We were all trying to breathe through our mouths, and despite his obvious pain, 45-year-old Mariano Garcia sat transfixed, watching his podiatrist Dr. David Millili cut through the bandages wrapped around Garcia's left calf.
It was one of those moments that takes forever, the smell filling the air. As the dressings came off, the room went quiet.
Garcia gagged, and Millili balked.
“I don’t have access to treat this right,” Millili said. “I don’t see any maggots or anything. I’m not dealing with this.”
Millili turned to Garcia: “When was the last time the bandages were changed?”
“Last time I was here,” Garcia said.
Millili was incredulous. “Really? A week?” he said.
Garcia’s been coming to Cooper University Hospital in Camden, N.J. for two years now, and everybody in the exam room knows exactly what needs to happen: Those bandages must get changed daily. But no matter how simple it sounds, it’s not happening.
Garcia says it hurts him too much to do it, and visiting nurses say they don’t feel safe going to his neighborhood. Frustrated and defeated, Millili has one choice right now, but he knows sending Garcia to the hospital is just a temporary fix.
“When we finally get things turned in the right direction again for him, how do we keep it that way?” Millili says. “Three weeks after he leaves the hospital, why are we not in the same situation? I can’t control infection. I can’t control pain. I can’t control these wounds.”
The doctor is talking about Garcia, but he may as well be talking about one of the biggest puzzles in this new era of healthcare. How can doctors keep people healthy when they have almost no control over what happens outside the four walls of the hospital?
It’s the edge of the healthcare world.
“A lot of clinical care is kind of like the tree falling in the forest,” saysRebecca Onie who runs the non-profit Health Leads, which works with medical providers to connect their patients to social services. “For example, a patient will come in to manage her diabetes but needs to refrigerate her medication and hasn’t had electricity for six weeks.”
Onie says now that hospitals either must drive down costs, or face what could be crippling financial penalties. Healthcare executives must leave the medical map behind and head out for the uncharted territory.
“They are going to have to begin paying for a set of things that have historically [been] considered outside the scope of traditional healthcare,” she says.
And so we are beginning to see healthcare’s first, hesitant steps, where doctors and hospitals wade into the world of social services.
Health Leads works with 20 providers, serving some 15,000 families. Kaiser Permanente, one of the top health systems, has several pilot programs, including one in Oregon where ambulance staff act more like social workers – helping solve would-be domestic problems, and avoiding trips to the ER.
“We spend almost 1.5 times more than the next most expensive country and yet our health outcomes are among the very worst in all high income countries,” says Yale public health professor Elizabeth Bradley.
She says it’s no mystery that education, poverty and safety have more to do with a person’s overall health than medical care does. In her book last fall, Bradley and her co-author, Lauren Taylor, found people in countries that spend less on medical care but more on social services were healthier than people in the United States.
“The major reason we are not doing better... the unnamed culprit is that we are probably spending less on the social services than is necessary,” Bradley says.
This social service healthcare frontier isn’t as popular as the California Gold Rush, but it's close. It’s on the tip of tongues at healthcare conferences. The Robert Wood Johnson Foundation identified it earlier this year as one of three critical steps to move healthcare forward. Even the nation’s largest healthcare program for the poor – Medicaid – has signaled its willingness to pay for some care outside the traditional stuff -- for example, air conditioners for asthmatics.
“We recognize that it can’t just be the office visit,” says Dr. Stephen Cha, the chief medical officer for Medicaid. “That’s the core of it, but we have to think about when we face this patient, we are looking at much more than just what we can do in that 15-minute span.”
In this first wave of programs, insurers aren’t paying for job training, hospitals aren’t moving families out of dangerous neighborhoods. But if interventions save money, then the game changes.
Kaiser Permanente’s Raymond Baxter, who oversees several non-medical projects, including the paramedic pilot, says it’s early, but that he sees promise.
“We are now adding a cost to the system in the short term,” he says. “However, if that intervention averts a series of visits to emergency rooms, in the long run you are going to see some real gains here.
Harvard health economist Amitabh Chandra has his doubts. Providers can only save money if they can pinpoint which patients truly benefit – a tall order – he says.
“I think of that as analogous to the man mission to Mars,” Chandra says. “It’s something that can be done. There is no theorem in economics or statistics that says it’s not possible. But you need absolutely terrific data to be able to make that happen. And I’ve just never seen it.”
Chandra’s driving at the X-Factor so often at the crux of healthcare: What can make people change their behavior?
Which brings us back to Mariano Garcia in Camden.
“I wish I could get better and get all this cleared and get me a job and work,” Garcia says.
Garcia’s life is so precarious, his options all risky. If he lands a spot in an inpatient treatment program for his leg, he’s not sure what happens to his one-room apartment.
“I don’t want to lose my place because I’ve going to the hospital,” he says. “When I get discharged from the hospital, then I’m where am I going to go out?”
There’s no easy answer, which is what makes wading outside medical care tricky. But hospital staff addressing Garcia’s social needs has helped him keep appointments and – even once or twice – change his own bandages.