Dr. Gawande, using a common sense narrative laced with some rich anecdotes, correctly argues on behalf of the vulnerable. While they may be few in number, the non-compliant, disabled and socially isolated persons with multiple illnesses are the most likely to be victimized by a dysfunctional and inflexible care system. Instead of oil and war, it's millions of dollars in claims expenses and a fraying primary care safety net. Dr. Gawande describes how the vulnerable can be protected with a high concentration of community-minded docs, nurses and social workers who can simultaneously reach out to these patients and save taxpayers millions of dollars.
And yet, maybe the DMCB's wartime analogy is appropriate. Drawing battle lines at the end of his article, Dr. Gawande points out that "the new health-reform law's" targeted approach, could be "scuttled" by a sinister and unnamed "well organized opposition."
Really? "Where?" asks the DMCB. The "protect the vulnerable" approach has been the standard of care for commercial insurers for years. Population health management (PHM) vendors have been using health insurance claims in very sophisticated statistical algorithms (for example) to spot who is most likely to end up in an emergency room or be hospitalized. Once identified, just as The New Yorker article describes, professional care managers can coordinate with the docs and telephone or visit these patients in an attempt to reduce their risk. Since a single avoided hospitalization can save thousands of dollars, it's not long until the nurses can more than make up for their salaries - and then some - using the same common sense approaches described in Gawande's article.
Until the Affordable Care Act (ACA) was passed, there was no coverage by standard Medicare or Medicaid for care described in Gawande's article. Even with passage of the ACA, it will still not be explicitly covered, pending years of further study of various pilots by CMS. What's more, until the regulations were clarified, there was a good chance that the onerous Medical Loss Ratio (MLR) requirements of the Act would scuttle the commercial insurers' "protect the vulnerable" programs.