Community-Based Nursing

Doctor Hotspot

Dr. Atul Gawande: Camden, New Jersey sits in the shadow of Philadelphia. It is a city that seems in a constant state of peril. Poverty here is rife. Unemployment is double the national average. Public institutions are in crisis, or like the local library, simply shuttered. It is officially one of America’s most dangerous cities. But Camden may also be the city to help solve one of America’s most intractable problems: lowering the cost of healthcare.

As a doctor and writer for The New Yorker, I came here to meet the local physician and began to figure it out. It all started 10 years ago with a shooting.

Dr. Jeffrey Brenner: I was working in my house one evening and heard gunshots, then got a call from a neighbor so I went running down the street. The police had gotten there already, so I ran up and said, ‘You know, I’m a physician. Where’s the victim?’ They all sort of turned around and said, ‘He’s over there.’ He was lying on his side facing the back tire, and he had a pulse. He wasn’t breathing. I started rescue breathing. Eventually his pulse stops, so I was just pretty overwhelmed by the whole thing and angry.

Gawande: You are angry that they hadn’t even been tending to the victim.

Brenner: You know, I said, ‘Why didn’t you guys help them?’ The police officer said, ‘We didn’t want to dislodge the bullet.’ I mean, it was just a complete blowoff. I couldn’t imagine how we could have reached the point in our society in the city where you would just leave a victim lying there in their own blood.

He was a Rutgers student, and he was close to graduating. You know, he was one of the wonder kids that make it out of urban communities, and here he was just about to make it out.

Gawande: Brenner’s immediate response was to get involved in police reform. He thought if he could get a hold of crime statistics, he could map hotspots—the places where good policing would make a difference. But the department wasn’t interested in helping a local doctor, so he went to another place, one he knew well—the hospital. There, buried in billing records from the ER where violent assaults get treated, he found crime patterns. As he crunched the hospital data, Brenner discovered something totally unexpected—other kinds of hotspots.

Brenner: It became clear that there were hotspots of everything. They were hotspots by disease, hotspots by patient. There were certain patients who had been over and over and over going to the emergency room in the hospital too much. There were hotspots by ZIP Code and by neighborhood, so you sit and begin to look through the data and I’m looking at my patients who are in the data and realizing I had no idea how much healthcare cost. I had no idea how expensive it was, and it was just shocking.

Gawande: Brenner says the number showed that 1% of people living in Camden accounted for 30% of hospital charges, most of those racked up in the emergency room.

So you are compiling all of this information coming from all of the hospitals in the local area.

Brenner: Compiling massive amounts of data.

Gawande: Brenner then turned that raw information into visual information.

Brenner: So this is a map of the city of Camden, and this is looking at cost data. The red areas are high cost hotspots. These are parts of the community where people who have more than $1 million in payments due to hospitals live, and this is over a 5-1/2-year period.

Gawande: So here you pulled out the two most expensive city blocks…

Brenner: Yep.

Gawande: But you found in your community there are two buildings—

Brenner: That’s right.

Gawande: That are the most expensive places.

Brenner: That’s exactly right. So the building on the bottom, Abigail House, is a nursing home, and the top one, Northgate II, is an apartment tower with elderly and disabled people.

Gawande: $83 million in bills.

Brenner: That’s right.

Gawande: That’s probably more than the cost of the building.

Brenner: Yes, yep.

Gawande: This being America, we all demand the best that medicine can offer. You might assume that at least for the money, the residents were getting good care, but Brenner found the majority of the care for chronic diseases, from asthma to cancer to diabetes, was being done in the ER—not a good place to treat chronically ill patients. Treatment was not coordinated. Follow-ups were not part of the plan.

Brenner: It was really obvious in the data that the most expensive people were getting terrible care, and I knew them so I would walk in the exam room and say ‘Mrs. Rodriguez, I haven’t seen you in three months. Where have you been?’ ‘Well, I’ve been in the ICU for a month-and-a-half. I’ve been in the hospital for another couple of weeks,’ and I would said, ‘Well, what happened?’ And she’d say ‘Well, I’m not really sure. A lot of doctors came in the room. They never really explained anything to me, but I’ve got this whole bag of medicine,’ so American healthcare doesn’t do a good job taking care of sick people. The way we have built our system is really a system that is very hard to access. It works well for the average patient, but if you are blind, if you’re deaf, if you are disabled, if you are in a wheelchair, if you don’t speak the language, if you are developmentally delayed, if you have a complex mix of illnesses with many providers involved whole system starts to break down.

Gawande: Brenner’s big insight was to use his data to target the sickest and most expensive patients in the city. In 2007, supported by small grants from foundations, he put together his team of medical hotspotters.

[Coalition Member]
Hey Angela, it’s Kathy Jackson from the Coalition. I was wondering if you had a chance to do your blood glucose logs?

Gawande: The most visible part of the Camden Coalition of Healthcare Providers are these nurses, social workers and medical assistance.

[Coalition Member]
I think it’s also important to show that he was really going all over the state.

Gawande: Three years later, his team of troubleshooters has sought out and organized care for more than 300 people.

[Coalition Member]
Make sure we have transportation. That’s going to be accommodated on disability.

Gawande: When I visited, Kathy Jackson was making a house call to one of her most challenging patients, Derek.

Gawande: Do give me the briefing on Derek, because I haven’t met him yet.

Kathy Jackson: Derek is in his 30s and has seizure disorder.

Gawande: Okay.

Jackson: And, then his other problem which gets him into the hospital most of the time is asthma. It’s always an issue. He is always wheezing in the house isn’t—it’s dirty, it’s dusty, roaches. All kinds of triggers, so we took a contractor there and the contractor said that he really wouldn’t want to be liable to fix it up because he is afraid it would actually crumble.

Jackson: Hey Derek, how you doing?

Derek: I’m all right.

Gawande: I’m Atul Gawande. I’m a doctor from Boston but also a writer. Derek, you have had a number of hospital stays and emergency room visits because of asthma, I hear.

Derek: Right.

Gawande: What happens when you have your asthma attack?

Derek: When I start wheezing, my lungs are actually—you know, it’s like a rubber band. It just closes up like really tight and it will be hard for me to breathe.

Jackson: Do you think the house is probably part of it? There’s a lot of dust—the walls.

Gawande: Would you mind, Derek, if I have Kathy just show me around the places in the house that she thinks might be contributing to your asthma?

Derek: Yeah, sure.

Gawande: Okay. I would just like to see for myself.

Derek: Okay.

Jackson: Do you want to lead the way then?

Gawande: Before Kathy started working with him, Derek was in the emergency room 35 times over six months.

Gawande: There’s lots of mold in here. That cannot help your asthma.

Kathy’s work with Derek includes everything from inhalers to insurance to finding a contractor willing to rehab the house.

Gawande: Why don’t we just say, ‘Derek, fix your house. You’ve got this and that falling apart.’

Brenner: His family probably lives on about $1000 a month, so they are not really capable. They’re barely able to make ends meet.

Gawande: Without the team, Derek didn’t have enough help with another medical problem—epileptic seizures.

What are all the crosses?

Derek: That helps me in case I have epilepsy.

Gawande: How does that help you?

Derek: Well, I just start praying, that’s all.

Gawande: Wow, okay.

Jackson: Have you had any seizures recently?

Derek: No.

Jackson: Okay, how long has it been? A week, a month?

Derek: A week. I feel more comfortable with Kathy Jackson then the doctors and nurses in the hospital. You know, I can tell Kathy my problems, you know I’m wheezing and stuff like that. She checks me out, you know, hearing my lungs, you know, I mean, talking to me.

Jackson: As always, you always have some wheezes but you are moving pretty good here so that’s good.

Derek: She’s the one that keeps me out of the hospital.

Jackson: We are going to come back in one month, June 13.

Gawande: Under Kathy’s care, over the last six month Derek’s ER visits have been reduced from 35 to just two.

Jackson: See you!

Gawande: And Brenner thinks they can do even better. If you can get other people from around the city to think like hot spotters—

Brenner: This is really a way of beginning to think agency by agency how we can pull together for the most challenging cases.

Every month, the whole city comes together—frontline providers, social workers, and we do anonymous case discussions at the city level, so when someone like Derek shows up at one of the emergency rooms they will call us right away.

Jackson: Actually in 2011 he had two hospitalizations, and none in April and only one since May.

Gawande: So, how much has your team been able to lower the costs for this really expensive group of patients?

Brenner: So, we have seen some preliminary results of 40% to 50% reductions in visits and cost.

Gawande: 40% to 50% reduction in costs?

Brenner: In costs and visits.

Gawande: The savings are hard one, and it takes persistence.

[Coalition Member]
Mr. Harris, it’s Kelly and Anna from the Coalition.

Brenner: You can’t completely alter people’s life circumstances. We are not going to cure poverty. The question is how can you take the current situation that the patient is in and improve it enough to make them a little bit healthier and lower their unnecessary ER and hospital use and make them have a more productive interaction with the healthcare system?

[Coalition Member]
Do you see anything?

Gawande: This idea of focusing on the sickest to lower costs for everyone seems to be working here in Camden. But there are hotspots in every community. What if you took this idea and put it in play across the country? It might just work, but there is a catch. How would the medical establishment react if suddenly their most expensive and lucrative patients started costing half of what they do now?

As this kind of an experiment works, though, you are talking about dropping the number of hospital visits as a whole.

Brenner: Yes.

Gawande: You are talking about removing people from emergency rooms.

Brenner: Yes.

Gawande: They could have to shut down floors and beds. They are not going to be with you on this, are they?

Brenner: This kind of work is a game changer, and this is a Blockbuster video moment for America’s hospitals.

Gawande: What do you mean by a Blockbuster video moment?

Brenner: So, along comes Netflix and there had to have been a moment when that young executive walked in and said, ‘Hey, they are starting to rent videos online,’ and Blockbuster said, ‘Nah. People like coming to the video store. We are not going to make any change.’ So disruptive change comes along and I think better care for sick people is disruptive change. We have inflated a capacity bubble in our country to do expensive, high-tech hospital-based care.

Gawande: So what is your ultimate goal here?

Brenner: I would like Camden to be the first city in the country that bends the cost curve dramatically while improving quality. Because if the poorest city in the country can do it, it makes the rest of the country look silly.