House Calls Are Cheaper Than Hospital Beds

All too often I am forced to describe unfortunate happenings in healthcare. Occasionally, there are good things and smart people to share. Dr. Jeffrey Brenner and his work more than qualify. We can (and must) learn a great deal from what he did.

In brief, Dr. Brenner identified what he called "super-utilizers" of health care in Camden, New Jersey. They were 36 patients with various combinations of asthma, cancer, diabetes, drug addiction, emphysema, heart disease, mental illness, obesity, etc.

Brenner and his Camden Coalition of Healthcare Providers began to provide what I would call "total care." They did not just sit in their offices, write prescriptions for the appropriate medications, and then move on to the next patient. They made house calls to assure that the patients actually got their medicines and took them.

Coalition providers got social services to help the patients apply for various forms of aide. They went to the patients' homes to make sure that equipment such as wheelchairs or apnea machines were delivered, worked, and that the patients used them properly. When necessary, they literally took the patients from their homes to the doctor or therapy visits to make sure the necessary contact actually happened.

In other words, they did whatever it took to guarantee that the patients' medical needs were satisfied and stay satisfied.

Two outcomes resulted from this activity. 1) The patients were much healthier than ever before. Some returned to productive work. 2) Total expenditures for these patients plummeted.

Before Brenner began the Camden Coalition, this small cohort of patients averaged 62 ER or hospital visits per month. After the Coalition was functioning, the same patients averaged 37 visits per month, a decrease of forty percent.

For these 36 patients, hospitals bills had averaged $1.2 million per month, hence the name "super-utilizer."  Due to the Coalition's efforts that expense dropped to half a million dollars - a fifty-six percent cut in cost. 

There are several important lessons to learn from Dr. Brenner's research. Research comes from French rechercher, which means to look again or to look back. First lesson: you do not need government review and approval and you certainly do not need 87 different steps to do useful, valid "looking again" that helps patients.

Lesson #2: Generally accepted wisdom is generally wrong. For instance, good research must follow government all rules and regulations, right? Except that Brenner didn't and he obtained useful, valid results.

Except when five intensive care units banded together to create the Michigan infection checklist that saved hundreds of millions of dollars and 1800 lives.  They did this without government approval, so what did the government do? NIH said they couldn't use it. After all, the government is expert at the practice of defensive bureaucracy.

Lesson #3: The Camden Coalition showed us the right way to reduce healthcare expenditures. The government's approach is to cut reimbursements and increase oversight. Brenner and his team 'spent money' and got around-went around-sometimes ignored the rules and regulations in order to get whatever patients needed medically so they could recover their health or at least reduce their illness.

Lesson #3 is divided into two parts. (A) The best way to save money is to spend money...on making people healthy. Spending to make people healthier is cheaper than treating their illnesses. (B) Government oversight (and over-regulation) - indeed the entire bureaucracy of healthcare - wastes lots of money, offers no net value, and fails to protect patients.

The "lots of money" is roughly one trillion dollars, yes with a "t". That is the amount of money that went in to healthcare (the system) but did not come out as any form of heath care (the service).

Lesson #4 starts as a corollary of #3. House calls are cheaper than hospital beds. That is literally true. Ten thousand house calls at $50 each equals $500,000. Hospitals beds cost well over $1 million each. Heck, the 36 patients alone were costing over $1 million per month.

As Dr. Brenner showed, house calls are both cheaper and improve the health of people. So lesson #4 is: Being healthy is cheaper than being sick, whatever the cost to stay healthy or to restore health.

Everyone knows lesson #4 is true...except our healthcare system and the massive bureaucracy that supports it, actually feeds off of it. The incentives are perverse: the system encourages exactly what we do not want. The system pays for "performance" but not for positive outcomes. We reward people (insurance companies) for not giving care. The way the system "saves" actually costs more money and our lives.

The final and most important lesson is how the Camden Coalition did what they did. They saved money and at the same time made people healthier by practicing good medicine on sick people. If we want to save money and simultaneously improve our system, we should practice good medicine on sick healthcare.

Deane Waldman MD MBA, is the author of Uproot U.S. Healthcare.
All too often I am forced to describe unfortunate happenings in healthcare. Occasionally, there are good things and smart people to share. Dr. Jeffrey Brenner and his work more than qualify. We can (and must) learn a great deal from what he did.

In brief, Dr. Brenner identified what he called "super-utilizers" of health care in Camden, New Jersey. They were 36 patients with various combinations of asthma, cancer, diabetes, drug addiction, emphysema, heart disease, mental illness, obesity, etc.

Brenner and his Camden Coalition of Healthcare Providers began to provide what I would call "total care." They did not just sit in their offices, write prescriptions for the appropriate medications, and then move on to the next patient. They made house calls to assure that the patients actually got their medicines and took them.

Coalition providers got social services to help the patients apply for various forms of aide. They went to the patients' homes to make sure that equipment such as wheelchairs or apnea machines were delivered, worked, and that the patients used them properly. When necessary, they literally took the patients from their homes to the doctor or therapy visits to make sure the necessary contact actually happened.

In other words, they did whatever it took to guarantee that the patients' medical needs were satisfied and stay satisfied.

Two outcomes resulted from this activity. 1) The patients were much healthier than ever before. Some returned to productive work. 2) Total expenditures for these patients plummeted.

Before Brenner began the Camden Coalition, this small cohort of patients averaged 62 ER or hospital visits per month. After the Coalition was functioning, the same patients averaged 37 visits per month, a decrease of forty percent.

For these 36 patients, hospitals bills had averaged $1.2 million per month, hence the name "super-utilizer."  Due to the Coalition's efforts that expense dropped to half a million dollars - a fifty-six percent cut in cost. 

There are several important lessons to learn from Dr. Brenner's research. Research comes from French rechercher, which means to look again or to look back. First lesson: you do not need government review and approval and you certainly do not need 87 different steps to do useful, valid "looking again" that helps patients.

Lesson #2: Generally accepted wisdom is generally wrong. For instance, good research must follow government all rules and regulations, right? Except that Brenner didn't and he obtained useful, valid results.

Except when five intensive care units banded together to create the Michigan infection checklist that saved hundreds of millions of dollars and 1800 lives.  They did this without government approval, so what did the government do? NIH said they couldn't use it. After all, the government is expert at the practice of defensive bureaucracy.

Lesson #3: The Camden Coalition showed us the right way to reduce healthcare expenditures. The government's approach is to cut reimbursements and increase oversight. Brenner and his team 'spent money' and got around-went around-sometimes ignored the rules and regulations in order to get whatever patients needed medically so they could recover their health or at least reduce their illness.

Lesson #3 is divided into two parts. (A) The best way to save money is to spend money...on making people healthy. Spending to make people healthier is cheaper than treating their illnesses. (B) Government oversight (and over-regulation) - indeed the entire bureaucracy of healthcare - wastes lots of money, offers no net value, and fails to protect patients.

The "lots of money" is roughly one trillion dollars, yes with a "t". That is the amount of money that went in to healthcare (the system) but did not come out as any form of heath care (the service).

Lesson #4 starts as a corollary of #3. House calls are cheaper than hospital beds. That is literally true. Ten thousand house calls at $50 each equals $500,000. Hospitals beds cost well over $1 million each. Heck, the 36 patients alone were costing over $1 million per month.

As Dr. Brenner showed, house calls are both cheaper and improve the health of people. So lesson #4 is: Being healthy is cheaper than being sick, whatever the cost to stay healthy or to restore health.

Everyone knows lesson #4 is true...except our healthcare system and the massive bureaucracy that supports it, actually feeds off of it. The incentives are perverse: the system encourages exactly what we do not want. The system pays for "performance" but not for positive outcomes. We reward people (insurance companies) for not giving care. The way the system "saves" actually costs more money and our lives.

The final and most important lesson is how the Camden Coalition did what they did. They saved money and at the same time made people healthier by practicing good medicine on sick people. If we want to save money and simultaneously improve our system, we should practice good medicine on sick healthcare.

Deane Waldman MD MBA, is the author of Uproot U.S. Healthcare.