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Using data to treat the sickest and most expensive patients

Patient Hector Riviera in Camden, New Jersey.

Patient Hector Riviera in Camden, New Jersey.

Driving to a big data conference a few weeks back, Dr. Jeffrey Brenner brought his compact SUV to a full stop – in the middle of a short highway entrance ramp in downtown Philadelphia.

He shrugged, a grin playing at the corner of his mouth.

"Wait for the car in front of you to go, and then gun it," he told me.

As we picked up speed, I could only watch as we headed straight for traffic down below. Brenner laughed. And we end up merging pretty seamlessly.

"Sitting at the other end of the ramp as 50-mile-an-hour traffic goes flying by you," he said. "You can’t get on the highway. You have to try something different, right?"

Here’s what you need to know about Dr. Jeffrey BrennerHe really likes to figure out how things work. And he’s willing to go to extremes to do it – so far that he’s risking his health policy celebrity status.

Perhaps it’s not the smartest move from a guy who just last fall was named a MacArthur Genius, but this month, Brenner began to test his theory for treating some of the sickest and most expensive patients.

"We can actually take the sickest and most complicated patients, go to their bedside, go to their home, go with them to their appointments and help them for about 90 days and dramatically improve outcomes and reduce cost," he says.

That’s the theory anyway. Like many ideas when it comes to treating the sickest patients, there’s little data to back up that it works.

Brenner’s willing to risk his reputation precisely because he’s not positive his approach for treating folks who cycle in and out of the healthcare system -- “super-utilizers” -- actually works.

“It’s really easy for me at this point having gotten a MacArthur award to simply declare what we do works and to drive this work forward without rigorously testing it,” Brenner said. “We are not going to do that,” he said. “We don’t think that’s the right thing to do. So we are going to do a randomized controlled trial on our work and prove whether it works and how well it works.”

Helping lower costs and improve care for the super-utilizers is one of the most pressing policy questions in healthcare today. And given its importance, there is a striking lack of data in the field.

People like to call randomized controlled trials (RCTs) the gold standard of scientific testing because two groups are randomly assigned – one gets the treatment, while the other doesn’t – and researchers closely monitor differences.

But a 2012 British Medical Journal article found over the last 25 years, a total of six RCTs have focused on care delivery for super-utilizers.

Randomized Clinical Trials (RCTs)

“All we have are tiny pieces, when what’s needed is a full arsenal of evidence given the enormity of the challenge,” says Jon Baron, president of the Coalition for Evidence-Based Policy.

Now, to be fair, researchers admit RCTs can be tricky to set up, time-consuming and expensive. And certain situations call for different study designs.

But the bottom line, said WellPoint Chief Medical Officer Dr. Sam Nussbaum, is that most health folks agree the nation needs more rigorous studies that will lead to more reliable data.

“If we look back over the past decades, many of the results we saw were overstating the capability of the program to deliver the results that the programs believed they were achieving,” he said.

Every major health insurance company – Medicare and Medicaid, too – has spent billions on programs for super-utilizers. The absence of rigorous evidence raises the question: Is all this effort built on health policy quicksand?

Health worker Margarita Santiago recruits patients for RCTs. Here she is in Camden, New Jersey, talking with patient Hector Rivera.

Not being 100 percent sure can be dangerous, says Duke behavioral scientist Peter Ubel, particularly in healthcare.

Ubel said back in the 1980s and 90s doctors prescribed certain drugs for irregular heartbeats. The medication, he said, made those weird rhythms go away, leaving beautiful-looking EKGs.

“But no one had tested whether people receiving these drugs actually lived longer, and many people thought, ‘Why would you do that? We can look at their cardiogram and see that they're getting better,’" Ubel said. “Finally when somebody put that evidence to the test of a randomized trial, it turned out that these drugs killed people.”

WellPoint’s Nussbaum said he hoped Brenner’s project would inspire others to follow his lead and insert data into the discussion.

“I believe more people should be bold in challenging the status quo of our delivery system,” Nussbaum said. “The Jeff Brenners of the world should be embraced. We should be advocating for them to take on these studies.”

So why aren’t more healthcare luminaries putting their brilliance to the test? There are a couple of reasons.

Harvard economist Kate Baicker said until now there have been few personal incentives pushing people.

“If you’re focused on branding and spreading your brand, you have no incentive to say, ‘How good is my brand after all?’” she said.

And Venrock healthcare venture capitalist Bob Kocher said no one would fault Brenner if he put his brand before science, an age-old practice in this business.

“Healthcare has benefitted from the fact that you don’t understand it. It’s a bit of an art, and it hasn’t been a science,” he said. “You made money in healthcare by putting a banner outside your building saying you are a top something without having to justify whether you really are top at whatever you do.”

Duke’s Ubel said it’s too easy – and frankly, wrong – to say the main reason doctors avoid these rigorous studies is because they’re afraid to lose money and status. He said doctors aren’t immune from the very human trap of being sure their own ideas are right.

He says psychologists call it confirmation bias.

“Everything you see is filtered through your hopes, your expectations and your pre-existing beliefs,” Ubel said. “And that’s why I might look at a grilled cheese sandwich and see a grilled cheese sandwich and you might see an image of Jesus,” he says.

Even with all these hurdles, MIT economist Amy Finkelstein – who is running the RCT with Brenner – sees change coming.

“Providers have a lot more incentive now than they use to,” she said. “They have much more skin in the game.”

Finkelstein said hospital readmission penalties and new ways to pay doctors are bringing market incentives that have long been missing.

Brenner said he accepts that the truth of what he’s doing in Camden may be messier than the myth.

But he said he can live with that.

“I think a lot of people are afraid to be wrong,” he said. “It's kind of fun to be wrong. Because being wrong frees you up from things that are not true and lets you move on to figuring out what's true.”

If his brand does take a hit, it means more time at work and more time to figure out what works. And Brenner said he’s willing to go wherever that takes him.

This ongoing series on healthcare and data is produced in partnership with Healthy States.

About the author

Dan Gorenstein is the senior reporter for Marketplace’s Health Desk. You can follow him on Twitter @dmgorenstein.

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