The challenge in pairing the sick with social services

Dan Gorenstein Jun 23, 2015

The challenge in pairing the sick with social services

Dan Gorenstein Jun 23, 2015

Indiana Jones, he’s not.

“I’m a 5’7” guy from Portland, Oregon, raised in a Jewish family,” says Dr. David Labby, making him perhaps more Woody Allen than Harrison Ford.

But like the daring archaeologist from the movies, Labby is after a rare and elusive prize: He wants to keep chronically ill and poor patients in Portland from landing in the hospital again and again.

“These are people who have lived in some form of constant crisis, so they know how to survive in crisis,” he says. “They don’t know how to take care of a chronic disease. And so they come to us for help. What we think is help to them is not helpful. It doesn’t work for them. It doesn’t work for us. We just have to start over.”

What doesn’t work is prescribing medications that must be kept cool for someone who doesn’t have a refrigerator. What doesn’t work is pressing patients to eat better when they don’t know where their next meal is coming from.

But Labby thinks he’s finally found a way to get that fresh start — to work with these super-sick, super-expensive patients.

“What I’ve learned is if I’m going to help somebody, I really need to know about their life,” he says, “what it’s like for them on a day-to-day basis. And that takes a lot of work to really understand.”

There’s plenty of incentive to do just that. The sickest and most expensive 5 percent of patients use about half of the healthcare dollars.

Many wind up in the emergency room or the hospital again and again, because they can’t manage their chronic illnesses. Combine that with an environment where there are new financial incentives for doctors to find better outcomes, not simply provide service after service, and the landscape is ripe for this kind of innovation.

In Portland, Labby and others at the insurance company CareOregon have created the Health Resilience Program.

The idea is that healthcare providers leave the exam room and spend more time developing relationships with patients in their kitchens and living rooms.

Now “health resilience specialists” — effectively social workers — spend a chunk of their time dropping in on patients like Scott Freeland.

Freeland, 52, was paired with specialist Marika Shimkus in 2013. They’ve become close enough that finishing each other’s sentences comes easy for these two.

“Without you, I’d be lost almost sometimes,” Freeland says. “She is really good at her job. She’ll even let me use her phone to call and make appointments right at the doctor’s office or something.”

Shimkus demurs. “I want to be sure that it’s clear the credit is really you,” she says. “You’ve let me pester you.”

Shimkus’ job is to pester Freeland — and her 20 other clients — to help them figure out what they need to take care of themselves and to hook them up to services like housing, food, help applying for an ID or maybe make an appointment with a specialist.

The Portland program serves about 600 of the sickest and most expensive Medicaid patients in the city. For Freeland, it’s made a difference. He says before he met Shimkus, he was living hard.

“I think that year I was in the hospital 17 times or something,” he says. “I was doing crystal meth, the devil’s dandruff. Every time I did it I’d start throwing up blood. I’ve had to have a transfusion before. My throat has been so raw. It’s messed my eyes up too, my diabetes has. It’s a crazy life I used to lead. But I’m actually doing pretty good now.”

Matched with Shimkus, Freeland was in the hospital once in their first year together.

The Health Resilience Program cranks out these sorts of stories.

In two and a half years, this program has put up some gaudy numbers, cutting emergency room and hospital visits by 35 percent.

Labby and the team are now household names in this little corner of the healthcare world, where doctors try to administer social services to solve medical problems.

The consulting firm Oliver Wyman says there are $300 billion in potential savings every year, if this type of work lowered costs for all of us.

This is what healthcare’s city of gold looks like, where money is saved and health is better.

Harvard health economist Amitabh Chandra says it’s a nice theory.

“There’s so many things we do in American health care because we think that they must work,” he says. “We have incredibly powerful narratives that each one of these things is going to generate billions and billions in savings.

“But every time we looked, we’ve found the answer has been a big giant zero,” he says.

We asked Chandra to look over data from the Health Resilience Program, and he says while the program may improve health, it’s impossible to say whether it’s saving money long term.

Odds are these sorts of programs are unlikely to save any real money, says Dr. Ashish Jha.

“There are almost no interventions that we know of that improve health and save money,” says Jha, who is also at Harvard. “There are a couple of things that we do know. Vaccinations are probably the No. 1 thing. Once you get beyond that, it starts to get pretty tough.”

Jha says what makes this work tough is that patients each have their own costly web of issues and illnesses that can’t be resolved with a one-size-fits-all solution like a vaccine.

Pinpointing the underlying social challenges can be a guessing game for doctors, where they try to tackle very deep, persistent problems — like addiction, mental illness and obesity — with treatments that often don’t work.

These obstacles, not to mention limited evidence, help explain why there’s no line of healthcare chief financial officers outside Labby’s door.

“Until we have a business case for healthcare providers, for large organizations to really take this on, I think it’s going to be a series of pet projects,” Jha says.

Since his great run that first year working with health specialist Shimkus, Freeland’s life has become complicated again. A few months back he got beat up trying to protect his cousin from her husband.

“He broke my jaw and a couple of ribs, and I was in the hospital for 10 days,” Freeland says.

Additional health complications and drinking have led to an uptick in trips to the emergency room. Freeland says he’s trying to keep things under control, and as he does, his cell phone rings. It’s his cousin, telling him he’s bought him some beer.

The cousin and Freeland’s uncle live next door.

“They’re my closest friends that I have, and I hang out with them quite a bit, watch TV. And they drink every day — like a lot.”

The hard reality of this work is that healthcare providers are trying to help fix someone’s life, a process is full of half steps, missteps and backslides.

“They first tell me you can’t have sugar, and then tell me I can’t have salt. Now it’s like you guys want me to stop drinking, too,” Freeland says.

“I will probably never ever stop drinking. Just trying to be realistic. And sometimes you almost have to drink just to get through all your problems and stuff,” he says.

Is this what success looks like — progress and then relapse? How much time and money do you invest in trying to help someone like Freeland? Is his setback just temporary?

Important questions, says Labby, that he admits are hard to answer.

“Our experience has been people we are dealing with have had really rough lives,” he says. “They are not going to recover from those lives in one moment.”

The program’s goal is to build stable lives. That takes time, which takes money.

It’s a tough enough road that it’s fair to wonder if the Labbys of the world see something in this healthcare jungle that most of us can’t — or if he’s a do-gooder, lost on a never-ending hunt.

Click the media player below to hear reporter Dan Gorenstein speak with Marketplace Morning Report host David Brancaccio about social issues and healthcare.


 This story was reported with the support of the Dennis A. Hunt Fund for Health Journalism and the National Health Journalism Fellowship, programs of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.

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