Dr. Jeffrey Brenner, Executive Director of the Camden (NJ) Coalition of Healthcare Providers, spoke at the recent Society of Teachers of Family Medicine (STFM) Medical Student Education conference, on “Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities” (powerpoint available at the Family Medicine Digital Resource Library, www.fmdrl.org). His work first came to major national attention about a year ago with the publication of the New Yorker article “The Hot Spotters” by Dr. Atul Gawande (January 24, 2011). This article discussed how Dr. Brenner and colleagues had used mapping techniques to identify where the largest number, and highest cost, utilizers of health care services in Camden lived, and developed programs to try to address their needs. These programs both improved their health and lowered the cost of care. This is not magic or simple; it requires hard work and results can be slow, but they do make a difference.
Dr. Brenner’s talk had two major sections. The first dealt with both the high cost of care in the US and the bizarre way that the money spent on care is allocated. One component is the huge regional disparity in the cost of care that is not explained by the overall cost of living. This topic is the subject of an earlier Gawande New Yorker piece, “The Cost Conundrum” (June 1, 2009), which focuses on the enormous difference in per capita Medicare expenditures in two similar Texas communities on the Mexican border: McAllen (one of the highest cost) and El Paso (one of the lowest). Brenner and Camden are in New Jersey, the state with the highest per capita expenditure in the nation, especially in the last 2 years of life (see his slide #5). Beyond the regional variation in health costs is the enormous disparity in what kinds of care Medicare, Medicaid, and other insurers pay for. They pay for procedures, but not for preventive care. Hospital emergency care is paid for, primary care is not. Early diagnosis and intervention that can make a difference both to people, in terms of the quality of their lives, and to the system, in terms of preventing future high costs are not paid for. Those later high-cost interventions, which former head of the Center for Medicare and Medicaid Services (CMS), Donald Berwick, MD, refers to as “rescue care” (see interview in the film “Money-driven medicine: the real reason health care costs so much”, also discussed by Bill Moyers August 28, 2009), of course are. That is, the US health system excels, rather than in primary and preventive care. This model is also illustrated in cartoon form by Camara Phyllis Jones, MD, of the Centers for Disease Control, in “Social Determinants of Health and Equity, the Impacts of Racism on Health”, which I have previous cited (Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010).
Jeff Brenner had a solo practice in Camden (slide #2), but despite being willing to work for very little, cuts to Medicaid reimbursement made it impossible for him to continue to run the business and stay In practice. But, while reimbursement to primary care providers like him are cut, the cost of late-stage care is driving our national debt, with expenditures on health care rising as Social Security and other obligations are relatively static (see graphic).
The other part of Dr. Brenner’s talk dealt with conditions in Camden, a destitute, end-of-the-road, best-days-are-far-behind, city of just under 80,000 across the Delaware River from Philadelphia, and the programs that have been developed to begin to help the people who live there. Brenner and his colleagues were able to pinpoint two buildings where the highest utilization of services, and thus cost, was located. Gawande states “…that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.” But Dr. Brenner’s main point is that these patients did not see value for this cost. When he later helped to organize the residents of one of these two sites, the Northgate II apartment complex (slide #13), the residents could not believe that this much money had been spent on them. They felt that they were not even able to see a doctor when they were sick, not to mention get preventive care and management of their health conditions. For a tiny fraction of this money, Brenner and his colleagues were able to start a small clinic in the building, staffed by a nurse practitioner, to deliver primary care to its residents. They set up a broad-based coalition, staring with area churches, to help develop a systematic response (slides 15-20). They even managed to get legislation in New Jersey to establish a demonstration project for Medicaid accountable care (slide 21).
The work done by Dr. Brenner and others is beginning to be replicated in other cities in New Jersey (Atlantic City, also discussed by Gawande, and more recently Newark) and across the country. The Camden collaborative is part of a national coalition of community groups, predominantly faith-based, called PICO that is working in cities across the country to address many of the same needs that people have wherever they live. They are beginning to recognize that the way money is spent in the US health care system is perverse and backward, rewarding providers for high-cost interventions rather than for keeping people as health as possible. Just as the residents of Northgate II could not believe that tens of millions of dollars had been spent on their healthcare when it felt to them as if they had such limited access, people around the nation are realizing the same thing.
People live in communities where there are no jobs for those who are capable of work, and where the rest of society puts its (literally) most toxic contamination further adding to their health stressors (portrayed by Brenner in slides not on line). They live in communities that are often “food deserts” without access to healthful nutrition. Their neighborhoods are not safe, both in terms of crime and in terms of toxic waste. Their homes are often inadequate, and they may not have heat in the winter. When they do develop chronic disease, there is no primary care in their community (see what happened to Dr. Brenner’s practice) and sometimes they cannot even get downstairs because the elevator is broken and their untreated chronic conditions make it impossible to walk down stairs. Their basic social structure is often disrupted to non-existent. They do not have to core survival needs of life met, and they do not have reasonable access to basic health care, but when they do make it to the emergency room, millions of dollars of medical care is provided. The fact is that we patch holes in people’s lives and communities with dollars spent on medical care. Think of the irony here: to us, to our country, and most painfully to these people.
And things are not as bad for the economically better off, for the working and middle class, for folks who do not live in Camden or similar communities, it is still not so good. We are all part of a health care system in which providers game the system to do the services that make the most money by delivering them to the best insured. We are part of a health care system that emphasizes expensive “rescue care” rather than primary care; that emphasizes medical care rather than the basic social needs people have that will move them farther from the “edge of the cliff” (as depicted by the CDC’s Dr. Camara Phyllis Jones in “Social Determinants of Health and Equity, the Impacts of Racism on Health”, discussed in my blog Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010).
Of course, while Jeff Brenner and others are mostly concerned with improving the lives and health of people, the amazing thing is that this can be done by lowering costs. Of course, costs to one part of the system are profits to another, so those profiting from the current arrangement are predictably resisting change. But this opportunity, to spend less overall to improve health, is one we cannot afford – in financial or human terms – to pass up.
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