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MEDICAL REPORT THE HOT SPOTTERS

Can we lower medical costs by giving the neediest patients better care?

BY

f Camden, , 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 , 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 , a police reform mostly out of idle interest. The incident became a local . 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 . But social workers and emergency-room doc- med student, hanging out with him for an in his experience the people with the tors from hospitals around the city. He hour, hour and a half every day, trying to highest medical costs—the people cycling showed them the cost statistics and use figure out what makes the guy tick,” he re- called. He learned that Hendricks used to be an auto detailer and a cook. He had a longtime girlfriend and two children, now grown. A toxic combination of poor health, Johnnie Walker Red, and, it emerged, cocaine addiction had left him unreliably employed, uninsured, and liv- ing in a welfare motel. He had no consis- tent set of doctors, and almost no pros- pects for turning his situation around. After several months, he had recovered enough to be discharged. But, out in the world, his life was simply another hospi- talization waiting to happen. By then, however, Brenner had figured out a few things he could do to help. Some of it was simple doctor stuff. He made sure he fol- lowed Hendricks closely enough to recog- nize when serious problems were emerg- ing. He double-checked that the plans and prescriptions the specialists had made for Hendricks’s many problems actually fit together—and, when they didn’t, he got on the phone to sort things out. He teamed up with a nurse practitioner who could make home visits to check blood- sugar levels and blood pressure, teach “Can you imagine how being the only one here makes me feel?” Hendricks about what he could do to 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. Brenner got a social worker to help Hendricks apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of physicians. The team also pushed him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous, and, when Brenner found out that he was a devout Christian, he urged him to return to church. He told Hendricks that he needed to cook his own food once in a while, so he could get back in the habit of doing it. The main thing he was up against was Hendricks’s hope- lessness. He’d given up. “Can you imag- ine being in the hospital that long, what that does to you?” Brenner asked. I spoke to Hendricks recently. He has gone without alcohol for a year, cocaine for two years, and smoking for three years. “Harry seldom leaves his retirement cubicle .” He lives with his girlfriend in a safer neighborhood, goes to church, and weath- • • ers family crises. He cooks his own meals now. His diabetes and congestive heart failure are under much better control. He’s ner, too. “His whole premise was ‘I’m here ance system is built. So he applied for lost two hundred and twenty pounds, for you. I’m not here to be a part of the small grants from philanthropies like the which means, among other things, that if medical system. I’m here to get you back Robert Wood Johnson Foundation and he falls he can pick himself up, rather than on your feet.’ ” the Merck Foundation. The money al- having to call for an ambulance. An ordinary cold can still be a major lowed him to ramp up his data system and “The fun thing about this work is that setback for Hendricks. He told me that hire a few people, like the nurse practitio- you can be there when the light switch he’d been in the hospital four times this ner and the social worker who had helped goes on for a patient,” Brenner told me. past summer. But the stays were a few him with Hendricks. He had some desk “It doesn’t happen at the pace we want. days at most, and he’s had no more cata- space at Cooper Hospital, and he turned But you can see it happen.” clysmic, weeks-long I.C.U. stays. it over to what he named the Camden With Hendricks, there was no mirac- Was this kind of success replicable? As Coalition of Healthcare Providers. He ulous turnaround. “Working with him word went out about Brenner’s interest in spoke to people who had been doing sim- didn’t feel any different from working patients like Hendricks, he received more ilar work, studied “medical home” pro- with any patient on smoking, bad diet, referrals. Camden doctors were delighted grams for the chronically ill in Seattle, San not exercising—working on any particu- to have someone help with their “worst of Francisco, and Pennsylvania, and adopted lar rut someone has gotten into,” Brenner the worst.” He took on half a dozen pa- some of their lessons. By late 2010, his said. “People are people, and they get into tients, then two dozen, then more. It be- team had provided care for more than situations they don’t necessarily plan on. came increasingly difficult to do this work three hundred people on his “super-uti- My philosophy about primary care is that alongside his regular medical practice. lizer” map. the only person who has changed anyone’s The clinic was already under financial I spent a day with Kathy Jackson, the life is their mother. The reason is that she strain, and received nothing for assisting nurse practitioner, and Jessica Cordero, a cares about them, and she says the same these patients. If it were up to him, he’d medical assistant, to see what they did. simple thing over and over and over.” So recruit a whole staff of primary-care doc- The Camden Coalition doesn’t have he tries to care, and to say a few simple tors and nurses and social workers, based enough money for a clinic where they can things over and over and over. right in the neighborhoods where the see patients. They rely exclusively on I asked Hendricks what he made of costliest patients lived. With the tens of home visits and phone calls. Brenner when they first met. millions of dollars in hospital bills they Over the phone, they inquire about “He struck me as odd,” Hendricks could save, he’d pay the staff double to emerging health issues, check for insur- said. “His appearance was not what I ex- serve as Camden’s élite medical force and ance or housing problems, ask about pected of a young, clean-cut doctor.” to rescue the city’s health-care system. unfilled prescriptions. All the patients get There was that beard. There was his man- But that’s not how the health-insur- the team’s urgent-call number, which is

THE NEW YORKER, JANUARY 24, 2011 43 able to get him into housing where his medications could be dispensed on a schedule. He had made an overnight visit the previous weekend to test the place out. “I liked it,” he said. He moved in the next week. And, with that, he got a chance to avert dialysis—and its tens of thousands of dollars in annual costs—at 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 habit. The crack causes severe asthma attacks and puts her in the hospital over and over again. The team members have managed occasionally to track her down in emer- gency rooms or recognize her on street corners. All they can do is give her their number, and offer their help if she ever “I thought that driving around all day picking kids up and dropping wanted it. She hasn’t. them off, then waiting for them, would be more fulfilling.” Work like this has proved all-consum- ing. In May, 2009, Brenner closed his • • regular medical practice to focus on the program full time. It remains unclear how the program will make ends meet. But he covered by someone who can help them sulin dose and change his blood-pressure and his team appear to be having a major through a health crisis. Usually, the issue medicine. But you wouldn’t grasp what impact. The Camden Coalition has been can be resolved on the spot—it’s a head- the real problem was until you walked up able to measure its long-term effect on its ache or a cough or the like—but some- the cracked concrete steps of the two- first thirty-six super-utilizers. They aver- times it requires an unplanned home visit, story brownstone where he lives with his aged sixty-two hospital and E.R. visits per to perform an examination, order some mother, waited for him to shove aside month before joining the program and tests, provide a prescription. Only occa- the old newspapers and unopened mail thirty-seven visits after—a forty-per-cent sionally does it require an emergency blocking the door, noticed Cordero’s reduction. Their hospital bills averaged room. shake of the head warning you not to $1.2 million per month before and just Patients wouldn’t make the call in the take the rumpled seat he’s offering be- over half a million after—a fifty-six-per- first place if the person picking up weren’t cause of the ant trail running across it, cent reduction. someone like Jackson or Brenner—some- and took in the stack of dead computer These results don’t take into account one they already knew and trusted. Even monitors, the barking mutt chained to an Brenner’s personnel costs, or the costs of so, patients can disappear for days or inner doorway, and the rotten on a the medications the patients are now tak- weeks at a time. “High-utilizer work is newspaper-covered tabletop. According ing as prescribed, or the fact that some of about building relationships with people to a state evaluation, he was capable of the patients might have improved on their who are in crisis,” Brenner said. “The ones handling his medications, and, besides, own (or died, reducing their costs per- you build a relationship with, you can he lived with his mother, who could help. ma nently). The net savings are undoubt- change behavior. Half we can build a re- But one look made it clear that they were edly lower, but they remain, almost cer- lationship with. Half we can’t.” both incapable. tainly, revolutionary. Brenner and his One patient I spent time with illus- Jackson asked him whether he was team are out there on the boulevards of trated the challenges. If you were a doctor taking his blood-pressure pills each day. Camden demonstrating the possibilities meeting him in your office, you would Yes, he said. Could he show her the pill of a strange new approach to health care: quickly figure out that his major problems bottles? As it turned out, he hadn’t taken to look for the most expensive patients in were moderate developmental deficits and any pills since she’d last visited, the week the system and then direct resources and out-of-control hypertension and diabetes. before. His finger-stick blood sugar was brainpower toward helping them. His blood pressure and blood sugars were twice the normal level. He needed a bet- so high that, at the age of thirty-nine, he ter living situation. The state had turned eff Brenner has not been the only one to was already developing blindness and ad- him down for placement in supervised Jrecognize the possibilities in focussing vanced kidney disease. Unless something housing, pointing to his test scores. But on the hot spots of medicine. One Friday changed, he was perhaps six months away after months of paperwork—during afternoon, I drove to an industrial park on from complete kidney failure. which he steadily worsened, passing in the outskirts of , where a rapidly You might decide to increase his in- and out of hospitals—the team was finally growing data-analysis called

44 THE NEW YORKER, JANUARY 24, 2011 Verisk Health occupies a floor of a non- care with asthma attacks three times over took her medicine, but it wasn’t working. descript office complex. It supplies “med- the last year, probably because Mom and When the headaches got bad, she’d go to ical intelligence” to organizations that pay Dad aren’t really on top of it.” That’s the the emergency room or to urgent care. for health benefits—self-insured busi- sort of patient Gunn uses his company’s The doctors would do CT and MRI nesses, many public employers, even the medical-intelligence software program to scans, satisfy themselves that she didn’t government of Abu Dhabi. zero in on—a patient who is sick and get- have a brain tumor or an aneurysm, give Privacy laws prevent U.S. employers ting inadequate care. “That’s really the her a narcotic injection to stop the head- from looking at the details of their em- sweet spot for preventive care,” Gunn ache temporarily, maybe renew her imip- ployees’ medical spending. So they hand said. ramine prescription, and send her home, their health-care payment data over to He pulled up patients with known only to have her return a couple of weeks companies that analyze the patterns and coronary-artery disease. There were nine later and see whoever the next doctor on tell them how to reduce their health- hundred and twenty-one, he said, read- duty was. She wasn’t getting what she insurance spending. Mostly, these com- ing off the screen. He clicked a few more needed for adequate migraine care—a panies give financial advice on changing times and raised his eyebrows. One in primary physician taking her in hand, try- benefits—telling them, say, to increase seven of them had not had a full office ing different medications in a systematic employee co-payments for brand-name visit with a physician in more than a year. way, and figuring out how to better keep drugs or emergency-room visits. But even “You can do something about that,” he her headaches at bay. employers who cut benefits find that their said. As he sorts through such stories, Gunn costs continue to outpace their earnings. “Let’s do the E.R.-visit game,” he went usually finds larger patterns, too. He told Verisk, whose clients pay health-care bills on. “This is a fun one.” He sorted the pa- me about an analysis he had recently done for fifteen million patients, is among the tients by number of visits, much as Jeff for a big information-technology com- data companies that are trying a more so- Brenner had done for Camden. In this pany on the East Coast. It provided phisticated approach. employed population, the No. 1 patient health benefits to seven thousand em- Besides the usual statisticians and was a twenty-five-year-old woman. In the ployees and family members, and had economists, Verisk recruited doctors to past ten months, she’d had twenty-nine forty million dollars in “spend.” The firm dive into the data. I met one of them, Na- E.R. visits, fifty-one doctor’s office visits, had already raised the employees’ insur- than Gunn, who was thirty-six years old, and a hospital admission. ance co-payments considerably, hoping to had completed his medical training at the “I can actually drill into these claims,” give employees a reason to think twice University of California, , he said, squinting at the screen. “All these about unnecessary medical visits, tests, and was practicing as an internist part claims here are migraine, migraine, mi- and procedures—make them have some time. The rest of his time he worked as graine, migraine, headache, headache, “ in the game,” as they say. Indeed, al- Verisk’s head of research. Mostly, he was headache.” For a twenty-five-year-old most every category of costly medical care in meetings or at his desk poring through with her profile, he said, medical pay- went down: doctor visits, emergency- “data runs” from clients. He insisted that ments for the previous ten months would room and hospital visits, drug prescrip- it was every bit as absorbing as seeing sick be expected to total twenty-eight hundred tions. Yet employee health costs contin- patients—sometimes more so. Every data dollars. Her actual payments came to ued to rise—climbing almost ten per cent tells a different human story, he said. more than fifty-two thousand dollars— each year. The company was baffled. At his computer, he pulled up a data for “headaches.” Gunn’s team took a look at the hot set for me, scrubbed of identifying in- Was she a drug seeker? He pulled up spots. The outliers, it turned out, were formation, from a client that manages her prescription profile, looking for nar- predominantly early retirees. Most had health-care benefits for some two hun- cotic prescriptions. Instead, he found multiple chronic conditions—in particu- dred and fifty employers—school dis- prescriptions for insulin (she was appar- lar, coronary-artery disease, asthma, and tricts, a large church association, a bus ently diabetic) and imipramine, an anti- complex mental illness. One had badly company, and the like. They had a hun- migraine treatment. Gunn was struck by worsening heart disease and diabetes, and dred thousand “covered lives” in all. Pay- how faithfully she filled her prescriptions. medical bills over two years in excess of outs for those people rose eight per cent a She hadn’t missed a single renewal— eighty thousand dollars. The man, deal- year, at least three times as fast as the em- “which is actually interesting,” he said. ing with higher co-payments on a fixed ployers’ earnings. This wasn’t good, but That’s not what you usually find at the income, had cut back to filling only half the numbers seemed pretty dry and ab- extreme of the cost curve. his medication prescriptions for his high stract so far. Then he narrowed the list to The story now became clear to him. cholesterol and diabetes. He made few the top five per cent of spenders—just five She suffered from terrible migraines. She doctor visits. He avoided the E.R.—until thousand people accounted for almost a heart attack necessitated emergency sur- sixty per cent of the spending—and he gery and left him disabled with chronic began parsing further. heart failure. “Take two ten-year-old boys with The higher co-payments had back- asthma,” he said. “From a disease stand- fired, Gunn said. While medical costs for point, they’re exactly the same cost, right? most employees flattened out, those for Wrong. Imagine one of those kids never early retirees jumped seventeen per cent. fills his inhalers and has been in urgent The sickest patients became much more

THE NEW YORKER, JANUARY 24, 2011 45 expensive because they put off care and medical hot-spotting can really succeed looks like any other doctors’ office. But it prevention until it was too late. on a scale that would help large popula- houses an experiment started in 2007 by The critical flaw in our health-care sys- tions. Yet there are signs that it can. the health-benefit programs of the casino tem that people like Gunn and Brenner A recent Medicare demonstration workers’ union and of a hospital, Atlanti- are finding is that it was never designed program, given substantial additional re- care Medical Center, the city’s two largest for the kind of patients who incur the sources under the new health-care-reform pools of employees. highest costs. Medicine’s primary mecha- law, offers medical institutions an extra Both are self-insured—they are large nism of service is the doctor visit and the monthly payment to finance the coördi- enough to pay for their workers’ health E.R. visit. (Americans make more than a nation of care for their most chronically care directly—and both have been ham- billion such visits each year, according to expensive beneficiaries. If total costs fall mered by the exploding costs. Yes, even the Centers for Disease Control.) For a more than five per cent compared with hospitals are having a hard time paying thirty-year-old with a fever, a twenty- those of a matched set of control patients, their employees’ medical bills. As for the minute visit to the doctor’s office may be the program allows institutions to keep union, its contracts are frequently for just the thing. For a pedestrian hit by a part of the savings. If costs fail to decline, workers’ total compensation—wages plus minivan, there’s nowhere better than an the institutions have to return the monthly benefits. It gets a fixed pot. Year after year, emergency room. But these institutions payments. the low-wage busboys, hotel cleaners, and are vastly inadequate for people with com- Several hospitals took the deal when kitchen staff voted against sacrificing their plex problems: the forty-year-old with the program was offered, in 2006. One health benefits. As a result, they have drug and alcohol addiction; the eighty- was the Massachusetts General Hospital, gone without a wage increase for years. four-year-old with advanced Alzheimer’s in Boston. It asked a general internist Out of desperation, the union’s health disease and a pneumonia; the sixty-year- named Tim Ferris to design the effort. fund and the hospital decided to try some- old with heart failure, obesity, gout, a bad The hospital had twenty-six hundred thing new. They got a young Harvard in- memory for his eleven medications, and chronically high-cost patients, who to- ternist named Rushika Fernandopulle to half a dozen specialists recommending gether accounted for sixty million dollars run a clinic exclusively for workers with different tests and procedures. It’s like ar- in annual Medicare spending. They were exceptionally high medical expenses. riving at a major construction project with in nineteen primary-care practices, and Fernandopulle, who was born in Sri nothing but a screwdriver and a crane. Ferris and his team made sure that each Lanka and raised in Baltimore, doesn’t Outsiders tend to be the first to recog- had a nurse whose sole job was to improve seem like a radical when you meet him. nize the inadequacies of our social institu- the coördination of care for these patients. He’s short and round-faced, smiles a lot, tions. But, precisely because they are out- The doctors saw the patients as usual. In and displays two cute rabbit teeth as he siders, they are usually in a poor position between, the nurses saw them for longer tells you how ridiculous the health-care to fix them. Gunn, though a doctor, visits, made surveillance phone calls, and, system is and how he plans to change it mostly works for people who do not run in consultation with the doctors, tried to all. Jeff Brenner was on his advisory board, health systems—employers and insurers. recognize and address problems before along with others who have pioneered the So he counsels them about ways to tinker they resulted in a hospital visit. concept of intensive outpatient care for with the existing system. He tells them Three years later, hospital stays and complex high-needs patients. The hospi- how to change co-payments and deduct- trips to the emergency room have dropped tal provided the floor space. Fernando- ibles so they at least aren’t making their more than fifteen per cent. The hospital pulle created a point system to identify cost problems worse. He identifies doc- hit its five-per-cent cost-reduction target. employees likely to have high recurrent tors and hospitals that seem to be provid- And the team is just getting the hang of costs, and they were offered the chance to ing particularly ineffective care for high- what it can do. join the new clinic. needs patients, and encourages clients to The Special Care Center reinvented shift contracts. And he often suggests that ecently, I visited an even more radi- the idea of a primary-care clinic in almost clients hire case-management compa- Rcally redesigned physician practice, every way. The union’s and the hospital’s nies—a fast-growing industry with tele- in Atlantic City. Cross the bridge into health funds agreed to switch from paying phone banks of nurses offering high-cost town (Atlantic City is on an island, I the doctors for every individual office visit patients advice in the hope of making up learned), ignore the Trump Plaza and and treatment to paying a flat monthly fee for the deficiencies of the system. Caesars casinos looming ahead of you, for each patient. That cut the huge ex- The strategy works, sort of. Verisk re- drive a few blocks along the Monopoly- pense that most clinics incur from billing ports that most of its clients can slow the board streets (the game took its street paperwork. The patients were given rate at which their health costs rise, at least names from here), turn onto unlimited access to the clinic without to some extent. But few have seen de- Avenue, and enter the doctors’ office charges—no co-payments, no insurance creases, and it’s not obvious that the im- building that’s across the street from the bills. This, Fernandopulle explained, provements can be sustained. Brenner, by ninety-nine-cent store and the city’s long- would force doctors on staff to focus on contrast, is reinventing medicine from the shuttered supermarket. On the second service, in order to retain their patients inside. But he does not run a health-care floor, just past the occupational-health and the fees they would bring. system, and had to give up his practice to clinic, you will find the Special Care Cen- The payment scheme also allowed sustain his work. He is an outsider on the ter. The reception area, with its rustic him to design the clinic around the things inside. So you might wonder whether taupe upholstery and tasteful lighting, that sick, expensive patients most need

46 THE NEW YORKER, JANUARY 24, 2011 SKETCHBOOK BY J. J. SEMPÉ and value, rather than the ones that pay had seen on a medical mission in the Do- They reviewed the requests that patients the best. He adopted an open-access minican Republic. The coaches work had made by e-mail or telephone, the scheduling system to guarantee same-day with the doctors but see their patients far plans for the ones who had appointments appointments for the acutely ill. He cus- more frequently than the doctors do, at that day. Staff members made sure that all tomized an electronic information system least once every two weeks. Their most patients who made a sick visit the day be- that tracks whether patients are meeting important attribute, Fernandopulle ex- fore got a follow-up call within twenty- their goals. And he staffed the clinic with plained, is a knack for connecting with four hours, that every test ordered was re- people who would help them do it. One sick people, and understanding their viewed, that every unexpected problem nurse practitioner, for instance, was re- difficulties. Most of the coaches come was addressed. sponsible for trying to get every smoker to from their patients’ communities and Most patients required no more than a quit. speak their languages. Many have experi- ten-second mention. Mr. Green didn’t I got a glimpse of how unusual the ence with chronic illness in their own turn up for his cardiac testing or return clinic is when I sat in on the staff meet- families. (One was himself a patient in calls about it. “I know where his wife ing it holds each morning to review the the clinic.) Few had clinical experience. I works. I’ll track her down,” the reception- medical issues of the patients on the ap- asked each of the coaches what he or she ist said. Ms. Blue is pregnant and on a pointment books. There was, for starters, had done before working in the Special high-blood-pressure medication that’s the very existence of the meeting. I had Care Center. One worked the register at unsafe in pregnancy. “I’ll change her pre- never seen this kind of daily huddle at a a Dunkin’ Donuts. Another was a Sears scription right now,” her doctor said, and doctor’s office, with clinicians popping retail manager. A third was an adminis- keyed it in. A handful of patients required open their laptops and pulling up their trative assistant at a casino. longer discussion. One forty-five-year-old patient lists together. Then there was “We recruit for attitude and train for heart-disease patient had just had blood the particular mixture of people who skill,” Fernandopulle said. “We don’t re- tests that showed worsening kidney fail- squeezed around the conference table. As cruit from health care. This kind of care ure. The team decided to repeat the blood in many primary-care offices, the staff requires a very different mind-set from tests that morning, organize a kidney ul- had two physicians and two nurse prac- usual care. For example, what is the an- trasound in the afternoon if the tests titioners. But a full-time social worker swer for a patient who walks up to the confirmed the finding, and have him seen and the front-desk receptionist joined in front desk with a question? The answer is in the office at the end of the day. for the patient review, too. And, out- ‘Yes.’ ‘Can I see a doctor?’ ‘Yes.’ ‘Can I get A staff member read out the hospital numbering them all, there were eight help making my ultrasound appoint- census. Of the clinic’s twelve hundred full-time “health coaches.” ment?’ ‘Yes.’ Health care trains people to chronically ill patients, just one was in the Fernandopulle created the position. say no to patients.” He told me that he’d hospital, and she was being discharged. Each health coach works with patients— had to replace half of the clinic’s initial The clinic’s patients had gone four days in person, by phone, by e-mail—to help hires—including a doctor—because they without a single E.R. visit. On hearing them manage their health. Fernando- didn’t grasp the focus on patient service. this news, staffers cheered and broke into pulle got the idea from the promotoras , In forty-five minutes, the staff did a applause. community health workers, whom he rapid run-through of everyone’s patients. Afterward, I met a patient, Vibha Gandhi. She was fifty-seven years old and had joined the clinic after suffering a third heart attack. She and her husband, Bharat, are Indian immigrants. He cleans casino bathrooms for thirteen dollars an hour on the night shift. Vibha has long had poor health, with diabetes, obesity, and congestive heart failure, but things got much worse in the summer of 2009. A heart attack landed her in intensive care, and her coronary-artery disease proved so advanced as to be inoperable. She arrived in a wheelchair for her first clinic visit. She could not walk more than a few steps without losing her breath and getting a viselike chest pain. The next step for such patients is often a heart transplant. A year and a half later, she is out of her wheelchair. She attends the clinic’s Tuesday yoga classes. With the help of a walker, she can go a quarter mile with- “I’ve decided to leave my family to devote more time to myself.” out stopping. Although her condition is three per cent of smokers with heart and lung disease quit smoking. In surveys, EGUSI SOUP service and quality ratings were high. But was the program saving money? The first time I met my father, he ordered The team, after all, was more expensive hot-pepper fish soup in the hotel bar than typical primary care. And certain and told me his favorite soup was egusi costs shot up. Because patients took their served with semo, eba, or pounded yam. medications more consistently, drug costs His wife makes good egusi, he tells me, were higher. The doctors ordered more with stockfish, dry fish, and crayfish, mammograms and diagnostic tests, and with local Nsukka Maggi; with goat meat caught and treated more cancers and or beef meat, and, of course, pounded egusi, other conditions. There’s also the statisti- protein-rich seeds of a large-seeded variety cal phenomenon known as “regression to of watermelon, fried in palm oil first— the mean”: the super-high-cost patients be careful the oil doesn’t splash—and you must may have been on their way to getting remove the bones from the dry fish and break better (and less costly) on their own. into big pieces, add chili and pepper to taste. So the union’s health fund enlisted an For maximum flavor, add curry powder and thyme. independent economist to evaluate the I like a lot of chili, do you like things hot, clinic’s one-year results. According to the he asks me? Then, at the end, she throws data, these workers made up a third of in bitter leaf or ugwu or celosia. the local union’s costliest ten per cent of It helps if you have a cow’s tongue, members. To determine if the clinic was something like that, or a beef- or ox-tail. really making a difference, compared their costs over twelve months I told my father of a villager with those of a similar group of quoted by Achebe who told his wife never casino workers. The results, he cautioned, to give him egusi soup; so every evening the man are still preliminary. The sample was gets to eat his favorite soup, egusi, I say. small. One patient requiring a heart trans- I see what you mean, I see what you mean, he says, plant could wipe away any savings over- laughing his laugh that is a little like mine. night. Nonetheless, compared with the Then he put down his bowl and his spoon Las Vegas workers, City as if he were from a fable or a fairy tale, workers in Fernandopulle’s program ex- a bear or a woodcutter, a wolf in a frock perienced a twenty-five-per-cent drop in and vanished like a cow jumping over the moon, costs. or the dish running away with the spoon. And this was just the start. The pro- gram, Fernandopulle told me, is still dis- —Jackie Kay covering new tricks. His team just recently figured out, for instance, that one reason some patients call 911 for problems the still fragile—she takes a purseful of med- “Jayshree pushes her, and she listens clinic would handle better is that they ications, and a bout of the flu would to her only and not to me,” Bharat said. don’t have the clinic’s twenty-four-hour send her back to an intensive-care unit— “Why do you listen to Jayshree?” I call number at hand when they need it. her daily life is far better than she once asked Vibha. The health coaches told the patients to imagined. “Because she talks like my mother,” program it into their cell-phone speed “I didn’t think I would live this long,” she said. dial, but many didn’t know how to do Vibha said through Bharat, who trans- that. So the health coaches began doing it lated her Gujarati for me. “I didn’t want ernandopulle carefully tracks the sta- for them, and the number of 911 calls fell. to live.” Ftistics of those twelve hundred pa- High-cost habits are sticky; staff members I asked her what had made her bet- tients. After twelve months in the pro- are still learning the subtleties of unstick- ter. The couple credited exercise, dietary gram, he found, their emergency-room ing them. changes, medication adjustments, and visits and hospital admissions were re- Their most difficult obstacle, however, strict monitoring of her diabetes. duced by more than forty per cent. Sur- has been the waywardness not of pa- But surely she had been encouraged to gical procedures were down by a quarter. tients but of doctors—the doctors whom do these things after her first two heart The patients were also markedly health- the patients see outside the clinic. Jeff attacks. What made the difference this ier. Among five hundred and three pa- Brenner’s Camden patients are usually time? tients with high blood pressure, only two uninsured or on welfare; their doctors “Jayshree,” Vibha said, naming the were in poor control. Patients with high were happy to have someone else deal health coach from Dunkin’ Donuts, who cholesterol had, on average, a fifty-point with them. The Atlantic City casino also speaks Gujarati. drop in their levels. A stunning sixty- workers and hospital staff, on the other

THE NEW YORKER, JANUARY 24, 2011 49 hand, had the best-paying insurance in And there are ways to benefit. At a We’ve been looking to Washington to town. Some doctors weren’t about to let minimum, a successful hospital could at- find out how health-care reform will that business slip away. tract patients from competitors, cushion- happen. But people like these are its real Fernandopulle told me about a woman ing it against a future in which people leaders. who had seen a cardiologist for chest pain need hospitals less. Two decades ago, for two decades ago, when she was in her instance, Denmark had more than a uring my visit to Camden, I at- twenties. It was the result of a temporary, hundred and fifty hospitals for its five Dtended a meeting that Brenner and inflammatory condition, but he contin- million people. The country then made several community groups had organized ued to have her see him for an examina- changes to strengthen the quality and with residents of Northgate II, the build- tion and an electrocardiogram every three availability of outpatient primary-care ing with the highest hospital billing in the months, and a cardiac ultrasound every services (including payments to encour- city. He wanted to run an idea by them. year. The results were always normal. age physicians to provide e-mail access, The meeting took place in the building’s After the clinic doctors advised her to off-hours consultation, and nurse man- ground-floor lounge. There was juice in stop, the cardiologist called her at home agers for complex care). Today, the num- Styrofoam cups and potato chips on little to say that her health was at risk if she ber of hospitals has shrunk to seventy- red plastic plates. A pastor with the Cam- didn’t keep seeing him. She went back. one. Within five years, fewer than forty den Bible Tabernacle started things off The clinic encountered similar trou- are expected to be required. A smart hos- with a prayer. Brenner let one of the other bles with some of the doctors who saw pital might position itself to be one of the coalition members do the talking. its hospitalized patients. One group of last ones standing. How much money, he asked, did hospital-based internists was excellent, Could anything that dramatic happen the residents think had been spent on and coördinated its care plans with the here? An important idea is getting its test emergency- room and hospital visits in the clinic. But the others refused, resulting in run in America: the creation of intensive past five years for the people in this one longer stays and higher costs (and a fee for outpatient care to target hot spots, and building? They had no idea. He wrote every visit, while the better group hap- thereby reduce over-all health-care costs. out the numbers on an easel pad, but they pened to be the only salaried one). When But, if it works, hospitals will lose reve- were imponderable abstractions. The res- Fernandopulle arranged to direct the pa- nue and some will have to close. Medical idents’ eyes widened only when he said tients to the preferred doctors, the others companies and specialists profiting from that the payments, even accounting for retaliated, trolling the emergency depart- the excess of scans and procedures will get unpaid bills, added up to almost sixty ment and persuading the patients to squeezed. This will provoke retaliation, thousand dollars per person. He asked choose them instead. counter-campaigns, intense lobbying for how many of them believed that they had “ ‘Rogues,’ we call them,” Fernando- Washington to obstruct reform. received sixty thousand dollars’ worth of pulle said. He and his colleagues tried The stats-and-stethoscope upstarts health care. That was when the stories warning the patients about the rogue doc- are nonetheless making their dash. Ru- came out: the doctors who wouldn’t give tors and contacting the E.R. staff to make shika Fernandopulle has set up a version anyone on Medicaid an office appoint- sure they knew which doctors were pre- of his Special Care program in Seattle, ment; the ten-hour emergency-room ferred. “One time, we literally pinned a for Boeing workers, and is developing waits for ten minutes with an intern. note to a patient, like he was Paddington one in Las Vegas, for casino workers. Brenner was proposing to open a doc- Bear,” he said. They’ve ended up going Nathan Gunn and Verisk Health have ’s office right in their building, which to the hospital, and changing the doctors landed new contracts during the past year would reduce their need for hospital vis- themselves when they have to. As the say- with companies providing health benefits its. If it delivered better care and saved ing goes, one man’s cost is another man’s to more than four million employees money, the doctor’s office would receive income. and family members. Tim Ferris has ob- part of the money that it saved Medicare The Atlanticare hospital system is in a tained federal approval to spread his pro- and Medicaid, and would be able to add curious position in all this. Can it really gram for Medicare patients to two other services—services that the residents could make sense for a hospital to invest in a hospitals in the Partners Healthcare Sys- help choose. With enough savings, they program, like the Special Care Center, tem, in Boston (including my own). Jeff could have same-day doctor visits, nurse that aims at reducing hospitalizations, Brenner, meanwhile, is seeking to lower practitioners at night, a social worker, a even if its employees are included? I asked health-care costs for all of Camden, by psychologist. When Brenner’s scenario David Tilton, the president and C.E.O. getting its primary-care physicians to was described, residents murmured ap- of the system, why he was doing it. He extend the hot-spot strategy citywide. proval, but the mention of a social worker had several answers. Some were of the it’s- brought questions. the-right-thing-to-do variety. But I was “Is she going to be all up in my busi- interested in the hard-nosed reasons. The ness?” a woman asked. “I don’t know if Atlantic City economy, he said, could not I like that. I’m not sure I want a social sustain his health system’s perpetually ris- worker hanging around here.” ing costs. His hospital either fought the This doctor’s office, people were slowly pressure to control costs and went down realizing, would be involved in their with the local economy or learned how to lives—a medical professional would be benefit from cost control. after them about their smoking, drinking,

50 THE NEW YORKER, JANUARY 24, 2011 diet, medications. That was O.K. if the person were Dr. Brenner. They knew him. They believed that he cared about them. Acceptance, however, would clearly depend upon execution; it wasn’t guaran- teed. There was similar ambivalence in the neighborhoods that Compstat strate- gists targeted for additional—and poten- tially intrusive—policing. Yet the stakes in health-care hot-spot- ting are enormous, and go far beyond health care. 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. For each dollar added to school budgets, the costs of maintaining teacher health benefits took a dollar and forty cents. Every country in the world is battling “I said, ‘You’re starting to get on my nerves’!” the rising cost of health care. No commu- nity anywhere has demonstrably lowered • • its health-care costs (not just slowed their rate of increase) by improving medical services. They’ve lowered costs only by the ability of private and public insurers to needs state legislative approval to bring his cutting or rationing them. To many peo- cut high-cost patients from their rolls, and program to Medicaid patients at North- ple, the problem of health-care costs is improve the quality of care. The law au- gate II and across Camden. He needs fed- best encapsulated in a basic third-grade thorizes new forms of Medicare and eral approval to qualify as an accountable lesson: you can’t have it all. You want Medicaid payment to encourage the de- care organization for the city’s Medicare higher wages, lower taxes, less debt? Then velopment of “medical homes” and “ac- patients. In Camden, he has built support cut health-care services. countable care organizations”—doctors’ across a range of groups, from the state People like Jeff Brenner are saying that offices and medical systems that get fi- Chamber of Commerce to local hos- we can have it all—teachers and health nancial benefits for being more accessible pitals to activist organizations. But for care. To be sure, uncertainties remain. to patients, better organized, and ac- months—even as rising health costs and Their small, localized successes have not countable for reducing the over-all costs shrinking state aid have forced the city to yet been replicated in large populations. of care. Backers believe that, given this contemplate further school cuts and the Up to a fourth of their patients face prob- support, innovators like Brenner will layoff of almost half of its police—he has lems of a kind they have avoided tackling transform health care everywhere. been stalled. With divided branches at so far: catastrophic conditions. These are Critics say that it’s a pipe dream— both the state and the federal level, “gov- the patients who are in the top one per more money down the health-care sink- ernment just gets paralyzed,” he says. cent of costs because they were in a car hole. They could turn out to be right, In the meantime, though, he’s forging crash that resulted in a hundred thousand Brenner told me; a well-organized oppo- ahead. In December, he introduced an ex- dollars in and intensive-care ex- sition could scuttle efforts like his. “In the panded computer database that lets Cam- penses, or had a cancer requiring seven next few years, we’re going to have abso- den doctors view laboratory results, radi- thousand dollars a week for chemo and lutely irrefutable evidence that there are ology reports, emergency-room visits, and radiation. There’s nothing much to be ways to reduce health-care costs, and they discharge summaries for their patients done for those patients, you’d think. are ‘high touch’ and they are at the level from all the hospitals in town—and could Yet they are also victims of poor and dis- of care,” he said. “We are going to know show cost patterns, too. The absence of jointed service. Improving the value of the that, hands down, this is possible.” From this sort of information is a daily impedi- services—rewarding better results per dol- that point onward, he said, “it’s a political ment to the care of patients in Boston, lar spent—could lead to dramatic innova- problem.” The struggle will be to survive where I practice. Right now, we’re no- tions in catastrophic care, too. the obstruction of lobbies, and the parti- where close to having such data. But this, The new health-reform law—Obama- san tendency to view success as victory for I’m sure, will change. For in places like care—is betting big on the Brenners of the other side. Camden, New Jersey, one of the poorest the world. It says that we can afford to Already, these forces of resistance have cities in America, there are people show- subsidize insurance for millions, remove become Brenner’s prime concern. He ing the way. 

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