What the home team knows

If you swing a bag of boiled peanuts near Raleigh these days you are likely to hit a lobbyist from an out-of-state managed care organization. If you have an American flag in your lapel, they will think you are a legislator and tell you why they should manage the $13 billion of Medicaid for poor people with their magical software . This is happening in every single state where Medicaid is in play, whether that state is considering expanding it or, as in NC, trying to figure out how to “fix it” so then they can expand it.

The legislators would rather spend some of those billions on roads, schools or something they can name after themselves. Only one of the 178 legislators has any experience in healthcare themselves and don’t entirely trust their own large healthcare providers much more than they do those from New York. (The best hospitals were founded with tobacco money, so there’s not a lot of moral high ground among us.) So they are receptive to the cost-saving promise. Why not let the financial geniuses from out of state run things?

The only way to save money in healthcare is to manage the slow-developing conditions –usually linked to smoking, bad food, depression and anxiety—at the lowest cost point of care. And do that year after year. Every hospital and doctors office in America today is hoping that the criminally expensive electronics wwe’ve invested in will help. In practice this means digesting large amounts of data about patients to tell the doctor which patient needs what kind of early intervention or pill and what kind of test might be helpful to diagnose the next most important condition. Doctors know that kind of thing anyway without any machines at all.

What the doctor (and surely the computer) does not know is how to get their patient to get themselves within range of at least the drug store clinic in order for nifty 21^st century medicine to work. Health care refers to this challenge as “patient activation”— the person needs to be active in their own life. Poor people live with everyone them telling them how to do everything better, so they are not excited about adding computers to their list of advisors, especially those owned by wealthy strangers trying to make money off their poverty.

Activating patients one at a time is daunting when you are spending billions on millions. That’s why you have to activate neighborhoods—the streets, churches, small stores and soccer clubs where people live. Neighborhoods are the patient and like any patient, crucial to turn into a partner. All Southern streets may look alike to a northerner, but every one has its own pattern of health conditions (young Hispanics with work injuries; retired tobacco workers, cancer). And they have their own pattern of assets to activate. There is a lot to know.

To give you an idea of what is possible look to Winston-Salem where five kinds of doctors and two kinds of healers are weaving a fabric of less costly care:

• Paul Laurienti is applying nero-science modeling to patient data, producing what look like brain maps that illuminate the expensive conditions emerging at neighborhood level.
• Teresa Cutts of Public Health Science runs a complex participatory process producing a map of the assets in those same neighborhoods, including which are most trusted from those not.
• Russ Howerton, the Chief Medical Officer activates a huge team of medical providers of every type and license to care for those sick enough to need a hospital (almost all of whom go back home quickly)
• The doctors of the NC Community Cares Network manage all the outside the wall care now for Medicaid and while they are the constant whipped yard dog of the legislator, they have a rich array of field and clinical staff.
• Marlon Hunter runs the County Public Health Department, wonderfully placed, but woefully underfunded working on the long slow problems through partnerships with school, apartments (while inspecting the food and preparing for the next epidemic).
• Grace Terrell is the home-grown genius behind Cornerstone, a partnership of nearly 400 physicians who have distilled their complex knowledge into computer analytics that give our docs a highly tuned intelligence about their patients now being adapted by hospitals partners.

None of this works without a ground game activated by two other kinds of knowing:

• Annika Archie used to clean the rooms at the hospital, a low wage job with exquisite opportunity to learn what really matters to large numbers of patients. Last year, in a decision only a locally owned hospital could imagine, she was retrained and deployed into the toughest neighborhoods to follow the most vulnerable and poor patients home. As a Supporter of Health, she knows things computers don’t—including the fact that their silicon prescriptions are cruel without power or food in the house.
• Sam Hickerson worked for the hospital for decades while also pastoring New Gospel Light Baptist Church right in the heart of the toughest streets in Winston-Salem. Now he is a FaithHealth Liaison using  what a pastor knows about the life of insults and deprivation, but also where to find honor and generosity.

Archie and Hickerson are the sharp edge of the lancet that can open the ancient wound and let the science in to do some good. You can calculate the community scale affect already in the pattern of charity care. As this new pattern in East Winston has emerged in the past two years charity care has decreased by 6% while going up in all the other zip codes in the surrounding counties. Laurienti would say this is positive story is as complex as a recovering brain. It is also simple: nearly $900,000 in reduced costs buys a very large bag of boiled peanuts.