Atul Gawande's latest piece in the New Yorker is out this week and I suspect the raves will be soon to follow. President Obama is assuredly frantically scrambling to slide a reference to it in his upcoming State of the Union Address.
The article deals with a possible solution to the conundrum of "high utilizers" in the health care system. By "high utilizers" (HU's) we mean those 1% of patients who, due to a combination of generalized sickness/ non-compliance/poor physician management, account for gargantuan shares of systemic health care costs (sometimes up to a third of all hospital expenses). Gawande investigates why this is the case and hangs out with a couple of idealistic physicians who may have stumbled upon a potential fix.
Unsurprisingly, HU's tend to come from lower socioeconomic classes. The diabetic who doesn't have health insurance and only rarely seeks medical attention for severe complications of his diabetes in an ER is obviously going to accumulate more societal costs for his disease over the course of a lifetime compared with the compliant diabetic with decent health coverage who sees a doctor every six months for preventative therapy. So Gawande discovered a couple of altruistic visionaries who decided to create entire medical practices devoted to the care and management of these HU's. Sounds pretty cool so far, right? Focus on the non-compliant patients without insurance who plow through health resources like my buddy Starhay does sliced cheddar at a fantasy football draft and you may be able to lower overall expenditures.
But here's where Gawande's paragons of medical philanthropy start to lose me. The practices he follows around (one in Camden, NJ and the other in Atlantic City) aren't just garden variety charity clinics for unhealthy, uninsured patients. These practices are High-Intensity, Life-Management Centers for the downtrodden and woebegone. Multidisciplinarian teams of doctors, nurses and social workers attack these HU's like it's the first day of July two a days for a team coming off an 0-10 football season. Patients are assigned "health coaches" who schedule appointments, make sure patient X has a ride to office, double check that patient X has filled prescriptions, double checks that pills are actually being taken on a daily basis, arrange exercise time, suggest dietary changes, encourage religious worship (?!?!), make follow up house calls, fill out paperwork for disability/public aid, provide psychologists for mental health issues, enroll in Yoga classes, improve housing conditions, and provide hour long full body massages once a week. (OK, I made the last one up). There's even a passage detailing how one health coach was able to reduce 911 calls and ER visits. Initially, the patients were told to simply program the clinic number into their cell phone speed dials. But too many didn't know how to do this. So the coaches did it for them. Voila. Reduced 911 calls.
I mean seriously? Aren't we talking about grown adults here? Apparently there are professionals who think that taking someone's cell phone and programming a number into his speed dial because he can't figure out how to do it himself, or even just write the damn clinic number down on a piece of paper taped to his refrigerator is some sort of triumph in social re-engineering? This isn't a solution to the health care crisis. It a thinly veiled play for bureaucratized, state-sponsored citizen dependency.
I mean, I'm all for social safety nets and making sure a bare minimum of health care is universally available to all. But this is crazy. Whatever happened to personal responsibility? Why is it "inhumane" to expect an adult human being to take care of himself? People talk about the encroachment of the "nanny state" with health care reform--- but this is a Mommy State plan. Besides, how many people are going to want government-subsidized social workers and psychologists crawling up their ass every minute of every day, asking if they ate their vegetables for dinner.
To be clear, I am impressed by the results achieved by the doctors cited in the article. Their selfless toil and humanistic approach to health care is admirable. But we have to expect a little more from our citizenry. There are many ways we can be better. Foremost involves acting like a freaking responsible adult.