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In this week’s New Yorker, Atul Gawande presents a case for lowering health-care costs by focussing on the most expensive patients. Inspired by law-enforcement techniques that zero in on clusters of crimes, Jeffrey Brenner, a physician in Camden, New Jersey, decided to combat excessive medical costs by treating the “super-utilizers.” (In Camden, one per cent of patients are responsible for thirty per cent of medical costs.)

Brenner’s team, which includes a nurse practitioner and a social worker, make regular home visits and phone calls to check in about new and existing complaints, unfilled prescriptions, and other complications that could land them back in the hospital. They help apply for disability insurance and fill out paperwork for state-run housing where their medication can be overseen. They encourage these super-utilizers to improve their lives with steps like quitting smoking, cooking more, joining Alcoholics Anonymous—even going to church.

Brenner found that his first thirty-six patients saw a forty-per-cent reduction in average monthly hospital and E.R. visits. They also saw a fifty-six-per-cent reduction in average hospital bills—savings that Gawande describes as “revolutionary.”

Similar results were found at an Atlantic City clinic dedicated to super-utilizers on the health plans of the casino union and a local hospital; doctors at the clinic are paid a flat monthly fee per patient and the patients receive unlimited access to care. Rushika Fernandopulle, who runs the clinic, found that after twelve months the first twelve hundred patients had forty per cent fewer emergency-room visits and hospital admissions and twenty-five per cent fewer surgical procedures. An independent economist who studied these Atlantic City hospital workers found that their costs dropped twenty-five per cent compared to a similar population of high-cost patients in Las Vegas.

These experiments in intensive outpatient care could transform health care well beyond southern New Jersey. As Gawande writes:

An important idea is getting its test run in America: the creation of intensive outpatient care to target hot spots, and thereby reduce over-all health-care costs. But, if it works, hospitals will lose revenue and some will have to close. Medical companies and specialists profiting from the excess of scans and procedures will get squeezed. This will provoke retaliation, counter-campaigns, intense lobbying for Washington to obstruct reform. The stats-and-stethoscope upstarts are nonetheless making their dash. Rushika Fernandopulle has set up a version of his Special Care program in Seattle, for Boeing workers, and is developing one in Las Vegas, for casino workers. Nathan Gunn and Verisk Health have landed new contracts during the past year with companies providing health benefits to more than four million employees and family members. Tim Ferris has obtained federal approval to spread his program for Medicare patients to two other hospitals in the Partners Healthcare System, in Boston (including my own). Jeff Brenner, meanwhile, is seeking to lower health-care costs for all of Camden, by getting its primary-care physicians to extend the hot-spot strategy citywide. We’ve been looking to Washington to find out how health-care reform will happen. But people like these are its real leaders.

Subscribers can read the article in the digital edition, and non-subscribers can purchase the individual issue to read online or on an iPad. Join a live chat with Gawande about medical costs on Thursday, January 20th, at 1 P.M. E.T.

Photograph: Phillip Toledano