“Marilyn is not a physically imposing person,” said Montana Board of Investments Executive Director Dan Villa, who worked closely with Bartlett in state government. “She is a blend of your favorite aunt, an accounting savant and a little bit of July Fourth fireworks.”

Bartlett, whose faith in data borders on fervent, hauls binders full of numbers everywhere she goes. “My focus has always been following the dollars,” she said. “You’ve got to roll up your sleeves and get down to the nitty-gritty detail, especially in health care.”

Bartlett’s success in Montana saved the state more than $30 million in three years by pegging hospital prices to a multiple of what Medicare pays. Now, she is an in-demand adviser to states, counties and businesses all trying to control health care costs. But as she’s hit the road, binders in tow, she’s found it difficult to replicate the Montana solution.

A Montana Miracle

Bartlett earned her reputation as administrator of the Montana state employee health plan, a role she assumed in 2014 as the plan hurtled toward insolvency. As Bartlett dug into the data, she discovered hospitals were charging the state as much as what they charge Medicare, the federal insurance program — for exactly the same services.

Historically, the state had accepted the seemingly arbitrary prices set by hospitals. Bartlett, staring down a $9 million shortfall, knew that had to change. She wanted the state to start dictating the rates they were willing to pay, but she needed a benchmark first.

She turned to Medicare. Unlike most payers, who bury prices in secret contracts, Medicare makes its payments public. Bartlett borrowed those rates and then more than doubled them — to 234% — knowing that hospitals often complain Medicare pays too little. This new kind of contract, known as reference-based pricing, was among the first attempted at this scale.

Bartlett expected the hospitals to chafe at the offer, but with Montana’s plan insuring 30,000 people, more than any other employer in the state, she had the upper hand. Despite what Bartlett described as “very, very tense” negotiations, all the state’s hospitals signed on.

Five years later, the state health plan regularly runs in the black. Villa, who was former Gov. Steve Bullock’s budget director, said governors dip into the plan’s reserves to fill budget gaps. “I now refer to the state health plan as the ATM,” he said.

The Player Becomes the Coach

Montana’s success became a small sensation, at least in health policy circles. Now, one big question remains — the same one that has deflated the highest hopes of so many health care leaders. Can it be replicated?

Many of the country’s employers are desperate to find out. Their costs have in just the past decade. Employee spending on health care is also on the rise, . Leading economics researchers point to as a key culprit.

Since retiring from Montana state government in December 2019, Bartlett said she has spoken at numerous conferences, given hours of free advice, and answered a seemingly endless stream of calls.

One of the first calls came from Trish Riley, executive director of the National Academy for State Health Policy (NASHP). Riley hired Bartlett in 2019 to serve as “a coach, cheerleader and mentor” for officials from dozens of states trying to cut costs, including New Jersey, which passed a bill in 2020 the state’s health coverage for teachers and estimated to save the state $30 million annually.

Bartlett is also advising regional business coalitions stretching from Houston to Maine and seeing early signs of progress.

In Colorado, Bartlett is coaching , including city, county and state health plans, that have come together to negotiate with hospitals. The group recently notched its first win, signing one hospital to a Medicare-benchmarked contract.

In Indiana, Bartlett is advising the , a coalition that insurer Anthem to renegotiate its contract with a notoriously expensive health system.

Bartlett is even shaping legislation, including recent failed attempts in the to more broadly control hospital prices and in the to increase transparency.

‘A Hard, Hard Thing to Tackle’

Bartlett has learned over the past five years just how difficult her model is to export. “It’s a hard, hard thing to tackle,” she said.

Opposition from hospitals is often fierce. In Montana, the deal Bartlett negotiated has actually boosted some hospitals’ bottom lines, but the Montana Hospital Association still criticizes it. MHA President Rich Rasmussen faults the contract for focusing on prices and largely neglecting issues of quality and access. “It doesn’t connect all the dots,” he said. Rasmussen also argued Medicare rates are an “inadequate” starting point for negotiations because they fall short of covering the full cost of care.

That opposition pales in comparison to what Bartlett has seen crisscrossing the country. “What I faced in Montana was nothing like North Carolina faced,” she said, her eyes widening as she described the sheer of the “mega systems” she encountered while advising North Carolina officials.

North Carolina’s plan to pay hospitals roughly twice Medicare rates in 2019 after just five hospitals agreed to the deal and several giant health systems refused to budge.

Bartlett understands that, as a result of , more states face hospital landscapes like North Carolina’s, with its , than Montana’s, with its more than 40 rural hospitals. And the insurance industry nationwide also is , leaving employers with fewer alternatives.

Saying No to Employees

For employers to have any chance at the negotiating table, Bartlett said, they must be willing to make tough calls. In practice, that might mean dropping a hospital that delivered an employee’s twins or a surgeon who cured a CEO’s cancer. “That’s pretty damn hard,” she acknowledged.

“Employers don’t want to disrupt their employees’ care,” said Elizabeth Mitchell, CEO of , which represents Fortune 500 companies like Walmart and Microsoft. “It takes a lot of fortitude to carve a marquee-brand hospital out of a network.”

A 2020 KFF found only 4% of employers had dropped a hospital from a network in order to cut costs. (KHN is an editorially independent program of KFF.)

Bartlett is quick to remind cold-footed employers that continuing to contract with expensive hospitals and doctors has a price, too. “You’re going to disrupt members when they get less and less benefits and pay more and more,” she said. High health care costs also eat up wage increases in the private sector and school funding in the public sector.

Will Covid-19 Be a Catalyst?

Bartlett’s work has hit a crossroads during the pandemic. It is harder to criticize hospitals and their business practices as they play such a vital role. Meanwhile, employers and workers are hurting financially.

“Many large employers are facing economic pressures they frankly haven’t had for a while. They’re laying off tens of thousands of employees,” said Mitchell. “There’s a new sensitivity to costs.”

Bartlett sees an opportunity and is hustling to help employers meet it. She has teamed up with researchers at Rice University on a NASHP project called the Hospital Cost Tool.

“It breaks open this black box and lets you ask where these dollars are going and why,” said Riley of NASHP. The tool aims to automate the kind of forensic accounting of hospitals’ finances that Bartlett had been doing on a one-off basis.

‘You’re Not Going to Be Liked’

There’s one final test Bartlett has tried to prepare employers for — one for which numbers won’t help. It’s the personal toll that comes with challenging the status quo.

While working for the state health plan and before her work delivered results, Bartlett lost close friends, was cut out of meetings and even discovered her co-workers had created a Facebook group to criticize her. “You’re not going to be liked. You’re going to be ridiculed.”

She reminds employers they have a moral and fiscal duty.

“The reality is this is hard work, and it became harder than I ever anticipated,” said Bartlett. “But employers have been given this money, by the taxpayer, by the member, for these benefits. They are responsible for every penny spent. You can’t turn your back on that.”

In Montana, the premiums and copays state workers pay have not increased a single cent since Bartlett and colleagues renegotiated with the hospitals. Over that same time, the average premium paid by American families with employer-based insurance .

Dan Gorenstein is the creator and host of the podcast and Leslie Walker is a senior producer on the show. Their Feb. 18 episode profiles employers’ efforts to purchase health care in new ways.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Researchers tested whether pairing frequently hospitalized patients in Camden, New Jersey, with nurses and social workers could stop that costly cycle of readmissions. The study found no effect: Patients receiving extra support were just as likely to return to the hospital within 180 days as those not receiving that help.

The results are a blow to , the organization he founded nearly 20 years ago.

“It’s my life’s work. So, of course, you’re upset and sad,” said Brenner, who now does similar work with health insurance giant UnitedHealthcare.

The model of care, pioneered in part by Brenner and profiled in a widely read 2011 article in The New Yorker, has inspired dozens of similar projects across the country and attracted millions in philanthropic funding.

“This is the messy thing about science,” said Brenner, who won a MacArthur Foundation “Genius Grant” for his efforts. “Sometimes things work the way you want them to do work and sometimes they don’t.”

The Hope

Many hospital and insurance executives have pinned their hopes on this work because it promised to solve a common problem: when patients lives are so complicated by social factors like poverty and addiction that their manageable medical conditions, like diabetes and asthma, lead to expensive, recurring hospital stays.

Writer and physician Atul Gawande introduced Brenner as a brash visionary crusading on behalf of the “worst-of-the-worst patients” in the New Yorker piece, .” (Gawande, who now , a joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase, declined to be interviewed for this article.)

Brenner’s prescription: Pair these people with front-line care workers who would shepherd them to the social and medical services they needed. Early evidence was promising, the anecdotes inspiring. Brenner boiled the model’s potential down to four words and two tantalizing goals: better care, lower costs.

As word spread, breathless headlines popped up like “” and “”

“Lots of organizations make claims that their programs work and they’ve never been rigorously tested,” Brenner said.

Instead, Brenner took the unusual step of inviting the scrutiny of respected researchers.

In 2014, Massachusetts Institute of Technology economist Amy Finkelstein began a randomized controlled trial, the same rigorous method used to evaluate new drugs. Over four years, the coalition enrolled 800 patients, all who had been recently hospitalized and struggled with social problems. Half received the usual care patients get when leaving the hospital. The other half got about 90 days of intensive social and medical assistance from the coalition.

And the result: The 400 patients who received the intensive help were just as likely to return to the hospital as the patients who didn’t. In both groups, nearly two-thirds of people were readmitted within 180 days.

So why did the coalition fail? Why did the savings touted in their early data, which Gawande had declared “revolutionary” in The New Yorker nearly a decade ago, disappear when put to this rigorous test?

‘My Daily Routine’

Larry Moore, who has hypertension, alcohol addiction, chronic seizures and difficulty walking, was one of the first people to enroll in the coalition’s trial.

Moore’s experience serves as a road map for understanding why the coalition missed its mark.

His first months were promising: prescriptions filled, medical appointments attended, Social Security benefits claim in process. The 47-year-old even started to trust the team with the details of his deep-seated addiction, confiding how he would consume mouthwash, vanilla extract and even hand sanitizer at times.

“You couldn’t keep anything with alcohol in it” around him, Moore recalled. “That’s addiction.”

But all the progress suddenly stopped when Moore seemed to disappear from the coalition’s radar.

“We didn’t see Mr. Moore after November,” said nurse Jeneen Skinner. “We went to the house. We sent text messages. We [made] phone calls.”

The coalition has learned that for people living in poverty and with poor health, a small hiccup — in Moore’s case, a missed rent payment — can spiral into a major setback.

Moore spent the next 2½ years mostly homeless, completely out of touch with the coalition.

“I was going from place to place. I sleep on a bench or a rock until the next day when the liquor store opens,” remembered Moore. “That was my daily routine.”

Seventy emergency room visits and six hospital admissions later, Skinner reconnected with Moore.

He told her the one thing that would keep him out of the hospital: housing.

The ‘Camden Coalition’

Too many times, during the trial, people ended up back in the hospital despite the intervention. But the coalition is convinced it didn’t fail as much as the larger social safety net did.

“The bottom line is, we built a brilliant intervention to navigate people to nowhere,” said Brenner.

Coalition staff and their patients usually knew what was needed — evidence-based addiction treatment, housing, mental health services — but resources were often in short supply.

Over the past three years, the coalition set out to fill in those gaps, undergoing a kind of metamorphosis.

“We think of ourselves now as the Camden Coalition” steering away from the “health care providers” part of the name, said Kathleen Noonan, who succeeded Brenner as head of the organization.

It has forged partnerships with jails, lawyers and legislators, and started its own housing program. Many of these efforts began as the clinical trial was ongoing — a sign the coalition had seen the writing on the wall.

‘I Kid You Not’

“I would have never imagined this,” said Moore, sweeping his arm around his one-bedroom apartment.

A green houseplant sits in the sunshine. A fluorescent-colored stuffed animal decorates the bed.

“When I first moved in here,” Moore explained, “it took me about a month to even sleep in my bed. I slept on a couch.”

Housing made it easier to face his other problem, choosing to try the drug naltrexone, a long-acting injection to treat alcohol addiction.

Moore is nearly two years sober today. He meets with a coalition support group on Wednesdays. He’s becoming a deacon at his church. In the 22 months he has lived in the apartment, Moore’s trips to the hospital have plummeted: just one admission and one ER visit.

“I kid you not, when I saw Mr. Moore probably a month ago, I was standing next to him and did not recognize him,” said nurse Skinner. “He looked at me, and said, ‘Jeneen, it’s me. And I was like, ‘My God, you look amazing!’”

Larry Moore’s story is just that: one story.

Yet it represents a larger trend. Insurers — including UnitedHealthcare under Brenner’s direction — hospitals and many state Medicaid agencies have begun spending millions to meet patients’ social needs.

The new study, though, backs up the skepticism of other researchers that, when it comes to saving money at least, these approaches don’t work well. For one, programs are expensive and hard to scale. The coalition’s housing effort currently serves only 50 people and costs about $14,000 per person per year. Secondly, the data is lacking, cautioned Boston University economist Austin Frakt. “Despite what people would like to believe, there’s not a lot of evidence you can reduce health spending by spending more in other areas.”

Finkelstein said that as health care companies move further beyond the four walls of a hospital, the need for rigorous evaluation grows. “I think a lot of well-intentioned people in health care can’t handle the truth,” she said. “They’re trying to do good, but they don’t have the courage to say, ‘Let’s do a gut check on ourselves.’”

Dan Gorenstein is the creator and co-host of podcast and Leslie Walker is a producer on the show, which features the study on the Camden Coalition in episode 7.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).