July | August 2017






Doctor Says, ‘We Need to Rationalize Care’

By Jennifer Ginn, CSG Associate Editor
Dr. Jeffrey Brenner—executive director of the Camden Coalition of Healthcare Providers, a 2013 MacArthur Fellow and family physician—thinks we don’t need to ration health care.
“We need to rationalize care,” Brenner said at a recent CSG eCademy session, “Delivering Better Health Care for Less.” The webcast was broadcast live as part of CSG’s 2015 Medicaid Policy Academy in Washington, D.C.
“We have an obsolete way of delivering services,” Brenner said. “The basic infrastructure that was laid down by Medicaid is 50 years old and not enough of that has changed. The basic architecture of health care and how health care is paid for is very old.
“Your service delivery models are old, the way they’re administered by state governments are old, the contracts are old. All of that is going to have to shift. The work of your generation as state leaders is going to be (a) tremendous transformation of the system. It’s going to hurt; it’s going to be painful.”
Brenner said every Medicaid system has what he calls high utilizers, those who use the system—and other state services—the most often. Their care is often uncoordinated, inefficient and confusing. But the problem is not just limited to Medicaid, he said, it’s a problem with the health care system in general. He pointed to a CT scan of a middle-class woman with a master’s degree.
“This patient had 102 emergency room visits, 54 admissions, 147 CT scans and 73 CT scans of the head,” Brenner said. “This could be you; this could be your family member.
“This patient was found by a group of family medicine residents who were frustrated and they got a list of every patient who had admissions and rank-ordered them. (They) went and met with the most extreme patients and found her. She ended up having extreme anxiety, which was why she was going to the emergency room. They got her into therapy and she’s doing fine, so, a much better use of our money.”
Brenner is a family doctor in Camden, N.J., what he calls one of the poorest cities in the country. It is a city of nine square miles and 79,000 residents, most of whom are on Medicaid.
“It’s so small that it’s a really good incubator and laboratory to begin to change how we deliver health care,” Brenner said.
That incubator led to the 13-year-old Camden Coalition of Healthcare Providers, a nonprofit group that works with all of the services the highest-utilizers may come in contact with—including local hospitals, nursing homes, family doctors, behavioral health specialists and addiction services.
The coalition gets real-time data about hospital admissions and a staff member goes to the bedside of the highest utilizers. That person helps the patient create a treatment plan, goes with them to primary care provider visits and even coaches the patient and the doctor on how to talk to each other. Monthly meetings with all of the coalition’s partners to examine cases where things did not go smoothly pretty quickly points out “where all the cracks are,” Brenner said.
“Has anyone from Medicaid ever gone out and met your 10-highest utilizers?” he asked. “I guarantee, 8 of the 10 are complete fiascos; it’s like the roof has fallen down. Those stories are really powerful. Bring the patient, have the patient come and testify. … Some of the people are very eloquent spokespeople for what’s going on.”
Brenner said people may not need more medical care or more doctors. They just may need help navigating the system.
“We don’t need more licensed people to do the work,” he said. “We need lots and lots and lots of navigators, coaches, community health workers. They’re called different things. But they need to be supported, backed up. They need to be trained like qualified social workers and nurses.”
Although it is a long and painful process to get all of the health care and social service providers on one page, it is an important step for reforming the health care system, Brenner said.
“We don’t need to ration care,” he said, “we just need to get organized. This is not rocket science. This is extremely disorganized care where people get lost in the system.”
It’s time for change, Brenner said.
“Every generation gets a moment to rethink and reinvent and reshape services,” he said, “and now your generation’s leaders are going to be called upon to do that. When we’re done, these services are going to look completely different. … This is not incremental change. This is a tremendous shift that will have to occur.”
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