Seeing Spots

In the January 24th issue of The New Yorker, I wrote about health-care hot spotting. (Non-subscribers can now read the piece in full.) It’s a strategy, being tried in places like Camden, Atlantic City, and Boston, of focussing on the sickest five per cent of patients, who account for sixty per cent of health-care costs. Improving their care has created striking local successes: improved health, reduced hospitalizations, and lowered costs. But there have been critics, who fall into three camps: the defeatists, the catastrophists, and the triumphalists.

  1. The Defeatists. Megan McArdle, writing for the Atlantic online, makes the most eloquent case for despair. For her, reading about the hot-spotting programs was “ultimately pretty depressing.” They were “admirable local efforts that are unlikely to go anywhere.” She makes a historical argument. The annals of health care and education are filled with programs that promise to improve lives and save money, but costs still march inexorably upward. The local successes are too complex and require too much expertise and dedication to survive at a larger scale—to survive in the real world where ordinary people don’t want to change and aren’t going to be all that smart or dedicated. That’s especially a problem, she might have mentioned, if there isn’t money in it for them.

But that is, of course, the key. The greatest engine of social change the world has ever seen is money, and in each of the cases I described, the hot spotters are learning to harness their ideas, born of virtue and altruism, to the more mundane but lasting motives of economics.

This week, the New Jersey Senate Health Committee voted unanimously to advance a bill that would allow doctors like Jeff Brenner in Camden to form “Accountable Care Organizations”—organizations that get to keep a portion of every dollar they save Medicaid while maintaining or improving the quality of care. Key provisions in the new health reform law would allow Medicare to offer the same financial incentives. Elizabeth Gilbertson, the chief of the union health fund for casino workers, tells me it is now designing funding for new clinics to replicate its experimental Atlantic City clinic in Las Vegas and elsewhere. And other private insurers, including self-insured businesses, are offering the prospect of millions of dollars for companies like Verisk Health to scale these efforts. Some people can get rich making this stuff work. That’s long been a powerful motivator.

To be sure, the defeatists could be right. All such efforts could fail. But it is not a given. As I’ve recounted previously, American agriculture was transformed by a series of humble-sounding interventions. A century ago, the cost of food ate up forty per cent of family budgets. Farmers were too slow to adopt key cost-lowering farming practices like using animal power rather than human power, rotating crops rather than using up all the land, cultivating seed beds more aggressively, and mechanizing. Such strategies required hard work and new learning. It also required the kind of up-front investment that a country of tenant farmers and sharecroppers had no incentive to make. But the government set up farmer’s coöperative banks with low-interest loans for the farmers to become landowners, sent out extension agents to teach the better practices that were being discovered, and created the National Weather Service and crop reports to provide the information farmers needed.

And it worked. Crop production rose, and the abundance of affordable food in our grocery stores eventually became our best argument for the American way. We could yet tell a similar story in this century about the transformation of our health-care system.

  1. The Catastrophists. Jonah Goldberg, writing in the Los Angeles Times, worries that, by offering our most chronically sick citizens services from a team of nurses, social workers, and health coaches, we risk “medicalizing society.” He’s disturbed by the notion of doctors who push patients to change their self-destructive behaviors and offer strategies for doing so. If government insurance programs like Medicare and Medicaid pay doctors for such work, Goldberg argues, “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.”

For Goldberg, accepting a physician fee from Medicare makes you a government agent; by the same logic, we could describe surgeons like me as government agents going around cutting people open. And it would be creepy, if I were treating people against their will. But that’s not what surgeons do, and it’s not what hot spotters in primary care do, either. They are private-practice clinicians offering very sick people services that keep them less sick and out of the hospital. People can refuse, and some do. But most don’t—which is what may make this our best strategy for saving health-care costs.

  1. The Triumphalists. If the defeatists think that the hot spotters’ successes are too good to be true, the triumphalists think they’re too good not to be made universally available. As one doctor put it to me, “Why should rational care be the entitlement of [only] the very sick?”

Certainly, some of what the hot spotters provide is the kind of primary-care service that everyone should have. They offer e-mail access. They follow up when people miss appointments, skip their medications, keep smoking, or gain too much weight. But their work goes far beyond this. Arnold Milstein, a Stanford University professor who is one of the fathers of the hot-spotting concept and a key consultant for the Atlantic City program, calls it “ambulatory intensive care.” And just as the one-to-one nursing of a hospital I.C.U. only makes sense for the sickest, so goes for the extra staffing of an ambulatory I.C.U.—especially if it is also going to save costs.

The Defeatists strike me as having the most compelling argument. Solutions for great and complex societal problems are rare. There’s no guarantee that local successes can be replicated. But our best strategy is to look for ideas that work on a small scale and try to figure out how to make them work on a larger one. The right spirit is empirical: try things out, learn what you can, adjust, and try again. There are no foregone conclusions—except that we’ll fail if we don’t even try.