| January 24, 2011 | Medical
Report | The Hot Spotters
Camden, New Jersey, becomes the first American community to lower
its medical costs, it will have a murder to thank. At nine-fifty
on a February night in 2001, a twenty-two-year-old black man was
shot while driving his Ford Taurus station wagon through a
neighborhood on the edge of the Rutgers University campus. The
victim lay motionless in the street beside the open door on the
driver's side, as if the car had ejected him. A neighborhood
couple, a physical therapist and a volunteer firefighter,
approached to see if they could help, but police waved them back.
not going to make it," an officer reportedly told the
physical therapist. "He's pretty much dead." She called
a physician, Jeffrey Brenner, who lived a few doors up the street,
and he ran to the scene with a stethoscope and a pocket
ventilation mask. After some discussion, the police let him enter
the crime scene and attend to the victim. Witnesses told the local
newspaper that he was the first person to lay hands on the man.
was slightly overweight, turned on his side," Brenner
recalls. There was glass everywhere. Although the victim had been
shot several times and many minutes had passed, his body felt
warm. Brenner checked his neck for a carotid pulse. The man was
alive. Brenner began the chest compressions and rescue breathing
that should have been started long before. But the young man, who
turned out to be a Rutgers student, died soon afterward.
incident became a local scandal. The student's injuries may not
have been survivable, but the police couldn't have known that.
After the ambulance came, Brenner confronted one of the officers
to ask why they hadn't tried to rescue him.
didn't want to dislodge the bullet," he recalls the policeman
saying. It was a ridiculous answer, a brushoff, and Brenner
couldn't let it go.
was thirty-one years old at the time, a skinny, thick-bearded,
soft-spoken family physician who had grown up in a bedroom suburb
of Philadelphia. As a medical student at Robert Wood Johnson
Medical School, in Piscataway, he had planned to become a
neuroscientist. But he volunteered once a week in a free
primary-care clinic for poor immigrants, and he found the work
there more challenging than anything he was doing in the
laboratory. The guy studying neuronal stem cells soon became the
guy studying Spanish and training to become one of the few family
physicians in his class. Once he completed his residency, in 1998,
he joined the staff of a family-medicine practice in Camden. It
was in a cheaply constructed, boxlike, one-story building on a
desolate street of bars, car-repair shops, and empty lots. But he
was young and eager to recapture the sense of purpose he'd felt
volunteering at the clinic during medical school.
people shared his sense of possibility. Camden was in civic free
fall, on its way to becoming one of the poorest, most crime-ridden
cities in the nation. The local school system had gone into
receivership. Corruption and mismanagement soon prompted a state
takeover of the entire city. Just getting the sewage system to
work could be a problem. The neglect of this anonymous shooting
victim on Brenner's street was another instance of a city that had
given up, and Brenner was tired of wondering why it had to be that
that time, a police reform commission was created, and Brenner was
asked to serve as one of its two citizen members. He agreed and,
to his surprise, became completely absorbed. The experts they
called in explained the basic principles of effective community
policing. He learned about George Kelling and James Q. Wilson's
"broken-windows" theory, which argued that minor,
visible neighborhood disorder breeds major crime. He learned about
the former New York City police commissioner William Bratton and
the Compstat approach to policing that he had championed in the
nineties, which centered on mapping crime and focussing resources
on the hot spots. The reform panel pushed the Camden Police
Department to create computerized crime maps, and to change police
beats and shifts to focus on the worst areas and times.
the police wouldn't make the crime maps, Brenner made his own. He
persuaded Camden's three main hospitals to let him have access to
their medical billing records. He transferred the reams of data
files onto a desktop computer, spent weeks figuring out how to
pull the chaos of information into a searchable database, and then
started tabulating the emergency-room visits of victims of serious
assault. He created maps showing where the crime victims lived. He
pushed for policies that would let the Camden police chief assign
shifts based on the crime statistics—only to find himself in a
showdown with the police unions.
has no clue," the president of the city police superiors'
union said to the Philadelphia Inquirer. "I just think
that his comments about what kind of schedule we should be on, how
we should be deployed, are laughable."
unions kept the provisions out of the contract. The reform
commission disbanded; Brenner withdrew from the cause, beaten. But
he continued to dig into the database on his computer, now mostly
out of idle interest.
looking at assault patterns, he began studying patterns in the way
patients flowed into and out of Camden's hospitals. "I'd just
sit there and play with the data for hours," he says, and the
more he played the more he found. For instance, he ran the data on
the locations where ambulances picked up patients with fall
injuries, and discovered that a single building in central Camden
sent more people to the hospital with serious falls—fifty-seven
elderly in two years—than any other in the city, resulting in
almost three million dollars in health-care bills. "It was
just this amazing window into the health-care delivery
system," he says.
he took what he learned from police reform and tried a Compstat
approach to the city's health-care performance—a Healthstat, so
to speak. He made block-by-block maps of the city, color-coded by
the hospital costs of its residents, and looked for the hot spots.
The two most expensive city blocks were in north Camden, one that
had a large nursing home called Abigail House and one that had a
low-income housing tower called Northgate II. He found that
between January of 2002 and June of 2008 some nine hundred people
in the two buildings accounted for more than four thousand
hospital visits and about two hundred million dollars in
health-care bills. One patient had three hundred and twenty-four
admissions in five years. The most expensive patient cost insurers
wasn't all that interested in costs; he was more interested in
helping people who received bad health care. But in his experience
the people with the highest medical costs—the people cycling in
and out of the hospital—were usually the people receiving the
worst care. "Emergency-room visits and hospital admissions
should be considered failures of the health-care system until
proven otherwise," he told me—failures of prevention and of
timely, effective care.
he could find the people whose use of medical care was highest, he
figured, he could do something to help them. If he helped them, he
would also be lowering their health-care costs. And, if the stats
approach to crime was right, targeting those with the highest
health-care costs would help lower the entire city's health-care
costs. His calculations revealed that just one per cent of the
hundred thousand people who made use of Camden's medical
facilities accounted for thirty per cent of its costs. That's only
a thousand people—about half the size of a typical family
physician's panel of patients.
of course, got complicated. It would have taken months to get the
approvals needed to pull names out of the data and approach
people, and he was impatient to get started. So, in the spring of
2007, he held a meeting with a few social workers and
emergency-room doctors from hospitals around the city. He showed
them the cost statistics and use patterns of the most expensive
one per cent. "These are the people I want to help you
with," he said. He asked for assistance reaching them.
"Introduce me to your worst-of-the-worst patients," he
did. Then he got permission to look up the patients' data to
confirm where they were on his cost map. "For all the stupid,
expensive, predictive-modelling software that the big venders
sell," he says, "you just ask the doctors, ‘Who are
your most difficult patients?,' and they can identify them."
first person they found for him was a man in his mid-forties whom
I'll call Frank Hendricks. Hendricks had severe congestive heart
failure, chronic asthma, uncontrolled diabetes, hypothyroidism,
gout, and a history of smoking and alcohol abuse. He weighed five
hundred and sixty pounds. In the previous three years, he had
spent as much time in hospitals as out. When Brenner met him, he
was in intensive care with a tracheotomy and a feeding tube,
having developed septic shock from a gallbladder infection.
visited him daily. "I just basically sat in his room like I
was a third-year med student, hanging out with him for an hour,
hour and a half every day, trying to figure out what makes the guy
tick," he recalled. He learned that Hendricks used to be an
auto detailer and a cook. He had a longtime girlfriend and two
children, now grown. A toxic combination of poor health, Johnnie
Walker Red, and, it emerged, cocaine addiction had left him
unreliably employed, uninsured, and living in a welfare motel. He
had no consistent set of doctors, and almost no prospects for
turning his situation around.
several months, he had recovered enough to be discharged. But, out
in the world, his life was simply another hospitalization waiting
to happen. By then, however, Brenner had figured out a few things
he could do to help. Some of it was simple doctor stuff. He made
sure he followed Hendricks closely enough to recognize when
serious problems were emerging. He double-checked that the plans
and prescriptions the specialists had made for Hendricks's many
problems actually fit together—and, when they didn't, he got on
the phone to sort things out. He teamed up with a nurse
practitioner who could make home visits to check blood-sugar
levels and blood pressure, teach Hendricks about what he could do
to stay healthy, and make sure he was getting his medications.
lot of what Brenner had to do, though, went beyond the usual
doctor stuff. Brenner got a social worker to help Hendricks apply
for disability insurance, so that he could leave the chaos of
welfare motels, and have access to a consistent set of physicians.
The team also pushed him to find sources of stability and value in
his life. They got him to return to Alcoholics Anonymous, and,
when Brenner found out that he was a devout Christian, he urged
him to return to church. He told Hendricks that he needed to cook
his own food once in a while, so he could get back in the habit of
doing it. The main thing he was up against was Hendricks's
hopelessness. He'd given up. "Can you imagine being in the
hospital that long, what that does to you?" Brenner asked.
spoke to Hendricks recently. He has gone without alcohol for a
year, cocaine for two years, and smoking for three years. He lives
with his girlfriend in a safer neighborhood, goes to church, and
weathers family crises. He cooks his own meals now. His diabetes
and congestive heart failure are under much better control. He's
lost two hundred and twenty pounds, which means, among other
things, that if he falls he can pick himself up, rather than
having to call for an ambulance. . .
the entire report in the New Yorker, January 24, 2011, Issue . . .
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