Reduce health costs by nurturing the sickest? A highly promoted idea disappoints

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One study finds that matching patients with social workers, housing and medical care does not really reduce costly hospital readmissions. Still, some say it can transform lives.

One study finds that matching patients with social workers, housing and medical care does not really reduce costly hospital readmissions. Still, some say it can transform lives.

Katie Edwards / Ikon Images / Getty Images

One study finds that matching patients with social workers, housing and medical care does not really reduce costly hospital readmissions. Still, some say it can transform lives.

Katie Edwards / Ikon Images / Getty Images

According to a study published Wednesday in the New England Journal of Medicine, improving health and reducing costs for the sickest and most expensive patients in the United States is a harder dream to fulfill than many health care leaders expected.

The researchers tested whether pairing hospitalized patients frequently in Camden, N.J., with nurses and social workers could stop that costly cycle of readmissions. The study found no effect: patients who received additional support were equally likely to return to the hospital within 180 days than those who did not receive that help.

The results are a blow to Dr. Jeffrey Brenner and the Camden Health Provider Coalition, the organization he founded almost 20 years ago.

"It is the work of my life. Then, of course, you are upset and sad, "says Brenner, who now does a similar job with health insurance giant UnitedHealthcare.

The care model, promoted in part by Brenner and outlined in a 2011 article widely read in The New Yorker, has inspired dozens of similar projects across the country and attracted millions of philanthropic funds.

"This is the mess of science," says Brenner, who won a "Genius Grant" from the MacArthur Foundation for his efforts. "Sometimes things work the way you want them to work and sometimes they don't."

The hope

Many hospital and insurance executives have placed their hopes in this investigation because they promised to solve a common problem: when patients' lives are so complicated by social factors such as poverty and addiction that their manageable medical conditions, such as diabetes and asthma , lead to expensive, recurring hospitalizations.

The writer and physician Atul Gawande presented Brenner as a reckless visionary crusade on behalf of the "worst of the worst patients" in the New Yorker piece, titled "The Hot Spotters." (Gawande, who now runs Haven, a joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase, declined to be interviewed for this article).

Brenner Recipe: Match these patients with frontline care workers who will guide them to the social and medical services they need. The initial evidence was promising, the anecdotes inspiring. Brenner reduced the potential of the model to four words and two tempting goals: better attention, lower costs.

As word spread, breathless headlines appeared as "The best hope of medical care" and "Could the Camden Coalition save the medical care of the United States?"

"Many organizations claim that their programs work and have never been rigorously tested, "says Brenner.

Instead, Brenner took the unusual step of inviting the scrutiny of respected researchers.

In 2014, the economist at the Massachusetts Institute of Technology, Amy Finkelstein, began a randomized controlled trial, the same rigorous method used to evaluate new medications. For four years, the Coalition enrolled 800 patients; all had been hospitalized recently and all struggled with social problems. Half received the usual care patients receive when they leave the hospital. The other half received about 90 days of intensive social and medical assistance from the coalition.

And the result: the 400 patients who received intensive help were as likely to return to the hospital as the patients who did not. In both groups, almost two thirds of the people were readmitted within 180 days.

So why did the Coalition fail, at least in its initial goal of cost savings? Why did the savings promote their first data, which Gawande had declared "revolutionary" in New Yorker Almost a decade ago, did he disappear when he underwent this rigorous test?

The experience of Larry Moore, one of the patients in the MIT study, reveals a road map of why the Coalition did not hit the mark.

& # 39; My daily routine & # 39;

Moore, who has hypertension, alcohol addiction, chronic seizures and difficulty walking, was one of the first people to enroll in the Coalition trial.

His first months were promising: prescriptions filled, medical appointments attended, Social Security benefits claim in process. The 47-year-old man even began to trust the team with the details of his deep addiction, trusting in how he would sometimes consume mouthwash, vanilla extract and even hand sanitizer.

"I couldn't keep anything with alcohol," Moore says about his dependence on those days. "That is addiction."

But all the progress he had begun to make with the social workers suddenly stopped when Moore disappeared from the Coalition radar.

"We didn't see Mr. Moore after November," says nurse Jeneen Skinner. "We went to the house. We sent text messages. [made] phone calls."

Since then, the Coalition has learned that, for people living in poverty and in poor health, a single inconvenience, in Moore's case, a lost rent payment can become a major setback.

The lack of this rental payment led Moore to spend the next 2 and a half years mostly homeless, completely out of touch with the Coalition.

"I was going from one place to another. I [would] sleep on a bench or a rock until the next day when the liquor store [opened]"Remember Moore." That was my daily routine. "

Seventy visits to the emergency room and six hospital admissions later, Moore reconnected with Skinner.

He told her the only thing that would keep him out of the hospital: housing.

The & # 39; Camden Coalition & # 39;

Too many times, during the research study, people ended up in the hospital despite the intervention. But the Coalition is convinced that it did not fail as much as the largest social security network did.

Larry Moore (left) meets with Camden Coalition Housing Coordinator Brian Thompson and Coalition Nurse Jeneen Skinner at his apartment in Camden, New Jersey. Having a stable housing situation, as well as receiving addiction treatment dramatically reduced Moore's trips to the emergency department.

Dan Gorenstein / compensations


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Dan Gorenstein / compensations

Larry Moore (left) meets with Camden Coalition Housing Coordinator Brian Thompson and Coalition Nurse Jeneen Skinner at his apartment in Camden, New Jersey. Having a stable housing situation, as well as receiving addiction treatment dramatically reduced Moore's trips to the emergency department.

Dan Gorenstein / compensations

"The bottom line is that we build a brilliant intervention to take people nowhere, "says Brenner.

Coalition staff and their patients generally knew what was needed: evidence-based addiction treatment, housing, mental health services, but resources were often scarce.

In the last three years, the Coalition set out to fill those gaps and, along the way, suffered a kind of metamorphosis.

"We now consider ourselves as the Camden Coalition," moving away from the part of the name "health care providers," says Kathleen Noonan, who succeeded Brenner as head of the organization.

The Coalition has forged partnerships with prisons, lawyers and legislators, and began its own housing program. Many of these efforts began towards the end of the clinical trial, a sign that the Coalition was seeing the writing on the wall.

& # 39; No kidding & # 39;

"I would never have imagined this," Moore says, running his arm through the apartment of a room he lives in today.

A green houseplant sits in the sunlight. A stuffed animal decorates the bed.

"When I moved here for the first time," Moore explains, "it took me about a month to sleep in my bed. I slept on a couch."

Housing also made it easier for him to face his other problem: drinking. Moore decided to try the drug naltrexone, a long-acting injection to treat alcohol addiction.

After years of intermittent helplessness, Moore says it was a month after moving to his apartment before he could fall asleep in a bed.

Dan Gorenstein / compensations


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Dan Gorenstein / compensations

After years of intermittent helplessness, Moore says it was a month after moving to his apartment before he could fall asleep in a bed.

Dan Gorenstein / compensations

Today, Moore has been sober for almost two years. He meets with a Coalition support group on Wednesdays and is training to become a deacon in his church. In the 22 months he has lived in an apartment, Moore's trips to the hospital have collapsed: only one admission and one visit to the emergency room.

"I'm not kidding, when I saw Mr. Moore probably a month ago, I was standing next to him and I didn't recognize him," says Nurse Skinner. "He looked at me and said: & # 39; Jeneen, it's me. And I said: & # 39; Oh my God, you look amazing! & # 39;"

Larry Moore's story is just that: a story. However, it represents a major trend. Insurers, including UnitedHealthcare under the direction of Brenner, hospitals and many state Medicaid agencies have begun to spend millions to meet the social needs of patients.

Still, the study published on Wednesday supports the skepticism of other researchers that, when it comes to saving money at least, these approaches do not work well. On the one hand, programs are expensive and difficult to scale. The Coalition's housing effort currently serves only 50 people and costs about $ 14,000 per person per year.

It is an expensive proposal that may not be easy. "Despite what people would like to believe, there is not much evidence that they can reduce health spending by spending more in other areas," warns Austin Frakt, an economist at Boston University.

Finkelstein says that as health care companies go beyond the four walls of a hospital, the need for rigorous evaluation grows. "I think that many well-meaning people in health care cannot handle the truth," she says. "They are trying to do good, but they don't have the courage to say: & # 39; Let's do a bowel control of ourselves & # 39;".

Eighteen years ago, Brenner raised the hypothesis that the Coalition, with some intelligent navigation and trust gained with effort, could guide the most complicated patients towards better health and reduce expenses. Finkelstein's randomized controlled trial shows that the idea fell short.

The executive director of the Coalition, Kathleen Noonan, considers it a progress, even if it is not the progress that many had desired. "People like stories about success and they like stories about failure. They just love extremes. I really hope this is a story about complexity and courage."

Dan Gorenstein is the creator and co-host of Compensation Podcast and Leslie Walker is a producer on the show, which presents the study on Camden Coalition in episode 7. Kaiser Health News it is an editorially independent program of the Henry J. Kaiser Family Foundation.