We ignore sick people: a conversation with Dr. Jeffrey Brenner
The article talks about the practice of identifying patients who use the medical system the most (we’re talking hundreds of visits to the emergency room every year) and figuring out what’s really causing their health problems.
My piece focuses on similar efforts in Rhode Island, but I wanted a broader perspective on this approach, so I called up Dr. Jeffrey Brenner, the man at the center of Gawande’s New Yorker article. Brenner is the executive director for the Camden Coalition of Health Care Providers and he’s spent years developing ways to provide better care to Camden’s sickest residents.
Brenner will probably only appear as a quick sound bite in my radio piece, but I hate to waste our conversation, so I’m including a transcript of the best portions here.
The Pulse: How do you describe hot spotting to people who’ve never heard about it before?
Dr. Jeffrey Brenner: Hot spotting is the strategic use of health care resources to make sure that really sick patients get their needs met and if we do a good job meeting the needs of very complex, sick patients, we can reduce costs. Costs are going up and up and up and we need to make decisions about how we better allocate our health care resources.
There are two ways, broadly speaking, of reducing costs. You can ration care, which is not a good way of reducing costs, or we can rationalize the system and make sure that people are getting their needs met so that they’re not using unnecessary care.
The Pulse: What do you mean by “rationalize the system?”
Dr. Jeffrey Brenner: Right now, the way our health care system works, we deliver fragments of care and the more fragments of care you deliver the more money you make. The problem is as the patient population gets more and more complicated, delivering uncoordinated fragments of care starts to become very expensive and it’s also just not good care.
It can be really frightening if you’re a patient moving around in the health care system and you realize the doctors aren’t talking to one another, that they’re not coordinating with one another, that they’re giving you medications that are actually working against one another.
The Pulse: So how do you address this problem in your practice?
Dr. Jeffrey Brenner: We run a non profit in the city of Camden that’s been around about ten years and it’s a coalition of hospitals and primary care offices and social service providers working to improve quality and reduce costs…
We have a bunch of different interventions running, and one of the interventions for the last four years is to go out and meet and take care of the most complex expensive and challenging patients…
The Pulse: Can you give me an example of a patient you worked with?
Dr. Jeffrey Brenner: Sure. So give you an example of a patient who was in his 70s. Diabetic who was going to the emergency room and hospital for high sugars. He had a great doctor and was technically getting good medical care, but kept going to the hospital and the emergency room over and over for high sugars.
Our team went out to see him and visited his house. And first thing they wanted him to do was watch him use his insulin. And he set his insulin bottle down and put a syringe in the bottle and drew up 50 ccs [1 cc = 1 milliliter] of air and went to inject it into his arm. And the team was horrified and they realized the reason he’d been having such high sugars is he couldn’t see the bottle and he couldn’t see the syringe cause he’s sight impaired.
The Pulse: So he was just injecting air into his arm?
Dr. Jeffrey Brenner: Yes. He went to the refrigerator and he pulled out two bags filled with insulin bottles that were all partially full and he said ‘I use my insulin every day, but I can’t seem to empty the bottles.’ The pharmacy kept bringing him medicine. You think about what was going on and there were so many failures in that.
The failures could have been picked up at any point of care. Any of the emergency room nurses could have asked to see him use his insulin, any of the emergency room doctors could have asked to see him use his insulin… There are many ways that we could have figured this out but the bottom line is no one is really responsible for insuring that people get good care. There are no feedback loops. There are no systematic models of care to ensure that everyone every day is getting good care.
Dr. Brenner says the model of care where doctors are paid per office visit or per procedure prevents them from giving patients the attention they deserve. The only way to solve this problem is to rethink the way we pay for health care services.
Dr. Jeffrey Brenner: I think it’s important to realize that when you’re paid in a fee for service model, you make a lot more money from the average patient than you do from the really sick patient. So, if I can run from room to room to room and see head colds, I make a lot more money than when I get stuck in the room with a very sick patient. And then when I have to answer the phone calls, get on the phone with the family, or go out and do a home visit, all that work is unpaid often. So the problem in the fee for service model is that we ignore sick people.
So, if you really distill down what the message was of our work- pay attention to sick people. That’s the right thing to do from a moral, ethical point of view, but it’s also the right thing to do from a financial point of view. Ignoring sick people is costly. There’s more and more research coming out around the country that face to face, boots on the ground, community based care coordination where you’re actually going to people’s homes, you’re talking to them, you’re building relationships, works. And the most money is saved from the sickest people.
Brenner’s group is now part of a pilot project where a team of doctors and social workers and hospitals get no money up front, but they share in the cost savings if they manage to reduce the amount of expensive health care their patients need while still taking care of them. Camden experiences a 3% rate of increase in health care costs every year and he says he’ll have proved his project works if he can make that increase go down.
Right now the upfront costs are covered by grants and payments from local hospitals. He’s already thinking about how to expand this work to larger communities.
The Pulse: How do you scale up this program? It seems like this is so dependent on personal relationships and care and attention. Often when something gets big, it’s like a chain restaurant, you dilute that personal touch.
Dr. Jeffrey Brenner: That’s the big challenge and it’s the challenge we’re right in the middle of right now… How do you scale caring?
The Pulse: Can you?
Dr. Jeffrey Brenner: I look very hopefully at believe it or not, Southwest Airlines… So, in Southwest Airlines they are incredibly careful about the people they hire and they do a lot of training and… when a plane lands they have the fastest turnover of a plane because everyone on the plane participates in cleaning it and getting it ready and a plane on the ground is a wasted asset and there’s a lot of money lost.
They also realized you can’t have a lot of supervisors hanging over people all the time. You have to train up professionals and motivate them in a way that they’re going to want to be excellent every day even when no one’s hanging over their shoulder.
If you think about what care coordination is in health care, when you close that exam room door, no one knows what you do behind that door, when you do a home visit, I can’t hang over my staff’s shoulder. I just have to hire great people, train them really well, motivate them well, and make sure they’ve got the back up support and the data…
The Pulse: What do you say to critics that say this is sort of a nanny state? That the kind of work you’re doing is just babysitting people and it’s government that’s gotten too big or health care that’s gotten too big?
Dr. Jeffrey Brenner: It’s a really interesting critique. You know, when I give you specific stories and you distill it down, it just sounds like disorganized care. So, I can’t believe we’re framing delivering well organized care to be the nanny state. It just seems like a complete misread of what we’re doing.
You know, when your mom has been in the hospital, she’s maybe 80 or 85 years old and she’s getting more and more problems and she’s getting confused and she’s seeing doctor after doctor and their advice is conflicting and no one seems to be talking to one another and your heart is breaking because what’s going on.
Is it the nanny state to have someone come out to the house and sort out the meds and help you figure out the appointments? Isn’t that good caring? Isn’t that just compassion and the kind of system we should be setting up?
The Pulse: What do you think their real concerns are?
Dr. Jeffrey Brenner: I think there are going to be a lot of areas of push back on this. The biggest area of push back is going to be from the existing health care system that makes a lot of money from cutting, scanning, zapping, medicating, and hospitalizing.
This is 18% of the economy. It’s moving to 25% of the economy and you make a lot more money from doing those things than from talking to patients. It’s much more profitable to make a pill and sell it than it is to do what I do, which is to hire great people train them, put them out in the community. I’m not going to get wealthy doing it.
The Pulse: What keeps you doing this work?
Dr. Jeffrey Brenner: I spent ten years on the front line in Camden and I did full spectrum care, and got to know my patients really, really well and they deserve a lot better. And all Americans deserve much better for the amount of money we’re spending on health care.
I’m still deeply moved by the stories of my patients and the challenges they had getting care and the feeling that a well run health care system can catch people when they’re having very difficult moments and redirect them so that they’re able to move on in their lives in much more profound and productive and enlightened ways… I like to fix broken stuff and I can’t think of a more profoundly broken thing than health care.
The Pulse: Anything else you’d like to say?
Dr. Jeffrey Brenner: One thing I’d be careful with is, and I think this is really important, I would hate my work to be portrayed as poverty work. I don’t think it’s poverty work. I think good health care, well organized health care, can be done anywhere and the basic learning of how to do that, what we’re learning in Camden is applicable anywhere.
The Pulse: So what you’re saying is, ‘I’m working with cases that are the most challenging to prove that this can work in the worst possible circumstances.’
Dr. Jeffrey Brenner: Exactly. If we can care coordinate a homeless schizophrenic, diabetic baby boomer lying in a homeless shelter with a foot ulcer, we can do it for anyone. What we will learn will be widely applicable for every baby boomer facing a broken health care system in the future.
The Pulse: And hopefully for the rest of us too.
Dr. Jeffrey Brenner: Right.
What do you think of Brenner’s approach?