Fixing the 5%
An oversized poster of the Seinfeld character Kramer watches over Phil Rizzuto’s daily routine. When Rizzuto, named for the famous New York Yankees shortstop, swallows his 6 a.m. pills, Kramer is looming over him, looking quizzical. Same for the 9 a.m., noon, 6 p.m., and midnight doses, each fistful of pills placed in a carefully labeled Dixie cup. “I live on medication,” he says.
Rizzuto’s daily life in Haverhill, Massachusetts, is a litany of challenges: His aides have to hoist his paralyzed legs from his bed to his motorized wheelchair and back again; keep the bag that collects his urine clean; tend to the gaping wound on his backside, which developed when he was left to lie still in bed too long; and help him avoid the panic that could claim anyone in his situation—that last one is particularly difficult since Rizzuto’s obsessive-compulsive disorder drives him to want to do everything for himself.
After more than a year of emergency and rehabilitative care following a devastating car accident, Rizzuto moved into a YMCA-run housing complex in this gritty New England town. But he still endured constant medical emergencies. “I was back and forth and in and out of the hospitals so much, it was like I didn’t know I had an apartment here,” the 56-year-old says, sitting in his small studio. His open wound kept getting infected; his diaphragm, weakened by his injury and his inability to quit smoking, left him gasping for breath; his urine-collection bag slipped out; his demons kept getting the better of him. The government eventually covered the cost of his care, but the relentless need for medical attention was exhausting and demeaning.
Then he opted into a Massachusetts health-care program called One Care that focuses on people with complex medical needs who are on Medicare. One Care provides 71 hours of aide support a week, a twice-weekly visit from a massage therapist, twice-monthly psychiatric care, a wheelchair support group, and a nurse practitioner who oversees and coordinates Rizzuto’s care. If he struggles between visits—or just wants to talk—she’s available by phone, even on weekends and after hours. Now, his life has a routine and a discipline that keeps emergencies at bay. “The difference it’s made …” he says, unable to fully express his gratitude. He estimates his hospital visits have dropped at least 75 percent since the One Care program took charge of his health. “I would hate like hell to not have them.”
The program that has helped Rizzuto is part of a nationwide movement to improve care for people struggling with very complicated medical needs—so-called super-users—the 5 percent of patients who account for about half of the country’s health-care spending. (Surgeon and New Yorker writer Atul Gawande outlined the problem and one solution in a definitive 2011 pieceabout the Camden Coalition of Healthcare Providers.) Some of these super-user programs say they provide cost savings of as much as 20 to 40 percent after a few years, as well as provide the kind of advantages offered to Rizzuto: fewer stressful hospital visits, better mental and physical health, and the satisfaction of being treated like a person instead of a package of problems. The program accomplishes this by shifting the focus of medical care. Instead of responding to complications, the care team tries to prevent them. “You can’t even get to the medical issue until you’ve figured out: Do they have a place to sleep, do they have housing they’re not going to lose, do they have food in their refrigerator, do they have a refrigerator?” says Christopher Palmieri, the president and CEO of the nonprofit Commonwealth Care Alliance, which manages 80 percent of One Care patients, including Rizzuto.
Despite its successes, this care movement, which doesn’t go by any catchy name—one doctor gave it the clunky title “high-impact, relationship-based primary care”—is scattered among a handful of states and is advancing only very slowly across the country. There is general agreement that these programs must address a range of social and pragmatic needs, like transportation, housing, nutrition, isolation, emotional well-being, and medical problems. But the details of each program are different. “Everyone’s trying their home brew,” says Dr. Harlan Krumholz, a cardiologist and health-care researcher at Yale University and Yale-New Haven Hospital.
The one thing all of the super-user care programs have in common is a mantra that could have come from Cosmo Kramer himself: Stay the hell out of the hospital. Hospitals, these folks argue, often make sick people sicker. They’re sources of infection to vulnerable patients. They’re disorienting. They run costly tests and look for issues that are better left alone. Super-users, says Krumholz, “represent a failure of the system.”
(Read the rest of the story on TheAtlantic.com)
Photo: Bill Regan sprays water on Phil Rizzuto to keep him cool during a recent visit to a suburban Boston zoo with Rizzuto's wheelchair support group.