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Atul Gawande has put faces on the Accountable Care Organization potential. He is the author who put a face on Medicare spending in his documentation of the differences between doctors in McAllen Texas and Grand Junction Colorado which I wrote about here. In this months New Yorker he writes of primary care intervention in Camden New Jersey making a difference in an article entitled “The Hot Spotters.”

He first interviews a Family Physician named Jeffery Brenner who has devoted his professional career to trying to determine why folks who utilize a lot of health care do so and figuring out what can lessen costs. He figured out quickly that

“People are people, and they get into situations they don’t necessarily plan on. My philosophy about primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over.”

In other words, for a lot of people, a caring health care professional (coupled with knowledge of resources brought in by other professionals) was often (50% of the time) sufficient to dramatically reduce emergency room visits and hospitalizations

“High-utilizer work is about building relationships with people who are in crisis,” Brenner said. “The ones you build a relationship with, you can change behavior. Half we can build a relationship with. Half we can’t.”
The outcomes are impressive. When the first thirty-six super-utilizers from another group using the same techniques were studied in depth, they averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. There was a fifty-six-per-cent reduction in hospital costs, hospital bills averaged $1.2 million per month before and just over half a million after.
As Dr Gawande emphasizes
The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.
Obamacare, anyone?

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There is an ongoing argument between the people who say we have too few doctors and the people who say we just don’t have the right kind of doctors (it’s quality not quality). More evidence that more is not better, better is better, and better is Family Medicine was put forth once again in the New England Journal of Medicine recently. Thomas Bodenheimer and David West went back to the town that Atul Gawande wrote about in his classic New Yorker article about run away health care costs. Not McAllen Texas (the town with the highest cost) but Grand Junction Colorado (the town with the lowest cost) to see why this town succeeded where others failed. They went there because

The usual explanation is that this town of 50,000 benefits from a cooperative spirit among health plans, hospitals, and physicians, who work together to serve the population. But even if this explanation were accurate, cooperation could not be transferred to other geographic areas — nor could the small-town nature of the Grand Junction community with its relatively homogeneous racial makeup. So what aspects of the Grand Junction success story might be replicable in other communities?

What they found was

that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.

It wasn’t just any type of “primary care” physician, it was Family Physicians. These physicians created a culture of accountable care before it was popular. The fixes were not high-tech (in fact, several such as pay equity are exceedingly low tech) but they have created a culture of exceptional care.

A lesson for America? Perhaps. In the understated words of the authors

These features could be replicated in other markets — though generally not without political battles.

Accountable Care Organizations, anyone?

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