Tough patients

In the January 24 issue of The New Yorker, Atul Gawande reports on the work of Jeffrey Brenner, a medical doctor in Camden, New Jersy, who discovered that the toughest patients used an astonishing proportion of the health care dollars in Camden: “He made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots. The two most expensive city blocks were in north Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower called Northgate II. He found that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.”

Brenner went to work, enlisting social worker and a nurse to give intensive attention to one of the worst cases he could find – a 500-pound smoker and cocaine addict who had been in and out of the hospital for lengthy periods and had racked up huge expenses. Brenner and others who have embarked on similar programs have isolated a major flaw in the medical system: “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.”

Only intense, communal, wholistic care can help the tough patients. And that has the added benefit of helping to control costs. There is an opportunity here for churches to follow this kind of program.