The idea of 'hot-spotting' may work privately on a small scale. But nationalize it as part of 'Obamacare'? No thanks.
If professional writing was the guild it often appears to be, Atul Gawande would be a scab. A surgeon and professor, Gawande also writes beautifully for the New Yorker about healthcare.
His latest article, "The Hot Spotters," focuses on what Gawande claims is a revolutionary approach to healthcare. In Camden, N.J. — hardly a garden spot in the Garden State — just 1% of the people who used the city's medical facilities accounted for 30% of the costs. One patient had 324 hospital admissions in five years, costing insurers $3.5 million.
Another fellow, weighing 560 pounds, with both an alcohol and cocaine problem, spent more time over a three-year period in the hospital than out of it. But thanks to work by a crusading doctor, Jeffrey Brenner, the man was pulled back from the brink, cutting his hospital visits dramatically.
Brenner's theory is that we can save billions by delivering better healthcare to the sickest people. Brenner was inspired by the Compstat approach used by police in New York City during the 1990s to tackle crime where it is most concentrated. Just as cops got out of their cars and walked a beat in the worst areas, under Brenner's "Healthstat" approach doctors and nurses get out and get involved in the lives of the sickest patients.
Brenner's results are impressive. All it takes is a near-religious dedication to getting involved in the nitty-gritty of patients' lives.
In a similar effort, a clinic formed by Atlantic City's casino workers union and its biggest hospital treats only the patients with the highest medical costs. The clinic often hires health "coaches" from outside the healthcare profession, because too many of the professionals have become bureaucratized, trained to say "no" to almost any question.
Gawande recounts how one such coach — a former Dunkin' Donuts cashier named Jayshree who speaks Gujarati — helped a seriously ill Indian immigrant get well enough to use a walker instead of a wheelchair. Why did this patient listen to Jayshree, after she wouldn't take similar advice about diet and exercise following her first two heart attacks?
"Because she talks like my mother."
A preliminary study found that the Atlantic City effort achieved real cost savings. But it was also lucky, statistically speaking. A single heart transplant for any one of its gravely ill patients would have wiped out all of the savings.
Still, Gawande's enthusiasm is infectious, and so is the passion of professionals like Brenner. Where Gawande falls short is in explaining how all of this justifies "Obamacare" (apparently he hasn't gotten the memo about not using that term).
Yes, the Patient Protection and Affordable Care Act funds pilot programs like Brenner's, but it also fuels the sort of bureaucracy that even Gawande and Brenner concede strangles innovation. It makes insurance companies into even more sheltered monopolies — health utilities, in effect — and appeases many of the political constituencies that stand to lose money from this style of counterinsurgency medicine.
Also, we know that Obamacare incentivizes corporations to dump their most expensive patients onto public exchanges. Which means taxpayers will pick up a much bigger tab than we were told.
Given these disappointments with the latest cures for the system, perhaps a little skepticism about the ability of "hot-spotting" to make it all work out is in order too.
But what I find most striking about Gawande's celebration of the community policing model is how at odds it is with any notion of limited government. He is tone deaf to those who might bristle at the idea of medicalizing society.
In Camden, Brenner wants to put social workers in "hot spot" buildings so residents can be coached daily about their diet and exercise and harangued to quit smoking. He cajoled the 560-pound alcoholic drug addict to resume church attendance.
This all sounds fine, from a medical perspective. But citizens are not patients.
Brenner is a private citizen doing heroic work. But if this model were to be nationalized, you would in effect have agents of the government serving as lifestyle coaches and health "mothers." Surely you don't have to be a "tea partier" to find that creepy.
His latest article, "The Hot Spotters," focuses on what Gawande claims is a revolutionary approach to healthcare. In Camden, N.J. — hardly a garden spot in the Garden State — just 1% of the people who used the city's medical facilities accounted for 30% of the costs. One patient had 324 hospital admissions in five years, costing insurers $3.5 million.
Another fellow, weighing 560 pounds, with both an alcohol and cocaine problem, spent more time over a three-year period in the hospital than out of it. But thanks to work by a crusading doctor, Jeffrey Brenner, the man was pulled back from the brink, cutting his hospital visits dramatically.
Brenner's theory is that we can save billions by delivering better healthcare to the sickest people. Brenner was inspired by the Compstat approach used by police in New York City during the 1990s to tackle crime where it is most concentrated. Just as cops got out of their cars and walked a beat in the worst areas, under Brenner's "Healthstat" approach doctors and nurses get out and get involved in the lives of the sickest patients.
Brenner's results are impressive. All it takes is a near-religious dedication to getting involved in the nitty-gritty of patients' lives.
In a similar effort, a clinic formed by Atlantic City's casino workers union and its biggest hospital treats only the patients with the highest medical costs. The clinic often hires health "coaches" from outside the healthcare profession, because too many of the professionals have become bureaucratized, trained to say "no" to almost any question.
Gawande recounts how one such coach — a former Dunkin' Donuts cashier named Jayshree who speaks Gujarati — helped a seriously ill Indian immigrant get well enough to use a walker instead of a wheelchair. Why did this patient listen to Jayshree, after she wouldn't take similar advice about diet and exercise following her first two heart attacks?
"Because she talks like my mother."
A preliminary study found that the Atlantic City effort achieved real cost savings. But it was also lucky, statistically speaking. A single heart transplant for any one of its gravely ill patients would have wiped out all of the savings.
Still, Gawande's enthusiasm is infectious, and so is the passion of professionals like Brenner. Where Gawande falls short is in explaining how all of this justifies "Obamacare" (apparently he hasn't gotten the memo about not using that term).
Yes, the Patient Protection and Affordable Care Act funds pilot programs like Brenner's, but it also fuels the sort of bureaucracy that even Gawande and Brenner concede strangles innovation. It makes insurance companies into even more sheltered monopolies — health utilities, in effect — and appeases many of the political constituencies that stand to lose money from this style of counterinsurgency medicine.
Also, we know that Obamacare incentivizes corporations to dump their most expensive patients onto public exchanges. Which means taxpayers will pick up a much bigger tab than we were told.
Given these disappointments with the latest cures for the system, perhaps a little skepticism about the ability of "hot-spotting" to make it all work out is in order too.
But what I find most striking about Gawande's celebration of the community policing model is how at odds it is with any notion of limited government. He is tone deaf to those who might bristle at the idea of medicalizing society.
In Camden, Brenner wants to put social workers in "hot spot" buildings so residents can be coached daily about their diet and exercise and harangued to quit smoking. He cajoled the 560-pound alcoholic drug addict to resume church attendance.
This all sounds fine, from a medical perspective. But citizens are not patients.
Brenner is a private citizen doing heroic work. But if this model were to be nationalized, you would in effect have agents of the government serving as lifestyle coaches and health "mothers." Surely you don't have to be a "tea partier" to find that creepy.
Comments
TomFiore at 1:03 PM January 26, 2011 Jonah said
"Also, we know that Obamacare incentivizes corporations to dump their most expensive patients onto public exchanges. "
We don't know that. That is a right wing talking point, rather than the truth. Under health care reform (what the right wing refers to as Obamacare in order to demonize it) employers will be required to provide health insurance for their employees or pay a fee to not provide it, but this isn't going to start for a few more years anyway. What Jonah and his follower want is for government to work like crap and that is what they push for.
What we do know is that the current system keeps going up in price. We know that we are spending too much of our GNP and too many people have no coverage. We also know that for the over 10 years that the GOP controlled Congress they did nothing to control the costs or provide for those without coverage. Finally, we don't know, but can surmise that the right wing has no program to bring costs under control and what little they have proposed will make the quality of care worse for the average person.
"Also, we know that Obamacare incentivizes corporations to dump their most expensive patients onto public exchanges. "
We don't know that. That is a right wing talking point, rather than the truth. Under health care reform (what the right wing refers to as Obamacare in order to demonize it) employers will be required to provide health insurance for their employees or pay a fee to not provide it, but this isn't going to start for a few more years anyway. What Jonah and his follower want is for government to work like crap and that is what they push for.
What we do know is that the current system keeps going up in price. We know that we are spending too much of our GNP and too many people have no coverage. We also know that for the over 10 years that the GOP controlled Congress they did nothing to control the costs or provide for those without coverage. Finally, we don't know, but can surmise that the right wing has no program to bring costs under control and what little they have proposed will make the quality of care worse for the average person.
lancegmorton at 4:34 AM January 26, 2011 Jonah - What I find creepy is why you would illustrate a very successful progressive approach to health care and then, almost as an aside, pander to the right in criticizing it. Weird. In a similar and more costly vein look into "Million Dollar" Murray, a Reno alcoholic homeless man who, a local police officer determined, was costing the city $1,000,000 a year in emergency ER and police costs because he had a tendency to get drunk and fall on the street in sub zero weather. What this rather conservative city did, at the behest of the beat cop, was to find Murray an apartment and provide him with food and regular attention from a social worker. Guess what Jonah? Costs of care for Murray (apartment, food, staffing) ended up less than $100,000 a year) saving the city over $900,000 annualy. I know, Jonah, you went to the same math class as Ryan but this is a pretty good result. The city saved a ton of money and Murray is no longer on the streets. Murray had no insurance so the residents of Reno had to pay full costs for his care without any funding for prevention. There are Murray's in every community. Obamacare will provide that insurance and will pay for innovative programs like Reno's. Write about that Jonah if you really care about the deficit.
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