slightly overweight, turned on local school system had gone into receiv- city police superiors’ union said to the his side,” Brenner recalls. There was glass ership. Corruption and mismanagement Philadelphia Inquirer . “I just think that his everywhere. Although the victim had soon prompted a state takeover of the en- comments about what kind of schedule been shot several times and many minutes tire city. Just getting the sewage system to we should be on, how we should be de- had passed, his body felt warm. Brenner work could be a problem. The neglect of ployed, are laughable.” checked his neck for a carotid pulse. The this anonymous shooting victim on The unions kept the provisions out of man was alive. Brenner began the chest Brenner’s street was another instance of a the contract. The reform commission dis- compressions and rescue breathing that city that had given up, and Brenner was banded; Brenner withdrew from the should have been started long before. But tired of wondering why it had to be that cause, beaten. But he continued to dig the young man, who turned out to be a way. into the database on his computer, now Rutgers student, died soon afterward. Around that time, a police reform mostly out of idle interest. The incident became a local scandal. commission was created, and Brenner was Besides looking at assault patterns, he The student’s injuries may not have been asked to serve as one of its two citizen began studying patterns in the way pa- survivable, but the police couldn’t have members. He agreed and, to his surprise, tients flowed into and out of Camden’s known that. After the ambulance came, became completely absorbed. The experts hospitals. “I’d just sit there and play with Brenner confronted one of the officers to they called in explained the basic prin- the data for hours,” he says, and the more ask why they hadn’t tried to rescue him. ci ples of effective community policing. he played the more he found. For in- “We didn’t want to dislodge the bul- He learned about George Kelling and stance, he ran the data on the locations let,” he recalls the policeman saying. It was James Q. Wilson’s “broken-windows” where ambulances picked up patients a ridiculous answer, a brushoff, and theory, which argued that minor, visible with fall injuries, and discovered that a Brenner couldn’t let it go. neighborhood disorder breeds major single building in central Camden sent He was thirty-one years old at the crime. He learned about the former New more people to the hospital with serious time, a skinny, thick-bearded, soft-spo- York City police commissioner William falls—fifty-seven elderly in two years— THE NEW YORKER, JANUARY 24, 2011 41 than any other in the city, resulting in al- in and out of the hospital—were usually patterns of the most expensive one per most three million dollars in health-care the people receiving the worst care. cent. “These are the people I want to help bills. “It was just this amazing window “Emergency-room visits and hospital ad- you with,” he said. He asked for assistance into the health-care delivery system,” he missions should be considered failures of reaching them. “Introduce me to your says. the health-care system until proven oth- worst-of-the-worst patients,” he said. So he took what he learned from po- erwise,” he told me—failures of preven- They did. Then he got permission to lice reform and tried a Compstat ap- tion and of timely, effective care. look up the patients’ data to confirm proach to the city’s health-care perfor- If he could find the people whose use where they were on his cost map. “For all mance—a Healthstat, so to speak. He of medical care was highest, he figured, he the stupid, expensive, predictive-model- made block-by-block maps of the city, could do something to help them. If he ling software that the big venders sell,” he color-coded by the hospital costs of its helped them, he would also be lowering says, “you just ask the doctors, ‘Who are residents, and looked for the hot spots. their health-care costs. And, if the stats your most difficult patients?,’ and they can The two most expensive city blocks were approach to crime was right, targeting identify them.” in north Camden, one that had a large those with the highest health-care costs The first person they found for him nursing home called Abigail House and would help lower the entire city’s health- was a man in his mid-forties whom I’ll call one that had a low-income housing tower care costs. His calculations revealed that Frank Hendricks. Hendricks had severe called Northgate II. He found that be- just one per cent of the hundred thousand congestive heart failure, chronic asthma, tween January of 2002 and June of 2008 people who made use of Camden’s med- uncontrolled diabetes, hypothyroidism, some nine hundred people in the two ical facilities accounted for thirty per cent gout, and a history of smoking and alco- buildings accounted for more than four of its costs. That’s only a thousand peo- hol abuse. He weighed five hundred and thousand hospital visits and about two ple—about half the size of a typical fam- sixty pounds. In the previous three years, hundred million dollars in health-care ily physician’s panel of patients. he had spent as much time in hospitals as bills. One patient had three hundred and Things, of course, got complicated. It out. When Brenner met him, he was in twenty-four admissions in five years. The would have taken months to get the ap- intensive care with a tracheotomy and a most expensive patient cost insurers $3.5 provals needed to pull names out of the feeding tube, having developed septic million. data and approach people, and he was shock from a gallbladder infection. Brenner wasn’t all that interested in impatient to get started. So, in the spring Brenner visited him daily. “I just basi- costs; he was more interested in helping of 2007, he held a meeting with a few cally sat in his room like I was a third-year people who received bad health care.