Monday, February 07, 2011

Management of Care

As I have no doubt mentioned before, it is our general belief as a society that human activity is more efficient and productive if it is managed.

We apply that belief to almost every activity in which we are involved, with the notable exception of health care. In health care, we manage hospitals, we manage clinics, we manage laboratories and insurance companies, but as a general matter we do not managed care. I am currently under the care of five specialists and a family practitioner, but there is no formal relationship among them, none is responsible for what any of the others of them might be doing, and no one exercises any oversight over the group. One might suggest that the family practitioner should play this role, but the specialists are not accountable to her. Some of them give her reports, but otherwise pay her little attention.

I have recently been reminded of all that again by an article in the January 24 issue of the New Yorker magazine by Atul Gawandi, the Harvard surgeon who has become a popular author on health care issues. Gawandi writes about three physicians who have become involved in attempts to manage care.

The first, Jeffrey Brenner, is a family physician in Camden, New Jersey. Serving on a police reform commission, Brenner got exposed to the technique of mapping the incidence of crime and then concentrating law enforcement on high crime areas; so-called “hot spots.” From a data base built on hospital records he was able to identify the neighborhoods with the highest incidence of serious assaults. That got him interested in patterns of hospital use generally and he discovered that there were also “hot spots” of hospital use. He also found out that one percent of the people who used Camden medical facilities accounted for thirty percent of the cost.

One thing led to another and he now heads an organization called the Camden Coalition of Healthcare Providers that specializes in managing hard-to-care-for patients with multiple diagnoses. While the initial motivation was to improve the care these patients received, there has been a major impact on cost. For the first thirty-six patients, hospital utilization has been reduced by forty per cent and hospital bills by fifty-six per cent.

The second doctor was Nathan Gunn, who works for a company called Verisk Health. Using the same sort of data mining techniques, Verisk consults with employers and health insurance companies to identify their high users and suggests strategies for reducing unproductive and costly utilization.

The third doctor, Rushika Fernandopulle, works in an Atlantic City facility called the Special Care Center. The Center was created to address the cost of providing care to high-utilizing members of the casino workers’ union and employees of a hospital, AtlantiCare Medical Center, by focusing responsibility for the management of their care.

So it looks as though a few efforts to manage care are beginning, with special emphasis on patients using services at a high rate, with generally good results.

Perhaps the rest of us could benefit, too, if only somebody had the opportunity to try.

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