But the Camden Project that Atul Gawande muses on in his latest New Yorker reportage (-word abstract at the link; subscription or article purchase required to read the whole thing online) has things in common with, things to say about, retail clinics nonetheless.
At the center of Gawande’s piece is the value of identifying cases where there are opportunities for effective management at reasonable levels of investment. That is, situations in which with the application of measurable amounts of resources – clinician and non-clinician time, supplies, facilities, and so on – can produce reductions in spending on care for the identified individuals totaling many times the dollar value of the treatment resources. And if not many times the value, then substantial dollar amounts in absolute terms, so if a $100,000 investment of resources returns a $200,000 reduction in the gross cost of treating the person’s conditions, that means $100,000 available to devote, presumably more effectively, to care of others – or to something like “economic betterment” for a person or persons we don’t need to identify for the moment.
Gawande reminds us that the distribution of health care resources resembles the distribution of phenomena in many other corners of human social existence – book and music popularity, family names, incomes, and corporate salaries come to mind. A very few people account for a very large share of the total resource consumption. That means that if the goal is to get more for each dollar of resources that are going to be devoted to health care anyway, perhaps the easiest way to go about it is to a) identify people whose treatment currently consumes large amounts of resources b) determine if their consumption of resources is due more to lack of coordinated application rather than the pure cost of the resources required for effective treatment and c) if lack of coordination is the issue, to obsess about coordinating the use of resources in the cases identified.
The secret ingredient to coordinating more effectively is frequently to identify non-clinical matters that are confounding effective care – confused or non-existent communication among care providers, logistical issues that thwart a person’s ability to obtain the stuff of routine health preservation (nutritious food, practical exercise, removal of health-imperiling hazards in their day-to-day environment, etc). They have no way to communicate reliably, consistently, with concerned caregivers? Give them a pre-programmed cellphone. That kind of thing.
Another obvious implication is that care for super-utilizers is conducted by teams – and, ordinarily, not teams made up entirely of doctors. Care is provided systematically, with the most appropriate configurations of resources brought to bear on various facets of the activities that together comprise the “care management solution” (my kingdom for an elegant vocabulary for this stuff!).
So what does Gawande’s tale about subduing super-utilizers have in common with the story of retail clinics? Well, in a way, clinics address the same kinds of issues at the opposite end of the power law function that is the distribution of health care resource consumption. They embody conscious, pragmatic efforts to reconfigure resources used to address particular health care needs so that resources are employed more effectively – to get greater bang for each buck.
Which, if we want to get dramatic about it, involves re-imagining what we are talking about when we are talking about “health care”.
The New Yorker hosted a live chat with Gawande about his Super-Utilizers essay on Thursday 1/19. Not markedly revelatory, but some of the Q&A may interest you.
For those seeking extra credit, read or re-read Malcolm Gladwell‘s Million Dollar Murray, which does a much better job than Gawande of considering the problem(s) inherent in solving the challenge of health care spending by focusing on super-utilizers (spoiler alert: there are problems, which we human beings seldom resolve very effectively).
