Camden and you: the cost of health care to communities

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.

Freedom abroad, health at home: experiments in preventive health care

.
First, we must celebrate the victory of the people of Egypt in ousting the 30-year dictator Hosni Mubarak, and we revel in the democratic character of both this peaceful revolution and that in Tunisia last month. We hope that all of the dreams and aspirations of the masses of people involved are realized – freedom of speech, freedom for women and minorities, freedom from hunger. Thinking and reading about it brings tears of joy and admiration for these brave people. It is truly inspiring and encouraging to see this part of the world moving in the right direction. I feel that it may be wrong to have a post that dilutes this excitement with discussion of other topics, but take comfort in the fact that the papers, magazines, and blogosphere are talking about little else.
...

Unfortunately, at the same time it is sobering to think about how much, in the US, we are moving in the wrong direction (see Bob Herbert, “When democracy weakens”, NY Times, Feb 12, 2011). Politicians elected, with money coming from the wealthiest corporations and individuals, on the platform of promising to create jobs, do nothing of the kind (see Robert Reich, “The recession isn’t over until the jobs come back”, Kansas City Star, Feb 12, 2011. At the federal level, to the extent Congress is doing anything, it is giving money away to the richest and taking away from poor and working people. State legislatures are also focused on eliminating support for poor people, as well as oppressing immigrants and banning gay marriage – or any rights for gay people (see Charles Blow, “Repeal, restrict, and repress”, NY Times, Feb 12, 2011). And, of course, on further restricting abortion rights. Indeed, there are those in Congress who wish to eliminate Title X funding for contraception. Given that contraception is the most effective way to decrease the abortion rate, this seems bizarre, but only if you are into “reality-based” policy making.

Where is the good news in our country? We all know that there are lots of good people out there, doing lots of good things. In health care, much of the positive news is people pitching in, volunteering to try to fill the holes left by a health care system that does not, despite the Affordable Care Act (ACA), provide care for much of our population. One example is the JayDoc Clinic, an operation entirely run by students from the University of Kansas School of Medicine, featured in the Feb 12 Kansas City Star (“Student run JayDoc clinic serves the uninsured”). Great work, and a great article, but one result is going to be more people who are in need hearing about it, and further overwhelming the clinic. The JayDoc, like so many “safety net” clinics, is a “finger in the dike”, struggling to survive in providing basic care while billions are spent on what Don Berwick, currently head of the Center for Medicare and Medicaid Services (CMS) and his colleague Brent James at the Institute for Healthcare Improvement (IHI) call “rescue care”.

Meeting the basic health care needs of the really-needy is not only right and compassionate, but is likely to cost less (in dollars and pain) if it prevents serious illness later. Since this does not seem to be a focus of government, which is busy cutting taxes on billionaires like David and Charles Koch and cutting access to contraception, some progressive and thoughtful parts of the private sector have been creating models across the country. Many of these are detailed by surgeon and writer Atul Gawande in his article “The hot spotters: can we lower medical costs by giving the neediest patients better care?” (New Yorker, Jan 24, 2011).

Gawande examines several cities where efforts have been made to identify the sickest, neediest, and highest-cost-users of health care, and intervene to try to reverse or ameliorate the causes. Some of them, like the lead story of the program in Camden, NJ, are the result of hard and extended volunteer work, by Dr. Jeffrey Brenner and friends. Others, such as in Atlantic City, result from partnerships between existing institutions (in this case, a hospital and a union). None are the result of wise governmental leadership investing in these programs to reap a benefit of greater health and lower cost. In Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009, I discussed the implications of the fact that most people use little health care, and a small percent use most of it. Managed care in the late 1990s failed in part because it put major hurdles in the way of receiving health care for the large proportion of the population whose health care use accounted for a small percent of health care spending in any case.

The programs described by Gawande do the opposite; they identify the actual people who account for most of the health costs in these communities and provide services and support to help those people. In Camden, for example, 1% of the population – 1000 people – accounted for 30% of its costs. 900 people in two buildings (a nursing home and a low-income housing project) accounted for more than 4000 hospital visits and $200,000,000 in health care bills over a 6 ½ year period. And, as Gawande points out, Camden is not unique. There is no money for this from the public sector or insurance industry because it is being spent (in addition to insurance company profit and administrative waste) on “rescue care” for people with conditions that advanced so far because they never received sufficient preventive and primary care.

Public funds are also not being spent (indeed, as noted above, they are being cut) to support the myriad other “determinants of health”, social, economic, cultural and linguistic that are necessary for them to take advantage of preventive and primary care, to have the capability (Capability: understanding why people may not adopt healthful behaviors, Sep 24, 2010) of improving their health. Planning to achieve reductions in health care costs by “solutions” such as increasing copayments and deductibles so that people have “more skin in the game” are based on belief but not on facts. Gawande cites the experiences of benefit manager Verisk Health, which showed that such obstacles caused people to use less of all kinds of care – including primary and preventive care – until they finally got so acutely ill that needed to come to an emergency room, get admitted, go into an intensive care unit, so that costs in fact went up. One man “…had badly worsening heart disease and diabetes, and medical bills over 2 years in excess of $80,000. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the ER – until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure. The higher co-payments had backfired…” This outcome has been known for a long time; the RAND health insurance experiment in the 1970s and published in the New England Journal of Medicine in 1983[1] (see also: Joseph P. Newhouse, "Free for all?: lessons from the RAND Health Insurance Experiment", RAND 1993) showed that the opposite strategy – elimination of co-payments and deductibles -- resulted in higher utilization of health care; of both that which might be seen as “unnecessary” (colds) and that which was clearly necessary. And it saved money.

The interventions that have had success in Camden and other places were not “one size fits all”. Different people had different issues that required different interventions. Some were about poverty, some were about substance abuse or mental illness, some were about cultural misunderstandings or about language, and on and on. Interventions required more from nurse case managers for some people, social workers for others, physicians and nurse practitioners for others, and “health coaches” or promotoras for others. A lot of the latter; people who were familiar with the needs of the high-utilizer patients, who spoke their language, lived in their communities, and were often willing to “talk like [my] mother” to them.

And it is not always successful. But it is successful enough, far more successful than just pouring dollars into rescue care, that it needs to move beyond the limits that volunteers and a few forward-thinking institutions are constrained by. It needs to recognize the critical nature of teams, of integrating preventive and primary health care with basic social (and sometimes legal) services, with meeting core needs for food, housing and transportation that are all too often not even considered by policy makers. Funding is key; depending on volunteers in such efforts as these, or the JayDoc student–run free clinic will never come close to being a solution.

About Dr. Brenner’s program in Camden, Dr. Gawande writes “It remains unclear how the program will make ends meet”. In fact, these sorts of programs need to become the mainstream of health care and service delivery, and need to become the priority of federal, state, and local government.

[1] Brook RH, et. Al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”,N Engl J Med 1983; 309:1426-1434.
.