Dr Atul Gawande
Photo: Getty Images Today I was driving between meetings and caught a part of NPR's Fresh Air, where they were interviewing Atul Gawande, a staff member of Brigham and Women’s Hospital, an associate professor of surgery at Harvard Medical School and an associate professor in the Department of Health Policy and Management at the Harvard School of Public Health. He was a senior health policy adviser for President Clinton. He is a staff writer for The New Yorker magazine and also the author of several books, including The Checklist Manifesto and Better. Today was a particularly interesting day because of the House repeal of of Affordable Care Act, and so this Fresh Air interview was quite timely.
In the interview, Gawande outlined several examples where innovative initiatives to focus on health outcomes, rather than fee-for-service payment structures, saved communities huge amounts of money. For example, he profiles Jeff Brenner, a family practitioner working in Camden, N.J. In 2007, Brenner started treating chronically sick people who accounted for a significant percentage of the health care costs in Camden. By helping them, he could also lower the health care costs — not just for them but for the entire city of Camden. He decided to start, just one-by-one, taking care of the people who were in that top percentage of costs.
According to Gawande, after three years, Brenner and his team appear to be having a major impact. His patients "averaged 62 hospital and E.R. visits per month before joining the program and 37 visits afterwards — a 40 percent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after — a 56 percent reduction."
The method that Brenner used was not all too revolutionary - a simple mixture of social work, case management and primary care.
As Gawande explained in the Fresh Air interview:
He'd go and spend an hour a day just sitting and trying to figure out what made the guy tick. As he got better in the intensive care unit and started getting out into the regular floor of the hospital, and then into a rehab facility, they neared the point where he was going to be discharged.A transcript of that interview can be found HERE.
And the minute he goes out, you know, it's back to that world where there could be cocaine, there could be drugs, alcohol, he'd be homeless, he would lose, you know, any kind of basic care that would keep him going. And instead, he began providing that care.
He got a nurse practitioner, in addition to himself, who agreed to help pitch in. And she started visiting him every other day, at home, just to make sure his blood pressure was being checked and under control, and he was doing the right things by his diabetes.
He got a social worker to work with him and make sure that, you know, he got the Medicaid he qualified for. So he had steady insurance, and some of the specialists he needed would actually see him.
And probably the most important thing was simply working on him the way a primary care doctor works on people who have gotten into a rut in their lives. He said, you know, probably the most important thing that he did was just tried to care about him. And he worked on things like: How are we going to get you to stop smoking? How do we introduce value into your life again?
He pushed him to rejoin the church that he used to go to, that he didn't go to anymore. It turned out, he learned about him, that he was a line cook in his former life, before he got so sick, and that he knew how to cook. And so, you know, he said, start cooking for yourself so that you're getting back in the habits and eating better.
And slowly, it took three years, but I spoke to the patient, and he's not had any more of those catastrophic intensive care unit stays. He has lost 220 pounds. When he falls down, he does not have to call 911 to get up. He is off of cocaine for three years, alcohol for two years, smoking for a year.
While listening to the interview, I couldnt help but wonder why there's not more focus on these sorts of initiatives in the health care reform legislation. While there is some funding in the new legislation for these types of programs, it seems like a lot of energy and attention was paid to insurance companies, insurance subsidies, and risk pools. My opinion is that we should revisit the law and try to implement more programs like Brenner's. Through existing infrastructure with Community Health Centers, HRSA could fund grants to pay for the projects and provide analysis by using integrated electronic health record system, which are already being funded through health care reform.
I hope Congress spends less energy on political games like repealing legislation and more time looking into ways to integrate programs like the one Gawande described on Fresh Air into the existing law.
If you get a chance, listen to or read the interview, and pay special attention to the section ab
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