In Health Care, Where Does All the Money Go?

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I really do not know the answer to this question.  But now that I have your attention, let me talk about two articles that appeared recently.  The first article is titled “With health care, like anything else, we get what we pay for,” which appeared in a February 7, 2011, column by Winthrop Quigley in the Albuquerque Journal.  In that article he refers to another article titled “The Hot Spotters,” by Dr. Atul Gawande that appeared in the January 24, 2011 issue of The New Yorker.

In his article, Quigley tells the story about Dr. Alfredo Vigil, the former Secretary of Health for the State of New Mexico.  At close to 5:00 pm on a work day, he suggested that all of his employees who had children call their pediatricians and tell them that their children had temperatures of 103 degrees.  He was sure that each of the doctors would tell the callers to take their children to the emergency room.  His point was that the primary point of service is emergency rooms, and that doctors rely on that service all the time.  However, as study after study shows, emergency rooms are not designed to provide primary care and are the most expensive way to provide primary care.  They may fix, but they do not cure.

In his article, Dr. Gawande, who is a surgeon in Boston, wrote about a doctor in Camden, New Jersey, who identified “hot spots,” that is, those parts of Camden that sent the most people to the hospital most often.  He found that two buildings in Camden, between 2002 and 2008, sent 900 people to the hospital 4000 times, costing about two hundred million dollars in that period of time.  What was found was that people who had multiple chronic health issues were being cycled in an out of the hospitals and were not receiving good care.  This was not because the hospitals were inadequate, but because they are not designed to oversee the kind of care that these patients needed.

Dr. Gawande goes on to describe a project in Atlantic City, New Jersey, called the Special Care Center.  This medical practice was created by a local hospital and a casino workers’ union, both of which provide health insurance coverage on a self insured basis for their employees and members.  They were interested in reducing the costs of health care.  The Special Care Center is led by Dr. Rushika Fernandopulle, and it focuses on workers with exceptionally high medical expenses.  The practice is paid a flat monthly fee for providing comprehensive services to its patients.  This is done using social workers, nurse practitioners, doctors, and “health coaches.”  Patients have unlimited access to this practice.  The health coaches speak the language of the patients, visit them in their homes, and contact them as often as required to remind them about their medications, weight control and diet, exercise, and cessation of smoking.  They have reduced hospital visits dramatically and have improved the health of their patients, thus saving a great deal in costs.

This patient centered medical practice is generally known as a “health home” or “medical home.”  The University of New Mexico Hospitals have implemented this model to some extent.  There is funding directed to medical homes for both Medicare and Medicaid patients in the Affordable Care Act.  Perhaps this is one way to make health care dollars stretch further by addressing the health needs of seriously and chronically ill patients with a patient-centered methodology rather than just sending them to the emergency room.