Worst of the Worst

By Dr. Larry Chiaramonte

The January 24 issue of the New Yorker Magazine has an article by Dr. Atul Gawande about efforts to cut health care costs by improving services to the “worst of the worst” patients, i.e. those whose chronic diseases are not managed until they are compelled to call 911. A brave young doctor in Camden, New Jersey named Jeff Brennan, using techniques derived from the Comstat system of policing found that 1% of Camden’s residents consumed 30% of its health care expenditures.

I have used that phrase, worst of the worst, in my own blogging, because those are the people whose asthma interests me most in my own South Bronx practice. I was certainly not surprised to read in Dr. Gawande’s article that asthma is a thread that runs through most of the patients. I was heartened to read about a doctor named Nathan Gunn, who works at a company called Verisk, which helps companies lower their health care costs NOT by cutting benefits and raising co-payments, which Dr. Gawande shows can be highly counterproductive, but by targeting “hot spots” of costly and often misguided treatment. Of specific interest to you, our readers, is this statement by Dr. Gunn:

“Take two ten-year-old boys with asthma…From a disease standpoint, they’re exactly the same cost, right? Wrong. Imagine one of those kids never fills his inhalers and has been in urgent care with asthma attacks three times over the last year, probably because Mom and Dad aren’t really on top of it…That’s really the sweet spot for preventive care.”

I know, and that’s what Dr. Ehrlich and I keep coming back to. I’m glad to see that others are thinking about it, too.