John Baldessari, Conceptual Art Pioneer, Has Died

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Nearly two decades ago, a doctor in Camden, N.J., had a bold idea. He would tackle soaring health care costs by targeting the sickest, most expensive patients. The theory was this - giving those patients extra support with their medication, follow-up appointments, basic social services would keep them out of the hospital, away from emergency rooms. The model got a lot of media attention, with headlines describing it as health care's best hope. Now a study out today in the New England Journal of Medicine finds that the method made no difference. To explain why, we're joined by Dan Gorenstein of the health care podcast "Tradeoffs."

Hi, Dan.


SHAPIRO: Tell us more about the Camden project and the doctor behind it.

GORENSTEIN: Sure. So Dr. Jeff Brenner is brash, visionary guy, right? And he really wants to go around to all these doctors in Camden, which is a city that's known for its poverty. It's known for its violence. It's a very tough place to live. And he says to all these doctors, send me your worst of your worst patients because I've got an idea. I've got a plan for how I can treat them, improve their care and lower health care costs.

And basically, his idea, Ari, is that there's about 5% of patients who are responsible for 50% of the spending. Some of those people you can't really do much about. You've got people who are preemies. You've got people at the end of life. But then you've got these patients that Jeff was seeing - they've got asthma, they've got COPD, they've got diabetes. But they're not able to manage these sort of manageable health care conditions. And so his plan is to pair these people with social workers and nurses and get them better care.

SHAPIRO: The idea makes sense on its face, that if a diabetes patient monitors their insulin, if an asthma patient has their inhaler, they're not going to wind up in the emergency room so much. So Dr. Brenner invites researchers to study this method and see if it's making the impact that it appears to be having. And what did he find?

GORENSTEIN: So what they find is that these people, like one of the people that they first enrolled in the trial was this man named Larry Moore who had medical problems and also had alcohol addiction. Three months in, things are going great. And then all of a sudden, Larry loses his housing.


LARRY MOORE: And then I became homeless. I was just going from place to place to place to place, sleep on the bench or sleep on a rock until the next day and the liquor store opens. And then I'm - that was my daily routine.

GORENSTEIN: And the big insight over this trial and why this trial really probably didn't work in many ways, according to the coalition at least, is because when you have a small hiccup, it can cause this huge tailspin. And so Larry Moore misses his rent payment. He loses his housing. And then he loses touch with the coalition for 2 1/2 years. And, you know, Ari, over those 2 1/2 years, Larry Moore ends up in the ER 70 times. And ultimately, even when the coalition reconnects with Larry Moore, he wants to get housing, but there are just not services for people. There are not enough services.

SHAPIRO: So how has Dr. Jeffrey Brenner responded to these findings?

GORENSTEIN: So I spoke with Dr. Brenner, who left the coalition a couple of years back and is now at UnitedHealthcare, doing similar work for them. And as you might expect, Ari, he's pretty disappointed.


JEFFREY BRENNER: It's my life's work. So, of course, you're upset and sad. But this is the messy thing about science. Sometimes things work the way you want them to do and sometimes they don't.

SHAPIRO: So if this idea doesn't work, does the whole system just get scrapped or does the study have suggestions for how it might be made more effective?

GORENSTEIN: So this work is not going to get scrapped. There's no doubt about it. You've got some of the nation's largest health care companies investing in this work. Medicare and Medicaid are getting into this. Amy Finkelstein, the MIT economist who did the research, compares this to cancer research. And just, like, off the bat, if you don't have a cure for cancer, it doesn't mean you stop researching a cure for cancer. So this really is just the beginning. And this offers some good insight into how to better tailor a solution.

SHAPIRO: And the patient that you told us about, Larry Moore, where is he today?

GORENSTEIN: Yeah, Larry's got his own place. I was there. It's sunny. It's beautiful. He's got some nice plants. He has treated his alcohol addiction. He's going to be two years sober in the spring.


MOORE: It feels awesome to wake up without the shakes, to be able to function without a drink. I wasn't going to stop on my own.

GORENSTEIN: Of course, Ari, Larry's just one story. And that's one of the big lessons from this study that has been done. We need evidence even in the face of great stories like Larry's. And if programs like these do prove to be effective, they're going to be expensive. They're going to cost money. And it's not clear that there's the political will for that.

SHAPIRO: That's Dan Gorenstein of the podcast "Tradeoffs." He also reported on the study for NPR's Shots blog and our partner, Kaiser Health News.

Thanks, Dan.

GORENSTEIN: Thank you, Ari. Transcript provided by NPR, Copyright NPR.