Dr. Brenner tells the story of a patient with diabetes who simply could not get his condition under control. The patient saw a primary care doctor and specialists regularly, and a pharmacist regularly delivered insulin to the man’s home, but the patient continually ended up in the emergency department for care. No one could figure out the problem; many of his health care providers wrote him off as noncompliant, until Brenner and his team made a home visit. They observed the man injecting his insulin, and realized that he was not filling the needle properly. They discovered half-filled bottles of insulin in the refrigerator. The man was sight-impaired and could not see that he wasn’t injecting the proper medication. Once Brenner and his team recognized the problem, they were able to address it.
The main problem with this scenario, Brenner argues, is that there was not one accountable manager for that patient’s health. Because his care was everyone’s responsibility, it was no one’s. And because the current fee-for-service model of payment rewards a high volume of care, rather than paying for good patient outcomes, there are few financial incentives today for health care providers to work differently.
Brenner and his team set out to change that dynamic, particularly for the highest-cost, highest-need patients in Camden. Dr. Brenner, whose work received national attention in Atul Gawande’s New Yorker article “The Hot Spotters,” is the founder and Executive Director of the Camden Coalition of Healthcare Providers. He visited NYHealth on June 9, 2011, to discuss his team’s efforts to meet the needs of complex patients in one of the poorest urban communities in the nation.
First, Brenner looked at the data in Camden to understand more about the patients who were driving the bulk of health care costs in the community. He found that some patients were visiting the emergency department literally hundreds of times each year, getting care that cost millions of dollars annually but that delivered little value.
The biggest issue, it seemed to Brenner, was that the care system was not addressing the nonmedical factors that affect chronically ill patients’ health: poor housing; low income; limited transportation; and limited access to healthy foods and opportunities for physical activity. Addressing those issues would require a different kind of health care team, one that included not only physicians, but also nurses, social workers, and a community health worker. This team focused on changing care where people reside, eventually setting up clinics in the buildings where many of the highest-cost, highest-need patients live.
Importantly, those community members have formal representation within the coalition, and the health care team listens and responds to their needs, preferences, and opinions. Patients are engaged in their care, in their health, and in their community.
The Camden model has worked in large part because of the dedication and energy of a team of health care providers committed to improving the health and the lives of the people of Camden. The big issue now is aligning payments and incentives to better support this new model of care, allowing effective health care teams to share in the savings they achieve for high-cost, high-need patients. There is momentum toward this model, both through Federal legislation that supports development of Accountable Care Organizations and through pending legislation in New Jersey that would change payment structures for health care teams like Brenner’s.
As Dr. Brenner says, every patient deserves dignified, high-quality health care. The Camden model offers one promising step toward achieving that goal.