I read an article recently by Dr. Atul Gawande in the New Yorker that comes as close to anything regarding making an argument that more care to the right subset of patients (Hot Spotters) may actually result in overall lower system costs. There are some mind-boggling statistics in the article including the highest 1% of patients in a system account for 30% of overall care! It is a well-researched article and Dr. Gawande is respected and known for some groundbreaking articles on health care.
So why is this, in my opinion, such an important article. I think as an emergency physician we can all relate to the patient that cycles in and out, in and out, of the ED with various unsundry complaints. Many of these people have serious medical combined with (in many cases) psychiatric conditions or merely a lack of access to quality primary care. We all know when the nurse hands you the chart and say ‘Mr. Jones is here for his weekly visit’ the futility we feel as clinicians in a system that is set up to care for the most acute patient expeditiously.
As the article goes on to state:
“The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.” Read more
There are examples in which this cycle is being broken. I am aware of emergency departments that have taken the time to address this patient population and develop tailored programs to address specific patient needs whatever they may be. Issues such as housing, home health, social services and the like usually outside the purview of a routine ED visit. The end result is a better work environment for the providers and a better care environment for the patients. The real question is whether it makes a difference in the larger picture of care.
Another excerpt from the article regarding a clinical in Atlantic City that cares for 1200 of the most chronically ill casino workers makes this remarkable statement:
“The staff member read out the hospital census. Of the clinic’s twelve hundred chronically ill patients, just one was in the hospital, and she was being discharged. The clinic’s patients had gone four days without a single E.R. visit. On hearing this news, staffers cheered and broke into applause.” Read more
So indeed the cycle can be broken. Of course so many other issues come to mind such as payment mechanisms, which need to change so we can take time to address these issues and help break the cycle. The opportunity is there and for physicians and organizations that are innovative there is a strong business argument to be made. The saying ‘out of chaos comes opportunity’ could not be more appropriate for the time in which we live.