Just 5% of the U.S. population accounts for 50% of all health spending. So the idea of addressing the medical and social needs of the sickest and most expensive patients among us to keep them from making repeated visits to the hospital holds some obvious appeal as a way to bring down overall health care spending.
The promising concept, known as hot-spotting, was widely touted. Dr. Jeffrey Brenner, a New Jersey physician who helped pioneer the model and popularized it by founding the Camden Coalition of Healthcare Providers in 2002, was profiled in a 2011 New Yorker piece and won a MacArthur Foundation “genius” grant.
“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,” Dan Gorenstein and Leslie Walker explain at Kaiser Health News.
But a new study published by MIT researchers in the New England Journal of Medicine found the approach to be a disappointing failure in cutting hospital readmissions and total health care spending.
The Associated Press’s Marilynn Marchione reports:
“Researchers thought they had a way to keep hard-to-treat patients from constantly returning to the hospital and racking up big medical bills. Health workers visited homes, went along to doctor appointments, made sure medicines were available and tackled social problems including homelessness, addiction and mental health issues.
“Readmissions seemed to drop. … But a more robust study released Wednesday revealed it was a stunning failure on its main goal: Readmission rates did decline, but by the same amount as for a comparison group of similar patients not in the costly program.”
Why it matters: “The surprising lack of results offers a cautionary tale about how difficult it is to improve patients’ care and reduce costs,” writes New York Times reporter Reed Abelson. The researchers behind the new study say it’s important that we keep looking for answers — and rigorously test new ideas. “Of course it's disappointing to learn that a relatively cheap and short-term intervention wasn't the magic bullet for solving an incredibly complex, costly and important problem,” MIT economist Amy Finkelstein, an author of the new study, told Politico. "But that's how science makes progress."
The safety net may not be strong enough for these patients: “The study’s researchers offered several possible reasons for the program’s lack of success, including a lack of follow-up home visits or doctor’s appointments or insufficient resources,” Abelson says. Marchione notes, for example, that the program was able to meet two of its main goals —making a home visit and a trip to a health provider within a week of leaving the hospital — for just 28% of study participants.
Brenner says that the resources available to help the neediest patients were more limited than the Camden Coalition had estimated, and that the care coordination he pioneered was necessary — but insufficient without a stronger safety net.
“When we started this 10 years ago, the dominant belief was this was a coordination problem. As we got deeper into the work it became clear that even if you did a great job of navigating and coordinating services, there was a fundamental failure of these services to deliver what these patients need,” he told Reuters. And he provided this devastating summation to Kaiser Health News: “The bottom line is, we built a brilliant intervention to navigate people to nowhere.”
Brenner says that housing may play a more important role in breaking the cycle of hospitalizations for these patients. At UnitedHealthcare, where he is now an executive, he is leading an experiment to providing housing to high-cost patients.
Or a different approach might be more effective: The study’s result may indicate that a patient-centered approach might not be the answer to reducing waste, Boston University economist Austin Frakt writes at The New York Times:
“The other approach to fighting wasteful medical spending starts with looking at health care as a system of goods and services: medications and surgical procedures, administrative processes and physical infrastructure. Some of these enhance health and others don’t, while some of it costs more than its benefits warrant. If you can identify wasteful goods and services and deliver effective care at lower prices, you can make the system more efficient for everyone.”
But a systemic approach faces significant challenges that make it hard to implement, at least without harming the quality of care. “Directly and systematically reducing wasteful care is hard because the most successful strategies threaten the revenue of dominant health care providers,” Michael McWilliams, a professor at Harvard Medical School and a general internist with Brigham and Women’s Hospital, told Frakt. “One person’s waste is another’s income.”
Frakt’s conclusion: “The answer isn’t necessarily to pick a patient- or system-focused approach to reforming health care, but to do both effectively.”