Why the Camden Coalition Couldn’t Break the Cycle of Hospital Readmissions
Losing weight just by taking a pill. Good grades just by learning a memorization trick. Everyone wants to find the “silver bullet;” especially in healthcare. The Camden Coalition looked like healthcare’s silver bullet, until it didn’t; but that doesn’t mean we discount their work. Research doesn’t always turn out the way we hope it will, but we can always learn something.
Dr. Jeffrey Brenner and the Camden Coalition of Healthcare Providers hypothesized they could stop the cycle of costly hospital readmissions by pairing frequently hospitalized patients with nurses and social workers. But the New England Journal of Medicine recently shared a study that found the Coalition’s “buddy system” had no effect. Patients receiving extra support were just as likely to return to the hospital as patients who didn’t receive any help.
There is a lot to take away from what the Camden Coalition did. At the same time, I worry that the various programs working to address high-cost patients in America’s “hot spots” will, much like the Camden Coalition, struggle to move the needle on hospital readmissions. That is, unless future efforts spring from two simple underpinnings. First, we can’t expect success until we refine how the primary care physician (PCP) influences the equation. Second, we can’t expect success unless we get very clear about matching the right interventions to the right situations at the right time.
Positioning the Primary Care Physician for Success
Let’s start with the most important building block: PCP Accountability. So many PCPs are paid a fee for a service. That is antithetical to accountability for the patient’s improved health, and results in what I like to call, “workaround” solutions. In other words, the care programs are set up to let the PCP keep doing his or her job – but a bunch of coordinators and other roles step in to engage the patient in various ways. The more people added to the mix, the harder it is for anyone to be accountable. Instead, a “passing the buck” mentality prevails where everyone assumes someone else will handle things.
Accountability may be the core building block, but we’re not likely to get it by simply asking for it. We won’t get it even if we take the radical step of ending fee-for-service and dropping the financial responsibility of the outcomes in the PCPs’ lap.
PCPs were not selected, trained, or equipped for owning accountability of patient outcomes – especially outcomes in the hardest cases of the most complex patients. We selected them for book smarts, not for savvy in leading and influencing people. We didn’t train them to earn trust and change the course of a patient’s health through coaching, nutrition, lifestyle modifications, and navigating personal social and economic factors. We trained them to refer cases to specialists who make more money; thus, incentivizing many of the strongest PCP candidates to become specialists instead.
When we design programs to go after “hot spots,” we must start with the PCP. Select the strongest physicians, make sure they are trained for the social factors and team leadership role they are taking on, and give them every incentive (both financial and collegial pressure through results transparency and peer-to-peer case review) to care about the desired result – keeping the patient home and healthy.
The Right Interventions at the Right Time
Changing someone’s health trajectory is not easy, but it is possible in most cases. Of course, there are situations where trying to apply a clinical intervention to the problem is mismatched; making it unfair to label the results of a clinical program a failure. Health, after all, is a result of environmental, education, housing, food, and other policies as much (or more) than it is from medical care. That means we also need the right interventions to the holistic issue for the patient. But, even within what we control in the medical system, we have two huge intervention problems. We don’t really know what interventions work best to reduce hospitalizations and we usually intervene too late.
During my medical education, I learned a lot of things that we thought worked, but really don’t make a difference. These solutions may even increase admissions and total cost of care. For example, the complex patients targeted in hot spotting clearly need a lot of specialized expertise, right? So, more consultants with more specialized expertise means better outcomes, right? Maybe not. In decades of caring for complex patients in many geographies at ChenMed, we consistently see the opposite. Adding to the care team is akin to adding more instruments to an orchestra. If the orchestra didn’t sound good to start with, it only sounds worse by adding more instruments. If the orchestra did sound good, it may not be easy to fit in the extra instruments into the mix in a coordinated way. PCPs are the conductor and they need to get the music right first, then be the decision-maker to judiciously add in support. As our industry refines these hot spotter care programs, it is critical to identify what interventions actually reduce admissions, what things we learned in med school that were simply wrong, and then train doctors to make changes before throwing resources at a solution that is destined to fail.
Intervening too late is the cardinal sin, because that is the one thing that is simple to change. When programs target readmission, we’re already too late. We don’t wait for children to fail out of school before getting them some tutoring. Why do we wait for people to be hospitalized before intervening in their health? If the goal is to improve health, then we should work to minimize the need for being hospitalized at all. It’s not hard to identify people with risk factors and start working intensively on their lifestyle, care regimen, and building trust through frequent visits. If we can prevent admissions, we’ll make a much bigger dent in our overall healthcare problems than if we reduce a portion of hospital readmissions.
Decade after decade, ChenMed has improved total cost of care for our patients; both comparable to Medicare benchmarks and comparing patients in their first few months with us to patients who are long-established patients in our model of care. In America, we can make a difference by “hot spotting.” But the results will vary based upon whether we can match the right intervention to the right issue at the right time with an accountable, trained, and incentivized doctor making the calls. Let’s not ignore the Camden Coalition’s effort and revert to the broken American healthcare status quo. Rather, let’s take a refined approach and spread high-touch care models to more neighborhoods that need them.