This time this is a video about Camden, a suburb were cost of health care is very high and where an initiative is taken place to lower down this cost.

Aquest vídeo parla sobre Camden, un barri marginal on s'intenta reduir el cost del serveis sanitaris.

http://www.pbs.org/wgbh/pages/frontline/doctor-hotspot/

Camden, New Jersey, sits in the shadow of Philadelphia

It’s a city that seems in a constant state of peril. Poverty here is rife; unemployment is double  the national average, public institutions are in crisis, or, like the local library, simply shuttered.

It’s officially one of the America’s most dangerous cities.

But Camden may also be the city to help solve one of the America’s most intractable problems: lowering the cost of health care.

As a Doctor and writer for the New Yorker, I came here to meet the local physician, who began to figure it out.

It all started ten years ago, with a shooting.

I was working in my house one evening, heard gun shots, then got a call from a neighbour, so I went running down the street. The police had got there already, so I ran up and said, you know I am a physician, where is the victim? And they all sort of turned around and said it’s over there.

[Where is the location]

He was lying on his side facing the backtyre, and he had a pulse, he wasn’t breathing, I started rescue breathing, eventually his pulse stops. So, I was just pretty overwhelmed by the whole thing and angry and …”

You were angry that they hadn’t been even tending to the victim.

You know, why didn’t you guys help him?

And the police officer said, ’We didn’t want to dislodge the bullet.’ I mean it was just a complete blow off.

And I couldn’t imagine how we could have reached the point in our society in this city where you would just leave a victim lying there on their own blood.

He was a Rutgers’s student and he was close to graduating. You know he was one of the wonder kids that make it out of urban communities and here he was just about to make it out.

Brenner's immediate response was to get involved in police reform; he thought if he could get a hold of crime statistics, he could map hot spots he places where good policing would make a difference. But the department wasn’t interested in helping a local doctor, so he went to another place one he knew well, the Hospital.

There, buried in billing records from the ER where violent assaults get treated, he found crime patterns as he crunched the hospital data, Brenner discovered something totally unexpected: other kinds of hot spots.

It became clear that there were hot spots of everything; they were hot spots by disease, hot spots by patient. There were certain patients who had been over and over and over going to the emergency room and hospital too much. There were hot spots by the zip code and by neighbourhood and, so you sit and begin to look through the data and I am looking at my patients, who are in the data and realizing I had no idea how much health care cost. I had no idea how expensive it was. I was just shocking.

Brenner says that the numbers show that 1% of people living in Camden accounted for 30% of hospital charges. Most of those racked up in the emergency room.

-Compiling all of this information coming from all of the hospitals in the local area.

-Compiling massive amounts of data so…..

Brenner then turned that raw information into visual information:

-So this is a map of the city of Camden and this is looking at cost data, so the red areas are high cost hot spots, these are parts of the community were  people who have more than a million dollars in payments to the hospitals live and this is over a five year period .

-So here you pulled out the two most expensive city blocks.

-Yeah

-That you found in your community there are two buildings that are the most expensive places.

-That’s exactly right. The building on the bottom, Abigail house is a nursing home and the top Northgate is an apartment tower with elderly and disabled people.

-83 million dollars in bills, that is prime more than the cost of the building,

-yes, yeah…

-This being America where we all demand the best that medicine can offer. They might assume that at least for the money, the residents were getting good care.

But Brenner found the majority of the care for chronic diseases from asthma to cancer to diabetes was being done in the ER. Not a good place to treat chronically ill patients.

Treatment was not coordinated; follow-ups were not part of the plan.

It was really obvious in the data that the most expensive people were getting terrible care and I knew them so I’d walk in the exam room and say Mrs. Rodriguez, I haven’t seen you in three months, where have you been?

Well, I have been in the ICU for a month and a half; I have been in the hospital for another couple of weeks. And said what happened? Well, she’d say I’m not really sure, lot of doctors came in the room, they never really explained anything to me but I’ve got this whole bag of medicines so…

American health care does not do a good job taking care of sick people.

The way we built our system is really a system that is very hard to access. I works well for the average patient but if you are blind, if you are deaf, if you are disabled if you are in a wheelchair, if you don’t speak the language, if you development late, if you have a complex mix of illnesses with many providers involved, the whole system starts to break down.

Brenner’s big insight was to use his data to target the sickest and most expensive patients in the city. In 2007 supported by small grants from foundations he put together his team of medical hot spotters.

The most visible part of the Camden coalition of healthcare providers are these nurses, social workers and medical assistants.

Three years later his team of trouble shooters has sorted out an organized care for more than three hundred of people.

When I visited, Cathy Jackson was making a house call to one of her most challenging patients: Derek.

-Do give me the briefing on Derek because I haven’t met him.

-Derek is in his thirties and has seizure disorder and there’s other problems which gets him in the hospital most of the time, there’s asthma It’s always an issue, he is always wheezing and the house isn’t … it’s dirty, it is dusty, allergies, all kinds of triggers. So we took a contractor there and the contractor said that he really wouldn’t want to be liable to fix it up because he’s afraid it would actually like crumble.

-Hi Derek how are you doing!
- All right!

-Yeah-

-I am Atul Gawande; I’m a Doctor from Boston but also a writer. So Derek you had a number of hospitals stays and emergency room visits because of asthma I hear. What happens when you have an asthma attack? I start wheezing , my lungs are actually you know it is like a  rubber band  it closes up like really tight and it is really hard for me to breathe . We think that the house is probably part of it, with the dust and the open walls.

-Would you mind Derek if I have Cathy to show me around the places in the house that she thinks might be contributing to your asthma.

-Yes sure.

-Ok. It would be great if I would like to see for myself.

Before Cathy started working with him, Derek was in the emergency room thirty-five times over six months.

-That cannot help your asthma.

Cathy’s work with Derek includes everything from inhalers to insurance to finding a contractor willing to rehab the house.

-Are you ok Derek?

-Why don’t we just say: Derek, fix your house, you have got this and that falling apart.

-His family probably lives on about a thousand dollars a month, so they are not really capable, they barely able to make against me.

-Without the team, Derek didn’t have any help with another medical problem: epileptic seizures.

-What are all the crosses?

-This helps me you know in case I have epilepsy.

-How does this help you?

-Just I start praying, that is all.

- Oh yeah!

- That’s all!

-Have you had any seizures recently?

-No

- How long has it been? A week, a month.

-A week. I feel more comfortable with Cathy Jackson than the Doctors and nurses in the hospital. You know, I can tell Cathy, my problems, you know, wheezing and stuff like that. She checks me out, you know hear my lungs, you know, talk to me…

-Always you here some wheezers but you  are moving a pretty good air, so that’s good.

-She is the one that keeps me out the hospital.

- You are going to come back in one month. June 13^th at eleven o’clock.

Under Cathy’s care, over the last six months, Derek ER’s visits have been reduced from thirty five to just two and Brenda thinks that they can do even better if he can get other people from around the city to think as a hot spotters.

We inform that this is the beginning to see how agency by agency how we can pull it together for the most challenging cases.

Every month the whole city comes together from line providers, social workers  and we anonimus case discussions at the city level. When someone like Derek shows up at one of the emergency rooms they call us right away.

-…………….None in April and only one since May.

-So how much has your team been able to lower the cost for this really expensive group of patients.

- So we have seen some preliminary results a 40 %  to 50% reductions in visits  and costs.

- 40% to 50% reduction in costs.

-In costs and visits.

The savings are hard one and it takes persistence.

-Mr….. it’s  Kally in here from the coalition.

You can’t completely alter people live’s circumstances.

We are not going to cure poverty.

The question is how can you take the present current situation at a patients end and improve enough  to make people a little bit healthier and lower their stay at hospital and have a more productive interaction with the Health Care system.

This idea of focusing on the ……to lower cost seems to be working here in Camden but there are hot spots in every community.

What if we put this idea and put it in play across the country. It might just work but there is a cash.

How would the medical stumbles reaction , suddenly the more expensive and lucrative patients started to cost half on what they do now.

As this kind of experiment works though you are talking about dropping the number of hospital visits as a whole. 

You are talking about removing people from the Emergency rooms.  They could have to shutdown floors and beths. They are not going to be with you on that aren’t they?

This kind a work as a game changer and this is a blockbuster video moment for America's Hospital.

What do you mean by a blockbuster video moment?  Along comes Neflex and they had the moment when a young come in and said starting to rent blockbusters videos on line and they said, no,

People are coming to the video store, we are not going to make any change.

Disruptive change cames along and I think better care for sick people is disrupted change.

We haven’t inflated a capacity bubble in our country to do expensive hi-tech Hospital basic care.

So what’s is your ultimate goal here?

I would like to make Camden the first city that bends the cost dramatically while improving quality.

Because if a poor city in the country can do it, it makes the rest of the country look silly.