Modern Healthcare: What did you learn about the health of these patients and the care that they received?
Dr. Jeffrey Brenner: These are the patients that we largely ignore unless we're going to hospitalize them. They have lots of comorbidities. They're in and out of different hospitals, different ERs and different doctors' offices. They have behavioral health challenges, addiction, housing, a whole set of barriers to care. They can be in wheelchairs. They can be blind, deaf, disabled and have limited family structure. They have collections of barriers that begin to break down their ability to access the system. Ultimately, the question we need to ask is whether this is the patient's fault or a problem of the delivery system. This is a symptom of our success in keeping people alive and doing incredible things for them. But we've created an incredibly complex system that breaks down for these very challenging patients.
MH: What are the most effective strategies for improving their care and lowering their costs?
Brenner: You have to be both effective and efficient. By effective, I mean you have to build really good relationships with these patients. You've got to hire the healthiest, warmest, friendliest, most caring staff you could ever find and you've got to get them out in the field, and they've got to meet people, often right at the bedside in the hospital. They've got to do home visits.
They've got to accompany patients to their primary-care appointments and specialty appointments. But you've also got to be efficient, meaning you've got to have structure, roles, responsibility, training, delegation, data collection. And it's hard to do both of those well.
MH: What are the most stubborn barriers to improving their care and reducing those costs?
Brenner: We've got about 50 barriers. We don't pay for healthcare in the right ways. We don't understand how to work in team-based structures. We don't move data around. We don't properly analyze the data. We don't have workforce models that train people to do any of the stuff properly. We don't delegate. We don't protocolize and standardize. We don't know how to engage patients meaningfully as partners in their own care. We're giving our doctors too much power, status and autonomy to ever make a productive, efficient and effective delivery system. That's a pretty big set of problems. I think the most profound problem is really how we train doctors, who we recruit into medicine, and how much power, status and autonomy we give them.
It's hard to tell people who are in the top 1% of income in America that they might be doing something wrong and need to change their behavior. Do you think I'm winning any friends?