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The Daily Need

Can more care mean lower costs?

Dr. Atul Gawande

Dr. Atul Gawande has written a number of fascinating books and articles on low-tech, money-saving solutions to our health care woes, including importance of simple check lists in the emergency room and the costly problem of unnecessary tests and procedures that don’t actually improve heath outcomes. His latest article, published in the January 24 issue of The New Yorker, examines the benefits of providing personalized care — some might call it lifestyle coaching — for the neediest patients. Producer Shoshana Guy caught up with Gawande to learn more.

SHOSHANA GUY: Your recent article “The Hot Spotters” profiles Dr. Jeffrey Brenner, a family physician in Camden, N.J., who’s doing some innovative work to bring down health care costs. Explain to me — what is he doing?

ATUL GAWANDE: He took an approach that people had done in police work, which is look at the hot spots — the places in police work with the highest crime — and put your resources there. Only what he did was he made maps of Camden asking, “Where are the highest costs for health care?” And he found two city blocks that had about 1,000 people who lived in them who had $200 million in health costs over five years. He found that just one percent of the people in Camden accounted for 30 percent of the total costs. And that’s the story in every community around the United States.

The next thing he did was he then said one by one, I’m gonna try to help take care of those people, because he believed that the highest cost people were often getting the worst care. And that is exactly what he found.

He was taking care of people who had heart disease or lung disease or diabetes or obesity and smoking and alcohol problems. And would take them under his wing to say, “We’re gonna do everything we can do to make it so you don’t have to use the emergency room and you end up in the hospital less.” He reduced their cost on average by over 50 percent.

GUY: How could one person account for so much of the cost?

GAWANDE: His first patient was a man who had congestive heart failure, with his heart pumping only at a third of its capacity; 560 pounds, diabetes, a gall bladder infection, alcohol and drug abuse. When he caught up with him he was in an intensive care unit with a tracheostomy and a feeding tube. This was a man who spent seven out of 12 months in the hospital for the previous three years. He would be discharged to a homeless shelter or to a welfare motel and bounce back into the hospital within days.

Taking him under wing with a social worker who could make sure that he had housing and insurance; with a nurse practitioner who would see him every other day if necessary in order to make sure that he was on the right track with his medications; and then Jeff Brenner, working with this guy to get him into AA, working to, step by step, get into a program on weight loss, which allowed him to go, in two years, to becoming a guy who lost 220 pounds, quit smoking, no longer had his congestive heart failure, and barely spent anything more than a few days here and there with any kind of hospital visit.

GUY: All right, but we’re living in a climate right now where there’s all this talk about government not intervening. Your critics have called you tone deaf to those who might bristle at the idea of medicalizing society. So given the current political climate do you think it’s realistic to effectively have agents of government serving as, you know, almost lifestyle coaches?

GAWANDE: If medicine ends up being run out of Washington that is exactly what could happen. And that would be a disaster. We no more want Washington trying to help a patient through obesity than we want them doing their surgery for their cancer. The way that American health care works right now — and will continue to work in the future — is that private physicians are paid by insurers, whether it’s public or private insurers.

We as physicians should be rewarded for being better at keeping people out of the hospital. If we are switching from a system that just rewards us for the quantity of care to rewarding us for keeping people as healthy as possible and improving the quality of our care, then we’re on the right track. If we don’t even begin to try to do that then we’re consigning ourselves to an economy that ends up having health care suck the life out if it. It’s just what we have to do.

GUY: Do you think Brenner’s model is replicable? I mean, it relies on hundreds of people who are as dedicated as he is.

GAWANDE: That’s the test now. You almost could call these the charter schools for health care. So what he’s built, and I give other examples in Atlantic City, in Boston. And there are ones all over, including Lacrosse, Wisconsin and other places where they’ve tackled the patients who are in the top one percent of health care costs. What they are now starting to do is say, “Can we spread it more widely?” An approach that’s being tried in Atlantic City now they’re gonna try it in all of Las Vegas.

So this is the opportunity to find out if it can scale. No question it’s incredibly hard. We’re learning a lot. But we’ve got examples where we’ve scaled before. We took these ideas in police work where they started in New York City and now have spread to every police precinct almost in the country.

There’s no guarantee it’ll work. If this reduces costs, there will be a huge backlash from the people whose incomes get affected. Hospitals that don’t have so many patients anymore might be upset about these kinds of systems, for example. We have to be ready to defend and support these kinds of initiatives that actually are successful in making care better and less costly.

This week on Need to Know, Dr. Atul Gawande talks about the debate over end-of-life care. Tune in, or check back here on Friday afternoon.



  • Sunny Companions

    When someone from INSIDE an oprganisation offers advice on how to make things better – why wont anyone listen?? This guy talks sense.

  • Mcopelan8

    Here are a couple of ideas:
    Why doesn’t anyone ever report on the four largest health insurers, or holding
    companies (A holding company is organized specifically to hold the stock of other
    companies and ordinarily owns such a dominant interest in the other company or
    companies that it can dictate policy) that control them, and the association called Blue Cross Blue Shield.
    Blue Cross Blue Shield is an association that rents or sells its name to other insurance companies.

    The four largest insurers are Aetna, Well Point, CIGNA, United Health Care.
    These companies control most of health insurance in our country through their subsidiaries.
    One example; Well Point, our nation’s largest health insurer who owns Anthem Health Care, also owns another
    corporation called Anthem Blue Cross Blue Shield, which is in fourteen different areas
    or more, as well as they also own Unicare Health. These companies all sell the same or similar
    products, with four boards of directors, four sets of administrators, four sets of
    actuaries, four sets of attorneys, and even more. One group for each company. They also have
    four sets of claims departments, four separate sets of stock holders, etc…. all needing to meet the
    expectations of the parent company (Well Point) as well as Wall Street and their stockholders.
    Don’t they only need one set not four different ones?
    Let’s stop multiplying the effects of multiple administration costs.
    Let’s bring healthcare cost down.
    Let’s stop pseudo-monopolies.
    For an example; why aren’t the companies owned by Well Point all called Well Point?
    Let’s stop them, the insurance companies, from competing against themselves.
    Some even own the doctors as well as the medical facility (humanna) you have to go to.
    Where is the incentive to lower costs? Make them compete for our business.
    There are 255 million customers, that should be a huge quantity dollar discount for the American
    public with fair competition and the free market.

    Insurance companies now charge us more (in premiums) and give us less (cutting
    benefits). Doctors have complained for years about all the additional paperwork and the
    high cost of malpractice insurance. In other words, they want Tort Reform to limit our ability
    for compensation, wrongs, and harm done by the medical profession. (Tort is a system for compensating wrongs and harm done by
    one party to another’s person, property or other protected interests (e.g. reputation, under libel and slander laws).
    This is all caused and set by the insurance industry.
    They spread the expense of a few “bad” doctors over the entire medical field instead of
    making the “bad” doctors be held accountable for his or her own actions.
    Did you know insurance companies protect these “bad” doctors, hospitals, nursing homes, and so on, by keeping
    attorneys on retainers just to protect them so that they don’t have to pay claims (isn’t their job to pay our, the American people’s, claims)?
    Insurance companies have caused the problem with doctors, their paperwork and patient denials.

    Again, insurance companies now charge us more (in premiums) and give us less (cutting
    benefits). Remember when businesses said they could not afford health insurance for their
    employees? They had to lay people off and send jobs elsewhere.

    Remember, insurance companies now charge us more (in premiums) and give us less (cutting
    benefits). Patients have been blamed for being sick (it’s our fault for being sick. Insurance companies must have forgotten
    that we pay our premiums for them to pay our claims. That is their job).
    The insurance companies used to say “GOD forbid you got sick but thank GOD you have health insurance”. Nowadays it’s more like
    “GOD forbid you get sick now you can’t afford health insurance”.

    Look at their own greed!
    Who is more important to the insurance companies their stock holders or their customers?
    Without their customers they would have no money to pay their stockholders or business!

    Also, would someone please explain why no one seems to know that Medicare Advantage is not Medicare.
    It is an insurance plan sold by the for-profit insurance companies that takes
    money from the non-profit government Medicare Trust (that we have paid into) just to give to the for-profit
    insurance companies which is called Medicare Advantage.
    Then they (the for-profit insurance companies) charge you higher monthly premiums than
    non-profit government Medicare, deductibles, and co pays.

    MEDICARE ADVANTAGE IS NOT MEDICARE. Medicare is a non-profit. Medicare Advantage is not

    Let’s stop funding the for-profit Medicare Advantage from the non-profit government Medicare Trust.
    Money was given to the for-profit insurance companies out of the Medicare Trust for
    Medicare Advantage just to increase their bottom lines.
    Let’s use the funds from Medicare Trust to improve Medicare not fund Medicare Advantage.
    Don’t forget, insurance companies still offer Medicare supplements to
    cover what Medicare does not at a fraction of the cost.

    Using the four major health insurers and not allowing them to own other insurance companies (which
    has allowed them to compete against themselves instead of competing against each other)
    would greatly improve our cost control and gain better quality care.

    Finally, maybe we would have value for our dollar instead of our dollar for their value.

    With 255 million potential customers we should have better quality and better pricing. Don’t you think?


  • Drjonzdo

    The problem with our system is that when the patient is removed from the contract by 3rd party payers they expect the system to take care of them. The system gets rewarded for doing more to the passive public. Dr. Gawanda talks of the obese alcoholic who responded to being treated as a human being. The system doesn’t like dealing with the complexities if living humans so they rely on lab tests that can be evaluated by norms. People adapt to their environments and often do so in novel ways. Smart doctors try to alter the patients environment in healthy ways and let them adapt.

    I like the example of oral rehydration. Used to treat cholera OR keeps the drinking person optimally hydrated, even with the profuse watery diarrhea in this disease that looses so much water the people die of dehydration. In this country cholera is treated with an IV and antibiotics; the IV is the necessary part to replace fluids; the antibiotics shorten the time the bacteria is shed in the stool by about a day, but make no difference in survival. That’s a passive approach, but the system gets several thousand dollars for it. On the other hand if a poor person in Haiti is close enough to medical help that they can get OR they will recover in about the same amount of time and it will cost less than $5.00. And the system is not able to bill because they didn’t do anything to the patient. Which do you choose?

  • gall bladder symptoms


    Its very informative article guys brilliant work guys.