Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode above!

Dan Gorenstein (DG):  How many times a year do you go to the emergency room now?  

Larry Moore (LM): Probably about twice.

DG: And how’s that compare to what it was before you got the housing, before the Vivitrol?  

LM: I lived in the emergency room. They knew my name. [Laughs] Back and forth, back and forth. Then something clicked.

DG: Larry Moore’s path from homeless and addicted to five-years-sober and living in his own place is a tantalizing tale — the kind of cost-cutting, life-changing success story that hospitals, health insurers and care agencies have spent the last two decades trying to replicate at scale.

Today: Why that’s such a struggle and what’s been learned along the way.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

***

[Car engine starting]

DG: It’s a brilliant, blue December morning in Camden, New Jersey. 56-year old Larry Moore is behind the wheel of his black GMC SUV.

LM: Watch this, I’m gonna give you a quick tour of something. 

DG: He’s showing me around the neighborhood where he used to live…

LM: This is where it’s all at. The hood. All these streets right here, I slept out here. 

DG: Where are we at now? 

LM: We’re on Mount Ephraim Avenue.

DG: It’s a stretch where the poverty is pronounced: trash, vacant lots, abandoned homes. Larry slows the car. He points to the shell of a building. He tells me, with a touch of amazement, that he and his girlfriend lived here for two years.

DG to LM: What was her name? 

LM: Michelle, she wound up [overdosing].

DG: We round a corner and pass Sophie’s, his neighborhood bar. Larry’s addiction was so deep, he says, sometimes he’d sit in the ER, wait for nurses to turn their backs and he’d grab hand sanitizer and drink it in the hospital bathroom.

LM: That’s addiction.

DG: Then, we get to a concrete step on Chestnut Street. 

LM: This is right where I was at. 

DG: On a bitter night back in December 2017, Larry had nowhere to stay and too much to drink. He passed out on this stoop. Hypothermia set in. An ambulance found him. 

LM: I was in the hospital shivering, and they said, “Man, you almost froze to death.”

DG: Larry had come within a few degrees of dying.

A horror show of a life, but instead of slipping into that abandoned house, nodding off in front of Sophie’s, or just dead, now, Larry is here — in his own apartment.

He’s no longer worrying about where he’ll get that next drink, but looking for deals on home electronics.

LM: That’s a beautiful TV, but if you try to pick it up, it’ll kill you.

DG: Trying to find some ways to breathe a little life into his living room…

LM: I might put up some blinds, put a throw rug in here or something. 

DG: Larry says it a lot: He’s lucky to be alive. He’s a regular at his church. He’s got himself a nice, little collection of half-a-dozen boots and sneakers. He listens to friends talk about their struggles with addiction.

And, he has plans this summer to drive to Tennessee and meet his 36 year-old daughter for the very first time.

LM: Being able to give her something, even just a gift, a card from her father … that is such a blessing.

DG: After a very, very long time, Larry has the freedom — the power — to go where he wants. And that is what he’s doing.

The team of nurses and social workers at the Camden Coalition — the nonprofit that helped Larry land his place — they want Larry’s story to be more than a one off. They want it to be routine — like a pill lowering your cholesterol or an inhaler opening your lungs — that they can deliver, time after time. But 20 years into this work , that’s a puzzle that they and others all around the country are still trying to solve.

Jeff Brenner: The idea that someone should go to the emergency room a hundred times in a year is a sign of deep, deep system dysfunction. It should be fixable. And we’re clearly still struggling.

DG: Jeff Brenner, a primary care doc, founded the Camden Coalition back in 2002 to tackle a problem that health insurers and hospitals all had: A small but super pricey group of repeat customers using the ER 70, 80, 90 times a year. Nobody knew how to care for these patients, but everybody had a name for them — harsh ones: frequent flyers, super utilizers.

Brenner: Behind the scenes, nurses, doctors roll their eyes. They get angry at people that keep coming back. The worst term is people are called GOMERS and it stands for Get Out Of My Emergency Room. That’s horrible.

DG: Plenty of those ER trips became expensive hospital admissions often for avoidable reasons: poorly managed diabetes, untreated mental illness. The thinking went ‘prevent some of those hospital stays that cost $10,000 bucks a pop and the whole country could slow down its runaway health care spending train.’

And the Coalition had a cutting-edge fix: Make it easy to get primary care and tackle underlying social needs like removing mold or teaching someone to shop for healthy food.

Take those steps for just 3 months, the team believed, and you’d keep repeat customers out of the hospital, achieving two really important things at once.

Brenner: Better care, lower cost.

DG: Better care, lower cost. That was the promise. But did it actually work?

In 2014, the Coalition put the program to the ultimate test: a randomized controlled trial. They partnered with MIT’s Amy Finkelstein, one of the country’s leading health economists, to run it.

Amy Finkelstein: Usually, you know, many policies involve tradeoffs. We can make people better off if we spend more money.This was a possibility that we could make people better off by spending less money in a way that I thought was, you know, really compelling and credible.

DG: In early 2020, the study’s results came in. The program failed to keep people out of the hospital. 

People getting all this extra help from the Coalition were just as likely to end up back in the hospital as people who didn’t get those extra services.

The Coalition’s CEO, Kathleen Noonan told us in 2020 that the results devastated the team.

Kathleen Noonan: I mean, who doesn’t want to be able to say to the world that a 90-day intervention that, in the scheme of things, doesn’t cost that much, for the most complex patients could actually result in reduced hospitalizations? We really wanted to be able to say that. But we are not able to say that.

DG: Last year, Amy and her team published a follow-up paper showing that under the original model, Coalition clients were 50% more likely to see a doctor after leaving the hospital than people with no extra help.

Finkelstein: That’s like a huge impact, but that just isn’t turning out to be enough to break this cycle of readmissions.

DG: The final verdict: The Coalition did deliver on its promise of better care, but to break that cycle of readmissions — to have any hope of lowering costs — many people need more. More of what exactly is this the next big question.

The evidence Amy and her team compiled have helped the Coalition better understand what to ditch and what to double down on from their original model. They’ve tweaked their approach over the last few years including doing more to get clients like Larry Moore off the streets. 

But stories like Larry’s remain far from a sure thing. The Coalition says even after they get folks into stable housing about 1 in 5 people get evicted or leave the program. 

Staffer Brian Thompson says those failures still sting seven years into this work.

Brian Thompson: You know, I have that hope and that enthusiasm  that everyone is going to be successful and going to get it. And then when I don’t see it, it is heartbreaking.

DG: Some disappointment with some glimmers of hope, that’s about where the Coalition’s at these days. And they’re not alone. 

After the break, how the Coalition and other groups are building on what they’ve learned. And, Jeff Brenner makes a surprising leap from primary care doc to New York City landlord. 

MIDROLL 

DG: Welcome back. The Camden Coalition’s widely hyped original model proved to be a disappointment. But the quest to improve care and lower costs for some of the country’s sickest, most expensive patients remains as alluring as ever.

A new wave of experiments and investments is building on lessons learned. So we asked senior producer Leslie Walker to check them out and report back.

Hey, Leslie.

LW: Hey, Dan. 

DG: So, what did you find?

LW: Well I thought rather than giving you just a list of lessons, I’d try something a little different. I want to tell you three short stories — snapshots, really — that illustrate how this entire field is evolving.

DG: You know I love a good story.

LW: Well, gather round, Gorenstein. Here comes the first one.

Arthur Brown: My name is Arthur Brown. I am 41 years old. I live in Voorhees, New Jersey. 

LW: So Arthur’s also a client of the Camden Coalition. He’s been working with them for several years now. Arthur has struggled for a long time now to manage his Type 1 diabetes — out-of-whack blood sugars have left him unconscious on the bus,  even cost him both of his legs. He’s also got a big smile, lots of dreams and a pretty wild range of hobbies.

Brown: I have a bunch of machines in here. I can make different butters. I have a dehydrator. I can make teas. I also have some DJ equipment and am learning how to do that. I’m just, you know, just trying to figure what I’m good at

LW: Arthur’s part of the same housing program that helped Larry turn his life around. The thing is, Larry and Arthur got into housing around the same time, but it’s had a pretty different impact on their lives.

DG: I mean I saw firsthand how big of a difference having a stable place was for Larry. It let him focus on kicking his addiction and that opened up a whole new life.

LW: And now that Larry’s living that life, the Coalition told me, he doesn’t need much. They help with little stuff here and there, like when Larry wanted to open a credit card but wasn’t sure how.

But with Arthur, his community health worker Dottie Scott told us she’s still super-involved in his life even in little ways like reminding him to take his meds and eat healthy meals.

Scott: A lot of people think it’s you’re just going to come in and then it’s this magic pill and everything’s just good. In reality, it does not work like that. It takes time. 

LW: Now, to be clear, Dan: All of that help is doing a lot for Arthur. He used to go to the ER like once every other week. Now it’s more like once or twice a year.

DG: That’s impressive, but Dottie’s point, it sounds like, is that’s also far from the Coalition’s original theory — the one they tested in that big trial, which was give everyone a few months help getting hooked up with resources, doctors, food stamps, all that [and] they’ll be set. 

LW: Right  and for some people that is enough, but the first lesson that a lot of folks in this field have come to accept: ‘Enough’ is likely going to look different for every single person. And the more complex their needs are the more types of support and more time they’ll likely need.

DG: In other words here, Leslie, for this Camden-style approach to work, it’s going to take a whole lot more time and tailoring.

LW: Yes.

DG: Okay, what’s your second lesson — second story?

LW: This comes out of my own experience reporting on this episode. The lesson — really, the trend — is this: A lot of states and even private insurers like United are now doubling down on that hunch the Coalition had two decades ago that people’s social circumstances have a huge impact on their health.

DG: Sure, like with Larry, it was hard for him to tackle his addiction when he was constantly worried about where he was gonna sleep.

LW: Exactly, and we’re now seeing billions of dollars pouring into an even wider variety of social programs — delivering meals, removing mold from people’s apartments, paying their rent.

In fact, the trend to spend money on this stuff is growing so quickly that in the middle of my reporting, another state jumped in.

DG: Really?

LW: Yeah, that’s my second story: The federal government approving what officials call a waiver — a pilot, really — for New York’s state Medicaid program to spend up to $3 billion on people’s social needs. We’re talking short-term housing, bus fares, even cooking supplies.

Allison Hamblin, who’s CEO of the Center for Health Care Strategies, a nonprofit that helps state Medicaid agencies implement new programs, told me she sees New York’s waiver as a kind of barometer.

Allison Hamblin: There’s a big focus on health related social needs, investments and infrastructure to support that. I think it’s very reflective of what the priorities are today across states and across the country. 

LW: As you know well, Dan, from other reporting we’ve done here at Tradeoffs, California is another state with a similarly ambitious experiment in the works.

DG: Right, and so what it seems like, is that all these government officials have basically come around to the same conclusion as the Coalition: They need to do more, not less. To get at the root of people’s obesity or addiction, doctors and insurers need to go further outside the bounds of what we all typically think of as health care.

LW: Yeah, as Allison put it for me, the conversation has now moved from whether to address people’s social needs to how to do that.

DG: And just to stop you there, Leslie, that’s like a huge shift because I remember when I first started reporting on the Coalition back in 2012 they were one of a handful of health care groups focused on social needs.

LW: Yeah, and as glad as folks like Allison are to see that shift, she said it’s also given rise to some tough new questions.

Hamblin: Where do we find the money to do that? How much money should we spend on that? And where are those investments most effective?

LW: And one other big one, Dan: Should health insurers and doctors be the ones leading this kind of social work? Deciding what kinda housing gets built or who deserves help eating healthier meals? Researcher Paula Lantz, at the University of Michigan has her doubts.

Paula Lantz: This notion that we have a medical care solution for every health problem is not right. These are social problems that require social policy investments and resources.

LW: Paula agrees that health insurers and hospitals have a role to play here and they shouldn’t be let off the hook. There’s lots of simple stuff they could do better like getting patients connected to local food banks and shelters — even using their lobbying power to press for more housing or cleaner air.

DG: But that’s about where she thinks their role should end.

LW: Yes. And just to recap here, the real takeaway from this boom in social spending is that most people now agree it’s necessary. There’s just not yet a lot of agreement about how best to spend all these new dollars or who should be in charge of them.

DG: Those sound like some big open questions, for sure. 

Alright, so we’ve arrived at your third and final story here, which is what?

LW: I almost want to call it story 2a because it’s closely tied to that boom in social spending we just talked about. You’ve got all these new programs popping up that help people navigate social services and medical care. 

It’s a lot, potentially confusing and frustrating for patients. And veterans of this field see that risk and are taking different approaches to managing it.

One idea is to create more of what Kathleen calls ‘backbone organizations ‘to coordinate and coach up all these new service providers. It’s a role she says the Coalition is embracing.

Noonan: You know, maybe 25 or 30% of our work is direct service work, but the rest of our work is focused on building the ecosystem.

DG: I see, so the player is becoming the coach, pulling a Bill Russell.

LW: That’s right.

The other popular approach is organizations moving to bring more services under a single roof. For example, we’ve seen a rapid rise of so-called Certified Community Behavioral Health Clinics that offer addiction, mental health, some primary care … all in one spot.

DG: Got it, so instead of coordinating a bunch of separate services, try to combine them. The one-stop shop.

LW: Yeah, and this centralization approach, that’s the basket that Jeff Brenner has put his eggs in.

My third and final story is what the doctor and Coalition founder is up to these days, because it’s kind of surprising. Jeff’s now in charge of a much bigger organization: the Jewish Board, social service agency in New York City, with 45,000 clients and a budget over $200 million a year.

He’s building out 4 of those certified behavioral health clinics and clients can get housing all from this one agency.

DG: Sounds ambitious. How’s that going for Jeff?

LW: Well, it’s definitely a slog.

Brenner: I mean, now when there’s a hole in the wall of the apartment or the toilet doesn’t flush, who are they calling? [Laughs] I spend my day on, like, the most mundane things. 

LW: Jeff said directly delivering services like housing brings a whole new set of headaches. And centralizing services is no walk in the park either. Jeff said, for example, it took him a year and a half just to get licensed to start providing addiction treatment.

But as hard as it’s been, Jeff’s also excited. He feels like the whole here will eventually be greater than the sum of its parts.

Brenner: Lots and lots of people who have mental health may have a hidden addiction that they’re reluctant to talk about. Lots of people with addiction have a hidden mental health issue. Having all that care in one site makes a really big difference for people.

DG: Certainly sounds worth keeping an eye on.

So Leslie, these three stories leave me with one last big question. If everyone’s agreeing that this work takes more time, more tailoring, more money, is there any chance it can still lower costs? Because that was a big part of the appeal and the promise that Jeff Brenner made when he first started the Coalition, right?

LW: Ah yes, health care’s favorite holy grail: better care at lower costs. So I’d say overall, everyone’s a lot more sheepish on the money saving claims including Kathleen Noonan, the Coalition CEO who took over after Jeff left. 

Noonan: We’re certainly not leading with saving money, let’s put it that way. But we still believe that there’s tons of waste and use of the emergency department that could be reduced. But it’s going to take a lot longer.

LW: The definition of success has changed. A lot of folks are just focused on: Let’s improve people’s health. And if they can do that, then people told me, the savings would come from making sure people get the right “dose,” if you will, of these different interventions.

DG: I see. Not everyone needs all of the housing, all of the meals, all of the social work, like how Larry needs a little help and Arthur needs more.

LW: Exactly. 

DG: Okay, so it sounds like we’re still a long way away from saving big bucks here.

And it seems, to me, like the only way to get closer to finding those solutions is to study these new approaches that the Coalition, Jeff and others are testing.

I’m curious, Leslie. Did either of them say if they’d be willing to do another big study after the disappointment of the first?

LW: Yep, they both said they would down the road. And those states with the ambitious pilots, they’ve got big evaluations in the works too. Researchers Paula Lantz and Amy Finkelstein both told me that kind of commitment to learning is critical. Here’s Amy.

Finkelstein: These are too important problems to not keep working on, but they’re also too important to just declare victory without evidence. That’s how we progress is we try, we evaluate, we learn from what happened and we generate new hypotheses and keep testing. 

LW: Others like Kathleen Noonan and Allison Hamblin agree we need more studies, but they also urge researchers to think more broadly about how to measure the impact of this work.

DG: Right, I remember one of the big criticisms of that first trial is that it put so much focus on this one metric: Did people go back to the hospital or not? But there are a lot of other ways this work can affect people’s lives — their mental health, their happiness, their trust of the health care system.

LW: That’s right, and whatever you’re measuring, all of these studies take money. Kathleen, who heads the Coalition, said it’s hard to find funding to keep studying this work especially when good news is hard to come by.

Noonan: I mean, some organizations have to work on this, even if we get results that we’re not happy with, right? We’re a long way away from figuring out the solution.

DG: Leslie, thanks for your work on this story.

LW: You’re welcome.

DG: As far off as reliable, sustainable solutions are for folks like Kathleen Noonan, the need for them remains urgent. You can see it in the lives of people like Arthur Brown. You can see it financially, where homelessness and addiction combine to cost the health care system north of $20 billion a year and wreak havoc for millions of Americans. Kathleen says that’s why the search to repeat miracles like Larry Moore’s is unlikely to stop anytime soon. 

I’m Dan Gorenstein. This is Tradeoffs.

Tradeoffs’ coverage of complex care is supported, in part, by Arnold Ventures.