Increasing health care value through guerrilla medicine

"An important idea is getting its test run in America: the creation of intensive outpatient care to target hot spots and thereby reduce over-all health care costs."

Atul Gawande devotes 10 pages in the Jan. 24 edition of the New Yorker to discussing that idea. In cutting detail, the Boston surgeon illustrates the challenges many of the costliest patients face. In turn, he describes the difficulties health care providers confront when dealing with those patients. To date, the system has failed, resulting in fragmented but extremely costly care that leaves patients no healthier.

Gawande tells us about a patient in Camden, NJ who had 324 admissions in five years and another who cost insurers $3.5 million. But as Gawande points out, these patients live in communities across the country.

Five years ago as a California Health Journalism fellow, I wrote an article about a man in a suburban California town who racked up $1 million in hospital charges over three years. In the same series, I profiled a homeless woman, who after having a cancerous lung removed, cycled between the streets and hospital.

In these articles, I focused on the lack of supportive housing and transitional care that could help homeless patients stay out of the hospital and save taxpayers money. Gawande focuses on how the health care system could reorient itself to provide intensive outpatient services to the costliest patients, and in turn, save money. The idea is old news to the homeless services community. In fact, they have a name for what is required to get and keep these patients on track: "guerrilla social work."

"It means you're going out and getting your hands dirty. It's case management that doesn't have the smooth edges and refinement. It's doing anything that's needed to get that person what they need," a 73-year-old gorilla of a social worker told me.

Essentially, guerrilla medicine is what Gawande's protagonist Dr. Jeffrey Brenner and his team of nurses and health coaches are practicing, and so far, the results (albeit with sampling bias and only 36 patients) are promising - a 40% reduction in emergency room visits and a 50% reduction in overall costs.

While reading Gawande's article, I couldn't help but analyze it through the value-based health care framework developed by Harvard Business School Professor Michael Porter's. (Full disclosure Porter is a co-founder of the Global Health Delivery Project at Harvard, where I work.) Value, here, is defined as patient outcomes per dollar spent. Porter describes his framework with Elizabeth Teisberg in the book Redefining Health Care. In December in a New England Journal of Medicine articled called "What is Value in Health Care?," Porter wrote:

Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge.

In a NEJM response, Thomas Lee, who is the network president for Partners Healthcare System (Gawande's employer), wrote:

In this fractious context, value is emerging as a concept - perhaps the only concept - that all stakeholders in health care embrace. Providers, patients, payers, and policymakers all support the goal of improving outcomes and doing so as efficiently as possible. Making progress in the value framework requires real teamwork, which sometimes seems an unnatural act in health care. It means capturing data in different parts of the delivery system, which means that we all have to use the exact same terminology. And it means sharing accountability for performance.

Improving health care for even the most difficult patients likely could enable greater value generation in other areas of the system. Guerrilla efforts, however, take teamwork or at least incentives aligned around the patient's needs.

(Reposted from GlobalHealthHub.org)