Evelyn Powell is 68 years old and extraordinarily sick.
“I have emphysema. I’ve got arrhythmic heart failure; got asthma,” says Powell, who runs a rooming house in Portland, Oregon. “I was in and out of the hospital all the time — it would be a month, a whole month, I’d be in the hospital three or four times.”
She’s the kind of patient who gets labeled a “frequent flier” by healthcare providers. It’s a pejorative label, but it’s certainly easy to judge Powell.
She struggled to keep track of her medication. She ate lousy food. She kept smoking.
Physician assistant Cassie Ryan-Mapolski sees plenty of patients like Powell at her Portland clinic. Sooner or later, she says, you just get stuck.
“There can be those moments where you’re like, ‘I don’t know what else to do for you. Why are you here? What do you want? What do you want me to do? I have no way to help you, I have no way to help you help yourself,’” she says.
In virtually every city and town in America there are men and women who can’t keep up with chronic illnesses like diabetes and congestive heart failure. In virtually every city and town in America there are also doctors and nurses who believe poverty, mental illness and addiction are at the root of the problem.
These are among the most expensive patients in the healthcare system, and their ranks are growing. Under the Affordable Care Act, more people at the margins are getting insurance through Medicaid.
“If you were homeless and had a lot of healthcare needs, in the past you often couldn’t access healthcare, you would get sicker and you would often die,” says Harvard’s Dr. Ashish Jha. “Today we have a lot more people coming into the healthcare system, insurance expansion has meant a lot of these people thankfully can get healthcare.”
And that means the cost to taxpayers for prescriptions, ambulance rides and week-long hospital stays just keep climbing.
But unlike costs for people at the end of life, or even for those battling cancer, these costs – at least on paper – could be reduced or avoided if people get better care.
The consulting firm Oliver Wyman says delivering proper care to these patients nationwide could save $300 billion dollars a year.
The question, of course, is what proper care looks like.
What’s happening on a recent afternoon at the Dishman Community Center in Portland may be part of the answer.
Social worker Lisa Pearlstein leads her patient-client Tony Horst toward the pool. He’s a little nervous. He hasn’t been swimming in 15 years.
“It might be hard on me, it might be not hard,” he says. “Hope I don’t have chest pains in the swimming pool.”
Horst has heart problem. He’s got to lug around an oxygen tank. He also has a lot of anxiety.
The fact that he showed up at all – after getting lost on his way here – is because of the relationship he’s built with Pearlstein.
Pretty soon the two are tossing around a striped beach ball.
Horst is part of the Health Resilience Program run by Care CareOregon, an insurance company covering Medicaid patients. Under the program people like Pearlstein seek out the whole picture of a person.
She asks about their priorities, their worries and their pain. As that relationship develops, it helps her more clearly see the medical and the social roadblocks.
That’s crucial to building the kind of trust she’s built with Horst.
“This population of people has been affected by so much hell,” she says. “It’s overwhelming sometimes.”
It may be overwhelming, and time consuming, but CareOregon believes getting to know patients so intimately lets them do a better job. The company also collects a lot of data, which has helped it realize that not all poor patients with chronic illnesses are the same.
Some are able to manage their disease and don’t cycle in and out of the hospital. Those who do find themselves at the hospital so frequently are often socially isolated.
They’re patients like Joanie McVeigh. She’s married, but her husband is gone a lot, and she’s really sick. She has diabetes, OCD, PTSD, panic and anxiety attacks, asthma, sleep apnea, and plantar fasciitis.
McVeigh is asking for help from two people who are visiting her recently in her studio apartment at the Sandy Motel. This is her care team. CareOregon tackles social isolation by pairing patients with a social worker and a peer who has similar lived experiences.
McVeigh’s become fast friends with social worker Quinne Salemeh and with peer Sam Osborne, who also has bipolar disorder. McVeigh tells me about one day earlier this year when her feet and knee were driving her nuts.
“I was really frustrated,” she says, “and I was really in pain.” She couldn’t make headway with the doctor, and she felt her anxiety spooling up inside.
“I was emotionally feeling like I wanted to get to the hospital. I wanted to take pills. I was crying. It set my bipolar in. I wanted to throw things,” she says.
She was close to calling the ambulance, but instead she started scrolling through her phone, eventually texting Osborne.
“I remember she came and sat on my couch,” McVeigh says. “And we just had this amazing, connecting talk.”
Catastrophe averted. No 911 call, no ambulance, no ER admission.
CareOregon knows it still needs better data to prove the concept works, but this approach – with its focus on relationships and reaching the socially isolated – seems to be paying off.
Two-and-a-half years since the program launched, the company says it’s cut hospital and emergency room admissions by 35 percent
Part of that is because people like Joanie – and like Evelyn Powell, the “frequent flier” from earlier in our story, have never wanted to spend so much time in the hospital or ER. And now they don’t have to.
In Powell’s case, CareOregon has helped her avoid trips to the ER for the last year, and she’s only had one hospitalization of any kind in 2015.
Doctors love the program. They says it’s easier to work with these patients. Even the bean counters seem happy; CareOregon estimates that next year it will save at least double what it costs to run the program.
Improving health and saving money is the only measure of success for many in the industry. Some like CareOregon’s Lisa Pearlstein wonder if that bar is too high.
“We could do everything and still people are going to struggle,” she says. “It’s just poverty is so profound. Trauma is so profound.”
Pearlstein tells me about Bop, a 50-something woman addicted to heroin for more than 30 years, in and out of an abusive relationship, in chronic pain.
“We had a standing appointment,” Pearlstein says. “She would show up on Monday morning at 9:30. I could see her get off the bus, and I could be able to tell if she was high or not.”
Pearlstein says while they worked together for a couple of years, Bop kept going to the hospital and the ER about the same as always.
She was on the street until Pearlstein got her into hospice.
“She died in her sister’s home, in a bed, with treatment,” she says. “She wasn’t in pain. She died with dignity."
“She didn’t just fall down, face down, in the street in the gutter and get picked up and taken to the emergency room where nobody knew her,” Pearlstein says.
No one ever saved any money on Bop, but she died the way she wanted, and for Pearlstein, maybe that was enough.
That's how much demand for guns rose, year over year, immediately after Barack Obama was elected president in 2008, according to U.S. News and World Report. What's interesting is that the demand was tied specifically to Obama, surging as Hillary Clinton, who had similar policies on gun control, dropped out of the race.40 percent
That's the percentage of people who say they don't know their partner's income. That's according to a new study from Fidelity investments, which also says about a third of couples had differing answers about their investable assets. Also worth noting: most couples in the study said they had great communication.$41 million
That's how much candidates reported refunding in campaign contributions in the last election cycle, for public relations reasons, because the donor had been involved in criminal activity, or any number of other reasons. The New York Times' Upshot notes that campaigns don't give back money often — the refunds made up just 1.4 percent of contributions — but they don't often vet donors either.20 percent
That's how much the luxury car market in Greece has jumped since the spring. Something like a $60,000 Porsche 911 is not an item you'd expect folks suffering a financial crisis to purchase. But in Greece, some citizens feel their money is safer in luxury cars than in the bank.$47,000
That's about how much an iPhone 6 costs in Venezuela as a result of a lack of supply, and skyrocketing inflation. Bloomberg takes a look at the causes behind the country's unreasonable smartphone market, which prices the latest iPhone at about 41 times the monthly minimum wage.
Bulgaria has long been a drug trafficking hub. As recently as the the 1990s, the government looked the other way. Now an EU member, it's working to stop the flow of Afghan heroin into Europe.
As president of Georgia, Mikheil Saakashvili boldly took on much larger Russia in a 2008. He promptly lost. Now he's a governor in another country, Ukraine, which is also doing battle with Russia.
NPR reported today that the Department of Veterans Affairs didn't locate and compensate some 4,000 men exposed to mustard gas during World War II.
Defense attorneys for the two convicted football players successfully argued that a juror had intentionally withheld information that he was raped.
Instagram wants to be a source for your news. The photo-sharing app is rolling out an update that features trending tags and a beefed-up search tool that should help it compete with Twitter.
When it comes to test scores, students at Michigan's Brimley Elementary School are well above the state average. About half its students are Native Americans, many are from low-income families.
General Mills is one of the world's most successful food companies, with iconic brands like Green Giant. But fast-changing tastes are forcing it and other food firms to innovate to stay relevant.
The problem has had a wide impact, keeping farmworkers, Ultimate Fighting Championship athletes and foreign students from entering the U.S. The agency has 100 experts working on a fix.
Indiana Jones, he’s not.
“I’m a 5’7” guy from Portland, Oregon, raised in a Jewish family,” says Dr. David Labby, making him perhaps more Woody Allen than Harrison Ford.
But like the daring archaeologist from the movies, Labby is after a rare and elusive prize: He wants to keep chronically ill and poor patients in Portland from landing in the hospital again and again.
“These are people who have lived in some form of constant crisis, so they know how to survive in crisis,” he says. “They don’t know how to take care of a chronic disease. And so they come to us for help. What we think is help to them is not helpful. It doesn’t work for them. It doesn’t work for us. We just have to start over.”
What doesn’t work is prescribing medications that must be kept cool for someone who doesn’t have a refrigerator. What doesn’t work is pressing patients to eat better when they don’t know where their next meal is coming from.
But Labby thinks he’s finally found a way to get that fresh start — to work with these super-sick, super-expensive patients.
“What I’ve learned is if I’m going to help somebody, I really need to know about their life,” he says, “what it’s like for them on a day-to-day basis. And that takes a lot of work to really understand.”
There’s plenty of incentive to do just that. The sickest and most expensive 5 percent of patients use about half of the healthcare dollars.
Many wind up in the emergency room or the hospital again and again, because they can’t manage their chronic illnesses. Combine that with an environment where there are new financial incentives for doctors to find better outcomes, not simply provide service after service, and the landscape is ripe for this kind of innovation.
In Portland, Labby and others at the insurance company CareOregon have created the Health Resilience Program.
The idea is that healthcare providers leave the exam room and spend more time developing relationships with patients in their kitchens and living rooms.
Now "health resilience specialists" — effectively social workers — spend a chunk of their time dropping in on patients like Scott Freeland.
Freeland, 52, was paired with specialist Marika Shimkus in 2013. They’ve become close enough that finishing each other’s sentences comes easy for these two.
“Without you, I’d be lost almost sometimes,” Freeland says. “She is really good at her job. She’ll even let me use her phone to call and make appointments right at the doctor’s office or something.”
Shimkus demurs. “I want to be sure that it’s clear the credit is really you,” she says. “You’ve let me pester you.”
Shimkus’ job is to pester Freeland — and her 20 other clients — to help them figure out what they need to take care of themselves and to hook them up to services like housing, food, help applying for an ID or maybe make an appointment with a specialist.
The Portland program serves about 600 of the sickest and most expensive Medicaid patients in the city. For Freeland, it’s made a difference. He says before he met Shimkus, he was living hard.
“I think that year I was in the hospital 17 times or something,” he says. “I was doing crystal meth, the devil’s dandruff. Every time I did it I’d start throwing up blood. I’ve had to have a transfusion before. My throat has been so raw. It’s messed my eyes up too, my diabetes has. It’s a crazy life I used to lead. But I’m actually doing pretty good now.”
Matched with Shimkus, Freeland was in the hospital once in their first year together.
The Health Resilience Program cranks out these sorts of stories.
In two and a half years, this program has put up some gaudy numbers, cutting emergency room and hospital visits by 35 percent.
Labby and the team are now household names in this little corner of the healthcare world, where doctors try to administer social services to solve medical problems.
The consulting firm Oliver Wyman says there are $300 billion in potential savings every year, if this type of work lowered costs for all of us.
This is what healthcare’s city of gold looks like, where money is saved and health is better.
Harvard health economist Amitabh Chandra says it’s a nice theory.
“There’s so many things we do in American health care because we think that they must work,” he says. “We have incredibly powerful narratives that each one of these things is going to generate billions and billions in savings.
“But every time we looked, we’ve found the answer has been a big giant zero,” he says.
We asked Chandra to look over data from the Health Resilience Program, and he says while the program may improve health, it’s impossible to say whether it’s saving money long term.
Odds are these sorts of programs are unlikely to save any real money, says Dr. Ashish Jha.
“There are almost no interventions that we know of that improve health and save money,” says Jha, who is also at Harvard. “There are a couple of things that we do know. Vaccinations are probably the No. 1 thing. Once you get beyond that, it starts to get pretty tough.”
Jha says what makes this work tough is that patients each have their own costly web of issues and illnesses that can’t be resolved with a one-size-fits-all solution like a vaccine.
Pinpointing the underlying social challenges can be a guessing game for doctors, where they try to tackle very deep, persistent problems — like addiction, mental illness and obesity — with treatments that often don’t work.
These obstacles, not to mention limited evidence, help explain why there’s no line of healthcare chief financial officers outside Labby’s door.
“Until we have a business case for healthcare providers, for large organizations to really take this on, I think it’s going to be a series of pet projects,” Jha says.
Since his great run that first year working with health specialist Shimkus, Freeland’s life has become complicated again. A few months back he got beat up trying to protect his cousin from her husband.
“He broke my jaw and a couple of ribs, and I was in the hospital for 10 days,” Freeland says.
Additional health complications and drinking have led to an uptick in trips to the emergency room. Freeland says he’s trying to keep things under control, and as he does, his cell phone rings. It’s his cousin, telling him he’s bought him some beer.
The cousin and Freeland’s uncle live next door.
“They’re my closest friends that I have, and I hang out with them quite a bit, watch TV. And they drink every day — like a lot.”
The hard reality of this work is that healthcare providers are trying to help fix someone’s life, a process is full of half steps, missteps and backslides.
“They first tell me you can’t have sugar, and then tell me I can’t have salt. Now it’s like you guys want me to stop drinking, too,” Freeland says.
“I will probably never ever stop drinking. Just trying to be realistic. And sometimes you almost have to drink just to get through all your problems and stuff,” he says.
Is this what success looks like — progress and then relapse? How much time and money do you invest in trying to help someone like Freeland? Is his setback just temporary?
Important questions, says Labby, that he admits are hard to answer.
“Our experience has been people we are dealing with have had really rough lives,” he says. “They are not going to recover from those lives in one moment.”
The program’s goal is to build stable lives. That takes time, which takes money.
It’s a tough enough road that it’s fair to wonder if the Labbys of the world see something in this healthcare jungle that most of us can’t — or if he’s a do-gooder, lost on a never-ending hunt.
Click the media player below to hear reporter Dan Gorenstein speak with Marketplace Morning Report host David Brancaccio about social issues and healthcare.
This story was reported with the support of the Dennis A. Hunt Fund for Health Journalism and the National Health Journalism Fellowship, programs of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.
A Supreme Court decision is expected by the end of the month in King v. Burwell, a challenge to the Affordable Care Act that argues subsidies for health insurance should only be available in states that set up their own insurance marketplaces, or exchanges.
If the court rules against the Obama administration, millions of people in states using the federal exchange could lose their subsidies.
Enter entrepreneurs, who think they’ve found a way to help states set up exchanges almost immediately. Sanjay Singh is one of them. He's CEO and co-founder of hCentive, a tech start-up that supplies the software for state health care exchanges. hCentive helped Kentucky and New York set up their exchanges. They're two of the more glitch-free state marketplaces.
Singh is a political junkie and a techie. He got immersed in hearings on the Affordable Care Act, and read through the nearly 1,000-page bill. It was the first bill he ever read. And then Singh made a bet – he established hCentive before the Affordable Care Act even became law. Now he’s making another bet. If the Supreme Court rules that people in states using the federal exchange to buy their insurance aren’t eligible for subsidies, he’ll be ready with what he’s calling an "exchange-in-a-box" — a ready-made answer for states that suddenly need to build their own marketplaces.
“You can take what has been already built, package it in a way that a state can use it, almost out of the box,” Singh says.
He says hCentive's exchanges-in-a-box can be up and running in under six months. Singh says there wouldn’t be any big, up front down payment. States could pay hCentive a percentage of the fee they charge to insurers. But there is one giant unknown for Singh: politics. Twenty-six state legislatures won’t even be in session this summer.
"How will a state even decide it wants to do an exchange-in-a-box?," says David K. Jones, an assistant professor at the Boston University School of Public Health. "How will they get the legislation passed? Will it require a governor being brave enough to do an executive order?”
It’s hard to tell how Republican governors who've opposed the law would react. Some campaigned hard against the Affordable Care Act, and government involvement in healthcare. But Singh thinks they may be more open to a private-sector solution, like his exchange-in-a-box. And some observers say Singh may be onto something.
“If I’m a governor in one of the red states, I’m going to be concerned about making some kind of arrangement with the federal government to basically run my exchange," says Joel Ario, the first director of the federal exchange, now managing director at Manatt Health Solutions. "But I’m going to be more open to a private company.”
So Sanjay Singh, the political junkie, could bridge a political divide — and make a profit in the process.
Melissa Mayeux plays shortstop for two of France's national teams: the U-18 junior squad and the senior softball team. She's known as a smooth fielder who can also handle a bat.
Eaten at the Olive Garden lately? You probably thought more about the bread sticks than who owns the building — fair enough. However, Darden Restaurants, which owns the Olive Garden, Long Horn Steakhouse and some other chains, announced Tuesday that it’s going to spin off its real estate into something called a REIT — a real estate investment trust — and then lease the properties back.
REITs are everywhere, says Michael Grupe, with the National Association of Real Estate Investment Trusts. “If you work in an office building, for example, there’s a good chance that that property is owned by a REIT. If you live an apartment building, it may very well be owned by a REIT.”
Spinning off the properties only to lease them back may sound like a strange, circular kind of logic, but it’s actually a smart move, says Susan Wachter, a professor at the University of Pennsylvania’s Wharton School.
She says investors tend to like REITS because they have a steady source of income — typically rents — and they pay lots of that income back to investors.
“Investors are not willing to pay much for the volatile restaurant business,” she says. “But the real estate is far more predictable, and therefore Darden is able to raise more capital this way.”
Wachter says it makes sense for Darden to take the money it raises from the REIT, pay down some debt and then focus on its restaurant business, while letting people who know real estate focus on the properties.
“It’s the old Adam Smith, specialize, specialize and specialize,” she says. “Not location, location, location.”
Companies like McDonald's and Macy's are under pressure to do something similar, while Sears is also pursuing a similar strategy.
John Glascock, at the University of Connecticut, thinks Sears should have done it years ago.
“Probably over half the Sears out there would already be shut down,” he says. "Those [properties] would probably be something else much more productive, but when they kept them together, it’s tempting to say, ‘Well, I own the land, it’s only costing me opportunity cost. It’s not costing me real cash, let me try one more quarter.’ ”
Glascock says real estate can wind up subsidizing the bad decisions of the company it’s tied to, but separate, each side has to stand on its own.
Summertime is officially going all digital and social media.
Ad Age reports that Good Humor is bringing back its ice cream trucks.
I know — awesome, right?
Except, well, instead of that classic jingling of ice cream truck bells, you're going to have to follow the truck on Twitter to figure out where it's going to be.
Which just makes me sad, somehow.
For years, the federal school meals program has been one of the most powerful forces in education. Not just because it feeds kids, but because the percentage of students who qualify for free and reduced-price meals has been the main way schools measure poverty. That number, in turn, can impact everything from school funding levels to accountability programs.
But that’s changing. Massachusetts has introduced a new way of measuring poverty in its schools. Starting next school year, students will be considered “economically disadvantaged,” not according to their school lunch status, but if their families participate in programs like food stamps, welfare and Medicaid. According to the new data released today, schools look a lot less poor.
“It’s about two-thirds of the number of students that we had before,” says Jeff Wulfson, deputy commissioner of the Massachusetts Department of Elementary and Secondary Education.
Wulfson says Massachusetts had to come up with a different way of measuring poverty. It’s one of 49 states that now let high-poverty districts feed all students at no charge, rather than collecting applications for the school meals program.
Massachusetts' new measurement could more be more accurate, says Zoe Neuberger, senior policy analyst at the Center on Budget and Policy Priorities, in that it no longer requires schools to collect income data from families. That can be a challenge, "particularly with middle or high school students, because the children are embarrassed about receiving the meals," she says.
Federal poverty programs are also better-equipped to collect and audit income information, she says. "They have offices full of caseworkers whose job it is to assess family income and household composition," she says. "Schools are not set up to do that. Nor should they be."
Other states are adopting similar ways of measuring poverty, says Michael Griffith, a senior policy analyst with the Education Commission of the States. He worries the new standards could miss the working poor — families who earn too much to qualify for food stamps, but not enough to pay full price in the cafeteria.
“They are not poor by the definition of some of these programs, but they are clearly low-income and they are struggling,” he says.
Wulfson says Massachusetts plans to create new funding formulas so that high-poverty schools aren’t short-changed.
The U.S. is appealing because of its high standard of living and lack of an extradition treaty with China. The U.S. is also reluctant to arrest suspects unless provided with solid information.
Targeted advertising is everywhere these day. Be it your Facebook profile, your browser history or anything else online, all of your data is being collected for one purpose: to sell you more stuff.
Now there’s a new frontier in tracking technology: Facial recognition software. Companies want to be able to track your identity and keep note of the things you regularly consumer a near-constant basis.
“Connecting a person’s past behavior and data to their current location is kind of a holy grail for companies when it comes to marketing,” says Ben Johnson, host of Marketplace Tech. “Imagine you go into a store and there’s a camera on the shelf of items that you’re looking at, and that camera records the emotional reaction you have to the items you’re looking at.”
Facial recognition could make its way into many public spaces. However, privacy advocates are hoping that it will be opt-in only so that those who do not wish to make their identity open to the public have those wishes respected. “A lot of companies don’t want this,” Johnson says. “This is where these two kinds of organizations really part ways and are really having problems coming to an agreement on some sort of rules of the road.”
Still, most experts agree that this is an eventuality. “We have to think about the fact that no matter what, technology companies are going to build this stuff, they’re going to start using this stuff,” Johnson says. “They’re going to ask for forgiveness, not permission."
To hear the whole conversation, click the audio player above.
Several dozen rec centers offer aftercare and summer camp for children in Baltimore's poorest neighborhoods. But they also give the kids the family stability and structure that so many of them lack.
The fees will be used for park enhancements to make up for Federal budget cuts.