To Contain Costs, Some Hospitals Tackle Patients' Non-Medical Problems

Cheryl Clark, January 27, 2011

Surgeon-author Atul Gawande's latest essay in The New Yorker, "The Hot Spotters," contains an important message for providers looking to reduce costs and improve care for their most complex, troublesome, and expensive patients.

Doctors and triage nurses know these so-called "frequent fliers" or "boomerang" patients, all too well. And they'd keep them out of the hospital, if only they had the resources and know-how to do so.

Camden, New Jersey provides a perfect example. Gawande describes how a physician, Jeffrey Brenner, started playing with data showing hospitalization costs for patients based on their addresses. There it was as clear as day.

One percent of the 100,000 people who made use of Camden's medical facilities accounted for 30% of the city's healthcare costs. Gawande describes how Brenner discovered that one patient had 324 admissions in five years. The most expensive patient cost his insurers $3.5 million.

Gawande wrote that Brenner asked hospital emergency department physicians and social workers to show him these patients in person. "Introduce me to your worst-of-the-worst patients," Brenner said.

Gawande quoted Brenner saying, "For all the stupid, expensive, predictive-modeling software that the big vendors sell," he says, "you just ask the doctors, 'Who are your most difficult patients?' and they can identify them."

Alfred Sacchetti, MD, an emergency department physician in Camden who has been involved with Brenner's program from the beginning, says for many of these patients: "The issues are not medical but social. Example, a diabetic without a home could not cook their own meals, ate junk food and repeatedly presented to the ED with sugars out of control.  Get them an apartment, help with their diet, and they [stop] coming to the ED."

"Realistically, Sacchetti says, "it is all common sense.  It really is not about medicine, but [about] a very good team of social workers and care managers.  The ED is just the source in which these people in need are identified."

As a journalist, I saw this problem first-hand a few years ago when I was invited to undertake a "mini-residency" in a major city hospital emergency room, one with a lion's share of homeless and underinsured patients—many of whom were repeat customers.

It was clear from the start that the emergency department teams I watched knew these patients' names, ages, ailments, their addresses (if they had addresses), their habits and almost, to a certain extent, just about when they would "boomerang" back through the doors and in what condition. These "super-utilizers" even had their own nicknames – some charitable and some not– that providers used among themselves.

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