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In only a single week, I have had the opportunity to meet many amazing healthcare leaders in New Jersey ranging from the Robert Wood Johnson Foundation to Senator Robert Gordon. Although I may not yet completely understand the whole healthcare maze or have found a solution to our nation’s problem, this experience was unbelievably rewarding.

Before the trip, I knew absolutely nothing about our healthcare system. I have heard of ObamaCare, but I have never heard of anything called an Affordable Care Act (ACA)! I had no clue that compared to other nations, the United States spent the most money on healthcare and the outcomes were not even good! Our whole healthcare system was in need of drastic changes in order to restabilize the resources that were continuously going to waste! Hundreds of billions of dollars were going into unnecessary procedures. Patients were being recklessly paired up with the wrong employee (physician, nurse, surgeon, etc.) that would minimize wasted time and money. Financial incentives between hospitals and physicians were in conflict as physicians would want patients to remain in hospitals longer while hospitals would want them out as quickly as possible. Millions of Americans were uninsured and health insurance was becoming more expensive each year: Analysts expected the cost of health insurance for a typical family of four to be approximately $40,000 a year in 2020! The United States was dealing with a huge crisis and I had no idea!

BUT THEN, IN ONLY ONE WEEK, I FOUND THE SOLUTION! GIVE EVERY AMERICAN TWO MILLION DOLLARS AND EVERYTHING IS SOLVED! (Just kidding: http://www.youtube.com/watch?v=tkCf3MCuOLk)

Surely finding a solution to this whole thing is not easy. However, I have learned about the many organizations that are all working in their own way to improve healthcare. The Camden Coalition minimizes wasted healthcare money by working to keep the highest utilizers (the sickest patients who are repeatedly at the Emergency Room) out of the hospitals. DevCo takes a step back and brings a fresh grocer and fitness centers to the city of New Brunswick in order to prevent citizens from becoming patients by keeping them healthy and fit. The Trenton Health Team provides food and shelter to the homeless in Trenton, serving as a hotspot for the homeless. This also helps keep them out of hospitals by keeping them healthy and away from the unhealthy food or environments that would make them sick. These and other organizations are helping to fund (Robert Wood Johnson Foundation) and counsel (Schaffer Consulting) hospitals, insurance companies, and other organizations. The New Jersey Health Care Quality Institute helps to provide hospitals with the reputational incentives to provide the safest care as possible: LeapFrog is an online grader system that grades hospitals based on safety. We noticed the effectiveness of LeapFrog when Dr. Sue Walsh of the Jersey City Medical Center could immediately recall her hospital’s last four scores on LeapFrog! She was surely following up with the grader in order to keep their reputation up.

All in all, there may be many problems with the healthcare system, but many individuals and organizations are all improving the system and giving hope to many Americans for a brighter future for health!

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I think the biggest difficulty of the breakout trip was managing all the information we received from the community partners and connecting it into a single, cohesive picture. Earlier this week, we saw how effective the Affordable Care Act was in influencing the administrative decisions of hospitals when Dr. Bassett said that, because the ACA now rewards hospitals based on quality, there were more incentives for doctors to focus on social determinants of sick patients. Similarly, on our visit to Cooper University Hospital, we saw how consultancies fit into the greater scheme of health care. It was clear, from listening to Kathleen Stillo, the executive director of the Urban Health Institute, that, although government might create policies to solve the health care crisis, there were implementation policies that third-party consultancies had to solve; luckily, Cooper University Hospital had its own consultancy division.

If, say, a hospital has the general vision of making its office more “open” or accessible to customers, how would it implement this idea? Oftentimes, a organization is too close to its own pulse to make an informed decision, like putting one’s eyes up too close to a picture, or reading one’s own essay over and over but unable to make any edits. A third-party, necessary for its impartiality and separation, would be able to reset the interior, tear down walls, and change the color scheme of the hospital to ensure a more “open” and accessible setting for customers.

Later that day, we spoke with Dr. Mazzarelli of Cooper University Hospital to discuss the intricacies of health care. He noted that success is the enemy of innovation, and as such, great societies decline because they lose their competitive advantage to other rising, innovative societies. Luckily (and perhaps unluckily) for the sake of innovation, the US health care system is highly unsustainable. Even with John Brenner’s innovative data mapping, DevCo’s societal unity, TASK’s safety net approach, what is missing in the health care system? Perhaps there is something as essential as data mapping that we don’t even know what we don’t know, something yet to be discovered that can revolutionize health care once more. But I doubt that’s the case. Given that so many other countries have (relatively) sustainable health care systems with methods no more groundbreaking than ours, what is waiting for the US is simply to implement everything we have on the table. How can we compile everything we know about health care and create an effective machine out of it? I believe that this is where policy and implementation can intersect to make the health care system all that policymakers envisioned it to be.

-Daniel

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Talking to Dr. Mazzarelli this morning at the Cooper University Hospital was so refreshing because he brought up a point we had not yet discussed on the trip: excessive pricing of hospital services. The example he gave us was the price of medical gauze. While this product costs just over $3 when bought directly from a medical supply company, MD Anderson charges a shocking $77 when they bill insurance companies. Obviously, the whole group shared a sense of disbelief when we were presented with these numbers.  But Dr. Mazzarelli pointed out that the media capitalizes on the shock value of these massive sticker prices, as evidenced by the recent Time Magazine cover story, “Bitter Pill.” Although these insane prices reflect the crazy incentives of our healthcare system, they are certainly not the right issue to focus on. After all, no one actually pays these ridiculous prices because insurance companies ultimately haggle down the price. Therefore, it is only important to learn about these astronomical prices in order to identify them as a distraction from more important issues in the healthcare system.

-Colleen

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with Dr. Anthony Mazzarelli

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Are we in Camden? That was the thought running through my head as we pulled up to the shining hospital. As we walked through the sliding doors into the Cooper University Hospital, past the therapy garden and into the high-ceiling lobby the same thought ran through my head. I couldn’t believe that in the middle of America’s poorest, crime-filled city, there could exist such a pristine hospital with resources that could even draw patients from the suburbs.

We learned about Cooper University Hospital’s Urban Health Initiative (UHI). It was really interesting because CUH filled a different niche than the other hospitals, nonprofits, and corporations we had visited this week. While other organizations focused on addressing the issues of their worst off patients (the 50 highest users of the ER, for example, or homeless patients), CUH helps Camden’s underserved population through UHI by providing preventative care. To clarify, CUH defines underserved as anyone on Medicaid, Medicare, or is uninsured; these individuals comprise 15% of CUH’s patient population.

UHI’s program has a component that focuses on primary care. We learned on this trip that there’s a shortage of primary care physicians (PCP) and a lack of access to PCP, especially among the underserved. And even when a patient sees a PCP, an appointment generally lasts only 10-15 minutes because of how busy the doctor is. To alleviate this problem, UHI created “group appointments” where multiple patients come in for an appointment at once. The patients all enter a room where there are multiple stations set up (vitals station, paperwork station, etc.) plus a corner where the PCP conducts private one-on-one sessions with the patients. This streamlines the process and gives patients more time with nurses and the physician. After going through all the stations and seeing the PCP, the patients are then brought into a room and learn about a topic specific to a medical condition that they might all have, or about general healthfulness. At the end of the hour or hour and a half, the patients leave feeling like they had a much more meaningful experience at the hospital, and they often form friends within their groups. Patients often return together for future visits, and this encourages a generally healthier preventative mentality.

We learned that UHI may not work directly with the homeless like Camden Coalition does, for example, but they play a different role in urban healthcare: they provide underprivileged patients with a high-quality hospital experience. As we met with various groups this week, we learned that a major systemic change being implemented almost everywhere (and partially due to the ACA) was a shift from emphasis on service to emphasis on quality of care. CUH focused on providing the underserved with a hospital experience quality similar to one found in suburban areas, and I think that it’s easy to forget that having a positive experience in the hospital can have a large influence on encouraging patients to return to the hospital and stay healthy.

-Gwen

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            Yesterday, we talked with Chris Paladino and Sarah Clarke, two developers and key personnel of DEVCO, transformed New Brunswick via the creation of a community center involving a fresh grocery store (the first one in the area) and a fitness club that works in partnership with the Robert Wood Johnson Foundation and the Rutgers University medical facility. Because of the developers’ sheer determination, they were able to convince businesses to take a chance on New Brunswick. They ascribed their success, which is relatively unmatched in neighboring communities, to their willingness to focus on one issue. This success was in part due to their funding from the RWJ Foundation. Two percent of RWJ’s funding goes to development in New Brunswick, and one of the main initiatives in DEVCO. Their disconnectedness from any interest group – they are not accountable to the election cycle, business cycle (corporation’s ebb and flow of power and interest) – contributed to their success. It was an empowering discussion and after a semester of GHP (where critical questions about the role of outside actors in health), it was so interesting (and inspiring) to see (throughout this week by especially in this talk) the important role that outside actors have (and should have) in our domestic system.

Today we visited the Camden Coalition (CC). The CC outlined their structure – they target people who have two or more chronic diseases and have been admitted to the hospital twice or more in the six months. Camden is home to 80,000 people and rated as one of the most dangerous and crime-ridden areas in America. In Camden, one percent of the population incurs thirty percent of health care costs, a problem that communities across the country face. Unlike the Trenton Health Team, who was able to drastically reduce costs (overall by roughly 30%) via targeting the “frequent fliers” (patients who attend hospitals often once a day or more), the CC targeted a far different population but with similar results (reducing overall costs). Jon’s story – the struggle of diabetes type 1 and addiction to cocaine – outlined the multi-faceted problems and approach used by the CC. They connected him to a licensed practical nurse, a Camden citizen that helps him understand his treatment, his disease, and allows him to access services (housing, government provided health care, food, employment, etc.), they radically improve health indices at a far cheaper cost than repetitive hospital visits. Not only do LPNs helps their clients, but they also represent hope within the community. As individuals who live in Camden, LPNs demonstrate that there is opportunity for advancement. Not only are they better able to relate to their patients, but they improve the quality of their own neighborhoods. The greatest takeaway was that “scaling up” health care models is quite difficult. From an outsider’s perspective, Trenton and Camden seem very similar. They both face high crime, high rates of poverty and homelessness, high rates of unemployment, low rates of education, food deserts, and high costs, but the two groups have used nuanced plans to create change and reduce cost. While patients from both towns face barriers to health care access such as chronic disease, drug addiction, homelessness, transportation, lack of health knowledge, etc., THT targets “frequent fliers” (patients who go to the ER often) and the CC targets high-risk patients. This demonstrates part of the challenge faced by federal policy makers who try to make change to affect a diverse set of individuals and communities that face similar problems that play out in different ways. This is an area (setting aside technical glitches) where I believe the ACA has succeeded. The ACA focuses on health ideology and incentives via access to care and preventative medicine. We have talked to doctors, NGOs, and not-for-profits who have discussed the changing role of doctors (and the need for more primary care doctors, nurse practitioners, and community health workers) as the system moves away from fee-for-service towards focusing on the quality of the outcomes. It is the role of these not-for-profits to ensure that people are making use of the increase in health access, creating policies and practices to reduce costs within their communities using local expertise, and mediate the success of programs using data and individual stories. The women we spoke to with the CC believed that their model is quite replicable. She points to its success in Camden, a poverty-stricken extreme of the difficulties of providing care in urban America, as a beacon of hope for reducing health care costs in America – nationally 20% of the population incurs 80% of the costs. Using data-mapping techniques, we could reduce those costs through social and health interventions that target the multiple aspects of care. 

-Emma

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"Nationally, 20% of the population incur 80% of healthcare costs."

- Elizabeth Buck (Camden Coalition)
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I began this trip with the expectation of knowing a few vague things about the healthcare system. However, over the week, the organizations and people that we have met with have been of such great benefit to my understanding of urban healthcare problems AND solutions. I forgot to add, I only expected lots of unsolved issues in New Jersey’s healthcare system. It turns out that there are many successes around New Jersey that are being imitated across the nation!

DevCo’s work in New Brunswick has made the city a model of urban revitalization across the United States. A large health center equipped with a healthy grocer, pool, fitness center, massage therapy, exercise classes, and information hotspot was erected only a year ago. A new state of the art high school was just built. Transportation is so effective that many residents outside of the city come to New Brunswick just for their services. Many organizations all over the United States are now attempting to imitate New Brunswick’s revitalization procedures that aim at preventing its residents from having to be hospitalized in the first place.

The Camden Coalition’s (case-by-case) service to the sickest of the patient population in the city has proven to be very efficient and cost-effective. Many organizations in other states across the United States are even contacting the Camden Coalition in order to emulate what they have accomplished and are accomplishing: a reduction in the resources spent on treating the sickest one percent of patients who are using up thirty percent of resources in the United States.

These organizations and initiatives are slowly opening up the doors for improving the health of the citizens of New Jersey (and consequently, the United States as a whole). Although we might not have completely found a single solution to the maze of healthcare issues in urban cities, we have seen exciting potential and improvements!

-Mina

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"We are trying to get primary care physicians to be more efficient."

In twenty minutes, Dr. Alfred Tallia of the Robert Wood Johnson University Hospital gave us a clearer definition of accountable care organizations than any we had been able to extract from any sponsors we had met in the previous two days. We had heard much about the importance of increasing the number of primary care physicians for more active preventive care, but it was not until we spoke to Dr. Talia that we understood just how critical it was to the future of American healthcare quality. Dr. Tallia explained that more primary physicians would need to be trained over the years to act as the coordinators of care with other physicians, especially specialists. For now though, the current primary care physicians would simply have to learn to be more efficient with greater collaboration with nurse practitioners and other staff. He also explained that the incentives in the Affordable Care Act would be insufficient to convince most hospitals to become ACO’s or enter the bundled payment pilot program given the significant costs of restructuring hospitals would have to incur. It is much to the credit of Dr. Tallia and the Robert Wood Johnson University Hospital that they would take the initiative to lead the movement toward better quality, lower cost care.

-Lawrence

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After trick or treating with the cutest 5 year-old on the planet, our group got down to the business of creating a community map to reflect on our trip so far. We wrote down all of the names of our community partners and drew arrows to connect them to other actors that affect healthcare. As we scribbled away on our giant Post-It and discussed which name should go where, I couldn’t help but take a step back and appreciate the moment. It was just too inspiring to see how invested we each are in a project we are not being forced to do. After all, Breakout doesn’t require any assignments to be evaluated; instead, we have all been united under the shared goal of gaining a better understanding of the complicated maze that is our healthcare system. Even though all of our community partners have commented on how excited they were to see college students spending their fall break learning about healthcare, the significance of our Breakout commitment did not strike me until that moment. Maybe my excitement just reflects my freshman naivety, but I just feel really lucky to be a part of a group that cares so much about being part of the solution to some of the greatest challenges our community faces.

-Colleen

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Camden is the most violent and poorest city in the country, a fact I was not privy to prior our meeting with the Camden Coalition today. 80,000 people, live in, what The Nationwould call, “the physical refuse of postindustrial America.” Apart from what we had already learned from previous meetings, I was enlightened to the fact that the hospital costs don’t actually reflect the true economic cost the patient and the patient’s family incurred by losing time commuting to and back from the hospital, and from being sick and not working. Although the Camden Coalition is an admirable model that other cities can follow, I’ve learned that each city must have an individually tailored model.

In this meeting, we went over case studies of the Coalition’s successes, and ways in which they implement policies to overcome social determinants of poor health. John, a middle-aged man, was admitted to the hospital twice in six months for complications with his diabetes and crack-cocaine addiction. The Camden Coalition intervened, and the care team connected him with primary care and specialty providers, all while providing supportive services such as education on behavioral health, addiction counseling, and transportation. He has reportedly not returned to the hospital since December 2012, and has been off his crack-cocaine addiction.

I thought, though, that the example of John that we worked through was a relatively (and I don’t say this lightly) facile case of civic intervention because he was only addicted to crack cocaine at 37, not from the onset of his youth. Furthermore, John’s girlfriend seemed highly supportive in his effort to overcome his addiction, whereas in other Camden addicts their respective communities are mired in the same addiction. Although the Camden Coalition consistently does borderline miraculous work with the sick in Camden, it seemed to me that, for all the attention Jeff Brenner’s data mapping has received, the actual implementation of the Coalition’s vision is much more difficult than any outsider can understand. Attaching a social worker and care unit to each and every high utilizer, a patient who frequents the ED (Emergency Department), is not only financially costly but also emotionally costly; social work is extremely difficult taxing. And, even in the aftermath of such costly and full-scale intervention, the best success stories are only (and again, I don’t say this lightly) on the scale of John, a patient whose problems seemed relatively mild, and thus, not indicative of the greatest problems in Camden. Despite the systemic changes that the Camden Coalition works for, the fact that it is merely humans making social change one individual at a time is simultaneously encouraging and frightening. Leaving the meeting, I wasn’t left with the impression that simply having more social workers would solve the problems in Camden. 

 
-Daniel
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John
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with Elizabeth Buck