The recent New England Journal of Medicine study showing “hotspotting” failed to reduce hospital readmissions drew almost gleeful coverage in the media, which revel in debunking conventional wisdom.
Hotspotting, for those not familiar with the term, was popularized in 2011 by Dr. Atul Gawande in a New Yorker profile of a pioneering program in Camden, N.J. It identified the small number of patients, usually on Medicaid or Medicare with multiple chronic conditions, who accounted for a disturbingly high share of local hospital visits. Providers followed up with primary care, home visits and social services to prevent further hospitalizations, and thereby lower costs.
The study, which followed 800 patients in Camden for six months after being hospitalized, found both groups—those receiving the intervention and those receiving routine post-discharge care—experienced a 38% reduction in readmissions. It was a classic case of costs reverting to the mean, the study authors claimed in a counter to previous studies showing savings.
“Program meant to curb repeat hospital stays fails big test,” read the headline in Modern Healthcare. “Disappointing results of major study point to better ways to cut healthcare waste,” said the New York Times.
It would be a huge mistake if the healthcare providers and insurers that are using similar tactics drew that conclusion. As so often happens in long-running studies, the Camden experiment no longer reflects what is going on in the field. Moreover, the local and national reimbursement environments have changed substantially in the decade since the Camden program was launched.
For instance, in the four years it took to recruit participants, providers in Camden formed at least five accountable care organizations. It’s likely many in the control group received specialized attention not captured in the study.
More significantly, provider groups have dramatically changed their approach to high-utilizers. Rather than waiting for people with serious behavioral and medical problems to land in the emergency department, they use data-based tools to identify their most troubled clientele. The goal is to reach out to them with social workers, home visits, regular primary-care visits and rapidly deployed social services before they make their initial trips to the hospital.
To use a sports analogy, preventing the readmission means you’ve got a 1-1 record. Preventing the original admission means you’re at 1-0. Clearly, with the latter, costs are avoided and the patient is better off.
A small industry has emerged to deploy this approach. Startup primary-care companies like Iora Health, Cityblock Health, ChenMed and Oak Street Health are aggressively using intensive outreach, social work and preventive care for some of the most complex and costly patients in Medicaid and Medicare. Hospital systems working with Avia’s Medicaid Transformation Project, which is collaborating with former CMS Administrator Andy Slavitt, are pursuing similar programs, even though success will ultimately erode their top-line revenue.
It’s simply not realistic to expect a 180-day intervention that bolts on a few social services and home visits to immediately lower the healthcare costs of people with multiple chronic conditions, especially if they are unemployed (over 90% in the Camden study), homeless and suffering from substance use disorders. It takes constant engagement over several years. It’s not about addressing patients’ needs; it’s about changing peoples’ lives.
“This is hard work,” an Oak Street Health physician in Chicago told me recently. Sadly, less than 30% of the population in the intervention arm of the Camden study had more than one primary-care visit in those six months, a disturbingly low number given a population with such tremendous needs.
What we need now is real-time measurement of the outcomes and costs for patients who are in the long-term, managed-care programs being offered by these startups. The limited approach used by the Camden project has become passé.