Fixing the System

January 28, 2011 Tagged with: health-care

Lower Costs and Better Care for Neediest Patients: This is an amazingly interesting article about the possible future of health care. This is an actual, practical manifestation of the “let’s make health care more efficient” pipe dream.

(Atul Gawande is a great author. I loved his book, The Checklist Manifesto. As a practicing physician, and, I suspect, a frustrated economist, most of his writing is about how to improve the health care system.)

A doctor in Camden, New Jersey decided to try and fix their health care system by finding out which people were using it the most, and really try to address and solve their health problems. Too often, these people were just shuttled around the health care system, but he spent time working with them to improve their health in order to cut their reliance on the system and their overall health care expense.

For example:

The first person they found for him was a man in his mid-forties whom I’ll call Frank Hendricks. Hendricks had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds.

[...] Brenner visited him daily. “I just basically sat in his room like I was a third-year med student, hanging out with him for an hour, hour and a half every day, trying to figure out what makes the guy tick,” he recalled. [...] After several months, he had recovered enough to be discharged. But, out in the world, his life was simply another hospitalization waiting to happen.

[...] I spoke to Hendricks recently. He has gone without alcohol for a year, cocaine for two years, and smoking for three years. He lives with his girlfriend in a safer neighborhood, goes to church, and weathers family crises. He cooks his own meals now. His diabetes and congestive heart failure are under much better control. He’s lost two hundred and twenty pounds, which means, among other things, that if he falls he can pick himself up, rather than having to call for an ambulance.

Now, this becomes a sticky problem. The conservative anthem is personal responsibility – people should take care of themselves. Why should a doctor have to follow Frank around? Why do we coddle people like him? He should recognize that he has problems and take responsibility for them, right?

Well, yes. But history says he won’t, and you and I will suffer for it.

Now, when someone won’t take responsibility for their own problems, and this just hurts them, that’s one thing. When it becomes a massive drain on the system as a whole, that’s another. Maybe we just have to realize that a lot of people can’t or won’t step up, and we’re all paying the price for that.

At what point do we succumb to the nanny-state in order to reduce costs overall? If it can be proven to reduce health care expenses, is it okay to hold some peoples’ hands and help them do the right thing, even if we’re just catering to their laziness? Do we hold our nose, in effect, and do what has to be done to achieve the end goal we’re looking for? Does the end justify the means?

(Consider Social Security. In a perfect world, everyone would take care of themselves and save for their own retirement. But, left to their own devices, a big chunk of the population would do nothing, then become a huge burden on the system when they got too old to work. Hence, we force income redistribution on the entire population – we help people because they won’t help themselves, in order to make things better for everyone.)

This same scenario played out in Atlantic City, New Jersey. A union of casino employees was trying to figure out how to reduce costs. They identified 1,200 people who spent the most on medical care. They worked with each of them – followed them around, tried to get them to change bad habits, and took a vested personal interest in their medical care.

Fernandopulle carefully tracks the statistics of those twelve hundred patients. After twelve months in the program, he found, their emergency-room visits and hospital admissions were reduced by more than forty per cent. Surgical procedures were down by a quarter. The patients were also markedly healthier. Among five hundred and three patients with high blood pressure, only two were in poor control. Patients with high cholesterol had, on average, a fifty-point drop in their levels. A stunning sixty-three per cent of smokers with heart and lung disease quit smoking.

This is this antithesis of typical health care. Instead of a generic revolving door approach, these people honestly tried to effect a real change by seemingly taking a deep personal interest in their patients. Even accounting for the cost of the program,medical costs for this group dropped by 25%.

Some of the ways to reduce costs, it turns out, were extremely simple, and things that no emergency room physician in the world is going to notice, care about, or fix:

[...] one reason some patients call 911 for problems the clinic would handle better is that they don’t have the clinic’s twenty-four-hour call number at hand when they need it. The health coaches told the patients to program it into their cell-phone speed dial, but many didn’t know how to do that. So the health coaches began doing it for them, and the number of 911 calls fell.

The article also mentioned a point that I’ve made before: reducing someone’s costs means reducing someone else’s income, and that will be resisted. This next bit absolutely infuriated me.

Their most difficult obstacle, however, has been the waywardness not of patients but of doctors–the doctors whom the patients see outside the clinic.

[...] Fernandopulle told me about a woman who had seen a cardiologist for chest pain two decades ago, when she was in her twenties. It was the result of a temporary, inflammatory condition, but he continued to have her see him for an examination and an electrocardiogram every three months, and a cardiac ultrasound every year. The results were always normal. After the clinic doctors advised her to stop, the cardiologist called her at home to say that her health was at risk if she didn’t keep seeing him. She went back.

The clinic encountered similar troubles with some of the doctors who saw its hospitalized patients. One group of hospital-based internists was excellent, and coordinated its care plans with the clinic. But the others refused, resulting in longer stays and higher costs (and a fee for every visit, while the better group happened to be the only salaried one).

Towards the end, the article claims that this philosophy of genuine patient care and improved efficiency is at the core of Obama’s health plan, and that statement made me sad. Regardless of whether or not it’s true, I was suddenly smacked in the face with the politicization of health care. Labeling something as pro-Obama (or pro-Big Health Care, or whatever) just proves again that we’re never going to get anyone to agree on it.

The fact is, some people would oppose this because their political enemies are in favor of it, regardless of its actual merits. Just putting a label on it like that will automatically turn half the country against it, and that’s a damn tragedy.

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