NYAPRS Note: Included in this timely piece is an illuminating look at what community health workers, who function like peer wellness coaches and could be peers, do each day to help people with multiple conditions improve their own health and reduce their use of costly ER and inpatient services.
One Simple Idea Could Revolutionize Health Care in Philly
The question is: Will hospitals get on board?
By Samantha Melamed CityPaper July 25, 2013
Here’s the problem with health-care revolutions: They don’t always look like much.
There was, for example, no ribbon-cutting outside the cramped rowhouse in Kensington’s Norris Square section, the base camp from which Dr. Barbara Schneider and her team are quietly changing the lives of some of Philadelphia’s poorest and sickest residents. There were no press releases, no touting of technology innovations and no awarding of prestigious grants.
There are, however, results.
For the past year, Schneider’s practice, Care Coordination Services LLC, has been working with chronically ill (and extraordinarily expensive-to-care-for) diabetic patients - patients who’d been hospitalized as often as once a month. One man had been admitted 32 times in 18 months. In the first six months of that work, the number of emergency-room visits went down 33 percent. Inpatient admissions declined by half. The guy admitted for 32 inpatient stays, totaling more than 200 days? He has been hospitalized only once in the past year.
Those are impressive statistics - medical-breakthrough-type statistics - with dramatic impacts on both cost savings and the patients’ quality of life.
But what’s generating those impacts is so straightforward it sounds almost obvious. The CCS team finds out what issues are affecting the clients - all the issues, not just the medical ones - and then meets the patients where they are, both literally and figuratively, to proactively address those issues and keep patients connected to care.
The team - which includes a doctor, a nurse, community-health workers, a behavioral-health specialist and a pharmacist - have met patients in parks and at McDonald’s. Clinical manager Catherine Birdsall, the nurse on staff, recently took a patient’s blood pressure and discussed insulin levels in a grocery-store parking lot. They’ve visited addiction-recovery houses and boarding houses. They’ve done home visits for patients under house arrest.
They encourage patients to make positive changes, but they don’t judge.
For example, says Caroline Melhado, who recently left her job at CCS to go to medical school, “We have one client who smokes a ton of crack. He might never stop smoking crack, but he’s also a diabetic. So, we go around the crack part. If you’re going to smoke crack, your blood sugars are going to get high. We changed his insulin regimen so he can smoke and not have his blood sugar go up to 600. And if that helps him avoid some diabetes complications in the future, that’s great.” Schneider explains: “If we wait for these guys to go to rehab and come out clean, we’d be here forever. So we work around it.”
This approach - identifying the highest-need, chronically ill patients, the ones who don’t or can’t seek out help, and bringing the help to them - is the cornerstone of a movement that some see as the key to fixing a broken and unsustainable American health-care system that’s costing more and more but helping needy people less.
Over the past decade or so, a model for this type of community-based health care has emerged. It’s been refined by thought leaders like Dr. Jeffrey Brenner, a data-crunching, big-dreaming primary-care doctor who is trying to make Camden the first city in the nation to reduce its health-care costs, known as “bending the cost curve.” And it’s been proven by innovators like Dr. Ken Coburn, whose nonprofit Health Quality Partners has been sending nurses out to chronically ill elderly patients in Doylestown - on a regular basis, whether they’re feeling sick or not - and reduced the number of deaths by 25 percent.
Taken together, these measures offer an elegant solution to an extraordinarily complex problem. But there’s one colossal hitch that no one has quite resolved: Paying for it.
“There’s no long-term sustainable business model for what any of us are doing,” Brenner says. After years of lobbying, Brenner recently got New Jersey to pass a law allowing his organization to share in the savings it generates for hospitals and insurers, but that funding stream is a ways off. Coburn’s work is funded by Medicare as an experimental demonstration project; despite its success, the program has been nearly shut down three times, most recently on July 1, then saved with last-minute, temporary extensions.
Schneider’s operation, then, is something unique: It’s a for-profit business. And the patients’ insurance company - the same organization that’s realizing the savings - is footing the bill.
Up until last year, Schneider was a primary-care doctor in a private practice that consisted almost entirely of house calls.
“When you do home care and see how people live, you get a real good idea, real fast, of what’s going on in their lives,” she says. “They come [into the office] all dressed up and nice, and you don’t realize it’s a choice of eating dinner or getting their meds until you see how people really live.”
Still, she wanted to do something more. She had shopped around the idea behind CCS six years ago, she says. No one was interested.
Then the world found out what was happening in Camden.
A slew of reporters, most prominently Atul Gawande, the medical correspondent for the New Yorker and PBS’ Frontline, began making pilgrimages to America’s poorest city, to tell the story of how, over a decade ago, Bren-ner had been involved in efforts to reform the Camden police department, and then begun applying Comp-Stat principles to health.
Using data prised from the grip of area hospitals, Brenner began mapping “hot spots,” the locations of the worst-off patients, termed “super-utilizers” of the costly emergency-room-centered system. What he found were astounding symptoms of systemic dysfunction: Two city blocks, one containing a senior housing tower and the other a nursing home, generated $175 million in medical bills in less than six years. The top diagnosis in Camden emergency rooms was head colds. And 1 per-cent of patients were accounting for 30 percent of health-care costs.
Brenner and the organization he founded, the Camden Coalition of Healthcare Providers, responded by developing care-management teams, each consisting of nurses, a community-health worker and health coaches, to intervene and work with patients on an intensive basis to plug them back into the health-care system. The Coalition created a citywide health-information exchange, to coordinate care and locate patients in need of intervention. And they launched a citywide diabetes collaborative to target chronically ill patients.
Brenner’s work has been a game-changer, and not just in Camden. His sudden celebrity changed things for Schneider as well: “The thing that I tried to do six years ago - and they tried to have me committed when I asked if I could do it - now is a big deal.”
Last year, she connected with Keystone First, a Medicaid managed-care plan that had been exploring the same idea. That connection solved two of the biggest hurdles facing initiatives like Brenner’s: First, paying for intensive care-coordination intervention and, just as important, identifying the patients who needed the help.
“Most organizations only have a snapshot of when a person interacts with their system. But the insurance company, because everybody wants to get paid, sees the whole story,” says Grace Lefever, who oversees the program for Keystone First.
Though Keystone First, part of the AmeriHealth Caritas Family of Companies, already has community-outreach and phone-based care-coordination programs, AmeriHealth Caritas regional utilization-management medical director Dr. Glenn Hamilton says there were certain chronically ill patients that even those teams couldn’t reach.
Keystone gave CCS about 35 of their toughest (and costliest) cases - mostly diabetics who, due to mental-health issues, addiction or the everyday chaos of living in poverty, have seen their disease spin out of control. Diabetes has been a prime target for this type of work, Schneider says, because it’s a chronic disease with “multiple comorbidities: issues with their heart, cholesterol, nervous system - just about every disease and organ you can name is involved.”
Many of the cases assigned to CCS are Type 1, or childhood-onset diabetics. “We get them in their 20s, and they have end-stage disease by that time,” Schneider says. “This [disease] needs to be managed so meticulously. With people living this kind of chaotic life, that doesn’t happen. So we have people in their 20s with end-stage renal disease, who are going blind, who are losing limbs. The best we can do is stabilize them where they are, and try to keep them at whatever level we got them at.” A few patients, indeed, have died before CCS could stabilize them. Many others, they couldn’t even locate.
Because diabetes care is a lifelong challenge, so far CCS has - unlike many other programs - declined to put time limits on its interventions. Instead, they try to wean patients from daily visits down to weekly or biweekly ones, with lots of phone calls and texts in between. “A lot of these people will probably always need support,” Schneider says. “We try to get them into a place where we’re giving them support - and they’re doing the best they can as well.”
In this business, even the greatest success stories are riddled with setbacks. Birdsall points to the man who was hospitalized 32 times; he now sees his primary care doctor once a month, checks his blood sugar and keeps up with his insulin regime. But, “He’ll also sometimes go and buy five pounds of sugar from the grocery store and add it to his water, which he’s supposed to be drinking,” she says. She and a community-health worker recently held an in-service training in diabetes care at the boarding house where the man lives. The caretakers there “were feeling frustrated and burned out, but after the in-service they were revived, excited, talking about all these different ideas” to improve his care.
Talk to enough people who are trying to change the face of health care, and certain words come up over and over again. One of them is “barriers.”
One of those people is Penn Medicine’s Dr. Shreya Kangovi, who in February launched (without fanfare) the Penn Center for Community Health Workers. In a study published in the July issue of the journal Health Affairs, Kangovi examined how people of low socioeconomic status experience the health-care system. What she found was, they prefer the hospital - the expensive, ineffective, stressful hospital - to low-cost, highly effective preventative primary care. The reason? “Our preventive-care system is riddled with barriers that are driving people away from very low-cost primary care and into the open arms of hospitals.” Kangovi is talking about the barriers familiar to almost all of us as patients: difficulty in getting appointments, pricey co-pays, challenges in arranging child-care or transportation. For poor people, those barriers can prove insurmountable. It’s easier to wait until catastrophe hits and then go to the ER.
Spend a day with Amarili Lopez, one of CCS’s two community-health workers, and you begin to understand the sheer, towering height of those barriers. Lopez, a turbo-powered Puerto Rican woman in scrubs, crisscrosses the city all day long, texting and calling her patients, noting their blood sugar, shuttling them to doctor’s appointments, haggling with pharmacists and specialists - and dismantling barriers.
On this particular day, Lopez’ first stop is a North Philly addiction-recovery house, home to Jacqueline Turner, a Type 2 diabetic. Lopez is here to give Turner a poster she made herself, a laminated reminder that “there will always be someone who cares for you,” and to “take your Lantus before going to sleep.” But while she’s checking Turner’s blood pressure and reviewing her daily blood-sugar records, Lopez finds out that Turner had been to the emergency room just the day before - for a headache. Like every Keystone First client, Turner has a primary-care doctor; now, she also has support from CCS. But she’s used to the emergency room. That’s behavior Lopez is gently trying to change: “Next time you feel like going to the hospital,” she tells Turner, “call me. Because we could bring a doctor to you or troubleshoot with you on the phone.”
Next, it’s on to pick up Carmen Martinez and drive her to an appointment at Temple University Hospital. But when they arrive, they learn there was a miscommunication regarding what procedure, exactly, Martinez has scheduled. It turns out she fasted all morning unnecessarily. Lopez walks her to a different part of the hospital for a different type of scan.
“You tell a patient she needs to be fasting when that wasn’t necessary,” says Lopez, “and, instead of helping, you create even more confusion in the patient’s life. If I wasn’t here, she would’ve gone home without doing the test.”
Issues like that crop up incessantly. Consider Lopez’s third client of the day, an older man named Dennis who lives alone in a rowhouse where trash, papers and half-empty juice jugs are piled high in the living room and on the kitchen table. Lopez visited Dennis just yesterday, but she has to double back. The problem: The insurance company replaced his glucose meter with a different model made by a different company. He’s forgotten how to use it already. To Lopez, decisions like that signify a breakdown in understanding between insurers and the reality in the field. Whoever decided on the new meter, she says, was “looking into cutting costs, that’s about it, without looking at the effects. Maybe you’re cutting costs, but if people don’t end up checking sugars because they don’t understand the new meters, they might end up going to the hospital with ketoacidosis. And how costly is that?”
The thing is, the challenges CCS patients face - the problems all low-income, high-needs patients face - are hard to predict and manage if you’re not there, on the ground, listening. As Lefever puts it, “the number of loose ends to track down is just astounding. A regular doctor’s office, with the workflow that they have, is not equipped to deal with this.” She mentions a client who was referred to CCS by her primary-care doctor, who was afraid she’d overdose. The woman, who has behavioral-health issues, had been prescribed 14 different medications, but didn’t understand what they were or how to take them. Her response was to pick a pill - a random pill - and take it, once every two hours. CCS staff finally had the pills packaged at the pharmacy into morning and evening blister packs, so the patient would know what to take and when.
Despite the frustrations, Lopez is fundamentally optimistic: She points to her star clients, like Sarah Parker, a Type 2 diabetic who greets Lopez with a hug. Parker had a wake-up call last year when her grandson found her sprawled on the floor of her bedroom in a diabetic coma. In the end, “it was a big blessing,” Parker says. “That’s when Keystone started coming out.”
Before, Parker was doing nothing to stabilize her disease. Now, she says, “I’m more in control.” Life isn’t perfect: She has early-stage gastroparesis - a partial paralysis of the stomach that results in nausea and lack of appetite — so she has to force herself to eat a couple bananas, a half-slice of bread. Her home in Juniata is dim and cluttered, the carpet peeling up and the TV blaring. It’s after noon, and Parker’s in a nightgown. But she’s doing her best, she says. “I take my insulin and check my sugars.” Lopez’s support motivates her.
After all, this kind of work is only partly about troubleshooting. As Lefever puts it, “The secret sauce is relationships.”
Lopez gives out her personal cell-phone number, and constantly calls and texts clients. “It’s more about you giving them the sense that you’re here for them. At times, you don’t have to text them, they’ll text you.” That’s when she knows they’re engaged.
She often spends her own money to bring them healthy treats, like bananas or Greek yogurt. She says that introducing clients to new things - not simply lecturing them to eat better - is how to cultivate healthy habits.
When patients like Martinez see results, she says, their whole outlook changes. “Her A1c [blood-sugar levels] dropped, and her self-esteem went through the roof.” Later, Martinez mentions that she has been cooking with olive oil and using light salad dressing, even though it means she has to make separate meals for herself and her family. Lopez and Martinez are talking about taking a Zumba class together. “Now,” Martinez says, “I get out and do things I never felt like doing before.”
Despite its early success, CCS is only a pilot program. It has worked with just about 50 patients.
Why so few? For one thing, health care is a conservative industry, one that rarely makes a move without hard data.
Brenner says dealing with these extremely-high-cost patients is “like Moneyball. You don’t need to hit a home run every time; you just need to find the people that are ready to change.” But health systems and insurance companies tend to prefer indisputable studies in the form of randomized-controlled trials, the gold standard for scientific research.
Keystone First - which, against that backdrop, took a veritable flyer on CCS - is now analyzing the early data from the pilot. Hamilton, the regional medical director, is cautiously optimistic about expanding the program to patients with other chronic conditions, like coronary artery disease and asthma. “It is pretty exciting, the kinds of results that we’re seeing,” he says. “It’s a pretty high-intensity program in terms of the resources and the manpower, but it’s been very beneficial for the folks that have used it. Our task going forward is to figure out: Is it going to be 1 percent of the population that could benefit from this? Or 2 percent?”
Keystone First may be willing to do that number-crunching on its own, but Penn’s Kangovi says that for care providers across the country to adopt these innovations on a large scale, rigorous scientific proof of efficacy is required.
Kangovi is one of the doctors trying to develop that data - and, more to the point, to hone a “plug-and-play” model for deploying community-health workers within health systems. Her program studies the outcomes of using community-health workers in two different settings: as a short-term intervention for patients being discharged from hospitals and as longer-term helpers for primary-care patients with multiple chronic conditions.
Kangovi says Penn itself is looking to perfect and test this model, then expand it. After all, community-health workers are cost-effective, commanding about a fifth the salary of a nurse practitioner. So if a community-health worker, in just a few weeks, can reduce hospital readmission rates, the savings could be enormous.
But more than that, the workers could transform patients’ experience of the health-care system. “For a lot of patients, the experience of coming in to their doctor is unpleasant, because we sit across from them and judge them. Patients feel like they’re being set up to fail,” Kangovi says. “Community-health workers take the opposite approach, which is [asking], ‘What can we accomplish?’ and celebrating those triumphs.”
But the reality is, even when a clinical trial of a community-based intervention yields spectacular results, it may not be rewarded.
Consider Coburn’s Health Quality Partners - which, remember, reduced mortality by 25 percent among its elderly, chronically ill patients, simply by sending nurses into their homes on an ongoing basis. The program - the only one of 15 Medicare Coordinated-Care Demonstrations still going - has been “through several near-death cycles,” says Coburn. Rather than expanding the program, Medicare had threatened to stop funding it as of this past June, then gave it a last-minute extension to keep running through 2014.
Private insurers, among others, are taking an interest: For the past four years, Aetna has contracted with HQP to run the program for its own patients in the region. But for Medicare, which Coburn says has understandable worries about committing funds to a nursing program that could apply to millions of elderly people for the rest of their lives, “they want a super-high level of confidence that this thing could be implemented beyond Health Quality Partners, in a way that they feel confident they could get the return on investment and the savings that we’ve seen.”
Those savings, by the way, are very real. Among the highest-risk patients HQP enrolled, hospitalizations were reduced by a third. The cost to Medicare declined 20 percent.
In a nation where health-care costs are spiraling out of control - accounting for the bulk of the reason that middle-class workers haven’t seen a raise in more than 20 years - that type of cost savings could have a huge impact. Says Brenner, “That would be enough to shut down a couple of hospitals in Philadelphia. They wouldn’t be able to cover their costs to make their bond debt payments.”
Talk of “shutting down a couple of hospitals in Philadelphia” is probably not going to win Brenner any popularity contests in the medical community. In fact, this whole movement represents what you might call a health-care counterculture, grounded in the goal of disrupting a system that’s made a lot of people a lot of money.
As Kangovi explains, “When you look at the city of Philadelphia, the thing that pays hospitals is acute care. No one rewards health systems yet - although that is changing - for keeping people healthy.”
A few decades ago, it was different, Coburn points out. Philadelphia hospitals including Penn Health System had signed onto population-based risk contracts, which incentivized reducing complications and keeping patients healthy. But under financial strain in the 1990s, they bailed out of those contracts, and moved back toward a fee-for-service model, which is where we are today.
The results of that model are visible in construction sites across University City and Center City.
“The problem in Philadelphia and the problem in the country is that every crane that you see popping over Penn, building a new hospital building, is like an invisible tax on every city resident, because it’s going to show up in the costs of employee benefits, in the Medicaid costs to the state, in Medicare costs at the federal level,” Brenner says. “We all bear those costs, one way or another.”
Penn, for example, currently has two new buildings underway at Penn Presbyterian Medical Center - an Advanced Care Pavilion and a Center for Specialty Care, which together will add capacity for surgeries, acute care, radiology and exam rooms. Pennsylvania Hospital is adding yet another acute-care facility, Penn Medicine at Washington Square, in a $22 million package. And on the day this article is published, Lankenau Medical Center will celebrate the opening in Wynnewood of its new $465 million Heart Pavilion and campus expansion, touted as “the largest Main Line Health financial commitment in history.”
Brenner isn’t celebrating. He argues, “Does every hospital in Philadelphia need its own gamma knife for irradiating rare tumors? Does every hospital need a Level 1 [neonatal intensive-care unit]? Does every hospital need to be doing open-heart surgery? Do we need more billboards? We keep building more and more and more capacity, without ever asking the question: Do we need this?”
In other industries, a lousy value proposition doesn’t get rewarded. But in medicine, perhaps because of the powerful position of care providers to dictate the terms of care, it can. That, says Brenner, is why hospitals are investing in more of the stuff we overpay for - the surgical suites and expensive scanners - and doing less of the stuff that’s undervalued, the spending of time with patients that is the heart of primary care. This principle, that the number of hospital beds tends to dictate the number of patients, is known as Roemer’s law. Because of this effect, 35 states around the country have instituted laws requiring hospitals to demonstrate a need for additional capacity; 28 states have laws specifically around adding new acute-care beds. Pennsylvania has no such laws in place.
The good news is those incentives are slowly beginning to change. The Affordable Care Act advances what’s called the “triple aim” - reducing costs, improving the experience of care and improving health - and emphasizes preventive care. It provides for penalties for readmission to hospitals within 30 days or for mortality within 30 days of inpatient treatment. Coburn says that when HQP began reducing hospitalizations 10 years ago, “among some of our hospital partners there was a stepping back. Some of them actually withdrew support they were giving our organization. Now that these incentives have shifted, some of the hospitals that were fence-sitting or skeptical are starting to move in this direction.”
Likewise, Philly hospitals have recently - finally - signed onto a long-awaited health-information exchange, the HealthShare Exchange of Southeastern Pennsylvania. The exchange, which will go live as a pilot this year, could eventually resolve one of the critical problems with hospital care: that it’s fragmented and inefficient. HealthShare Exchange’s interim executive director, Martin Lupinetti, says it could help E.R. doctors avoid repeating costly and unnecessary tests, and ensure that primary-care physicians get discharge reports. But, he warns, “This needs to be looked at as an evolution.” How readily health systems and insurers will part with larger chunks of their business intelligence remains to be seen.
Hospitals may be interested in moving from an illness-centered model to a preventive model, says Kangovi. But they need a push: “In order for that to completely tip over, there need to be more financial incentives.” And even if they do start moving in that direction, without Medicaid expansion in Pennsylvania, hundreds of thousands of patients will be unable to take advantage. Those patients will continue to rely on the emergency room for charity care.
The ACA may be ushering in a transformation in health care. But it comes, Kangovi says, with a warning: “As we reimagine health care for the future, we need to let the patients be our guide. Unless we integrate that perspective, we might be designing another broken system.”