'Hot Spotters' on Trial
January 8, 2020
Photo by Leslie Walker
Nearly a decade ago, Dr. Jeff Brenner and his Camden Coalition looked like they had found a way to keep America’s costliest, most complicated patients out of the hospital. But a rigorous new evaluation shows the approach did not deliver on its revolutionary promise. Why did it fail? And what comes next?
Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints
Improving health and lowering costs for the sickest and most expensive patients in America is a dream harder to realize than many health care leaders had hoped, according to a study published Wednesday in the New England Journal of Medicine.
Researchers tested whether pairing frequently hospitalized patients in Camden, New Jersey, with nurses and social workers could stop that costly cycle of readmissions. The study found no effect: Patients receiving extra support were just as likely to return to the hospital within 180 days as those not receiving that help.
The results are a blow to Dr. Jeff Brenner and the Camden Coalition of Healthcare Providers, the organization he founded nearly 20 years ago.
“It’s my life’s work. So, of course, you’re upset and sad,” says Brenner, who now does similar work with health insurance giant UnitedHealthcare.
The model of care, pioneered in part by Brenner and profiled in a widely read 2011 article in The New Yorker, has inspired dozens of similar projects across the country and attracted millions in philanthropic funding.
“This is the messy thing about science,” says Brenner, who won a MacArthur Foundation “Genius Grant” for his efforts. “Sometimes things work the way you want them to work, and sometimes they don’t.”
The Hope
Many hospital and insurance executives have pinned their hopes on this research because it promised to solve a common problem: when patients’ lives are so complicated by social factors like poverty and addiction that their manageable medical conditions — like diabetes and asthma — lead to expensive, recurring hospital stays.
Writer and physician Atul Gawande introduced Brenner as a brash visionary crusading on behalf of the “worst-of-the-worst patients” in the New Yorker piece, titled “The Hot Spotters.” (Gawande, who now heads Haven, a joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase, declined to be interviewed for this article.)
Brenner’s prescription: Pair these patients with front-line care workers who would shepherd them to the social and medical services they needed. Early evidence was promising, the anecdotes inspiring. Brenner boiled the model’s potential down to four words and two tantalizing goals: better care, lower costs.
As word spread, breathless headlines popped up like “Health Care’s Best Hope,” and “Could Camden Coalition Save U.S. Health Care?“
“Lots of organizations make claims that their programs work and they’ve never been rigorously tested,” Brenner says.
Instead, Brenner took the unusual step of inviting the scrutiny of respected researchers.
In 2014, Massachusetts Institute of Technology economist Amy Finkelstein began a randomized controlled trial, the same rigorous method used to evaluate new drugs. Over four years, the Coalition enrolled 800 patients; all had been recently hospitalized, and all struggled with social problems. Half received the usual care patients get when leaving the hospital. The other half got about 90 days of intensive social and medical assistance from the Coalition.
And the result: The 400 patients who received the intensive help were just as likely to return to the hospital as the patients who didn’t. In both groups, nearly two-thirds of people were readmitted within 180 days.
So why did the Coalition fail, at least in its initial cost-saving goal? Why did the savings touted in their early data, which Gawande had declared “revolutionary” in The New Yorker nearly a decade ago, disappear when put to this rigorous test?
The Sidebar: Randomized Controlled Trial (RCT)
In the inaugural edition of our series, The Sidebar, we dive deeper into the randomized controlled trial (RCT) as a policy evaluation tool. Listen below or click here to learn more.
The Camden Coalition’s model was evaluated using an RCT, a method widely used to evaluate clinical treatments, but less commonly used to study policies and programs.
It is the most reliable way to determine if there is a causal link between an intervention and an effect.
But it’s not without its tradeoffs…
Strengths:
- Establishes causation, rather than just correlation, between an intervention and effect
- Clearly demonstrates what would have happened in the absence of the intervention
Limitations:
- Can be very expensive and take a long time
- Offers little explanation as to why an intervention succeeded or failed
'My Daily Routine'
The experience of Larry Moore, one of the patients in the MIT study reveals a road map as to why the Coalition missed its mark.
Moore, who has hypertension, alcohol addiction, chronic seizures and difficulty walking, was one of the first people to enroll in the Coalition’s trial.
His first months were promising: prescriptions filled, medical appointments attended, Social Security benefits claim in process. The 47-year old even started to trust the team with the details of his deep-seated addiction — confiding about how he sometimes would consume mouthwash, vanilla extract and even hand sanitizer.
He “couldn’t keep anything with alcohol in it” around, Moore says of his dependency in those days. “That’s addiction.”
But all the progress he’d started to make with the social workers suddenly stopped when Moore disappeared from the Coalition’s radar.
“We didn’t see Mr. Moore after November,” says nurse Jeneen Skinner. “We went to the house. We sent text messages. We [made] phone calls.”
The Coalition has since learned that, for people living in poverty and with poor health, a single hiccup — in Moore’s case, a missed rent payment — can spiral into a major setback.
Missing that rent payment led to Moore’s spending the next 2½ years mostly homeless, completely out of touch with the Coalition.
“I was going from place to place. I [would] sleep on a bench or a rock until the next day when the liquor store [opened],” Moore remembers. “That was my daily routine.”
Seventy emergency room visits and six hospital admissions later, Moore reconnected with Skinner.
He told her the one thing that would keep him out of the hospital: housing.
The 'Camden Coalition'
Too many times, during the research study, people ended up back in the hospital despite the intervention. But the Coalition is convinced it didn’t fail as much as the larger social safety net did.
“The bottom line is, we built a brilliant intervention to navigate people to nowhere,” says Brenner.
Coalition staff and their patients usually knew what was needed — evidence-based addiction treatment, housing, mental health services — but resources were often in short supply.
Over the past three years, the Coalition has set out to fill in those gaps, and, along the way, undergone a kind of metamorphosis.
“We think of ourselves now as the Camden Coalition” — steering away from the “health care providers” part of the name, says Kathleen Noonan, who succeeded Brenner as head of the organization.
The Coalition has forged partnerships with jails, lawyers and legislators, and started its own housing program. Many of these efforts began toward the end of the clinical trial — a sign the Coalition was seeing the handwriting on the wall.
'I Kid You Not'
“I would have never imagined this,” says Moore, sweeping his arm around the one-bedroom apartment he lives in today.
A green houseplant sits in the sunshine. A stuffed animal decorates the bed.
“When I first moved in here,” Moore explains, “it took me about a month to even sleep in my bed. I slept on a couch.”
Housing also made it easier to face his other problem: drinking. Moore chose to try the drug naltrexone, a long-acting injection to treat alcohol addiction.
Today Moore is nearly two years sober. He meets with a Coalition support group on Wednesdays, and he is in training to become a deacon at his church. In the 22 months he has lived in an apartment, Moore’s trips to the hospital have plummeted: just one admission and one ER visit.
“I kid you not, when I saw Mr. Moore probably a month ago, I was standing next to him and did not recognize him,” says nurse Skinner. “He looked at me, and said, ‘Jeneen, it’s me.’ And I was like, ‘My God, you look amazing!'”
Larry Moore’s story is just that — one story. Yet it represents a larger trend. Insurers — including UnitedHealthcare under Brenner’s direction — hospitals and many state Medicaid agencies have begun spending millions to meet patients’ social needs.
Still, the study published Wednesday backs up the skepticism of other researchers that, when it comes to saving money at least, these approaches don’t work well. For one, programs are expensive and hard to scale. The Coalition’s housing effort currently serves only 50 people and costs about $14,000 per person per year.
It’s an expensive proposition that may not pencil out. “Despite what people would like to believe, there’s not a lot of evidence you can reduce health spending by spending more in other areas,” cautions Boston University economist Austin Frakt.
Finkelstein says that as health care companies move further beyond the four walls of a hospital, the need for rigorous evaluation grows. “I think a lot of well-intentioned people in health care can’t handle the truth,” she says. “They’re trying to do good, but they don’t have the courage to say, ‘Let’s do a gut check on ourselves.'”
Eighteen years ago, Brenner hypothesized the Coalition — with some savvy navigation and hard-earned trust — could guide the most complicated patients towards better health and cut spending. Finkelstein’s randomized controlled trial shows that idea fell short.
Coalition CEO Kathleen Noonan, considers it progress, even if it’s not the progress so many had wanted. “People like stories about success and they like stories about failure. They just love extremes. I’m really hoping that this is a story about complexity — and about courage.”
This web version of our podcast story was produced in partnership with Kaiser Health News (KHN), a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. This story also appeared on NPR’s Shots blog.
Faces of the Camden Coalition
Want more Tradeoffs? Sign up for our weekly newsletter!
Episode Resources
Brenner and The Camden Coalition
Health Care Hotspotting — A Randomized, Controlled Trial (Amy Finkelstein, Annetta Zhou, Sarah Taubman and Joseph Doyle; New England Journal of Medicine; 2020)
“The Hot Spotters” (Atul Gawande, The New Yorker, 2011)
“America’s Largest Health Insurer Is Giving Apartments to Homeless People” (John Tozzi, Bloomberg, 2019)
Additional Research and Information on Social Determinants of Health
Housing And Health: An Overview of the Literature (Lauren Taylor, Health Affairs, 2018)
Drivers of Health (Robert Wood Johnson Foundation)
Social Interventions Research & Evaluation Network (SIREN) Evidence Library (UCSF SIREN)
Overview of Medicaid Spending on Social Determinants of Health (Center for Health Care Strategies, 2018)
Investing in Interventions That Address Non-Medical, Health-Related Social Needs (The National Academies of Sciences, Engineering and Medicine, 2019)
Evaluations of Other Complex Care Interventions
Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial (Donna M. Zulman, Christine Pal Chee, Stephen C. Ezeji-Okoye, et al, JAMA Internal Medicine, 2017)
Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial (Coburn et al, PLOS Medicine, 2012)
Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials (Deborah Peikes, Arnold Chen, Jennifer Schore, et al, JAMA, 2009)
Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial (Naylor et al, JAMA, 1999)
A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure (Rich et al, New England Journal of Medicine, 1995)
Episode Credits
Original music composed by Ty Citerman; additional music by Bacon and Whitewolf.
Thanks also to Fresh Air with Terry Gross and the WHYY Archive.
This episode was reported by Dan Gorenstein and Leslie Walker and mixed by Andrew Parrella. It was produced for the web by Ryan Levi.
Additional thanks to:
Kaitlan Baston, Sharon Bean, Bertha Carmichael, Bechara Choucair, Ken Coburn, Natasha Dravid, Tim Ferris, Austin Frakt, Jesse Gubb, Mark Humowiecki, Teagan Kuruna, Jake Lowary, Bill Nice, Pam Nicolls, Brian Smokler, Jeremy Spiegel, Sarah Taubman, Aaron Truchil, Sara Vinson, Diane Webber, Katie Wood, the Tradeoffs Advisory Board…
…and our stellar staff!