Improving health and lowering costs for the sickest and most expensive patients in America is a dream harder to realize than many health care leaders had hoped, according to
a study published Wednesday by the New England Journal of Medicine.
Researchers tested whether pairing frequently hospitalized patients in Camden, New Jersey, with nurses and social workers could stop that costly cycle of readmissions. The study found no effect: Patients receiving extra support were just as likely to return to the hospital within 180 days as those not receiving that help.
“It’s my life’s work. So, of course, you’re upset and sad,” said Brenner, who now does similar work with health insurance giant UnitedHealthcare.
The model of care, pioneered in part by Brenner and profiled in a widely read 2011 article in The New Yorker, has inspired dozens of similar projects across the country and attracted millions in philanthropic funding.
“This is the messy thing about science,” said Brenner, who won a MacArthur Foundation “Genius Grant” for his efforts. “Sometimes things work the way you want them to do work and sometimes they don’t.”
The Hope
Many hospital and insurance executives have pinned their hopes on this work because it promised to solve a common problem: when patients lives are so complicated by social factors like poverty and addiction that their manageable medical conditions, like diabetes and asthma, lead to expensive, recurring hospital stays.
Writer and physician Atul Gawande introduced Brenner as a brash visionary crusading on behalf of the “worst-of-the-worst patients” in the New Yorker piece,
titled “The Hot Spotters.” (Gawande, who now
heads Haven, a joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase, declined to be interviewed for this article.)
Brenner’s prescription: Pair these people with front-line care workers who would shepherd them to the social and medical services they needed. Early evidence was promising, the anecdotes inspiring. Brenner boiled the model’s potential down to four words and two tantalizing goals: better care, lower costs.
“Lots of organizations make claims that their programs work and they’ve never been rigorously tested,” Brenner said.
Instead, Brenner took the unusual step of inviting the scrutiny of respected researchers.
In 2014, Massachusetts Institute of Technology economist Amy Finkelstein began a randomized controlled trial, the same rigorous method used to evaluate new drugs. Over four years, the coalition enrolled 800 patients, all who had been recently hospitalized and struggled with social problems. Half received the usual care patients get when leaving the hospital. The other half got about 90 days of intensive social and medical assistance from the coalition.
And the result: The 400 patients who received the intensive help were just as likely to return to the hospital as the patients who didn’t. In both groups, nearly two-thirds of people were readmitted within 180 days.
So why did the coalition fail? Why did the savings touted in their early data, which Gawande had declared “revolutionary” in The New Yorker nearly a decade ago, disappear when put to this rigorous test?
‘My Daily Routine’
Larry Moore, who has hypertension, alcohol addiction, chronic seizures and difficulty walking, was one of the first people to enroll in the coalition’s trial.
Moore’s experience serves as a road map for understanding why the coalition missed its mark.
His first months were promising: prescriptions filled, medical appointments attended, Social Security benefits claim in process. The 47-year-old even started to trust the team with the details of his deep-seated addiction, confiding how he would consume mouthwash, vanilla extract and even hand sanitizer at times.
“You couldn’t keep anything with alcohol in it” around him, Moore recalled. “That’s addiction.”
But all the progress suddenly stopped when Moore seemed to disappear from the coalition’s radar.
“We didn’t see Mr. Moore after November,” said nurse Jeneen Skinner. “We went to the house. We sent text messages. We [made] phone calls.”
The coalition has learned that for people living in poverty and with poor health, a small hiccup — in Moore’s case, a missed rent payment — can spiral into a major setback.
Moore spent the next 2½ years mostly homeless, completely out of touch with the coalition.
“I was going from place to place. I sleep on a bench or a rock until the next day when the liquor store opens,” remembered Moore. “That was my daily routine.”
Seventy emergency room visits and six hospital admissions later, Skinner reconnected with Moore.
He told her the one thing that would keep him out of the hospital: housing.
The ‘Camden Coalition’
Too many times, during the trial, people ended up back in the hospital despite the intervention. But the coalition is convinced it didn’t fail as much as the larger social safety net did.
“The bottom line is, we built a brilliant intervention to navigate people to nowhere,” said Brenner.
Coalition staff and their patients usually knew what was needed — evidence-based addiction treatment, housing, mental health services — but resources were often in short supply.
Over the past three years, the coalition set out to fill in those gaps, undergoing a kind of metamorphosis.
“We think of ourselves now as the Camden Coalition” steering away from the “health care providers” part of the name, said Kathleen Noonan, who succeeded Brenner as head of the organization.
It has forged partnerships with jails, lawyers and legislators, and started its own housing program. Many of these efforts began as the clinical trial was ongoing — a sign the coalition had seen the writing on the wall.
The Camden Coalition helped Moore get an apartment. (DAN GORENSTEIN/TRADEOFFS)
Moore says it took him a month to sleep in his bed, after years of intermittent homelessness.(DAN GORENSTEIN/TRADEOFFS)
‘I Kid You Not’
“I would have never imagined this,” said Moore, sweeping his arm around his one-bedroom apartment.
A green houseplant sits in the sunshine. A fluorescent-colored stuffed animal decorates the bed.
“When I first moved in here,” Moore explained, “it took me about a month to even sleep in my bed. I slept on a couch.”
Housing made it easier to face his other problem, choosing to try the drug naltrexone, a long-acting injection to treat alcohol addiction.
Moore is nearly two years sober today. He meets with a coalition support group on Wednesdays. He’s becoming a deacon at his church. In the 22 months he has lived in the apartment, Moore’s trips to the hospital have plummeted: just one admission and one ER visit.
“I kid you not, when I saw Mr. Moore probably a month ago, I was standing next to him and did not recognize him,” said nurse Skinner. “He looked at me, and said, ‘Jeneen, it’s me. And I was like, ‘My God, you look amazing!’”
Larry Moore’s story is just that: one story.
Yet it represents a larger trend. Insurers — including UnitedHealthcare under Brenner’s direction — hospitals and many state Medicaid agencies have begun spending millions to meet patients’ social needs.
The new study, though, backs up the skepticism of other researchers that, when it comes to saving money at least, these approaches don’t work well. For one, programs are expensive and hard to scale. The coalition’s housing effort currently serves only 50 people and costs about $14,000 per person per year. Secondly, the data is lacking, cautioned Boston University economist Austin Frakt. “Despite what people would like to believe, there’s not a lot of evidence you can reduce health spending by spending more in other areas.”
Finkelstein said that as health care companies move further beyond the four walls of a hospital, the need for rigorous evaluation grows. “I think a lot of well-intentioned people in health care can’t handle the truth,” she said. “They’re trying to do good, but they don’t have the courage to say, ‘Let’s do a gut check on ourselves.’”
