Atul Gawande is a 45 year old surgeon at the Brigham and Womens hospital in Boston, Ma. He has become a prolific writer in the past decade, with much to say about health care policy. His third book “The Checklist Manifesto: How to get things right” published in 2009, is a provocative and entertaining explanation of why enforcing the use of checklists has become an essential part of the aviation industry and decreased airplane accidents to almost none. He then goes on to address the hospital environment, a place he claims is no place for sick people, with myriads of infections, missed diagnoses, dosage mistakes and complications arising from human error. He gives countless, entertaining and quite striking and convincing examples of how the simple, enforced use of checklists in hospitals can reduce human error to virtually zero.
In the January 24 edition of the New Yorker, Dr Gawande wrote an essay discussing an issue of grave import to the US and the rest of the world: the spiraling cost of health care. His article, “The Hot Spotters” cites the successful implementation of “hot spotting’ by the New York City police commissioner William Bratton in the 1990s. Bratton championed the concept of mapping crime in the city and focusing resources on the ‘hot spots’. A young primary care physician in Camden, New Jersey named Jeffrey Brenner took this concept and mapped health care costs, ER visits, hospitalizations in his city and found that just 1% of the 100,000 people who used Camden’s medical facilities, or 1000 people, accounted for 30% of the costs. The most expensive patient cost insurers $3.5 million. He made block by block maps of the city residents by health care costs and identified the two most expensive blocks in Camden: one that housed a nursing home, and a second low income housing tower. He found that in one 6.5 year span, the 900 people in the 2 buildings accounted for more than 4000 hospital visits and $200 million in health care bills. His goal then became identifying ‘hot spots’ and improving patient care at these sites. This improved patient care and implementation of preventative care for these ‘high utilizers’ would not only impact the lives of those individuals, but the tremendous reduction in health care costs would trickle down through society as a whole and have a major impact on health care costs overall. This rather idealistic concept of identifying the highest users of health care, most often individuals with complex, multiple problems who use the emergency room as primary care, and improving their access to primary care with the ultimate goal of instituting preventative care is not only hopeful, but backed by quite a few concrete examples of success.
The article follows Jeffrey Brenner over the next 5 years and discusses the positive impact he has had in Camden by opening clinics at the sites of greatest need, and supplementing the staffing with social workers, nurses and other assistants who have the specific goals of working one on one with the highest utilizers to improve their level of compliance, prevent future complications and emergency room visits, and ultimately lower the health care costs of the community. Dr Gawande also introduces us to a young doctor in Boston working at Verisk Health, a data analysis company. The company supplies “medical intelligence’ to organizations that pay health care benefits with the goal of identifying where costs were highest, why these costs were so high, and pointing out means of reducing this ongoing upward spiral. Of course, no patient identifiers are permitted in any of these analyses, but employers can turn their health care data over to companies such as Verisk Health to analyze patterns and make recommendations. The data supplied by the young doctor at Verisk was astounding. One data set of 100,000 individuals showed an 8% rise in health care costs per year. But just 5000 of these individuals, or 5%, accounted for 60% of the total costs for the year. It is possible to drill down into this data farther and find out what the diagnoses were in these high cost individuals and identify ways of improving patient care therefore reducing visits to the ER and hospital admissions. In this particular data set, the patient with the most number of visits was not a cancer patient on chemotherapy, or a patient on dialysis for kidney failure, but a 25 year old woman with chronic migraines who had been to the ER 29 times, the urgent care center 51 times and had 1 hospital admission in the past 10 months. She clearly did not have a primary care physician and was instead using the ER. Each time she got a migraine, she went to the ER and saw a different doctor, who administered a MRI and CT to rule out tumor or aneurysm and gave her something to temporarily stop the pain, and a prescription for the same medication which was evidently not working to improve her migraines. She was not getting what she needed: a primary physician who would work with her to systematically try a variety of medication and figure out how to better address her migraines.
Dr Gawande tells us several examples of this type of medical mismanagement, and then goes on to cite examples of people or organizations which are attempting to address health care costs through “medical hot spotting”. One is a relatively new Medicare program which has had substantial funding increases under ObamaCare. It provides an optional monthly payment to finance coordination of care for the most chronically expensive Medicare patients at a hospital. The hospital has to decrease total costs more than 5% compared to those of a matched set of control patients to keep the cost savings. If they fail, the hospital must return the monthly supplemental payments. In 2006, Massachusetts General Hospital took the deal from Medicare. MGH identified 2600 chronically high-cost Medicare patients who accounted together for $60 million in annual Medicare spending. Each practice within MGH which served these patients was assigned a nurse whose sole job it was to improve coordination of care for these high cost patients by seeing patients between doctor visits, coordinating care between doctors, calling the patients on the phone, and trying to recognize and address problems before they required a hospital visit. Three years later, hospital stays and trips to the ER have dropped more than 15%, and MGH has met its required 5% reduction in total costs as a result.
A group of employers in Atlantic City has taken this concept even farther, and instilled a clinic exclusively for 1200 workers with exceptionally high medical expenses. Their goal is “intensive outpatient care for complex high needs patients”. In addition, there has been a marked attempt to reduce overhead: the clinic is paid a flat monthly fee for each patient rather than a fee for each doctors visit. This change resulted in a drastic reduction in billing costs. After 12 months, ER visits and hospital admissions were reduced by more than 40%. And an independent economic analysis demonstrated a 20% reduction in total costs compared to a control group of patients.
Any change to health care is extremely difficult to institute (note the ongoing fights over such incremental changes as the current Health Care Act). Doctors fight to maintain the fee structure where they are paid on a per patient basis. Hospitals fight to increase patient visits to maintain their income. In 1990, the country of Denmark had 150 hospitals. Some simple changes in health care management were implemented including payments to encourage doctors to provide their email addresses and off hour consultations, and hiring of nurse mangers for complex cases. There are now only 75 hospitals in Denmark. While examples like these should incentivize hospitals to improve their patient care so they will be the last man standing, instead it strikes fear into the hearts of hospital managers, as well as companies supporting hospitals by providing medical imaging and procedures, and will likely provoke political retaliation and lobbying in Washington to obstruct reform. These forces of resistance have already become the primary concern of reformers like Jeffrey Brenner in Camden. Yet the stakes in health care reform are enormous. Dr Gawande gives the example of Massachusetts which sent nearly a billion dollars to school districts to finance smaller class sizes and improve teachers pay, yet Dr Gawande claims that every dollar ended up being diverted to covering rising health care costs. He says that for each dollar added to the school budget, the costs of maintaining teacher health benefits rose one dollar and forty cents.
This quite interesting tact could play an important role in beginning to address the exorbitant costs of health care in society today. The most elegant part of this philosophy is the targeting of the highest utilizers of health care and greatest spenders and improving care to these individuals rather than attempting to reduce access. We can hope that the work of the pioneers cited in this article continues despite the paralysis evident in Washington today, and perhaps their activities will inspire more grass roots initiatives which will eventually be perceived as successful examples and implemented on a broad scale.
1. Gawande, Atul. “Medical Report. The Hot Spotters.” The New Yorker 24 January 2011: 41-51.
No comments:
Post a Comment