Atul Gawande's latest New Yorker article, "The Hot Spotters," is a must-read for anyone concerned about the out-of-control growth of US healthcare costs (and that description should apply to everyone in this country). It's about possible solutions to the problem of the highest-cost patients, who account for a disproportionate share of healthcare spending but often aren't getting the kind of care that could really improve their lives. Gawande visits several organizations that are testing out ways to deliver better, more cost-effective care to patients with multiple chronic conditions and high medical bills, with some promising results.
Figures from the Kaiser Family Foundation illustrate what the issue is:
- 1% of the US population accounts for 21.2% of total healthcare spending
- 5% accounts for 47.7%
- 10% accounts for 63.3%
So, if we could reduce costs for the 10% of the US population that accounts for more than 60% of our country's healthcare spending, we could make significant progress toward at least slowing the rate at which healthcare costs are growing. Some people end up in the high-cost category because they're diagnosed with cancer or have a severe trauma, but many are people who have multiple poorly controlled chronic conditions.
Once a patient has developed multiple problems - say, obesity, diabetes, and heart disease - the risk of health crises increases. Several of the patients Gawande mentions in his article are regulars in their local ERs and ICUs (a key reason their expenses are so high), and while their hospital visits might stabilize them, they rarely address the underlying problems. Managing chronic conditions often requires coordinating an array of tests and medications performed and prescribed by different doctors, and complementing them with exercise, healthy eating, and other healthy behaviors. Some patients have enough education, time, and other resources to handle these tasks, but many don't. Some are dealing with disabilities, homelessness, and other serious challenges on top of their health problems. This article focuses on the individuals and organizations that are trying to provide this kind of help to some of the sickest patients.
Gawande visits the Special Care Center in Atlantic City, an experiment launched by the casino workers' union and a local hospital and run by internist Rushika Fernandopulle. The insurers pay the center a flat fee to manage patients' care, and the patients pay nothing for unlimited access to the clinic. The staff includes a social worker and eight "health coaches" as well as physicians and nurse practitioners. Health coaches - who come from diverse backgrounds and previously held jobs in retail, service, and other non-healthcare sectors - communicate regularly with patients to coordinate their care and encourage adoption of healthy behaviors. A comparison between Atlantic City casino workers who use the clinic (and accounted for one-third of the unions costliest 10% of members) and a similar group of Las Vegas casino workers who don't have access to this kind of intervention found that the Atlantic City workers in the program experienced a 25% drop in costs. Gawande met one patient, Vibha Gandhi, who illustrated how the program is achieving such savings:
She was fifty-seven years old and had joined the clinic after suffering a third heart attack. She and her husband, Bharat, are Indian immigrants. He cleans casino bathrooms for thirteen dollars an hour on the night shift. Vibha has long had poor health, with diabetes, obesity, and congestive heart failure, but things got much worse in the summer of 2009. A heart attack landed her in intensive care, and her coronary-artery disease proved so advanced as to be inoperable. She arrived in a wheelchair for her first clinic visit. She could not walk more than a few steps without losing her breath and getting a viselike chest pain. The next step for such patients is often a heart transplant.
A year and a half later, she is out of her wheelchair. She attends the clinic's Tuesday yoga classes. With the help of a walker, she can go a quarter mile without stopping. Although her condition is still fragile--she takes a purseful of medications, and a bout of the flu would send her back to an intensive-care unit--her daily life is far better than she once imagined.
"I didn't think I would live this long," Vibha said through Bharat, who translated her Gujarati for me. "I didn't want to live."
I asked her what had made her better. The couple credited exercise, dietary changes, medication adjustments, and strict monitoring of her diabetes.
But surely she had been encouraged to do these things after her first two heart attacks. What made the difference this time?
"Jayshree," Vibha said, naming the health coach [who previously worked at] Dunkin' Donuts, who also speaks Gujarati.
"Jayshree pushes her, and she listens to her only and not to me," Bharat said.
"Why do you listen to Jayshree?" I asked Vibha.
"Because she talks like my mother," she said.
I won't summarize the whole article - you should go read it for yourself. One important point is that the new healthcare law authorizes changes to Medicare and Medicaid payments to encourage providers to develop mechanisms for providing this kind of coordinated, prevention-focused care (medical homes and accountable care organizations). Our current fee-for-service system encourages a greater quantity of care but not necessarily higher-quality care, so changing the way we pay healthcare providers has the potential to lower costs while improving quality. Gawande's article suggests we can achieve this kind of win-win outcome for the highest-cost patients.
The article also hints at some other lessons that are important to bear in mind when considering how to get healthcare costs under control:
Cost-sharing is a blunt instrument. Gawande visited Verisk Health, a company that advises employers on ways to reduce their healthcare spending, and learned about the results of an analysis they ran for an information-technology company. The company hoped that by raising co-payments it could discourage employees from seeking unnecessary care, but health costs kept rising. Verisk found that many of those who accounted for high costs were early retirees who had multiple chronic conditions and started putting off preventive care when co-payments rose. Yet if co-payments are low or non-existent, people may use care they don't really need (and which could put them at risk of other problems - e.g., radiation from unnecessary CT scans).
Execution matters: It's clear from the article that the people who are trying to provide radically different care to the sickest patients are passionate and dedicated. The center in Atlantic City put a great deal of effort into hiring health coaches who could connect with the patient population. I suspect the staff involved in these efforts are pouring huge amounts of time and energy into their work, and that they have charisma to inspire others (patients, new staffers, funders) to join in. Can their efforts be replicated nationwide? I think they can be, at least to some extent - after all, the healthcare field is full of smart, dedicated, hardworking professionals. But if replication is sloppy, huge potential savings will become smaller actual savings.
One person's loss is someone else's income: All the inefficient care patients are getting is putting money in someone's pockets, and those recipients have a vested interest in seeing the system stay the way it is. Gawande notes that some of the Atlantic City patients' doctors were resistant to working with the new system. Paying doctors for quality rather than quantity would address this issue, but how do we get there from here?
Someone has to bear the risk: In the Atlantic City example, the insurers (the union and self-ensured hospital) have shifted risk from themselves to the Special Care Center: they're now paying a flat fee for their sickest patients, and the Center is hoping those payments will cover what it spends on those patients. Now that the Center is bearing the risk (and a potential reward), it has a powerful incentive to keep costs low through care coordination and preventive care. They have confidence in their system, but they could easily suffer financial losses if a few patients don't respond well to the model. But it's understandable that not all provider groups will be eager to take on such risk.
Saving money by providing more efficient care to the sickest patients isn't an easy fix, and won't by itself solve our problem with ballooning healthcare costs. But figuring out how to do it - and do it everywhere - is worth the effort.
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Which makes me ask: what could have been done to encourage that lifestyle change decades earlier? I can't help but believe that the earlier one starts to live a healthy lifestyle, the better. Especially for those who are suffering type 2 diabetes and its complications. Or perhaps: especially for those who would otherwise suffer type 2 diabetes.
I understand that the parts of the system that make money by providing more services to patients are afraid that they will lose money if care becomes more efficient. Is there any overlap with the parts of the system that are afraid there won't be enough resources to go around when the previously-uninsured get coverage and start seeking medical care? It seems the two trends might cancel each other out.
In other words, if you're getting oodles of new patients, why would you want to waste your resources on patients who won't need to come in all the time if they're getting proper prevention? Or have they just not thought things through?
Dean Ornish MD talks a lot about reducing healthcare costs with his very lowfat vegetarian (or vegan) diet. Apparently angina pain goes away in a few weeks on that diet, and over years the arteries actually widen.
I don't have heart disease so I can't speak for that personally. But I eat a very lowfat nearly-vegan diet and my last cholesterol was under 150, so I'm very unlikely to die of heart disease. The rest of my lipid panel was also excellent, including triglycerides which sometimes increase on this diet. My last blood pressure was 100/60.
A huge part of healthcare expenses is from self-caused illnesses, it seems. Smoking or drinking too much or bad diet. Those of us who take care of our bodies may resent being forced by insurance to pay the expenses of the Great Unwashed: obese smokers and drinkers and gobblers of saturated fat. Maybe there ought to be insurance companies specializing in cheap insurance for us.
Please don't offer your own medical advise. Dean Ornish diets have their own issues that affect other aspects of people's health. Diabetes and CVD are not the only issues.
Laura: There has been. For the past 30 years most insurance companies only took care of your holiness. Now, they also have to take care of the sick.
While you are unlikely to die of heart disease, you are also likely to come from a relatively wealthy family. Even middle class would make you wealthy compared to the people who are obese and smoking.
Low income families have one of the highest rates of obesity because they cannot afford vegan diets. There is a reason why people consume high levels of carbohydrates and meats in America. They are cheap. The great irony, of course, is that in the rest of the world meat and carbohydrates are indeed luxuries. You can thank the subsidized food industry in the US for that problem.
Not everyone has the time, the tradition, nor the money to switch to a vegan, or a low fat vegetarian, or even a healthy meat based diet. Making gross generalizations like you have just done does not offer solutions. If they were a solution, we would not be needing to hear these issues out. Of course, I'm sure the patient with congenital diabetes would have no problems with your assessment .
Finally,Russell, the lady described is a woman from India. She is also a low income individual. Most likely an extremely poor woman who came here for a better life. Unfortunately, I doubt she can afford a healthier lifestyle with the job her husband has. Furthermore, and I suspect, her traditions for rice has probably played a key role in hear current health situation.
Looking at other people with scorn because they appear lazy or fat is just that; an oversimplified observation that fails to take into account their history, income status, and situation. Basically, living healthy is about dumb luck. If you have the right opportunities you can live healthy.
Combating these issues, and ultimately putting more money in YOUR pocket, is about considering the variety of issues associated with preventable health conditions.
Mocking and bleating about your moral and health superiority is most likely the reason we are in this situation in the first place.
Jake, MD, you're absolutely right that healthy eating is generally much easier for those who are relatively well off. I'll also add that no matter how many advantages we have, our bodies have still evolved to crave calorie-dense foods. Combining low-fat eating with a demanding exercise routine is an exemplary lifestyle, but we shouldn't be surprised that only a small slice of the population adheres to it.
This doesn't mean that prevention is doomed to failure. There's a lot that can be done at both the national and local level to make it easier for people to eat more-nutritious diets and exercise more, and investments in these areas are worth it if they can reduce rates of diabetes and heart disease.
As far as insurance premiums go, we don't know until the end of our lives whether we've paid more in insurance premiums than we've spent on healthcare. Even the people with the healthiest lifestyles develop cancer or fall down the stairs sometimes. Those whose premium payments exceed their healthcare expenditures because they've enjoyed good health are far luckier than those who've had poor health and accounted for a large share of insurance payouts.
Jake MD -
Thank you for your assessment. As someone who has lived in poverty for most of his adult life, I have far more intimate knowledge of what you are talking about than I would like. As I am slowly working my way out of that (ironically, by going into not insignificant debt), I am also able to more functionally work on my general health - including my diet. I would just like to expand a little on what you said.
Living in poverty usually means that you are pretty much constantly living in crisis/survival mode. The human body does a lot of weird things when under a sustained stress load, including but not limited to mucking about with digestion. In terms of health care problems, poverty really screws things up.
When you live in poverty you can't, for example, afford to get sick. This means two things occur rather frequently when you do get sick - keeping in mind that the stress of crisis/survival mode makes it easier for you to get sick. First, you do not slow down or try to take time off when you start to get ill. You will continue to work until you are simply so sick that you can't possibly make it happen. Second, you will have an increase in stress at the onset of symptoms that will only get worse, the worse you feel. If you get sick enough that you can't work, that stress jumps exponentially. Of course the increased stress means that you are more likely to get even sicker and will interfere with your ability to fight it off.
Assuming that you don't have health insurance, this also means that you are unlikely to seek care until it has become acute. It also means you are very unlikely to get any follow-up care, or even fill a script unless they give it to you in the ER. This means that you may well be back in relatively short order, because of course you also went back to work as soon as you were able to stand without getting nauseous.
About four years ago I got a low grade pneumonia. I was sick for three weeks before I finally went into the ER and that was only after I wasn't capable of working for almost three days and had given my pneumonia to my son (who likely shared the initial bacterial infection with me in the first place). By the time I went to the ER, I had missed work - by the time it was over, I missed enough work that I was late with rent and was eating a package of ramen noodles on days I had my son and couldn't get to one of the various places that offered free meals. I also ended up going into the ER one more time and had to go to the health department for a STI test and tell them I might have contracted the clap, so they would give me free antibiotics (for those without health insurance, it isn't fun, but you will almost certainly get a round of antibiotics). From onset of symptoms, to actually feeling mostly normal again, was thirteen weeks. The cost was somewhere around $2100, plus the visit to the health department - had I seen a doctor before pneumonia set in, it would easily have cost less than $100. But at the time, $100 was nearly half my monthly food budget.
Laura -
I would find you and your commentary about those less privileged than you contemptible, but you honestly aren't worthy of my contempt. Indeed, you aren't worth the contempt of any of the people you so obviously believe are worthy of yours. Instead I pity you your ignorant, shallow and exceedingly narrow world view. If I cared less for my fellow humans, I might wish the misery of poverty on you, but I wouldn't wish that on anyone - especially as I understand that as rough as it has occasionally been for me, it is so very much worse for billions of people.
I would like you to consider something though. It is unlikely that you are so very secure in your privilege, that there is no way you would ever end up with nothing. The apparent difference between us, is that I would actually care if it happened to you. And given the opportunity and ability to help you, I would. I don't begrudge you your privilege - I am working hard to get there myself. I do however, find your attitude absolutely repulsive.
Liz -
As far as insurance premiums go, we don't know until the end of our lives whether we've paid more in insurance premiums than we've spent on healthcare. Even the people with the healthiest lifestyles develop cancer or fall down the stairs sometimes.
This is an important point that too many people fail to consider. There are innumerable ways that a person can find themselves needing tens, if not hundreds of thousands of dollars in healthcare.
What struck me about the article was the overwhelming role played by noncompliance with medication. Diet and exercise issues are secondary at best.After all, most Americans fail to get recommended fruits and vegetables and physical activity, but they do not land in that elite 1% group that consumes 21% of health care dollars. What the people in the costliest group all have in common is a failure to fill and refill prescriptions for chronic conditions, especially hypertension, diabetes and congestive heart failure. The innovative approaches have at their core a prescription reminder service to make sure people take drugs that keep them out of the ER and the hospital.