Toronto Dr. Atul Gawande writing in the current issue of The New Yorker (1/24/11) interjects himself once again into the national (global?) health care debate by pointing out that hard data often reveals, as it did in Camden, New Jersey, that as much as 30% of health care costs are generated by as few as 1% of the patients. Drawing from the Comstat work in policing, where computer aided analyzed systemic data collection and pointed to crime hot spots, arguably allowing police departments to focus more energy and personnel to deal with such problems, some of the same applications Gawande reports are shifting attention to patients with significant results in Camden, Atlantic City, and other innovative hospitals and health plans.
This would seem to be an “ah ha!” moment, it seems so obvious. In union organizing and administration it has long been an understood fact in the tension between organizing model and service model unions that the same rough distribution of resources, if not more, are true in membership maintenance: 1% of the members require 30 to 50% of the contract administration and grievance handling resources. In community organizing among lower income families I was introduced to the insights about “multi-problem” families virtually from the day I hit my first doors with welfare rights in Springfield, Massachusetts. I would run into other organizers in Boston who had gone to social work schools and they would joke about it all the time in a general way before computers allowed any of us to understand what such families said about gridlocks in resource and personnel distribution. Inevitably changing such patterns caused huge conflict, because inexperienced organizers would get drawn into virtually personal service relationships with particular members or leaders, which might have seemed a good idea to them when they were trying to win trust “on the cheap,” but always caused conflict when more real organizing programs more equitably distributed staffing to goals and membership production, rather than individual leader or member service. My memory of “firing” a volunteer when I began in Arkansas, upon realizing he had become little more than the chauffeur, lender, and problem solver for one old leader, made it possible to work with everyone, but was something the “leader” never forgave me for!
The community organizing opportunity around health issues here is also obvious. Gawande tells several stories where the data led health care folks to sets of buildings where the 1% usually lived right down to the point where it was possible to identify the top couple of buildings that generated costs that could run to $60,000 per resident annually. Stepping back there are few community organizers without computers who couldn’t identify the likely medical hot spots just from shoe leather already exhausted over the years. Even union organizers who have done a lot of house visits know the areas where on every drive of lower waged workers you always have 5 to 10 visits, because of section 8 congregations, low rents, no deposit policies, and so forth in some complexes. A couple of senior high rises quickly come to mind in different cities. And, if we didn’t already know, it wouldn’t take but a couple of hours standing in front of any public hospital and talking to ambulance drivers or doctor shuttle drivers for them to tell you where they do the bulk of their business.
So why would we care? We don’t necessarily gain immediately from cost reductions in the way the hospitals or health plans might, but that’s only half of the equation. Forcing hospitals and health plans to adopt targeted programs delivers better health care and organizing the residents of the health care hot spots to demand such a program would create tangible results in terms of increased medical and related social services delivered on the spot. In one case Gawande wrote of a building where a hospital located an on-the-spot clinic for example. People might not be willing to organize to live longer and better, but we could definitely organize them to demand – and win – more and better health care services.
And, that’s not all. It turns out, if Gawande, is right about where health care may be going, our very organizing could move the needle on which hospitals survive and which die, based on their attentiveness to our demands in this area. He writes about the experience of Denmark’s health care system which has already retooled along cost and capacity terms, leading to a downsizing of institutions which might have as few as 25% surviving when the shakeout is finished for “industrial health care.” It is clear that this is the basic incentive for the hospital administrator in Atlantic City. He wants to end up as one of the survivors.
For the campaign targets that “get it,” our winning could mean their survival, and targets that move to partners will mean that effective organizing allows us to leverage more community benefits.
It would be nice if we could win simply with the argument of saving lives, but the stories of doctor pushback in the article are also instructive. There are a lot of folks who are benefiting now because they get paid well to manage a broken system. Organizing in this way around health care with a localized focus, we could not only change the system, benefit our community, create more equity, but also save lives. What a win!
This is a campaign calling out to all organizers