Now that the Accountable Care Act is moving forward, there is increasing discussion around controlling health care cost. Massachusetts , which is a few years ahead of us all in this debate, just reached a compromise on cost control, settling on a fixed rate of inflation which effectively caps total tax supported expenditure.
Many health policy people link cost control to rationing. But for me, the most logical connection is between cost control and efficiency. My thinking goes like this: As we expand consumer rights and responsibilities, we need to encourage family and community based linkages in pursuit of strategic personalized health planning and management of chronic disease burden. To do this, we need to go where the action is – into the home.
Here’s a little graph(above) that illustrates a constellation of behaviors that originate in the home including nutrition, hygiene, fitness, education, financial stability and our genetic inheritance. And here’s a bar graph (below) of contributors to chronic disease burden which also emanate from home-based origins.
If logic dictates that disease prevention and disease management originates in the home, then it should follow that we would do well to apply a substantial amount of our health care resources to this source location. Three realities currently allow us to defy this logic. The first, and most obvious, is the power coalesced within an industrialized hospital-centric health care system where the center loop goes from hospital to doctor’s office and back again. The second problem is that resources and incentives continue to be targeted at ever site but the home. Third, and perhaps most critical, is that increasingly nobody is home at home.
Over the past half century, we’ve seen a series of social changes that have weakened home-based leadership. First, multi-generational ties have been undermined by geographic migration. The traditional pattern of learnings passing down the generational ladder and caring passing up the generational ladder as older family members age seems almost quaint – except for the fact that economic hardships and demographic, age-relate dementia is forcing many families to rediscover each other.
Second, we have allowed to go unchallenged the contention that most families now need a dual income to survive – and in the process kidded ourselves that there were no adverse physical or mental repercussions attached to placing weeks old infants into highly variable day care arrangements for 8 or 10 or 12 hours a day. While for a segment of the population, survival may require such a radical move, for many others this is not the case.
Finally, were we really to focus on home-based leadership in pursuit of healthy individuals and healthy homes, we would need to redirect resources – human and financial – into home-based health care. Where we have done this – for example with hospice - patient and provider scores have soared and costs (of hospital readmission and over-treatment) have declined. Imagine the benefits and savings were we able to provide loving care for all segments of the family not just when they were sick, but also when they were well.
But to do all this, parents and grandparents need to parent and grandparent – not make believe that infants and children can raise themselves. Employers must continue to support growth in flexible work schedules and home-work solutions. Hospitals and health care teams need to advantage technology to increase their mobility and reach. Successful health planning and execution need to be financially incentivized. And homes must be where both the heart and health reside.