By JUDITH VANDEWATER
PHILADELPHIA — It is not easy to provide high-quality, coordinated health care in a place like Camden, N.J., the gritty and poor city that Dr. Jeffrey Brenner chose as a laboratory to create and test new models of care. His data-fueled, hyper-local efforts might one day influence health care delivery nationwide.
As Brenner describes it, Camden is a community where an expensive, dysfunctional and disjointed health care delivery system is failing the most vulnerable patients. But, largely thanks to Brenner's initiative, Camden is also a place where hospitals, a federally funded clinic, insurance companies, private practice physicians and patients have agreed to stop blaming each other for their respective failings and to work together to remake a health care system with increased value and improved patient outcomes as the goal.
Cooperation among health care providers in Camden has enabled the creation of the Health Information Exchange, a real-time database that allows any provider in the community to check the medical records of any patient. The exchange is an innovation introduced by the Camden Coalition of Healthcare Providers, a 10-year-old-plus coalition that is composed of Our Lady of Lourdes Medical Center, a member of Catholic Health East; Cooper University Hospital; Virtua Camden, which operates an emergency room and provides outpatient imaging and dental care; most of Camden's primary care providers; and mental health and substance abuse facilities that treat patients covered by Medicaid. Brenner is the executive director of the coalition.
Intensive case reviews
In his keynote speech at the 2012 Catholic Health Assembly, Brenner said that each morning his team at the Camden Coalition of Healthcare Providers pores over a report that names all Camden residents who, within the past 24 hours, have been admitted to, or discharged from, Lourdes, Cooper University Hospital or a nearby Virtua hospital in South Jersey.
The data includes the patient's name, insurer, primary care physician, and, importantly, how many times the individual has been hospitalized recently. Patients who have been admitted more than four times in six months are deemed "high utilizers," and they are assigned to a Camden Coalition team made up of a nurse, community health worker and social worker. Cooper patients who fit the high-user profile get a bedside visit from a team member who participates in their discharge planning. Brenner said that bedside contact will be expanded to Lourdes in coming months.
The team nurse makes a home visit within 24 hours of a patient's release from the hospital. The social worker links the patient to community support services. The community health worker, usually an AmeriCorps volunteer, accompanies the patient to follow-up health care visits. The team provides any necessary service for a period of six months after hospitalization. "It is very time-intensive work," Brenner said.
The coalition has a staff of 35; these individuals are employed by Cooper, but they are under contract to the coalition. This arrangement allows Brenner to staff up quickly without concerns about securing malpractice coverage.
All of this is aimed at improving care and bending the health cost curve. Camden's 77,344 residents spend $100 million a year, mostly in public dollars, on hospital care and emergency room treatments. "I wouldn't be here today if I thought that all of us had spent our money well, but we didn't," Brenner said.
Health care providers "perform miracles once in a while, but the sum total of the heath care we do is fragmented and disorganized," Brenner said. "We could do much better; $100 million would buy a lot of primary care, it would buy a lot of diabetes educators, health coaches and lots of innovation."
Data is golden
One out of two Camden residents use the ER or are hospitalized every year, Brenner said. Many of the ER patients could have been treated effectively at a much lower cost by primary care doctors or pediatricians if they'd had ready access to such care, but they didn't and don't — it can take three months to get an appointment. So patients go to the ER instead and wait six hours or more for care. According to Brenner, between 2002 and 2007, head colds were the top diagnosis in Camden ERs followed by ear infections, viral infections and sore throats.
Brenner, a family physician and public health researcher, can state this with certainty because the city-wide patient database he helped create is one of the most robust in the nation. Since 2002, it has captured all the names, addresses, dates of birth, insurance status and admission charges for every Camden resident treated at Lourdes, Cooper University Hospital and Virtua Camden. "This is called an all-payer database, and people like me almost never get hold of data like this," Brenner said. "There are a few states that have all-payer databases, but they are hard to access."
That database is the primary tool he is wielding to understand, on a block-by-block, building-by-building basis, what is going on in Camden health care. He said the data prove the 80-20 rule of unequal distribution — which, when applied to health care, means that 80 cents of every health care dollar is spent on the sickest 20 percent of patients. In Camden, the data showed that 1 percent of patients had consumed 30 percent of the health care resources. Yet the system is failing them, he said.
"What we are doing is that we ignore the sickest patients because we are not paid to pay attention to them," Brenner told the audience. "The financial incentives in our health care system set by the Centers for Medicare and Medicaid Services pay you a whole lot of money if you cut, scan, zap and hospitalize a patient; and it pays you almost nothing if you talk to them and educate them and coordinate their care. So, as a primary care doctor, I actually make more money when I run from room to room seeing head colds than when I see a really sick patient. That fundamentally has to change."
Focusing resources
Brenner estimates the Patient Protection and Affordable Care Act could add about 15,000 new Medicaid recipients in Camden. "We can't even take care of the ones we have," he said. In many ways the situation in Camden foreshadows what Brenner expects to happen when 85 million Baby Boomers and 32 million new covered lives from health reform-related insurance expansion come "like a freight train at our delivery system" to be met by an inadequate primary care system with not enough doctors and misaligned payment incentives.
The knowledge that health care costs are concentrated in the sickest patients with multiple chronic conditions is not new, but the Camden data uncovered an interesting twist. It shows that many of the highest cost patients — so called dual eligible because they qualify for Medicaid and Medicare coverage — are clustered geographically. Many of these patients are disabled and have multiple chronic conditions. In Camden, many of them live in a subsidized housing tower called Northgate Two or the nearby Abigail House, a rehabilitation and nursing facility. In a 5.5-year period the combined health care costs of 600 Northgate residents reached $12 million.
"Residents in that building could not believe that someone had got that much money and they still felt so unwell," Brenner said. "They felt deeply disrespected."
Brenner and his community health colleagues worked with the residents and other care providers in Camden to open a small medical office at Northgate about 11 months ago that is staffed by a private practice physician. About 100 people in the building now receive primary care there. But Brenner isn't finished at Northgate. "My goal is to throw everything and the kitchen sink at this one building, including yoga classes and diabetes education," Brenner said. "If I bend the cost curve in this building, I'll know about it from the claims data. I can't bend the cost curve in the whole city if I can't do it in this one building."
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