Leana Wen, MD, an emergency physician who has worked in inner city hospitals in St. Louis, Boston and Washington, D.C., writes in her blog about the painful experience of administering short term fixes to patients whose long term afflictions lie beyond her realm.
She describes a 19-year-old who has come to the emergency room three
times with cuts and broken bones and gunshot wounds. An 8-year-old
without an inhaler living among relatives in an overcrowded house with
lots of smokers comes to the emergency room struggling to breathe. A
38-year-old single mother diagnosed with cervical cancer four years ago
never got to see a doctor as she struggled with three part time jobs,
the care of four children and inadequate insurance. By the time Dr. Wen
saw her in the emergency room, her cancer had spread to her lungs and
"We in the ER provide a necessary service, but it's far from being sufficient," she writes in her blog The Doctor is Listening.
"We need to recognize that health does not exist in a vacuum, that it
is intimately tied to issues such as literacy, employment,
transportation, crime and poverty. An MRI here, a prescription there,
these are Band-Aids not lasting solutions. Our communities need
innovative approaches to issues like homelessness, drug addiction,
obesity and lack of mental health services." The route to good health,
Dr. Wen says, is in the community. Dr. Wen is coauthor of the book When Doctors Don't Listen.
When he was still writing the Wonkblog for the Washington Post, Ezra Klein
described an experiment in Oregon to rebuild the state's Medicaid
program around community health rather than individual fee for service
treatments. Klein tells a story Oregon Gov. John Kitzhaber loves to
tell. Kitzhaber, a former emergency room physician himself, calls it an
illustration of what's wrong with our healthcare system. A 90-year-old
woman with well-managed congestive heart failure lives in an apartment
without air conditioning. When her apartment gets too hot, the strain on
her cardiovascular system causes heart failure. Medicare will pay for
an ambulance and $50,000 to stabilize her, but not $200 for a window air
The 90-year-old may be hypothetical, but the story illuminates a
common paradox, and Oregon's experimental approach starts with creation
of 16 Coordinated Care Organizations (CCOs) that are responsible for assessing the health of their communities. Kitzhaber has given the CCOs flexibility on how they can spend Medicaid money. They can buy that air conditioner. An NPR story
describes a Medicaid purchase of a minivan for community health workers
who can be available around the clock to pregnant women trying to stop
substance abuse, and to help mothers get to doctors' appointments,
school and jobs. What makes CCOs different from accountable care
organizations, or managed care, is the community component. Once they
assess needs, they have to come up with ways to address them. So money
can be spent on care coordination and community health workers with the
aim of preventing some expensive emergency care. Gov. Kitzhaber told
Klein, "We're investing in health. It's just a paradigm shift."
With thanks to Annette Garner, who teaches in the nursing program at the Health & Science University, Portland, Oregon.