Understanding Power Laws and Personal Networks May Save Lives and Cut Health Care Costs
Medical practices treating seriously ill patients in two of New Jersey's most impoverished communities may be proving that the best care saves money as well as lives.
Family physician Jeffrey Brenner
and his staff at the Camden Coalition of Healthcare Providers
serve some of the most medically complex patients in one of America's most troubled cities. Rushihka Fernandopulle
, an internist with a passionate interest in innovative primary care, runs the Special Care Center
(pdf) for medically needy patients in Atlantic City. An extraordinary New Yorker story by Atul Gawande
describes the pioneering work and achievements of both physicians and their colleagues.
Brenner, who lived in Camden and joined a medical practice there in 1998, studied patterns of how patients used Camden's hospitals. He discovered a disproportionate number of patients came from two city bocks, one with a large nursing a home and one with a low-income housing tower. His focus was care, not cost, Gawande writes. But his data was stunning: between 2002 and 2008, some 900 people in the two buildings had 4,000 hospital visits that cost about $200 million. One patient had 324 admissions in five years, and the most expensive patient cost insurers $3.5 million. His numbers also showed that one percent of the 100,000 people who used Camden's medical facilities accounted for 30 percent of its costs. Some authorities
say 20 percent of patients incur 80 percent
of all U.S. healthcare expenses.
Gawande tells how Brenner met and got to know the most medically complex patients. He learned about their lives and witnessed some of the conditions that contribute to the bodily disregard, obesity, addiction, deprivation and despair that ruin health. And he figured out things he could do to help. He adopted lessons from people who run "medical home
" programs in Seattle
, San Francisco
(pdf) and Pennsylvania
. Brenner's Camden Coalition and its team
, which includes physicians, nurses, social workers, data specialists and volunteers, builds relationships with patients in phone calls and home visits that help people manage their medical problems and focus on prevention and healthier lifestyles
. When the coalition measured their impact
on the first 36 medically complex patients identified as "super users," Gawande reports, their emergency room visits had dropped 40 percent, and their hospital bills were down 56 percent.
The Special Care Center in Atlantic City began in 2007 as an experiment by Local 54
of the Atlantic City casino workers union, and Atlantic City Medical Center
, to treat their sickest employees and save money. Fernandopulle identified the patients facing the worst and costliest health risks and invited them to join the center. The union's and hospital's health funds began paying the center a flat fee for each patient, rather than fees for each visit. Fernandopulle established unlimited access for patients, same day visits for the acutely ill, an electronic information system to track patients' health goals, and staff to help patients meet them. One of the two nurse practitioners was assigned to get every smoker to quit. The staff includes two physicians, a social worker and eight health coaches
from the community
. All practice relationship building with patients. Gawande writes that staff broke into cheers during a morning meeting when their statistical report showed only one of their 1,200 chronically ill patients was in the hospital, and none had been to an emergency room in four days. After a year, emergency visits and hospital admissions dropped 40 percent, and surgical procedures dropped 25 percent. Early reports show healthier patients who manage their chronic conditions better and generate less expense. Will this success spread? It may, but Fernandopulle and others found resistance from physicians who are unwilling to alter habitual ways of medical practice.