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.
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.
Fernandopulle's Special Care Center in Atlantic City is another model of a medical home. It accepts a flat fee for these 1,200 patients. After 12 months, he has found that ED visits and hospital admissions have been reduced by more than 40%. Surgical procedures were cut by one-fourth, and the patients are healthier, Gawande wrote. Patients with high cholesterol had an average 50-point drop in their lipid levels.
Brenner, Fernandopulle and Gawande are on to something that is perhaps one of the most exciting concepts in healthcare today. It's no big surprise that medical institutions and emergency rooms are perhaps the least appropriate places for patients like these.
Call them what you will – boomerangs, frequent fliers, super-utilizers or repeat customers. Yes, these are patients who now have true emergencies, but ones that could, weeks, months or years before, have been prevented.