In the eyes of some, health reform threatens to burn down the old house of the American health system before it has built the country a new one. There are many who will not mourn the passing of the old, but it is fair to say that most health care leaders are extremely anxious to see what the new one might look like. All of those who share this anxiety would be well served to pay close attention to the work of Dr. Jeffrey Brenner at the Camden Coalition of Healthcare Providers.
Dr. Brenner and the Camden Coalition have achieved notoriety lately, due to Atul Gawande’s excellent January New Yorker article “The Hot Spotters.” But the Coalition’s programs repays closer attention as an example of a model of health care delivery that, beginning with the sickest individuals patients, holds promise to transform health care delivery for millions of Americans over the coming years.
Since 2002, Camden Coalition has done an impressive job in collecting patient-level data from 3 local hospitals, erstwhile competitors. They have developed an ‘all-payer’ data base capable of geographically locating high cost health care users down to a highly granular level Analysis has shown a particularly unhappy application of Pareto’s Law: 20 percent of patients accounted for 90% of costs. But the sickest 1 percent accounted for 10 percent of hospital admissions and an astonishing $375 million in charges between 2002 and 2007. One single patient visited the hospital or ED 324 times in 5 years. Two neighborhood buildings alone accounted for $200 million in health care charges.
The Coalition decided to target the heaviest users of the ED with a special intervention team consisting of a nurse practitioner, a social worker, and a community health worker. The essential feature of these care management teams is that they bring the care to the patients, rather than waiting for them to present at the ED. But their job is not only to treat, it is to answer questions, calm anxieties, track compliance and build the relationships of confidence essential to helping the sickest patients, whose multiple pathologies are often compounded by substance abuse, mental health issues and homelessness. Relationship building is critical. A gesture as simple as a returned phone call can be enough to calm a patient’s fears and keep him or her from an unnecessary visit to the ED.
According to an article in Perspectives in Health Information Management (Spring 2010), the Camden initiative has cut in half the average per month hospital charge for its earliest group of super-users and nearly halved their number of monthly ED visits. All the while, the care team works to enroll uninsured super-users in forms of insurance for which they are eligible. This has led to a more than 50 percent increase in the average rate of reimbursement of medical charges for the cohort under study.
Part of the beauty of the Camden model is its immediacy. Considering the enormous resource wastage incurred by a patient who visits the ED or the hospital dozens of times a month, you can begin a meaningful super-user program with a single super-user. This is patient centric reform at a very focused level. Making your sickest and most difficult patients lives better now helps not only the patient, it frees limited resources for others who need care.
The development of a database showing patient specific costs and usage patterns across multiple providers will take time, patience, and investment. But Brenner insists that this process can go along in parallel with the commencement of a super-user program. It does not need to precede it.
The Care Management Program management plan is only one of the Coalition’s initiatives. It exists in concert with a Citywide Diabetes Collaborative, and the development of a live streaming Health Information Exchange that can supply up-to-the minute care histories to primary care offices.
With this kind of data network in place, the Coalition is in a position to constitute itself as an Accountable Care Organization that can capture some of the cost saving or payment improvements to its well-documented populations to reinvest in even more proactive care models. According to Brenner the ultimate goal is to invent a new kind of medical home: a sophisticated primary care office where providers come in every day “obsessed with the health of their sickest and most costly patients.” Their work may ultimately give birth to a new medical specialty.
The Coalition’s first focus has been on socially-excluded Medicaid patients with chronic disease. But similarly skewed usage patterns can be discovered in all sorts of populations, including the employees of health care organizations themselves. So in the end, focusing on your most costly patients first can be the impetus for technological developments that in the long run will increase quality and health outcomes for all patients.
Health reform is up ahead, and it is fair to say no one knows what America’s health care system will look like once the dust settles. It is perhaps to the credit of the framers of this reform that they have not imposed a single, clearly defined image of the future. The current legislation instead is an impetus to move away from where we are now via an eclectic mix of mandates, regulatory carrots and sticks, experimental payment models, and new information technology applications.
The success of the Camden Coalition is a challenge to all health care organization to anticipate new forms of health care delivery. You do not need sophisticated data systems to find super users. Just ask your doctors, says Brenner: they will know them by name.