Greedy Bastards Antidote: Dr. Jeffrey Brenner and Hot-Spotting HealthcareNovember 28, 2011
Is there a problem with the way we solve social problems in America? More often than not, our problems in government and society can be traced back to behavior we call “Greedy Bastardism” — decisions that seek to exploit lack of shared visibility and breach personal and group integrity to get what one group wants over what another group needs. On the other side, there are those out there who we consider to be the “scientists” fighting Greedy Bastardism in America — those who are finding the “Antidotes.” Over the next few weeks, we’ll be discussing creative methods of problem solving that can help pull our country out of the mess that we’re currently mired in.
The first is called hot-spotting. Hot-spotting was originally used in criminal justice in New York City when William Bratton, the city’s former police commissioner, revolutionized urban policing by using data to map when and where crimes took place, and then sending extra officers to the areas where crimes were committed most often. By putting extra resources to areas with the highest crime rates, Bratton found it was possible to lower crime across New York.
This is hot-spotting: a problem solving technique that targets the most expensive problems or in-need people by allocating resources to specific problem areas as revealed by data.
Let’s take a health care example. Imagine if you could identify a small number of patients who end up eating up most health care dollars. Let’s say you could focus resources just on them, improve their health outcomes,while also cutting the overall amount of health care spending dramatically. This wouldn’t be a question of how much, but how. This isn’t fiction, it comes from Camden, New Jersey, one of the poorest cities in the country. And the technique is known as hotspotting, or targeting resources to needs.
A remarkable physician, Dr. Jeffrey Brenner, is Founder and Executive Director of the Camden Coalition of Healthcare Providers. He figured out that the sickest patients in Camden were returning repeatedly to the emergency room, costing the health care system enormous sums of money. Because they were always seeing specialists or coming to the ER, they had no real advocate overseeing their health. The health care system was fragmented and passive, and so it failed to deliver care where it was needed even though it cost huge sums of money.
“So one of the problems in lots of fields, whether it be education, in policing, or in healthcare, is that that we don’t strategically allocate resources, that when a patient begins to feel overwhelmed, when their illnesses are overwhelming them, they are scared, they are frightened, we have a really passive healthcare system,” Dr. Brenner explains. “Doctors don’t wake up every day and think, “Which of my patients are having a hard time today? How do I deploy staff out to find those patients and take good care of them?” We are very reactive. We prefer patients to come to us and often when they come to us, it’s sort of too late, or it’s pretty far down the trajectory,” says Dr. Brenner.
Brenner told me of one older diabetic patient who kept getting sick. Brenner sent a community outreach team to his home to see what the problems were. As they asked the man to show them his his routine, the team realized he was sight impaired. So he would put a syringe into his bottle of insulin to draw medicine, but instead it would draw in 50 cc’s of air. That’s why he kept getting sick, there was no complicated medical issue here, he didn’t need to see another expensive specialist. The guy just needed glasses!
This process, of sending a team to one sick patient’s home to see what was going on saved money for all of us and improved health outcomes.
This is hotspotting.
Dr. Brenner believes that this community-based healthcare is the way to go for fixing our medical system. To solve the catastrophe of our ever-increasing healthcare costs, he believes that “we are going to need to de-institutionalize medical care. We are going to need to take all of this money and resource that we’ve applied to intensive care units in hospitals, and build the system on the outpatient side in the community to begin taking care of people better, which is going to create all kinds of new jobs and its going to eliminate some old jobs. And we probably need fewer hospitals beds, fewer specialists, we are going to need some of that and the money that we are spending on those things are going to be spend out on the community for primary care providers, community health workers, patient navigators, for care assistance, and a whole different kind of delivery system.
Dylan: Welcome to this, the second edition of Greedy Bastards Antidote. This, the laboratory where we identify scientists—in this case, we have an actual scientist—who are out in our own society experimenting to create antidotes to the greedy bastardism and dysfunction that is infected our government but doesn’t not infect us as people. What Dr. Brenner, Dr. Jeffrey Brenner, Founder and Executive Director of the Camden Coalition of Healthcare Providers is doing as I understand it in his antidote and we will learn from him in just a second, but he has identified some very interesting things and I just want to share them with you.
One, frequently in large urban environment across the country, healthcare deliveries is fragmented, episodic, uncoordinated, and extremely inefficient. That means it is very expensive for you, me, and everybody else. And, by the way, very unpleasant for the people who depend on that as a healthcare system. Often, you have many hospitals and several health systems in the same city but they don’t communicate with each other and the flow of information between them doesn’t exist. We’ve all been there.
After working for several years, Dr. Brenner and his coalition tried to gain and were able to gain access to hospital claims data that all three Camden health systems. The coalition together with CamConnect compiled a comprehensive database, very 21st century of them, to analyze and quantify the utilization of the hospitals by Camden residents. So in other words, they looked at the computer to figure out who was going to the hospital and what they were doing while they were there and how often they came and how much they spent. They said what the heck is going on around here.
So here is what they found out. In one year, nearly half of the city, the city of Camden, New Jersey, nearly half of the city’s residents visited the emergency department or hospital—half the city. That means half the city didn’t go at all. A single patient visited the city emergency department or hospital a total of 113 times which is roughly one out of every three days. Think about that. And the most common diagnosis were head colds, viral infections, ear infections, and sore throats, again, probably the most common of human ailments.
In Camden, 80% of the, get this, 80% of the costs were spent by 13% of the patients and 90% of the costs were spent by 20% of the patients. Dr. Brenner learned from what he saw in New York’s hot spotting of crime, identifying the crime creating regions and then allocating and creating systems to over-allocate to deal with those hot spots, has applied hot spotting to that data—80% of the costs, 13% of the patients, discreet data, I know who, where, when, what. And with no further ado, our hot spotter and chief for the day, Dr. Jeffrey Brenner, who is featured prominently in the book but regardless of that, you really are a teacher for, I suspect more people than you may realize, Dr. Brenner. Will you give us a sense of why you are doing what you are doing and what really is the antidote that you are carrying?
Dr. Brenner: Dylan, thank you so much for the chance to talk with you today. Most of my career, I have been a frontline family doctor and I have worked in the city of Camden for about 12 years and took care of Medicaid patients in a small office with three exam rooms and I saw kids, adults, I delivered babies, I did home visits, and I really struggled with making payroll, with taking good care of patients, with trying to deliver high quality care everyday to my patients. The way we pay for healthcare, the way we organize our healthcare system doesn’t really support good care for everyone, and what I found out is that I couldn’t just keep running from room to room to room, I actually went out of business and the payment rates kept getting lower and lower and lower and as I got deeper into understanding where the money was going in healthcare, I began to realize that we were spending a lot of money and not getting value for our money and that my patients, as much as I struggled to give them good care, weren’t getting good care and that I had to step out of the office and begin to think in a different way about this.
Dylan: So when you realized that you could isolate literally down to the building, down to the patient, the community of people that were the super users, as you put it, in the Camden healthcare system, what were you inclined to do with that information?
Dr. Brenner: What I – the average visit for a primary care doctor in Medicaid in New Jersey is $19 to $35 a visit and you have to run pretty fast from room to room to room. And what ends up happening is you shortchange sick people, and that’s really a theme in our entire health system, that healthcare is built really for the average patient, but as you get sicker and sicker and your needs go up, the system doesn’t really adjust to meet those needs. And as we looked our across this system in Camden, it became really obvious that our healthcare system in Camden and across the country doesn’t do a good job with really sick patients.
We do some amazing things. We can in some instances cure cancer, we can treat really complex illnesses, but we do it in a way that’s fragmented, we do it in a way that its organized, and many, many people have had the experience of sitting with their relatives who has been hospitalized in the ICU or in a hospital bed, sitting next to them and realizing that all these doctors are coming to the bedside, and that none of them were talking to one another and that if you don’t sit there and advocate for your family member, that the care is really disorganized and that you need to go with your family member to the doctor and advocate for them. I think that’s really a microcosm of all the things that we see in Camden.
So I will give you a small example, if a patient needs a kidney transplant in Camden, I can get them evaluated very quickly. If they need a basic appointment for controlling their blood pressure, controlling their diabetes, it can take weeks or months. And when they do finally get it, because of the way we pay for healthcare, it’s a 10 or 15 minute visit and the doctor is running for door handle. But then we don’t control…
Dylan: That’s why I stopped going to the doctor.
Dr. Brenner: That’s right. And then we don’t control [cross-talking 06:35].
Dylan: Which is also bad for healthcare costs [cross-talking 06:36], but that’s another problem. I am sorry, go ahead.
Dr. Brenner : Then when we don’t take good care of them, they ultimately end up in the hospital in ICU, which one trip to the emergency room can be you know $300, $500, $1,000, a trip to the hospital can be $10,000, a trip into the ICU can be $25,000. So it’s foolish not taking good care of sick people.
Dylan: And so how does hot spotting solve that problem?
Dr. Brenner : So one of the problems in lots of fields, whether it be education, in policing, or in healthcare, is that that we don’t strategically allocate resources, that when a patient begins to feel overwhelmed, when their illnesses are overwhelming them, they are scared, they are frightened, we have a really passive healthcare system. We don’t, doctors don’t wake up every day and think, “Which of my patients are having a hard time today? How do I deploy staff out to find those patients and take good care of them?” We are very reactive. We prefer patients to come to us and often when they come to us, it’s sort of too late, or it’s pretty far down the trajectory. So ultimately hot spotting is about doing what business has been doing in lots and lots of other fields, which is better targeting resources to the needs and providing a better patient and customer experience. So it’s taking stuff that business has been doing for 100 years but trying to move it into health, moving into education, and moving into policing.
Dylan: And so how does one do that in health? So I am sitting in the room with you, we are looking at the data set, it’s clear that there’s you know 5% or 10% of the population that’s spending a huge percentage, 13% is spending 80% of the money, how do we change the way we spend our healthcare money to hotspot for that, and how does that create jobs, and how does that affect healthcare costs, and how does that affect health?
Dr. Brenner: I will give you a small example. We put together an outreach team, that’s nurse practitioner, community health worker, and social worker and we decided to go out and meet all of the most expensive, complex people in the city. And while we had the database and we knew who they were, at that time we couldn’t use the database to go out and contact them. So we asked the emergency room doctors in the city, “When you’ve got a really hard patient, call us and we will come and meet them and we will help you work on the case.” And that turns out that it successfully helps us find these patients. And I’ll give you a small example of one patient we met. It was a 70 year old gentleman who is a diabetic and has a great doctor, we went off to see the patient, and he had really poorly controlled sugars. He had sugars in the 500s, and my team watched him use his insulin and he set the bottle down on the table, he put a syringe into the bottle and he drew up 50cc of air and went to inject it into his arm and the team was horrified. And it turned out that the patient was sight imparity, he couldn’t see the syringe and he has been doing this for some time now. And he went to the refrigerator and pulled out two bags of insulin and they had little bottles in there and they were mostly full bottles and he said I use my insulin everyday but I can’t seem to empty the bottle because he couldn’t see the bottle.
Dr. Brenner: And the problem with this is we don’t need to be a physician or a nurse to be able to figure this out that you know a patient navigator community health worker could have figured this out. And it really speaks volumes to the lack of feedback loops and accountability in our delivery system and that we don't respond to problems in real time. Every problem is not that easy to solve, but it takes real time information to know who is struggling and then it takes home visits, it takes staff going out and reaching out to this people to be able to solve the problem.
Dylan: And the interesting thing, if I understand correctly, is in order to get the staff to work with the patients in the community, is that you actually went into the community to places like the Dunkin Donuts and the check cashing store and offered the kids working there a job as a community health worker, is that correct?
Dr. Brenner : So we are pretty small team, our outreach team is three staff member. And I think what you’re going see in the years to come if we are going to solve the catastrophe that is happening in healthcare of ever increasing cost, is we are going to need to de-institutionalize medical care. We are going to need to take all of this money and resource that we’ve applied to intensive care units in hospitals, and build the system on the outpatient side in the community to begin taking care of people better, which is going to create all kinds of new jobs and its going to eliminate some old jobs. And we probably need fewer hospitals beds, fewer specialists, we are going to need some of that and the money that we are spending on those things are going to be spend out on the community for primary care providers, community health workers, patient navigators, for care assistance, and a whole different kind of delivery system.
Dylan: So Dr. Brenner, can I interrupt you for one second? Can I interrupt you for one second? So I am – if I was more with you, I would be running alongside you trying to help you do this. But as I listen to you, I know and you also know that the level of disruption and the level of incumbent interest from the AMA to the hospital industry itself, to the insurance companies, all of whom would see decline in revenue, is substantial. And it’s not for us to fret about that, but I am interested to hear from you how you have managed to do what I call occupying yourself, this whole occupation thing, everybody’s occupying whatever they’re occupying. It seems the only rational thing that a person can occupy is yourself and I think if more of us honestly were occupying ourselves, we might be in less trouble. But I am interested in how you maintain yourself direction, yourself occupation in knowing that you are really on a wonderful path, that the antidote that you carry to this system is incredibly powerful and yet at the same time obviously the system, what you represent, is very threatening.
Dr. Brenner: It is, and we have a capacity bubble that we’ve inflated and it’s the biggest capacity bubble in the history of mankind and its 18% of the economy, it will likely be 25% of the economy. And to put it in perspective, healthcare is 18% of the economy, housing is about 11%, finance is about 7%. So we are going to have to somehow, without creating too much unemployment in this location, deflate the hospital’s specialty capacity bubble that we’ve created and it’s going to be a very painful and wrenching process. I have been able to do what I’ve done in Camden because I went someplace that no one else wanted to be. There’s no one fighting over more markets share of Medicaid patients in Camden, and I have been very careful to couch everything I have done in shared interest amongst all of the stakeholders, meaning that I need to work closely with hospitals, insurers, with the state, with providers. But I am in a very unique environment in Camden in which most people view Medicaid patients as people that are caring for at a loss financially. So it’s much easier to contemplate [inaudible 14:03] ways of delivering care in an environment like this and if I were out in suburbs doing the same thing. Now…
Dylan: At the same time, just your success, we talked about how much money you saved, talk to me about the improved health of the patients in your model.
Dr. Brenner: The stories are so sad. I mean as you get out and you meet patients that are going over and over to the ER, the ER is not a very easy place to be. It’s loud, it’s noisy, it’s terrifying, it’s frightening, you get yelled at, you get infection.
Dylan: They are mean to you!
Dr. Brenner: They are mean to you and you know but there’s a better place to be, which is in the community and feeling like you’re getting your needs met and you know and we are going to need to figure these out. We have a free training with 85 million baby boomers headed to the delivery system, and if we don’t figure this out, we are going to get completely overrun. You know, we are seeing baby boomers in Camden because the poverty is falling apart 20 years before the rest of the baby boomers are going to fall apart. In our system, in many ways, Camden is a harbinger of what's to come. If you want to know what the world looks like when you’ve destroyed primary care, when you’ve got too much specialty in the hospital care, when patients can’t get access, come and visit us because it’s what the rest of the county is going to look like in 20, 30 years. Foreclosure crisis, we had that 20 years ago. You know, I can tell you I am frightened for our country of what it’s going to look like when you known the wait terms in the suburbs are going up, when people can’t get access to primary care.
Dylan: And this is something that is not a political concept, this is a human reality that you are speaking to, which is why it is so really wonderful that you have – are doing what you are doing and why I consider it so important, not only that I help you, people understand what you are doing and help find other people that want to do what you are doing, but also to continue to force the debate publicly to that end. Can I ask you briefly are there other organizations in the country that you can recommend me and our listeners to that you think that represent some of the same aspirations that you and your very small group in Camden do?
Dr. Brenner : I think there are groups all over the country and the interesting thing is they’re in out-of-the-way places, they are not at what we traditionally call the centers of power in our healthcare industry. They are not academic health centers, it’s not our you know Harvard’s and Yale’s and Columbia Presbyterians. It’s Geisinger in Pennsylvania, it’s the Geisinger health System, it’s the Group Health Cooperative, it’s southeastern Alaska, it’s places that I would consider that in the absence of resource, they have innovated and figured out how to do more with less. Sometimes having too much money and too much resources really prevents innovation and it keeps people from figuring out how to be more efficient with their resources.
Dylan: And how you do it matters more than how much and how is what you are talking about, Dr. Brenner, and I really – you inspire me and I thank you for your inspiration not only for myself but for anyone, others as they continue to learn about the values that you represent and the way that you’ve chosen to dedicate your professional life. And fear not, while the title of the book is Greedy Bastards, you are featured as a keeper of the antidote, not a proprietor of the practice of greedy bastardism, Dr. Brenner, so sleep well on that, all right.
Dr. Brenner: Thank you, Dylan. Thanks for the chance to talk with you today.
Dylan: Thank you for, again, your time; I know it’s precious, so I will let you go. Dr. Jeffrey Brenner, Founder and Executive Director of the Camden Coalition of Healthcare Providers. You will be hearing more from this man and you will be hearing more about this way of thinking about our healthcare system in the year to come. And that will do it for our second edition of the Greedy Bastard Antidote, in this case Hot Spotting Healthcare with Dr. Jeffrey Brenner. Talk to you next time.
Dr. Brenner: Thank you.
Dylan: Thank you, Doctor.