Can better care for the neediest patients lower costs?

In yet another inspiring, beautifully written, and potentially influential New Yorker article, Atul Gawande tells the story of pilot projects by rogue doctors who reduce medical costs by attending to the sickest and neediest patients.

Speaking of a health care service started by Dr. Jeffrey Brenner for the sickest and most expensive patients in Camden, NJ, Gawande writes: (emphasis added)

The Camden Coalition has been able to measure its long-term effect on its first thirty-six super-utilizers. They averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction.

These results don’t take into account Brenner’s personnel costs, or the costs of the medications the patients are now taking as prescribed, or the fact that some of the patients might have improved on their own (or died, reducing their costs permanently). The net savings are undoubtedly lower, but they remain, almost certainly, revolutionary. Brenner and his team are out there on the boulevards of Camden demonstrating the possibilities of a strange new approach to health care: to look for the most expensive patients in the system and then direct resources and brainpower toward helping them.

Revolutions overthrow the top of the food chain

The article concludes by acknowledging forces that may resist this approach to lowering costs. Gawande cites some statistics from Denmark. After strengthening the quality and availability of outpatient primary-care services, the number of hospitals was reduced from 150 to a projected 40. Hospitals and hospital-based doctors in this country have a vested interest in the status quo. Politcally, Republicans may very well see a solution to the health care crisis as a “victory for the other side.”

Then there are those who will see this approach to health care as an example of the nanny state. Caring for the neediest includes close attention from social workers. They help patients overcome bureaucratic obstacles and encourage healthy habits, like not smoking. As one conservative journalist wrote in response to Gawande’s article:

[I]f this model were to be nationalized, you would in effect have agents of the government serving as lifestyle coaches and health “mothers.” Surely you don’t have to be a “tea partier” to find that creepy.

Since most of those whose lives would be directly saved or improved by this approach are low income, there could be opposition simply because it benefits the “undeserving” poor.

This is a revolution that could happen. Ultimately everyone would benefit. But there will undoubtedly be resistance, motivated either by economic self-interest or conservative principles. Rising medical costs that threaten to bankrupt the country may not be enough. It may take a disaster to overcome such resistance.

Resources:

Image: NPR

Atul Gawande, The Hot Spotters – Can we lower medical costs by giving the neediest patients better care?, The New Yorker, January 24, 2011

Jonah Goldberg, The ‘Healthstat’ seduction, Los Angeles TImes, January 25, 2011

Ask the Author Live: Atul Gawande on Medical Costs, The New Yorker, January 20, 2011
http://www.newyorker.com/online/blogs/ask/2011/01/atul-gawande-medical-costs.html