Relationships, responsibility key to lowering costs for high-use patients, Brenner says

Dr. Jeffrey Brenner recently won a MacArthur Fellowship, popularly known as the MacArthur genius grant, for his work to improve primary care and reduce healthcare expenses for complex, high-cost patients in Camden, N.J. Brenner launched the Camden Coalition of Healthcare Providers to better coordinate care across the city. His efforts to identify high-use patients with hospital data, improve their care and reduce their costs have been profiled in the New Yorker magazine and by PBS' “Frontline.” Modern Healthcare reporter Melanie Evans spoke with Brenner about his work in Camden and the interest the coalition has gotten from other communities.

What follows is an edited excerpt:

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?

MH: Does the Patient Protection and Affordable Care Act finance the care that you have found to be effective for high-cost patients?

Brenner: The ACA increases the number of people who are covered. It also has a lot of innovative models to really drive the system toward delivering better care at lower cost. It's going to take a long, long, long time to shift the Titanic here, and I don't know that we're going to see the iceberg coming in time to turn the ship.

MH: Does the ACA go far enough to support the care that's proven effective?

Brenner: I think it has done a wonderful job of churning up the healthcare industry to get people to have new conversations and be much more willing to rethink the status quo. That's a tremendously positive outcome. I'm hearing people talking in ways that I've never heard them talk before.

MH: Do you have any thoughts on how winning the MacArthur award will help your work?

Brenner: I think it adds a lot of wind to our sails. This is such hard work. Trying to fix one of the most intractable and unproductive systems in our country in the poorest city in the country is a pretty tall task and pretty frustrating. I think it's a real vote of confidence and helps us keep moving forward.

MH: Outside of Camden, what interest have you gotten in the model of care you've developed?

Brenner: We work directly with 10 communities around the country. Six are part of the Robert Wood Johnson Foundation's Aligning Forces for Quality Initiative, and four of them are part of a multisite CMMI Innovation Grant. Beyond that, we have been called and contacted and visited by so many programs around the country that are trying to figure out how to deliver better care at lower cost to really complex patients. I think there's a huge hunger out there.

There are a lot of frustrated doctors, nurses, social workers, hospital administrators, insurance company people and patients that are hungering for new models.

I think lots of us are having experiences in our own families with our parents and grandparents that don't necessarily receive very good care when they get very sick. There's really a growing frustration and hunger for change. Our phone's ringing off the hook and that's very encouraging that there's lots of interest in new models out there.

MH: What advice would you give a community that's just starting out?

Brenner: Don't ask for permission, ask for forgiveness. Don't get stuck in planning, just do it. Go out and meet one high-utilizing patient and build your program and build your collaborations around that single patient. That's a form of root cause analysis.

Hire a phenomenally talented, business-trained project manager to help you get organized and stay organized. Hire the warmest, fuzziest, most relationship-centric nurses and social workers and let them form a team and begin to do the work. Go out and round up all of the stakeholders in your community who are sick and tired of the status quo and willing to work with you and don't take no for an answer.

Follow Melanie Evans on Twitter: @MHmevans