
A study examined coordinated care for the most expensive patients - Reedx
https://www.nytimes.com/2020/01/08/health/camden-coalition-chronic-illness.html
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jnwatson
I wonder if someone has done the cost/benefit analysis of prescribing housing.
What if it is just cheaper to house these at-risk patients (shelters don't
count)?

(n=1) The District of Columbia provided my schizophrenic grandmother a small
apartment to get her off the street. Evidently, her health dramatically
improved.

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joe_the_user
Article: _These individuals, frequently struggling with addiction or
homelessness, have extremely complicated medical conditions. By finding them
and connecting them to the right doctors and social services, dozens of costly
hospital stays could be avoided. The idea has been adopted in numerous
communities around the country._

So, patients who just happen to be broken in the way this country now commonly
breaks people, wind-up being extremely costly to the medical system, which
actually is going to ultimately add these bills to everyone's costs.

One way to deal with this is being very clever in how you treat these people.
But another idea would be to not break these people in the first place. That
would require some re-evaluation of where this country is going, of course.

~~~
whiddershins
There is absolutely so much wrong with this statement.

You are trying to assert that something about the way this country functions
is uniquely causing mental illness and other suffering, and that this should
be the primary vector of analysis and intervention.

There has been suffering and mental illness for as long as we know of.

Human psychological suffering empirically can not be only about access to
wealth and resources because otherwise every poor American would be free of
suffering while everyone in the 19th century, no matter how wealthy, would
have been a schizophrenic alcoholic.

OTOH if there was something uniquely and overwhelmingly bad about the current
United States versus other countries, we should be able to find that other
countries have uniformly better mental health, yet look at suicide rates in
Japan or Northern Europe.

Your assertion also diminishes the challenges faced by people who struggle
with these things, by making it about “the system” rather than really
acknowledging these problems and how pernicious they are.

And implied in your comment is disregard for human choice and how we each live
a unique, sometimes extremely difficult, path through life.

~~~
joe_the_user
The statistics showing "death from despair" as a significant cause of lowered
life expectancy in the US are my "prima faci" evidence for my comment above.

The idea that the situation of addicts and the homeless is "diminished" by
complaints that their condition is related to a society that has reduced the
minimum wage and failed to provide sufficient well-paid, satisfying jobs is
kind of double-talk.

Does talking about unaffordable rents in many major cities "diminish" the
efforts of the homeless as well?

~~~
whiddershins
“Does talking about unaffordable rents in many major cities "diminish" the
efforts of the homeless as well?”

Absolutely. This is actually a topic that I have moderate-to-substantial real
world knowledge of.

Long term homelessness is not primarily caused by high rents per se.

Although in some cases rents can be a contributing factor, it is more commonly
an issue of mental health, addiction, unemployability, and lack of access to a
familial or similar safety net that are the proximate causes.

Usually a combination of those issues.

Pointing to homeless people sleeping on the streets and bringing up high rents
is at best an uninformed opinion, and at worst using a suffering and
marginalized population as rhetorical pawns in a political game.

There was a lot more in what I said that you seemed to gloss over, but I
appreciate you providing the opportunity for us to discuss a concrete case.

~~~
joe_the_user
The relationship between high rents and homeless is both common sense and
reasonably well established by research [1] [2]. It should be noted that the
present or absence of a safety net is also strongly influenced by the cost of
survival - whether friends or family can take someone in depends their having
extra-rooms, extra-food, etc.

You're citing your personal knowledge without giving references or even
details of your knowledge.

The one factor confusing things is this; yes, once a person reaches hard-core
homelessness or hard-core addiction, they indeed need much more than lower
rents to get on their feet. But the chances of reaching that state are much
higher when a person experiences incidental homelessness.

And political? Yes, homelessness is political. There's no way to talk of
homelessness without talking politically.

[1] First reference: [https://www.zillow.com/research/rents-larger-homeless-
popula...](https://www.zillow.com/research/rents-larger-homeless-
population-16124/)

[2] Google it:
[https://www.google.com/search?client=ubuntu&channel=fs&q=cor...](https://www.google.com/search?client=ubuntu&channel=fs&q=correlation+between+rents+and+homelessness&ie=utf-8&oe=utf-8)

~~~
whiddershins
All I see is the Zillow study. It’s correlation, there’s nothing to imply
causation. Obviously large cities have very high rents, and most of the
homeless people. It’s also Zillow. I am uncertain why they are doing these
studies.

The fact that you keep saying homelessness is primarily political and keep
emphasizing that aspect kinda proves my point.

I’m curious if you’ve worked in homeless services, or know a number of
homeless people?

In my experience, there is such a thing as suffering that shouldn’t be pinned
on bad politics. Sometimes life is really hard, and it’s not the government’s
fault, or corporations, or any of that.

I think ... ideally ... the default first reaction to suffering should be
compassion?

~~~
joe_the_user
_All I see is the Zillow study. It’s correlation, there’s nothing to imply
causation._

Google can point you to several other studies. The phrase "correlation does
not imply causation" basically could best broken down as "the correlation of
two graphs doesn't mean much unless you have a decent model to explain why
they're correlated". But in this case, we have a good model for high rents
causing homelessness - people become homeless when they lose homes and can't
find another house or apartment. High rents make this more likely - high rents
also make it harder for someone who's working to "couch surf" until they find
another place.

Being a functional, short-term homeless person makes latent substance abuse
and mental illness issues more likely to appear and intensifying existing ones
- sleep deprivation is a major factor. The relationship between sleep
deprivation and many such problems has been studied in depth.

 _In my experience, there is such a thing as suffering that shouldn’t be
pinned on bad politics._

That's a pretty weird statement. Obviously, I'm politically to the left and
believe that society in general and highly destructive social policies, in
total is responsible for homelessness in aggregate but see below.

 _I think ... ideally ... the default first reaction to suffering should be
compassion?_

My default reaction to homelessness is generally an effort to step-in and
help.

I've spent thousands of dollars of my own money helping individual friends
avoid homelessness (sometimes successfully, sometimes not so), I've
distributed food at soup kitchens and I've protested the eviction of homeless
camps. I give money directly to homeless people when I can. I've know others
involved in social services. Oh, and I've been homeless for moderate periods.

Your statements seem to imply that seeing homelessness as political negates
efforts to help - but instead, my individual efforts to help give me the
strong impression this problem larger than my personal ability to solve, hence
it is a problem of society, a political problem in the sense of how do we run
our society (assuming, maybe mistakenly, some "we" exists today). I think most
people involved in homeless services feel also feel this problem requires more
than just the intervention of charity.

I understand that some people are so wholly dysfunctional that they aren't
going to easily join society when offered a minimum wage job or even,
necessarily, an ordinary apartment - mean, my original post mentioning broken
people is what started this off, right? That doesn't change the way that
social conditions are a large part of what creates this society.

Of those groups involved in interacting with homeless, your attitude seems
closest to that of the police and others in the "justice" system who
constantly claim far greater knowledge of the conditions of the homeless than
all others but who's views tend be twisted, cruel and malicious through their
impulse justify society's brutal dictates towards the homeless. Plus
unsupported by any objective studies. "You don't really know what these people
are like" is the common rhetoric.

I would mention that law enforcement sees the dysfunctional homeless primarily
because anyone functional and homeless stays as far as practical away from law
enforcement and any homeless service that aims to control people (ie, lots of
shelters, etc).

~~~
whiddershins
You are creating a false binary, and then ascribing my views to the ‘other’
side of the binary because they aren’t exactly the same as yours, therefore
they must be opposite.

What I’m saying is blaming “society” and “this country” for “breaking people
[...] nowadays” is wrong headed. Sure, society and our political system can be
harmful and damaging, but that’s not the main issue, it is a red herring.

In my view, society should very much participate in helping mitigate the
effects of bad luck, bad choices, being victims of abuse, horrible
circumstances, whatever bad befalls someone, regardless of the source. We very
much need a robust safety net in many dimensions.

Just because we could do better... much much better ... in that regard doesn’t
not automatically make for evidence our country is uniquely bad for people, or
that this criticism of our country is the most salient point to comment about
on an article about medical treatments for high need groups.

That is where we disagree. I don’t agree that the mere existence of suffering
people means a political system is screwed up. I think suffering is part of
existence, and people who want to try to get rid of all suffering by remaking
politics have created nightmare after nightmare throughout history. And I
think this idea that individual suffering is a priori a failure of the social
and political system means people hijack discussions about helping people to
take swipes at the system.

Edit: And if you want to know what I really think about homelessness and
systemic issues, I think regulations prohibiting boarding houses are cruel,
because it prevents someone who is in a tough spot from renting a cheap room
somewhere while they figure out what to do.

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eyeball
I wonder how this program’s performance would look if they had recruited
candidate members based on a predictive model of future utilization / need
rather than focusing on people who were already extremely complex / high cost.

~~~
benmaraschino
Likely there would be little to no difference, because as it turns out,
outcome risk is an awful predictor of benefit, especially among high-risk
patients. Many high-risk patients will be readmitted to the hospital anyway,
no matter how much preventative care you throw at them. On the other hand,
there are potentially many preventable readmissions among ostensibly low-risk
patients, and you can prevent more total readmissions by including them in
your targeting as opposed to focusing on a tiny high-risk group.

(A big part of my current PhD research involves building predictive models for
patients with complex needs, so I grapple with these issues day in and day
out, and often on huge scales—millions of patients. Prediction, at least in
the usual supervised ML sense, just doesn't cut it for these kinds of
problems—you need causal inference.)

~~~
eyeball
>Likely there would be little to no difference, because as it turns out,
outcome risk is an awful predictor of benefit, especially among high-risk
patients.

Wouldn’t that depend on what benefit you’re trying to achieve? If you want to
prevent re-admissions, wouldn’t it be better to focus on people at high risk
if future re-admission vs people with high past complexity. (I assume there
would be a lot of, but not perfect overlap)

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kova12
Fucking paywall again. Can I finally just stop seeing these articles? This
clickbaiting practice starts to really piss me off

~~~
jessriedel
HN long ago decided to allow articles behind a paywall. Still, it seems
legitimate for users to not have to stare at such headlines on the front page
all day, so I wonder why they don't make it an option to hide submissions from
the most well known paywall sites. It would also reduce the number of people
commenting on an article without reading it.

