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Med Hot Spots_New Yrkr 012420110001

Med Hot Spots_New Yrkr 012420110001

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Published by Elizabeth St John
Medical costs for the poor living in blight is 300x higher than for the rest of us. Ever wonder why? What does community policing have to do with it?
Medical costs for the poor living in blight is 300x higher than for the rest of us. Ever wonder why? What does community policing have to do with it?

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Published by: Elizabeth St John on Feb 23, 2011
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·MEDICALR.EPOR.T
THEHOTSPOTTER.S
Canwelowermedicalcostsbygivingtheneediestpatientsbettercare?
I
fCamden,NewJersey,becomesthe firstAmericancommunitytolowerits medicalcosts,itwillhaveamurderto thank.Atnine-fiftyonaFebruarynight in2001,atwenty-two-year-oldblack manwasshotwhiledrivinghisFordTau- russtationwagonthroughaneighbor- hoodontheedgeoftheRutgersUniver-sitycampus.Thevictimlaymotionlessinthestreetbesidetheopendooronthe driver'sside,asifthecarhadejectedhim. Aneighborhoodcouple,aphysicalthera- pistandavolunteerfirefighter,ap- proachedtoseeiftheycouldhelp,butpo- licewavedthemback. "He'snotgoingtomakeit,"anofficer reportedlytoldthephysicaltherapist. "He'sprettymuchdead."Shecalledaphysician,JeffreyBrenner,wholivedafewdoorsupthestreet,andherantothe scenewithastethoscopeandapocket ventilationmaskAftersomediscussion, thepolicelethimenterthecrimescene andattendtothevictim.Witnessestold thelocalnewspaperthathewasthefirst persontolayhandsontheman. "Hewasslightlyoverweight,turnedon hisside,"Brennerrecalls.Therewasglass everywhere.Althoughthevictimhadbeenshotseveraltimesandmanyminutes hadpassed,hisbodyfeltwarm.Brenner checkedhisneckforacarotidpulse.The manwasalive.Brennerbeganthechest compressionsandrescuebreathingthat shouldhavebeenstartedlongbefore.But theyoungman,whoturnedouttobea Rutgersstudent,diedsoonafterward. Theincidentbecamealocalscandal. Thestudent'sinjuriesmaynothavebeensurvivable,butthepolicecouldn'thaveknownthat.Aftertheambulancecame, Brennerconfrontedoneoftheofficersto askwhytheyhadn'ttriedtorescuehim. 'Wedidn'twanttodislodgethebul- let,"herecallsthepolicemansaying.Itwas aridiculousanswer,abrushoff,and Brennercouldn'tletitgo. Hewasthirty-oneyearsoldatthe time,askinny,thick-bearded,soft-spo-
BYATULGAWANDE
kenfamilyphysicianwhohadgrownup inabedroomsuburbofPhiladelphia.As amedicalstudentatRobertWoodJohn- sonMedicalSchool,inPiscataway,he hadplannedtobecomeaneuroscientist. Buthevolunteeredonceaweekinafree primary-careclinicforpoorimmigrants, andhefoundtheworktheremorechal-lengingthananythinghewasdoinginthelaboratory.Theguystudyingneuronal stemcellssoonbecametheguystudying Spanishandtrainingtobecomeoneof thefewfamilyphysiciansinhisclass. Oncehecompletedhisresidency,in 1998,hejoinedthestaffofafamily-med- icinepracticeinCamden.Itwasina cheaplyconstructed,boxlike,one-story buildingonadesolatestreetofbars,car- repairshops,andemptylots.Buthewasyoungandeagertorecapturethesenseof purposehe'dfeltvolunteeringattheclinic duringmedicalschool. Fewpeoplesharedhissenseofpossi- bility.Camdenwasincivicfreefall,onits waytobecomingoneofthepoorest,most crime-riddencitiesinthenation.The localschoolsystemhadgoneintoreceiv- ership.Corruptionandmismanagement soonpromptedastatetakeoveroftheen-tirecity.Justgettingthesewagesystemto workcouldbeaproblem.Theneglectof thisanonymousshootingvictimon Brenner'sstreetwasanotherinstanceofa citythathadgivenup,andBrennerwas tiredofwonderingwhyithadtobethat way.Aroundthattime,apolicereform commissionwascreated,andBrennerwas askedtoserveasoneofitstwocitizen members.Heagreedand,tohissurprise, becamecompletelyabsorbed.Theexperts theycalledinexplainedthebasicprin- ciplesofeffectivecommunitypolicing. HelearnedaboutGeorgeKellingand James
Q
Wilson's"broken-windows" theory,whicharguedthatminor,visible neighborhooddisorderbreedsmajor crime.HelearnedabouttheformerNewYorkCitypolicecommissionerWilliamBrattonandtheCompstatapproachto policingthathehadchampionedinthe nineties,whichcenteredonmapping crimeandfocussingresourcesonthehot spots.ThereformpanelpushedtheCam- denPoliceDepartmenttocreatecomput-erizedcrimemaps,andtochangepolice beatsandshiftstofocusontheworstareas andtimes.Whenthepolicewouldn'tmakethecrimemaps,Brennermadehisown.He persuadedCamden'sthreemainhospitals tolethimhaveaccesstotheirmedicalbill- ingrecords.Hetransferredthereamsof datafilesontoadesktopcomputer,spent weeksfiguringouthowtopullthechaos ofinformationintoasearchabledatabase, andthenstartedtabulatingtheemer- gency-roomvisitsofvictimsofseriousas- sault.Hecreatedmapsshowingwherethe crimevictimslived.Hepushedforpoli- ciesthatwouldlettheCamdenpolice chiefassignshiftsbasedonthecrimesta- tistics-onlytofindhimselfinashow- downwiththepoliceunions. "Hehasnoclue,"thepresidentofthe citypolicesuperiors'unionsaidtothe Philadelphia
Inquirer.
"1justthinkthathis commentsaboutwhatkindofscheduleweshouldbeon,howweshouldbede- ployed,arelaughable." Theunionskepttheprovisionsoutof thecontract.Thereformcommissiondis- banded;Brennerwithdrewfromthe cause,beaten.Buthecontinuedtodig intothedatabaseonhiscomputer,now mostlyoutofidleinterest. Besideslookingatassaultpatterns,he beganstudyingpatternsinthewaypa-tientsflowedintoandoutofCamden's hospitals."1'djustsitthereandplaywith thedataforhours,"hesays,andthemore heplayedthemorehefound.Forin- stance,heranthedataonthelocations whereambulancespickeduppatients withfallinjuries,anddiscoveredthata singlebuildingincentralCamdensent morepeopletothehospitalwithserious falls-fifty-sevenelderlyintwoyears-
THENEWYOR.KEI\,JANUAR.Y24,201141
 
thananyotherinthecity,resultinginal-mostthreemilliondollarsinhealth-carebills."Itwasjustthisamazingwindowintothehealth-caredeliverysystem,"hesays.Sohetookwhathelearnedfrompo-licereformandtriedaCompstatap-proachtothe
city's
health-careperfor-mance-aHealthstat,sotospeak.Hemadeblock-by-blockmapsofthecity,color-codedbythehospitalcostsofitsresidents,andlookedforthehotspots.ThetwomostexpensivecityblockswereinnorthCamden,onethathadalargenursinghomecalledAbigailHouseandonethathadalow-incomehousingtowercalledNorthgateII.Hefoundthatbe-tweenJanuaryof2002andJuneof2008·someninehundredpeopleinthetwobuildingsaccountedformorethanfourthousandhospitalvisitsandabouttwohundredmilliondollarsinhealth-carebills.Onepatienthadthreehundredandtwenty-fouradmissionsinfiveyears.Themostexpensivepatientcostinsurers$3.5million.Brennerwasn'tallthatinterestedincosts;hewasmoreinterestedinhelpingpeoplewhoreceivedbadhealthcare.Butinhisexperiencethepeoplewiththehighestmedicalcosts-thepeoplecyclinginandoutofthehospital-wereusuallythepeoplereceivingtheworstcare."Emergency-roomvisitsandhospitalad-missionsshouldbeconsideredfailuresofthehealth-caresystemuntilprovenoth-erwise,"hetoldme-failuresofpreven-tionandoftimely,effectivecare.Ifhecouldfindthepeoplewhoseuseofmedicalcarewashighest,hefigured,hecoulddosomethingtohelpthem.Ifhehelpedthem,hewouldalsobeloweringtheirhealth-carecosts.And,ifthestatsapproachtocrimewasright,targetingthosewiththehighesthealth-carecostswouldhelp
lower
theentire
city's
health-carecosts.HiscalculationsrevealedthatjustonepercentofthehundredthousandpeoplewhomadeuseofCamden'smed-icalfacilitiesaccountedforthirtypercentofitscosts.That'sonlyathousandpeo-ple-abouthalfthesizeofatypicalfam-ilyphysician'spanelofpatients.Things,ofcourse,gotcomplicared.Itwouldhavetakenmonthstogettheap-provalsneededtopullnamesoutofthedataandapproachpeople,andhewasimpatienttogetstarted.So,inthespringof2007,heheldameetingwithafewsocialworkersandemergency-roomdoc-torsfromhospitalsaroundthecity.Heshowedthemthecoststatisticsanduse
"Canyouimaginehowbeingtheonlyoneheremakesmefeel?"
patternsofthemostexpensiveonepercent."ThesearethepeopleIwanttohelpyouwith,"hesaid.Heaskedforassistancereachingthem."Introducemetoyourworst-of-the-worstpatients,"hesaid.Theydid.Thenhegotpermissiontolookupthepatients'datatoconfirmwheretheywereonhiscostmap."Forallthestupid,expensive,predictive-model-lingsoftwarethatthebigvenderssell,"hesays,"youjustaskthedoctors,Whoareyourmostdifficultpatients?,'andtheycan
id
~;h,
h"~
1
enLllY
t
em.Thefirstpersontheyfoundforhimwasamaninhismid-fortieswhomI'llcallFrankHendricks.Hendrickshadseverecongestiveheartfailure,chronicasthma,uncontrolleddiabetes,hypothyroidism,gout,andahistoryofsmokingandalco-holabuse.Heweighedfivehundredandsixtypounds.Inthepreviousthreeyears,hehadspentasmuchtimeinhospitalsasout.WhenBrennermethim,hewasinintensivecarewithatracheotomyandafeedingtube,havingdevelopedsepticshockfromagallbladderinfection.Brennervisitedhimdaily."Ijustbasi-callysatinhisroomlikeIwasathird-yearmedstudent,hangingoutwithhimforanhour,hourandahalfeveryday,trying
to
figureoutwhatmakestheguytick,"here-called.HelearnedthatHendricksusedtobeanautodetailerandacook.Hehadalongtimegirlfriendandtwochildren,nowgrown.Atoxiccombinationofpoorhealth,JohnnieWalkerRed,and,itemerged,cocaineaddictionhadlefthimumeliablyemployed,uninsured,andliv-inginawelfaremotel.Hehadnoconsis-tentsetofdoctors,andalmostnopros-pectsforturninghissituationaround.Afterseveralmonths,hehadrecoveredenoughtobedischarged.But,outintheworld,hislifewassimplyanotherhospi-talizationwaitingtohappen.Bythen,however,Brennerhadfiguredoutafewthingshecoulddotohelp.Someofitwassimpledoctorstuff.Hemadesurehefol-lowedHendrickscloselyenoughtorecog-nizewhenseriousproblemswereemerg-ing.Hedouble-checkedthattheplansandprescriptionsthespecialistshadmadeforHendricks'smanyproblemsactuallyfittogether-and,whentheydidn't,hegotonthephonetosortthingsout.Heteamedupwithanursepractitionerwhocouldmakehomevisitstocheckblood-sugarlevelsandbloodpressure,teachHendricksaboutwhathecoulddotostay
 
healthy,andmakesurehewasgettinghismedications.AlotofwhatBrennerhadtodo,though,wentbeyondtheusualdoctorstuff.BrennergotasocialworkertohelpHendricksapplyfordisabilityinsurance,.sothathecouldleavethechaosofwelfaremotels,andhaveaccesstoaconsistentsetofphysicians.Theteamalsopushedhimtofindsourcesofstabilityandvalueinhislife.TheygothimtoreturntoAlcoholicsAnonymous,and,whenBrennerfoundoutthathewasadevoutChristian,heurgedhimtoreturntochurch.HetoldHendricksthatheneededtocookhisownfoodonceinawhile,sohecouldgetbackinthehabitofdoingit.ThemainthinghewasupagainstwasHendricks'shope-lessness.He'dgivenup."Canyouimag-inebeinginthehospitalthatlong,whatthatdoestoyou?"Brennerasked.IspoketoHendricks
recently,
Hehasgonewithoutalcoholforayear,cocainefortwoyears,andsmokingforthreeyears.Heliveswithhisgirlfriendinasaferneighborhood,goestochurch,andweath-ersfamilycrises.Hecookshisownmealsnow.Hisdiabetesandcongestiveheartfailureareundermuchbettercontrol.He'slosttwohundredandtwentypounds,whichmeans,amongotherthings,thatifhefallshecanpickhimselfup,ratherthanhavingtocallforanambulance.''Thefunthingaboutthisworkisthatyoucanbetherewhenthelightswitchgoesonforapatient,"Brennertoldme."Itdoesn'thappenatthepacewewant.Butyoucanseeithappen."WithHendricks,therewasnomirac-ulousturnaround.'Workingwithhimdidn'tfeelanydifferentfromworkingwithanypatientonsmoking,baddiet,notexercising-workingonanyparticu-larrutsomeonehasgotteninto,"Brennersaid."Peoplearepeople,andtheygetintosituationstheydon'tnecessarilyplanon.Myphilosophyaboutprimarycareisthattheonlypersonwhohaschangedanyone'slifeistheirmother.Thereasonisthatshecaresaboutthem,andshesaysthesamesimplethingoverandoverandover."Sohetriestocare,andtosayafewsimplethingsoverandoverandover.IaskedHendrickswhathemadeofBrennerwhentheyfirstmet."Hestruckmeasodd,"Hendrickssaid."HisappearancewasnotwhatIex-pectedofayoung,clean-cutdoctor."Therewasthatbeard.Therewashisman-
L
v
''Harryseldomleaveshisretirementcubicle."
ner,too."Hiswholepremisewas'I'mhereforyou.I'mnotheretobeapartofthemedicalsystem.I'mheretogetyoubackonyourfeet.'"AnordinarycoldcanstillbeamajorsetbackforHendricks.Hetoldmethathe'dbeeninthehospitalfourtimesthispastsummer.Butthestayswereafewdaysatmost,andhe'shadnomorecata-clysmic,weeks-longLC.U.stays.Wasthiskindofsuccessreplicable?AswordwentoutaboutBrenner'sinterestinpatientslikeHendricks,hereceivedmorereferrals.Camdendoctorsweredelightedtohavesomeonehelpwiththeir"worstoftheworst."Hetookonhalfadozenpa-tients,thentwodozen,thenmore.Itbe-cameincreasinglydifficulttodothisworkalongsidehisregularmedicalpractice.Theclinicwasalreadyunderfinancialstrain,andreceivednothingforassistingthesepatients.Ifitwereuptohim,he'drecruitawholestaffofprimary-caredoc-torsandnursesandsocialworkers,basedrightintheneighborhoodswherethecostliestpatientslived.Withthetensofmillionsofdollarsin,hospitalbillstheycouldsave,he'dpaythestaffdoubletoserveasCamden'selitemedicalforceandtorescuethecity'shealth-caresystem.Butthat'snothowthehealth-insur-
ancesystemisbuilt.SoheappliedforsmallgrantsfromphilanthropiesliketheRobertWoodJohnsonFoundationandtheMerckFoundation.Themoneyal-lowedhimtorampuphisdatasystemandhireafewpeople,likethenursepractitio-netandthesocialworkerwhohadhelpedhimwithHendricks.HehadsomedeskspaceatCooperHospital,andheturneditovertowhathenamedtheCamdenCoalitionofHealthcareProviders.Hespoketopeoplewhohadbeendoingsim-ilarwork,studied"medicalhome"pro-gramsforthechronicallyillinSeatde,SanFrancisco,andPennsylvania,andadoptedsomeoftheirlessons.Bylate2010,histeamhadprovidedcareformorethanthreehundredpeopleonhis"super-uti-lizer"map.IspentadaywithKathyJackson,thenursepractitioner,andJessicaCordero,amedicalassistant,toseewhattheydid.TheCamdenCoalitiondoesn'thaveenoughmoneyforaclinicwheretheycanseepatients.Theyrelyexclusivelyonhomevisitsandphonecalls.Overthephone,theyinquireaboutemerginghealthissues,checkforinsur-anceorhousingproblems,askaboutunfilledprescriptions.Allthepatientsgettheteam'surgent-callnumber,whichis
THENEWYOR.K.ER.,JANUAR.Y24,201143

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