Hotspotting revisited

The Camden Coalition and tailoring treatments to patients

As I get back into writing this newsletters, I’m going through my archives to see what I wrote about when I started (5 years ago!). One, from 2020, was on a topic that’s captivated me since 2011: the Camden Coalition.

For those unfamiliar, the Camden Coalition is a nonprofit organization aiming to improve the care of medically complex patients. Its approach is based on the principle of “hotspotting,” or providing extra care to the small percentage of patients who have the most complex health needs and therefore cost the system the most money.

The Coalition was the subject of a 2011 New Yorker article by Dr. Atul Gawande, who followed the Coalition’s founder, Dr. Jeffrey Brenner, as he experimented with house calls and providing services that went far beyond traditional healthcare — like connecting patients with social workers, encouraging them to go to Alcoholics Anonymous or return to church services, and reminding them to care for themselves.

“The fun thing about this work is that you can be there when the light switch goes on for a patient,” Brenner told me. “It doesn’t happen at the pace we want. But you can see it happen.”

With Hendricks, there was no miraculous turnaround. “Working with him didn’t feel any different from working with any patient on smoking, bad diet, not exercising—working on any particular rut someone has gotten into,” Brenner said. “People are people, and they get into situations they don’t necessarily plan on. My philosophy about primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over.” So he tries to care, and to say a few simple things over and over and over.

It was a beautiful and inspiring article, and it brought a lot of attention to community-based healthcare efforts that worked hard to meet patients where they were and help them get better.

The Coalition continued its efforts in Camden, and major health insurers like UnitedHealth Group (where Dr. Brenner went to work next) began experimenting with wraparound services themselves. UHG in particular has made affordable housing a central piece of its external-facing community investment, spending over $1 billion on construction projects.

A pair of studies

Then, in 2020, a study came out in the New England Journal of Medicine showing that the Camden Coalition didn’t reduce readmissions. 

At the time, I wrote about a few reasons why I thought that was the case:

First, the patients maybe have been just too challenging. As the authors of the study wrote, “It is possible that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases.”

Second, the study, which ran for 180 days, may have been too short to see outcomes. It’s also possible that a lot of the patients in the study regressed to the mean, meaning that they would’ve stabilized regardless of the intervention (which would explain why readmissions went down in both the intervention and control groups).

Finally, it’s possible that superutilizer programs have extremely positive outcomes for just a few individuals; lives changed for sure, but not necessarily money that makes major insurers change their business practices.

At the end of 2023, another study published in Health Affairs explored the 2020 findings further. The Health Affairs study linked most of the individuals from the 2020 study to Medicaid data and found that, while the Camden Coalition’s model was able to increase the patients’ primary and specialty care visits, those successes did not reduce overall hospital readmissions in the study population. 

Of my three hypotheses from 2020 about why the Camden Coalition fell short, my first and third appear to be closest to the truth: superutilizer programs can be life changing for some, but these patients are extremely complex in a way that’s resistant even to high levels of wraparound services.

It goes without saying that advocates for hotspotter programs also argue that a better social safety net (including, perhaps most glaringly, affordable housing), and better coordination between different programs and care providers could better address these patients’ needs.

Applying a cancer care model

Last year, the Tradeoffs podcast reported that the Coalition (and similar programs) are now experimenting with tailoring services to the individual patient. Tradeoffs quotes Aaron Truchil of the Camden Coalition comparing this approach to cancer treatment — it must be specific to the individual patient’s problems and personality, rather than being a blanket solution.

I like this analogy and it makes sense to me — a patient with severe mental illness is not the same as a patient with an amputation from uncontrolled diabetes. As Dr. Brenner discusses in the original 2011 article, the Coalition’s model is most successful when practitioners have time to listen to individual patients and hear from them what they need the most. This isn’t a new insight; doctors who are successful with smoking cessation conversations, for example, are successful because they really know their patients and have time to meet them where they are.

The problem is that this isn’t really scalable. It requires a certain type of practitioner, a certain type of patient, and a lot of time. I’m interested to see how the Camden Coalition institutes a tailored approach on a formal level in the coming years.

Takeaways

So now what? The excitement of 2011 gives way to the realities of 2025. My takeaways:

• Complex patients really are complex. A schizophrenia patient with substance use disorder isn’t the same as a diabetic patient with heart disease. Even within these categories, one patient might have family support and another might live on the street. Tailoring approaches to each patient might unlock reduced readmissions. However, comparing these tailored approaches to cancer treatment might be true in more than one way — more effective, but also far more expensive.

• When I wrote my original 2020 article, I wrote about how Cityblock might make up for some of the shortfalls of the Camden Coalition. I’m no longer sure that venture-funded startups like Cityblock have the ability to care for these patients while still being “successful” in a venture capitalist sense. If the Camden Coalition follow-ups have proved anything, it’s that work to reduce the health burden of superutilizers is a slog, and if it’s going to use anything other than nonprofit dollars, those dollars have to be very, very patient.

• I’m interested to see if major health insurers like UnitedHealth Group continue to invest in affordable housing and other socioeconomic improvements for their patient population. I would love a study about whether these affordable housing units changed the patients’ trajectories, and if that redounds to any cost savings for UHG. I can’t find much about these investments besides the press releases that UHG puts out, which are short on details. The only other information is from a white paper that UHG collaborated on with Stewards of Affordable Housing for the Future, a consortium of affordable housing providers (primarily accounting and law firms that help structure these deals). Some of UHG’s funding seems to be through a fund set up by SAHF, including investments in developments and grants for wraparound services. (If anyone understands how affordable housing development structures works and wants to explain it to me, please reply to this email and let me know!)