The hours I spent inside the ED were among the week's busiest. Its hallways were cramped with crying, coughing, staggering, screaming, sleeping, and malodorous patients waiting to be seen; waiting for a CT; waiting for a test result; waiting for a bed; waiting for a psych consult; waiting ...
There they were amidst the clatter of gurneys, oxygen tanks and other equipment being squeezed along the narrow passageways. Still, amid all the commotion, emergency teams managed to address these frequent flyers with friendly familiarity. One patient came in every Thursday, I was told. Since this was Thursday, sure enough, there he was, slumped over on a chair with a cut on his head.
One ED staff member who worked with the homeless on a special program for the dually diagnosed confided in me that she was extremely frustrated and was about to quit. Many of those patients didn't need to be there, and could have been prevented from being there altogether, but there just wasn't enough money available to coordinate the disjointed preventive services.
It was infuriating, she told me, because the very program she worked with that would keep many of these patients out of the hospital was probably going to be cut.
As hospital teams well know, these scenarios repeat throughout the country today. The idea that accountable care organizations, medical homes, or some Kaiser Permanente-like managed care or capitated model might improve how money is spent for these patients at least offer some promise.
That's part of the underlying message in Gawande's latest article, which shows how the system could change. He illuminates, on a human level, how two doctors are having remarkable success in slowing down expensive, revolving door care, simply by taking care of patients' social, non-medical problems, as well as their medical needs.
One of them is Brenner, the Camden doctor who subsequently started the Camden Coalition, with the help of some funds from the Robert Wood Johnson Foundation, to hire nurses and social workers to manage patients in their homes and keep them out of the hospital.
The other is Rushika Fernandopulle, a Harvard-educated internist in Atlantic City, who runs a labor union clinic with a dedicated focus just on 1,200 employees of the casino and the hospital, AtlantiCare Medical Center, that rack up the most medical bills.
Now Brenner's Camden Coalition has had a chance to measure its impact in its first 36 "super-utilizers." Before joining the program, they averaged 62 hospital and emergency room visits per month and 37 visits after the program began, a 40% reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after, a 56% reduction, Gawande wrote.