Zinberg spent almost two years struggling to recruit physicians to launch his program. “During 1991 and ’92 my wife barely saw me,” he recalls. “I was having dinner four nights a week with groups of doctors, explaining my concept. I was begging them, literally begging them, to help me create a new health-care-delivery system.”
Fortunately, a few of the doctors Zinberg approached were moved to join by their personal connections with him or by the depth and sincerity of his commitment to the cause. By 1993, physicians and teams of physicians operating 28 separate medical offices had agreed to become affiliates of Zinberg’s new system, CareMore Medical Group.
Zinberg had always seen his vision of coordinated care as especially well suited to the needs of the elderly. As a gastroenterologist, he naturally saw a high percentage of older patients in his practice, and as he himself grew older, his interest in the physiology of aging deepened. (His ideas on the subjects of exercise, nutrition, genetics, and memory retention would lead to his 2003 book, Win in the Second Half.) And Zinberg recognized that elderly patients covered by Medicare—the people normally regarded as the greatest drain on the health-care system—could benefit the most from special attention. Because the existing system failed to connect the dots, they experienced a variety of unnecessary complications: avoidable hospitalizations, duplication of treatment, misdiagnoses, needless suffering, and sheer neglect.
At first, CareMore accepted patients of all ages, but in 1997 Zinberg and his team restructured the company around his original concept, focusing on the elderly and eventually accepting payment exclusively from the Medicare Advantage program. Rather than paying for services rendered (the traditional fee-for-service model), Medicare Advantage pays CareMore an annual per-patient fee, adjusted according to each client’s risk profile. This system, by replacing the distorted incentives of the fee-for-service economic model, allows CareMore to be rewarded for innovative, results-oriented care. In particular, it enables the company to build specialized programs for its highest-risk patients, who generally suffer more—and run up astronomical costs—under traditional fee-for-service plans.
One of CareMore’s critical insights was the application of an old systems-management principle first developed at Bell Labs in the 1930s and refined by the management guru W. Edwards Deming in the 1950s: you can fix a problem at step one for $1, or fix it at step 10 for $30. The American health-care system is repair-centric, not prevention-centric. We wait for train wrecks and then clean up the damage. What would happen if we prevented the train wrecks in the first place? The doctors at CareMore decided to find out.
An early discovery was that CareMore’s elderly patients failed to show up for as many as one-third of their doctor appointments. As Charles Holzner, one of Zinberg’s initial partners at CareMore and now a senior physician with the company, explains, “About one in three of the elderly people we were taking care of were home by themselves. They’d outlived their family resources, they couldn’t drive, and their kids lived out of town. So when they got sick, they ended up calling 911. And when it came to routine doctor visits, they sometimes just couldn’t make it at all.”
CareMore’s unconventional solution to the problem was to provide transportation, at no charge, to get patients to their medical appointments. Local car-service companies were happy to have the business, and while the transportation cost money, it ultimately saved a lot more. Increased regularity and consistency of medical care meant that many simple problems were recognized and treated in their early stages: complications were avoided, and rates of hospitalization and nursing-home admittance began to fall.
The problem of “noncompliance” isn’t limited to missed appointments, either. Patients, especially elderly ones, also leave prescriptions unfilled, medicines untaken, exercise-and-diet regimens unfollowed, and symptoms unnoticed and unreported. Health-care professionals often grumble about noncompliance, but given the myriad demands on their time, they generally can do very little about it. At CareMore, by contrast, Zinberg decided, “noncompliance is our problem, not the patient’s.” So the company began adding more nonmedical services to its routine care in order to improve compliance rates—for example, sending health-care professionals to its patients’ homes to make sure they had scales to keep tabs on their weight, to look for loose throw rugs that might cause falls, and to provide “talking pill boxes” that remind patients to take their medicine with preset alarms. Each of these innovations led to a small improvement in patient wellness and a corresponding improvement in the economics of providing care.
Next, CareMore began experimenting with an aggressive treatment of diabetes, one of the most widespread and debilitating illnesses suffered by elderly patients. The primary treatment for diabetes, insulin injection, had long been considered inappropriate for the elderly—too intrusive, too difficult, and too costly for patients whose life expectancy was already short. But CareMore doctors made insulin-injection treatment available to their patients. They also set about investigating exactly how the worst complications associated with diabetes occurred.
Take amputations, for example. The typical chain of events begins with a small cut on the foot suffered by a diabetic patient and self-treated using an ordinary home remedy such as a Band-Aid. If the cut resists healing for a week or more, the patient visits her primary-care physician. The doctor cleans the wound, changes the dressing, and advises the patient on further care, but with no way of knowing whether the advice will be followed. A week later, with the wound getting worse, the patient visits her doctor again and is referred to a surgeon. After the typical two-week wait for an appointment, the patient learns from the surgeon that gangrene is now beginning to develop, and she is referred to a specialized vascular surgeon. After yet another two-week delay, the vascular surgeon sees a wound so serious that a hospital stay and amputation are now inevitable—at a cost of many thousands of dollars and an untold degree of suffering. All beginning with a single, scarcely noticeable cut.