"High-touch" medicine leads to lower costs--and yet it's low-resource in its way

One of the things I admire about low-resource medicine is that, by definition, it doesn't cost much. By contrast, ER visits and hospitalizations in the high-resource American system can be tremendously expensive. And it's sobering to consider how those visits could so often have been prevented, how many of those resources are spent wastefully. We've all heard about how many trauma patients might not have been hurt if only some simple measures had been in place: helmets, handing over the car keys, wearing a seat belt. What's less obvious is that ER visits for chronic diseases could also be reduced--not with even snazzier drugs and higher-tech diagnostics, but with little things, the kinds of things that the US system isn't designed to pay for. Things like careful follow-up for outpatients, coordination of prescriptions among all a patient's doctors, and robust social supports.

One Dr. Jeff Brenner is trying to do just that in Camden, New Jersey. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” Brenner told Atul Gawande in the latter's recent New Yorker article about "high-touch" medical care. Damn right.

Gawande's article examines strategies by Brenner and some like-minded colleagues to cut costs by preventing repeat ER visits and hospitalizations in the people most vulnerable to them. In any given group of patients, it often turns out that a small number of people account for a huge chunk of medical costs; these reformers scrutinize databases and figure out who those patients are. Is it the residents of a particular building, who seem to suffer a lot of injurious falls? Is it someone suffering from several overwhelming chronic diseases and not enough social support? Is it a woman who faithfully fills her ineffective ER migraine prescriptions, yet never seems to find an outpatient neurologist who will tweak them till they work?

The reformers target those patients for meticulous outpatient care--"high-touch" care that relies heavily on building trust between patients and caregivers and on locating medical care in its social context. Their methods are revolutionary and low-tech. For starters, these caregivers are organized, and they talk to each other. Doctors and nurses and social workers and lay health "coaches" hold daily team meetings about their patients, making changes to prescriptions, discussing whom to track down via relatives after a no-show or who needs a same-day follow-up for that test result. Then, they pick up the slack for patients who don't adequately care for themselves. They send nurse practitioners to do blood sugar checks and health coaches to deliver moral support. They see to it that prescriptions get filled and that patients get help taking their meds. They work with social services to get vulnerable people into better housing. They even forestall 911 calls by physically taking the patient's cell phone and entering the clinic's 24-hour number into them, since some patients don't have the number handy and don't know how to program their own phones. The result: Tailored medical regimens that actually get followed, not just prescribed and forgotten. And patients grow to believe the clinic workers really do have their interests in mind, and that trust inspires many of them to do what they can to improve their own health--they quit smoking, they lose weight, they join AA.

All the attention at these clinics reminds me of Directly Observed Treatment Short-Course (DOTS) for tuberculosis, in which health workers actually watch TB patients swallow their medications several days a week throughout the long slog of treatment, routinely traveling to patients' homes when necessary. That simple strategy turns out to be both powerful and cost-effective--much more so than simply prescribing TB meds to an unsupervised patient, a method which for various reasons often leads to treatment failures and drug-resistant TB. Prescriptions are not enough. DOTS works so well that researchers have proposed using this strategy for other difficult diseases like hypertension and type I diabetes.

Similarly, when the numbers are crunched, the high-touch clinics Gawande investigated are worth it: They prevent hospitalizations and save money. (Hospitals stand to lose patients, of course: the country of Denmark, Gawande reports, has closed half its hospitals using similar strategies to prevent hospitalization.)

In short, high-touch clinics don't just examine and prescribe. They act as if they care about sick people, and they do whatever it takes to get the best available care into patients' hands. How interesting: That's often all we can do in a low-resource clinic here on the other side of the world. Our DOTS workers ride their bicycles to patients' houses, sit down with them, and help them take their pills; their efforts are the reason we cure most of our TB patients. It's high time the American health system realizes what low-resource practitioners already know: sometimes, it's the little things.

Some of the reasons why it's hard to treat TB in rural areas

Here at our clinic in rural Indonesia, we send an ambulance out with doctors and nurses twice a week to run mobile clinics in remote villages. This morning, one of my fellow American doctors told me with frustration that many of the patients she saw yesterday clearly had TB, but that she wasn't able to prescribe DOTS ("directly observed treatment short course," for tuberculosis) because there is no DOTS worker in that village.

Turns out it isn't quite that simple. That village has had DOTS workers in the past, but there have been bad logistical barriers to them doing their jobs. For one thing, the roads to that village are bad at the best of times, and sometimes well-nigh impassable. For another, that village isn't covered by cell phone service, so our clinic's DOTS coordinator can't easily communicate with them. And many of the villagers leave for weeks at a time to work on palm oil plantations, where they are out of reach of even the most dedicated local DOTS worker.

Lack of infrastructure is largely to blame here. But it also seems to me to be a clear example of how environmental devastation (in this case, the clearing of rainforest for palm plantations) can erode public health.

The road to a village in rural Kalimantan, Indonesia.

One of the bridges along the way.