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The edge of health care: When medical care isn't enough

The edge of health care: When medical care isn't enough

Picture of Dan  Gorenstein
Mariano Garcia rests at home in Camden, N.J.
Mariano Garcia rests at home in Camden, N.J. (photo by Jessica Kourkounis)

We've entered an interesting moment in health care. The patients hospitals and doctors have historically made money on — the so-called "frequent fliers" — have become millstones around their necks. In this ACA-era, healthcare providers and insurers must find ways to limit the number of patients returning to hospitals or face what could be crippling fines.

And that's starting to happen. The Centers for Medicare and Medicaid Services reported more hospitals were penalized than received bonuses for these readmissions in the fall of 2013. As we see a rise in bundled payments, ACOs and other alternatives to fee-for-service payments, there are very real financial incentives for providers to keep patients out of the hospital. 

There's just one thing: this is incredibly hard work, particularly on a large scale. What the healthcare system is beginning to learn is that often medical care just isn't enough to help their "super-utilizer" patients remain healthy.

A quick story. Earlier this year I met Mariano Garcia, a middle-aged man who lives alone, is unemployed and struggles with addiction. Healthwise he's got horrible leg wounds that make it virtually impossible to get around. Despite multiple efforts by his doctors, and visiting nurses, it's proven nearly impossible for Garcia to change his bandages, making the situation that much worse. To solve his health problems and keep him out of the hospital, Garcia needs a variety of services that includes mental health counseling, access to a local methadone clinic, financial support and transportation. And don't forget, Garcia is just one patient. Every community in America has people with chronic health conditions and difficult social needs.

My project looks at how far providers and insurers are willing to go to keep the Mariano Garcias out of the hospital. Will they pay for services that fall outside traditional medical care? If not, then what? Everybody is talking about the importance of "social determinants" of health these days. As I begin this series of stories, I'm looking forward to learning about the providers who are pushing the boundaries of "healthcare" and whether they are saving money and improving people's lives.


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