The Doctor on a Medical Mission
In the early 2000s, the city of Camden, New Jersey—across the Delaware River from Philadelphia—was one of the poorest and most crime-ridden in the nation. When gunshots rang out on a night in February 2001, it was nothing out of the ordinary. This time a promising 22-year-old African American student from nearby Rutgers University lay dying in the street. According to reports in thePhiladelphia Inquirer, onlookers complained that police did little to save him, assuming he was too far gone.
Neighbors called Jeffrey Brenner ’90, a then 31-year-old family physician who lived up the street, for help. He performed chest compressions and rescue breathing, but the man died.
That Brenner was there at all was the result of a surprising change in the trajectory of his career. As a med student at the Robert Wood Johnson Medical School, he was on track to become a neuroscientist. But volunteering once a week at a free primary care clinic for poor immigrants changed his mind. Upon completing his residency in 1998, Brenner joined a family practice in Camden. It was a choice that many of his medical colleagues would not have made, but, as it would turn out, Camden is exactly where he was needed most.
Brenner and many in Camden were outraged at the lack of action from the police that dark February night. Their vocal outcry prompted the Camden County prosecutor to launch an investigation into the police response to the shooting. Meanwhile, Brenner organized local groups and individuals to provide CPR and basic first aid training to Camden’s police officers in what was known as the Camden City Save a Life Project. “I don’t know how to prevent violence,” Brenner told the Inquirer. “But I can … make sure people are able to respond in the event of an emergency.”
In the wake of the 2001 shooting, the New Jersey State Attorney General appointed a police reform commission—the Camden Commission on Public Safety—and Brenner was asked to join as one of two citizen representatives. There he heard about strategies for effective community policing, including New York City’s Compstat approach, which centered on mapping crime and focusing resources on hot spots.
The police reform commission’s 2006 report declared “the Camden Police Department had failed in its duty and responsibility to provide adequate police services” and noted an “apparent lack of willingness of the Department’s leadership to adopt the changes necessary to address the crisis.” Brenner walked away in frustration, but not without an idea of his own—to apply the Compstat approach to crime to healthcare.
Brenner slowly obtained healthcare cost data from three of Camden’s main hospitals. This alone was no small feat. “Hospitals consider this to be business intelligence,” he explains. But with Camden’s status as one of the most dangerous cities in the country at the time, “the situation was so dire, it was hard for them to say no,” Brenner says. He sifted through the data in his spare time, constructing a block-by-block map of the city, color coded by the hospital costs of residents, looking for hot spots. His findings were staggering.
Just one percent of Camden’s patients accounted for 30 percent of medical costs. The two most expensive blocks were in North Camden: one with a large nursing home, the other with a low-income housing tower. Between 2002 and 2008, 900 people from those two buildings alone accounted for more than 4,000 hospital visits and $200 million in healthcare bills. A single patient had 324 hospital admissions in five years. The most expensive patient racked up $3.5 million in healthcare costs.
From Brenner’s perspective, those people with the highest medical costs and the greatest number of emergency room visits were usually receiving the worst care. They visited overburdened local clinics, were uninsured or otherwise remiss about seeing a primary care doctor for preventative care, were on welfare or otherwise poor and making detrimental lifestyle choices with little capacity for change, or were in a cycle of prescription medicine and other treatments that dealt with superficial symptoms rather than root causes of health problems. When such a scenario spiraled downward far enough, patients would go to the hospital, where the ER served as a kind of default primary care doctor—one where patients would be assured at least basic treatment, but where they also could default on paying for such services.
Brenner considered such a pattern to be a fundamental failure of the healthcare system; chronic “super users” were missing out on opportunities to find healthcare sooner, in less expensive ways. So, he set out to do something about it.
Brenner founded the nonprofit Camden Coalition of Healthcare Providers, where he serves today as full-time executive director. The group started ten years ago, in early 2002, as a less formal “Camden healthcare providers breakfast group.”
Local doctors started sending him their “worst of the worst” patients. Brenner helped them pro bono, in addition to trying to run his family practice. His approach was comprehensive—he saw the patients in the hospital, visited them at home, worked with them on lifestyle improvements. Soon, they numbered in the hundreds. The work was so consuming and underfunded that Brenner shut down his practice in 2009, deciding instead to focus on his work with the Camden Coalition.
A look back at Brenner’s first 36 “super users”—tracked from 2002 through 2007—is insightful. An average 62 hospital/ER visits per month dropped 40 percent to 37. Some $1.2 million in hospital bills per month dropped 56 percent to just over $500,000. According to the journal Perspectives in Health Information Management, every dollar spent by Brenner and his team on such patients reduced monthly emergency room/hospital charges in Camden by nearly $55.
Brenner’s positive impact is substantial and undeniable, and he has—until recently—performed his work quietly, in a city not known for its success stories. But all that’s changed. In January 2011, the New Yorker prominently featured Brenner and his work. More recently, he appeared on CNN with Fareed Zakaria. Now the country has its eyes on the innovative healthcare work he’s been doing for the last decade.
The medical hot-spotting approach has been adopted in various ways in other cities across the country: Austin, Texas; Atlantic City, New Jersey; Danville, Pennsylvania; Boston; San Francisco; Seattle; and Las Vegas, to name several.
Today, however, Brenner’s focus has shifted from the individual to the collective. His big picture efforts revolve around better coordination of care across providers, and better delivery of that care to patients, thus reducing the incidence of medical hot spots. His Coalition works with primary care offices to help redesign how they operate, using electronic health records, patient education programs, and other methods to improve the efficiency and efficacy of care.
The Coalition also fields a team of “transition nurses,” people who show up at the hospital (usually on the last day of a patient’s hospitalization) to help with care, aid with discharge planning, show up at the person’s house the next day, go with them for their primary care follow-up visit, and see the patient in a series of visits over the subsequent six months. Brenner does this on a shoestring budget with Americorps volunteers, super-smart college grads—many of them pre-med or nursing majors—who spend a year with his organization as health coaches.
Brenner is critical of healthcare’s current fee-for-service business model, which he says is “like a turnstile at a circus. The more people that go through, the more money you make, without regard for quality or necessity.” Fixing healthcare is not a technical problem, he says. “It’s a moral, spiritual, and political problem. And the fact that a stubborn family doctor in Camden working with young people and students and little funding is having to innovate speaks volumes about what’s not occurring and how far behind we are.”
Still, Brenner remains hopeful, thanks in part to a new bill, recently signed by New Jersey’s Governor Chris Christie, which calls for health care providers to form accountable care organizations (ACOs) in places such as Camden, Newark, and Trenton. In this model, reimbursements from the state and federal government and from insurance companies are tied to the quality, efficiency, and appropriateness of the care they provide; and healthcare professionals share a portion of the cost savings as added financial incentive. By delivering better care, the hope is that they can both improve people’s health and decrease costs. “It’s a business model for behaving virtuously in healthcare,” he says. “I’m betting the farm on it, but it’s a wonderful bet.”