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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.