Based on the experience of a prior Allied raid and knowing that oil was vital to the German war machine, the High Command agreed. Herr General got his flak gunnery and fighters. When the Allies finally launched "Operation Tidal Wave" against the enemy on August 1, , the losses were horrific. While the military parallels may be a bit of a stretch for the peace-loving peoples of the Disease Management Care Blog, the question remains: should everyone get the same protection, or should we concentrate our special resources on those who are especially vulnerable? Gawande, using a common sense narrative laced with some rich anecdotes, correctly argues on behalf of the vulnerable. While they may be few in number, the non-compliant, disabled and socially isolated persons with multiple illnesses are the most likely to be victimized by a dysfunctional and inflexible care system.

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Shopping 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. Americans make more than a billion such visits each year, according to the Centers for Disease Control. Outsiders tend to be the first to recognize the inadequacies of our social institutions. But, precisely because they are outsiders, they are usually in a poor position to fix them.

Gunn, though a doctor, mostly works for people who do not run health systems—employers and insurers. So he counsels them about ways to tinker with the existing system.

He identifies doctors and hospitals that seem to be providing particularly ineffective care for high-needs patients, and encourages clients to shift contracts.

And he often suggests that clients hire case-management companies—a fast-growing industry with telephone banks of nurses offering high-cost patients advice in the hope of making up for the deficiencies of the system. The strategy works, sort of. Verisk reports that most of its clients can slow the rate at which their health costs rise, at least to some extent. Brenner, by contrast, is reinventing medicine from the inside. But he does not run a health-care system, and had to give up his practice to sustain his work.

He is an outsider on the inside. So you might wonder whether medical hot-spotting can really succeed on a scale that would help large populations. Yet there are signs that it can. If total costs fall more than five per cent compared with those of a matched set of control patients, the program allows institutions to keep part of the savings.

If costs fail to decline, the institutions have to return the monthly payments. Several hospitals took the deal when the program was offered, in One was the Massachusetts General Hospital, in Boston. It asked a general internist named Tim Ferris to design the effort. The hospital had twenty-six hundred chronically high-cost patients, who together accounted for sixty million dollars in annual Medicare spending.

The doctors saw the patients as usual. In between, the nurses saw them for longer visits, made surveillance phone calls, and, in consultation with the doctors, tried to recognize and address problems before they resulted in a hospital visit. Advertisement Three years later, hospital stays and trips to the emergency room have dropped more than fifteen per cent. The hospital hit its five-per-cent cost-reduction target. And the team is just getting the hang of what it can do.

Recently, I visited an even more radically redesigned physician practice, in Atlantic City. On the second floor, just past the occupational-health clinic, you will find the Special Care Center. It gets a fixed pot. Year after year, the low-wage busboys, hotel cleaners, and kitchen staff voted against sacrificing their health benefits.

As a result, they have gone without a wage increase for years. They got a young Harvard internist named Rushika Fernandopulle to run a clinic exclusively for workers with exceptionally high medical expenses. Jeff Brenner was on his advisory board, along with others who have pioneered the concept of intensive outpatient care for complex high-needs patients. The hospital provided the floor space. Fernandopulle created a point system to identify employees likely to have high recurrent costs, and they were offered the chance to join the new clinic.

The Special Care Center reinvented the idea of a primary-care clinic in almost every way. That cut the huge expense that most clinics incur from billing paperwork.

The patients were given unlimited access to the clinic without charges—no co-payments, no insurance bills. This, Fernandopulle explained, would force doctors on staff to focus on service, in order to retain their patients and the fees they would bring. The payment scheme also allowed him to design the clinic around the things that sick, expensive patients most need and value, rather than the ones that pay the best.

He adopted an open-access scheduling system to guarantee same-day appointments for the acutely ill. He customized an electronic information system that tracks whether patients are meeting their goals. And he staffed the clinic with people who would help them do it. One nurse practitioner, for instance, was responsible for trying to get every smoker to quit. I got a glimpse of how unusual the clinic is when I sat in on the staff meeting it holds each morning to review the medical issues of the patients on the appointment books.

There was, for starters, the very existence of the meeting. Then there was the particular mixture of people who squeezed around the conference table. As in many primary-care offices, the staff had two physicians and two nurse practitioners.

But a full-time social worker and the front-desk receptionist joined in for the patient review, too. Each health coach works with patients—in person, by phone, by e-mail—to help them manage their health.

Fernandopulle got the idea from the promotoras, community health workers, whom he had seen on a medical mission in the Dominican Republic. The coaches work with the doctors but see their patients far more frequently than the doctors do, at least once every two weeks. Their most important attribute, Fernandopulle explained, is a knack for connecting with sick people, and understanding their difficulties.

Many have experience with chronic illness in their own families. One was himself a patient in the clinic. Few had clinical experience. I asked each of the coaches what he or she had done before working in the Special Care Center. Another was a Sears retail manager.

A third was an administrative assistant at a casino. This kind of care requires a very different mind-set from usual care. For example, what is the answer for a patient who walks up to the front desk with a question? They reviewed the requests that patients had made by e-mail or telephone, the plans for the ones who had appointments that day.

Staff members made sure that all patients who made a sick visit the day before got a follow-up call within twenty-four hours, that every test ordered was reviewed, that every unexpected problem was addressed.


Hot-Spotters Aren’t “The Problem”...But They Are Emblematic of the Failure of U.S. Healthcare

Metrics details In his very influential article in the New Yorker, Atul Gawande shined a bright light on the small group of neediest patients who access the healthcare system extremely frequently. Even so, their health outcomes were notoriously poor, implying that the system could do a far better job of taking care of them. One of the ways to help accomplish this, Gawande suggested, was through care management and coordination, something that is, unfortunately, generally inadequate in American medicine, and likely even less available for this most vulnerable group of patients. Lee et al. Unlike Gawande, these authors choose not to highlight these striking problems among this small group of patients, but stress instead the fact that these frequent users—which Lee et al. Because of this, they point out that even if it were possible to lower costs dramatically within this subgroup, our hugely bloated healthcare budget would not be greatly affected overall. Although we believe that certain aspects of the methodology used in this study—and thus the precision of its conclusions—can be challenged, we have no doubt that the results are largely correct.


The Hot Spotters

Goltigul A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back. At nine-fifty on a February night ina twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. In the Hot Spotter article Gawande writes about several innovative approaches to reducing health-care costs. This idea led to spottters creation of hhot Camden Coalition of Healthcare Providers. Gawande then describes the difficulties in implementing these and other innovative ideas on a larger scale, including opposition from insurance companies and the health-care lobby. Link to full text in the New Yorkert: Joel Greenberg has been a science journalist for four decades. Gawande also describes a visit he made to the Special Care Center, a clinic in Atlantic City, an experimental approach to primary care.

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