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A study examined coordinated care for the most expensive patients (nytimes.com)
20 points by Reedx 4 days ago | hide | past | web | favorite | 20 comments





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.


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.


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.


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?


“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.


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...

[2] Google it: https://www.google.com/search?client=ubuntu&channel=fs&q=cor...


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?


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).


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.


My uncle has been an alcoholic / drug addict his entire adult life. Inherited the family dairy farm from my grandpa. Drove it into the ground. Eventually lost the farm. Ended up living in a trailer on a plot of land he got from my grandpa.

My understanding is this trailer had electricity but no plumbing. He lived there for probably a decade. At some point he picked up a lady who I'm fairly certain is addicted to opiates.

This was all in northern Minnesota (gets real cold in the winter). Anyway, two winters ago, he couldn't be bothered to stoke the fire at night and ended up getting super bad frost bite on his feet. A few weeks later, he got both his feet amputated below the knees. Spent several months getting recovered.

In the meantime, the family had sold off Grandpa's house and land. Split evenly between the kids (6 of them). Gave him enough cash to build a little shed with proper plumbing and heating.

At some point this spring, he fell out of his wheelchair and his lady left him there for twelve hours of so. A friend happened to stop by and called the ambulance.

He's been on the brink of death for a good six months now. His esophagus was disconnected at some point (maybe still is?). He is basically riddled with health issues from a life spent making the wrong choices.

I think it's safe to say at this point he falls squarely in the "most expensive patients" category this article talked about.

Which is a long-winded way of saying, yes, my uncle is broken. But there was no obvious moment along the way where that happened. He had many opportunities and just chose to squander them.

It's sad. But it's also a messy story with no clean-cut snap your fingers solution.


Family intervention 30 years ago and force him to rehab?

Not sure if you read Knausgard but theres an analogous story with his father that you might find comfort wading through.


Who knows what they've tried. I would like to believe that no one is without the capacity to change. To believe that people can be born destined to squander, destroy, and consume without providing is a worldview that I cannot conceive. I believe we are all products of our environments with varying levels of ability. When one of us fails it is a reflection of us all. When one of us succeeds it is likewise a reflection. To deny our interconnectedness and interdependence is to ignorantly absolve ourselves of responsibility to treat each other fairly, and kindly. Anything less is textbook antisocial behavior. [1] Yet, such behavior is celebrated across all demographics. No wonder vulnerable and poor people are despairing. antisocial behavior is rampant in our world. These behaviors effect everyone, though the weight of these assaults increases as someone's resources and support network decreases.

If the definition of antisocial behavior sounds familiar its because the evidence of these mentally ill people are everywhere. Virtually every company wantonly engages in these behaviors. As companies are a sum of their resources and employees (assuming resources like cars and buildings aren't sentient) it must be the employees choosing to engage in these behaviors. Whether someone overtly chooses to engage in antisocial behavior, allows antisocial behaviors to occur without protest, or protests and fails these actions have a waterfall of consequences that we all bare. Should we continue to deny our collective responsibility we shall obviously continue to suffer the consequences of our failures to treat those around us kindly and fairly.

[1] https://www.mayoclinic.org/diseases-conditions/antisocial-pe...

..."Disregard for right and wrong Persistent lying or deceit to exploit others.

Being callous, cynical and disrespectful of others.

Using charm or wit to manipulate others for personal gain or personal pleasure.

Arrogance, a sense of superiority and being extremely opinionated.

Recurring problems with the law, including criminal behavior.

Repeatedly violating the rights of others through intimidation and dishonesty.

Impulsiveness or failure to plan ahead.

Hostility, significant irritability, agitation, aggression or violence.

Lack of empathy for others and lack of remorse about harming others Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others.

Poor or abusive relationships.

Failure to consider the negative consequences of behavior or learn from them.

Being consistently irresponsible and repeatedly failing to fulfill work or financial obligations."


The phenomenon that a small percentage of patients comprise the majority of health costs is not unique to the US, nor is it unique to this moment in time. There are many studies from other countries -- in Asia, Europe etc -- and even of the US decades ago -- that all highlight the same phenomenon

It's Pareto's Principle that a small number of patients at any particular point are going to produce most of the costs.

But that doesn't mean that way Pareto's Principle manifests isn't going to be different in different circumstances.


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.

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.)


>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)


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

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.

The article doesn't seem paywalled for me.

In any case, try: https://outline.com/dEfbj4




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