The ‘Healthstat’ seduction

If professional writing was the guild it often appears to be, Atul Gawande would be a scab. A surgeon and professor, Gawande also writes beautifully for the New Yorker about healthcare.

His latest article, “The Hot Spotters,” focuses on what Gawande claims is a revolutionary approach to healthcare. In Camden, N.J. — hardly a garden spot in the Garden State — just 1% of the people who used the city’s medical facilities accounted for 30% of the costs. One patient had 324 hospital admissions in five years, costing insurers $3.5 million.

Another fellow, weighing 560 pounds, with both an alcohol and cocaine problem, spent more time over a three-year period in the hospital than out of it. But thanks to work by a crusading doctor, Jeffrey Brenner, the man was pulled back from the brink, cutting his hospital visits dramatically.

Brenner’s theory is that we can save billions by delivering better healthcare to the sickest people. Brenner was inspired by the Compstat approach used by police in New York City during the 1990s to tackle crime where it is most concentrated. Just as cops got out of their cars and walked a beat in the worst areas, under Brenner’s “Healthstat” approach doctors and nurses get out and get involved in the lives of the sickest patients.

Brenner’s results are impressive. All it takes is a near-religious dedication to getting involved in the nitty-gritty of patients’ lives.

In a similar effort, a clinic formed by Atlantic City’s casino workers union and its biggest hospital treats only the patients with the highest medical costs. The clinic often hires health “coaches” from outside the healthcare profession, because too many of the professionals have become bureaucratized, trained to say “no” to almost any question.

Gawande recounts how one such coach — a former Dunkin’ Donuts cashier named Jayshree who speaks Gujarati — helped a seriously ill Indian immigrant get well enough to use a walker instead of a wheelchair. Why did this patient listen to Jayshree, after she wouldn’t take similar advice about diet and exercise following her first two heart attacks?

“Because she talks like my mother.”

A preliminary study found that the Atlantic City effort achieved real cost savings. But it was also lucky, statistically speaking. A single heart transplant for any one of its gravely ill patients would have wiped out all of the savings.

Still, Gawande’s enthusiasm is infectious, and so is the passion of professionals like Brenner. Where Gawande falls short is in explaining how all of this justifies “Obamacare” (apparently he hasn’t gotten the memo about not using that term).

Yes, the Patient Protection and Affordable Care Act funds pilot programs like Brenner’s, but it also fuels the sort of bureaucracy that even Gawande and Brenner concede strangles innovation. It makes insurance companies into even more sheltered monopolies — health utilities, in effect — and appeases many of the political constituencies that stand to lose money from this style of counterinsurgency medicine.

Also, we know that Obamacare incentivizes corporations to dump their most expensive patients onto public exchanges. Which means taxpayers will pick up a much bigger tab than we were told.

Given these disappointments with the latest cures for the system, perhaps a little skepticism about the ability of “hot-spotting” to make it all work out is in order too.

But what I find most striking about Gawande’s celebration of the community policing model is how at odds it is with any notion of limited government. He is tone deaf to those who might bristle at the idea of medicalizing society.

In Camden, Brenner wants to put social workers in “hot spot” buildings so residents can be coached daily about their diet and exercise and harangued to quit smoking. He cajoled the 560-pound alcoholic drug addict to resume church attendance.

This all sounds fine, from a medical perspective. But citizens are not patients.

Brenner is a private citizen doing heroic work. But if this model were to be nationalized, you would in effect have agents of the government serving as lifestyle coaches and health “mothers.” Surely you don’t have to be a “tea partier” to find that creepy.

jgoldberg@latimes columnists.com