Consistent with last year’s findings, the trustees of the Medicare program forecast that Medicare’s hospital fund (Part A) would begin to run out of money beginning in 2024.

Parts B and D, which cover outpatient care and prescription drugs respectively, don’t face insolvency because they automatically draw money from the U.S. Treasury.

According to the trustees, payments for hospitals and other inpatient care would be cut automatically if the Part A trust fund reaches insolvency.

An aging population and the rise of healthcare costs are driving Medicare’s bleak forecasts. This year, trustees said, the hospital fund will pay out $38 billion more in benefits than it collects in taxes and premiums from seniors and the disabled. The trustees stressed the need to look beyond the exhaustion date for Medicare to the toll health care costs are already taking. “A more immediate issue is the growing burden that the program places on the federal budget well before exhaustion of the trust funds,” the report said.

While the upcoming elections in November will drive a lot of talk and speculation over how to rein in the costs of Medicare spending, at the Coalition, we’re already solving this problem – one day at a time – one patient at a time.

Nine societies in all, including the American College of Cardiology, the American College of Radiology and the American College of Gastroenterology, created lists of Five Things Physicians and Patients Should Question.

The American College of Radiology recommends “Don’t do imaging for uncomplicated headaches.” The American Academy of Family Physicians listed “Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.” Cardiologists weighed in with “Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.”

This is not completely new territory. Back in 2002, the New England Journal of Medicine published a randomized controlled study of arthroscopic surgery for osteoarthritis of the knee. The participants in the study (180) received either a real arthroscopy or a sham arthroscopy. The study showed there was no difference in outcomes, the participants got better at the same rate.

Doctors are paid through a fee for service model that rewards doing – not educating or listening. They don’t get paid to spend time talking to you. They get paid by the number of scans they run, procedures they perform and surgeries they complete. The profit margin for performing an arthroscopy is very high, so doctors are incentivized to do them. Preventative services and patient education have very low profit margins which is why you get about 15 minutes with your doctor at an office visit.

Anyone who cares about reducing healthcare costs in this country needs to trumpet the recommendations from “Choose Wisely” and empower and educate patients to question the need for expensive tests and unnecessary procedures. This is how we slowly bend the cost curve so that our healthcare system is sustainable in the long term.

Victoria is a nurse here at the Coalition and yesterday was her first case conference. Her patient has advanced COPD. He had been discharged from the hospital to a rehab center where he desperately needed physical therapy to help him recover some mobility and strength.

Her patient was very anxious about the mucus in his lungs choking him so he wasn’t getting enough sleep and while his wife knew how to suction him, she didn’t have a suction machine at home. That would mean a rushed trip to the Emergency Department (ED) if he needed help.

Victoria had spoken with his wife the day before and knew everything he would need at home to manage his condition once he left rehab. Her goal –manage him through rehab and try to keep him out of the ED once he got home.

As she listened to the care team, she realized they were discharging him that day because his wife couldn’t get his portable oxygen (O2) tanks to the rehab center. Without the O2 tanks, he couldn’t walk and if he couldn’t walk, the physical therapist wouldn’t be able to report any progress to the insurer. So his discharge papers were being signed as she watched.

Victoria is new and she didn’t want to overstep her bounds. But her patient was at risk of discharge, so she asked the simple question – “What if I go and pick up his tanks and bring them here – would that help?”

That question made the difference between discharge to the home and probably more visits to the hospital and weeks of therapy in a rehabilitation facility that will enable him to leave stronger and healthier and reduce his need for ED visits to manage his condition. The staff was grateful for the help. They are a good staff that will deliver great care during his stay.

Oh, and Victoria made sure he would get a suction machine delivered to his home after discharge.  Sometimes it’s just simple problem solving that can make all the difference.

Now imagine delivering healthcare to this population.

Each year, approximately 10 million unique individuals cycle through our country’s 3,300 jails. Eighty percent of detainees have substance abuse problems and 70% suffer from mental illness. And, when they’re not incarcerated, over half this population uses the local emergency room to receive care for their many chronic diseases. They have no other choice – 90% do not have health insurance.

The Community Oriented Correctional Health Services (COCHS) a non-profit organization that works to build partnerships between jails and community health care providers through funding by the Robert Wood Johnson Foundation produced a short video “The Unseen Provider: Health Care in our Jails” highlighting the challenges and ways to improve care and reduce costs.

The reality is that inmates are cut off from the rest of the healthcare system once they enter corrections. During intake, jail staff – with no access to previous medical history must begin the expensive and timely task of assessing detainee’s health status. So expensive tests are duplicated, time is wasted, and security is compromised, while the cost is borne by the county government.

Providing connectivity between healthcare providers in the jail and the local healthcare community is essential to reducing cost and waste.

Typically, 45-50% of inmates in the Camden County Correctional Facility are Camden residents and therefore cycle through Camden’s hospitals for care. The Coalition is working with Camden County and the Correctional Facility to provide the jail staff with access to the Camden Health Information Exchange (HIE). With access to the HIE, the intake and screening process will be dramatically improved – costs will decrease and quality will increase among this vulnerable population.

According to Dr. Jeffrey Brenner, “Embracing patients who have been in jail is the right thing to do as a society and it’s the smart thing to do.”

CNN and TIME Magazine have joined together to produce a quarterly series on American Renewal. The inaugural broadcast will air this Sunday at 8pm and 11pm EST. The topic: Global Lessons: the GPS Road Map for Saving Health Care.

Jeffrey Brenner, MD, Executive Director of the Coalition, is one of several people interviewed in the piece and he will discuss how bending the cost curve in healthcare can be done by targeting the highest utilizers and providing innovative care management and care transition strategies. The broadcast will also include footage with Camden patients. The companion article for TIME will be in the edition that is on newsstands Friday, March 17.

According to program host Fareed Zakaria “We Americans need to recognize that there are many areas where we could learn a lot from what other countries are doing.  America’s best companies routinely benchmark to global standards.  What we’re trying to do in this series is just that – look around the world and ask, ‘what can we learn?’  In the process, we also found areas where we could teach the rest of the world a thing or two.”

Others  interviewed are David Goldhill, the president and CEO of the Game Show Network, who penned an editorial for The Atlantic magazine (“How American Health Care Killed My Father,” Sept. 2009); New Yorker magazine’s Atul Gawande, MD; William Hsiao, PhD, an economics professor at Harvard who helped design Taiwan’s health care system; and The Washington Post’s T.R. Reid, author of The Healing of America: A Global Quest for Better, Cheaper, and Fairer Care (2010) for insights from his tour of health systems around the world.

One example of where we have innovated the use of data in this space is through our Health Information Exchange (HIE). The HIE provides historical data on utilization patterns within Camden. This arms our program staff with on how current clients or potential clients have been interacting with a specific hospital.

Initially, we were only providing the number of ED and inpatient visits. For example, our staff member knew that Patient A visited the ED 93 times and had 12 inpatient visits during 2011.

That was only partially useful. We recognized we were omitting important information such as length of stay and dates of utilization. The challenge was to incorporate all of this data into a display that would allow our staff member to easily understand what was happening with the patient.

The Solution
We created a time series depiction of each patient’s 2011 utilization patterns. (See example below) .The blue lines depict the ED visits and the red lines represent inpatient visits. The height of the red line depicts the length of stay. This chart gives staff a better understanding of the patient’s utilization pattern.

The Result
Now our staff member has important information that will allow them to better understand significant events that led to an inpatient visit; care transitions; patterns, etc. For new patients the chart helps the care management staff see if utilization was continuously high throughout the year or if their utilization was concentrated in a few clustered episodes.  They can also see if there are certain times of year when the patient’s utilization was low. This allows them to sit with and talk with them about what was going on at various times in their care. For patients currently receiving CCHP services the chart helps us see the big picture and potential utilization trends that they could not detect through qualitative information.

In her 40s, she was raising two children with her husband, running  a household and working nights as a school custodian in Cherry Hill.Now 52, she is confined to a small bedroom in her tidy East Camden rowhouse crowded with medical equipment, including a ventilator to help her sleep through the night. Her pills are stored in buckets. A television and a laptop help her pass the time.

Perez, a diabetic who weighs more than 300 pounds, breathes through a plastic tube in her trachea as a result of chronic obstructive pulmonary disease. “I was so independent. I took care of the kids, the car, everything. I had too much energy. Now, I live here,” said Perez, her voice mixed with resignation and frustration.

Perez came to the attention of the Camden Coalition of Healthcare Providers, a nonprofit organization founded eight years ago to improve health care for the city’s poor, when her health problems made her a regular in the city’s emergency rooms.

“Every 29 days she was admitted to the hospital, plus multiple ER visits in between, generally for respiratory issues,” said Jason Turi, clinical manager for the Coalition, which tracks hospital traffic to Cooper University Hospital and Our Lady of Lourdes Medical Center.“With intervention from us, she hasn’t been to the hospital in 10 weeks. That’s a strong sign that she has things under control and, ideally, she won’t need us anymore.”

Every weekday at 9 a.m. about a dozen health care people — from nurses to so-called wellness coaches — gather around a conference table on Market Street to view data from the two city hospitals. Projected on a wall is a list of people admitted the day before; it includes each patient’s name, their history of admissions and emergency room visits, the reason for their visit and their insurance carrier.

The record-holder for hospital trips is 113 visits in one year.

Many of the “regulars” who use hospitals as doctors’ offices and pharmacies are already enrolled in the Coalition and receive help in managing their care.The team also looks for new people among the daily reports and others they have helped in the past.Once a patient agrees to work with the Coalition, he or she becomes a “participant.” All are Camden residents receiving Medicaid. Many have chronic health problems, like diabetes, hypertension, asthma or an addiction.Many are on kidney dialysis three days a week. Most need transportation and help with time management to get to a doctor’s appointment.

The barriers to care can be daunting.

Jen Abraczinskas, a fourth-year medical student at University of Pennsylvania who took a year off from school to work at the Coalition, described a diabetic woman in a wheelchair who could not keep her blood sugar under control.“She couldn’t see well enough to read her sugar level and she was too shaky to prick her finger. When her caregiver was gone, she had no access to food because her house was not wheelchair-accessible.“Once we saw all this, we knew why she was in the hospital and we knew we had to come up an alternate plan.” The most powerful tool, she said, is the data-sharing of high users among competitive hospitals with the Coalition.

Another participant had part of his leg amputated due to infection and diabetes. When the prosthesis arrived for the black man, it was white. The Coalition is working on getting a replacement.The professionals at the table pass no judgments. When a regular does not show up on the hospital admissions list for 30 days, “we clap,” said Susan Liu, assistant executive director. “That’s a benchmark.”

Funded by grants and contributions from four hospitals, the Coalition hopes to become New Jersey’s first accountable care organization, or ACO, a model of care created through legislation last year.The Camden Coalition was, in fact, a model for the legislation and Brenner, its founder, helped craft the bill.The Coalition expects to complete its application to the Department of Human Services this summer.

ACOs are similar to the HMOs of the 1990s, but new and improved. They’re patient-centered, with a well-staffed family practice as the first line of defense.One of the differences is that health care providers — from doctors to hospitals — will be paid based on successful outcomes, not how fast can a doctor can run from room to room to see the maximum number of patients.

ACOs will be made up of doctors, hospitals, clinics, home health aides, wellness coaches.Members join voluntarily and commit to sharing responsibility for a patient’s health. They also share in the anticipated savings.“No outcome, no income,” said Turi, summing up a challenging, but essential, difference between an ACO and traditional, fee-for-service health care.

Frequent hospital admissions are symptomatic of no follow-up care, noncompliance by a patient, poor communication and other variables that get in the way of a reasonable and healthy outcome from illness or chronic condition.“We estimate $10,000 per hospital admission, $500 for emergency room visits. If all sectors work together to keep people out of hospitals, the long-term cost is substantially less and the outcome is better,” said Turi.

There is very little about the current health-care model that Brenner, a family physician in Camden, would save.“There are too many hospitals and too many specialists doing unnecessary things to people. Doctors make money from cutting, scanning and hospitalizing. They don’t make it from talking to patients. Patients have become organs with legs. Nobody puts the whole picture together. Providers just walk around going ka-ching, ka-ching.” Standard cost-saving methods, like raising co-pays and deductibles, only reduce the number of people who can afford to go to a doctor, he added.

Brenner is not sure he has found a solution, but is certain the current system is unsustainable.“The bulk of the federal debt is health care. The cost of health care for employers cuts into people’s raises. Towns are broke buying health care for their employees. We are being crushed as a nation in lots of ways.”Brenner is hopeful his model will catch on nationally for all income levels, including Medicare.

“Now health care is a passive model. We wait for patients to come to us. An ACO would offer more-organized, wrap-around care, opportunities for classes, and regular follow up — like an orchestra.“It would be ironic if Camden becomes a model. But if we can take care of extreme cases like a homeless diabetic with a brain tumor, suburbia would be cake.”

Lou Bezich, Cooper’s newly appointed chief of staff, said the hospital supports the Coalition with an annual $250,000 stipend. It also has representation on its board.Hospitals with high incidence of readmission will be penalized under federal health care reform. “It’s hard to say what Cooper will look like in five years, but we are trying to be nimble and position ourselves for change,” he said.

Courier Post staff writer: Eileen Stillwell