Health
care policy mavens are finally recognizing that we need to do a better job
taking care of the sickest and costliest patients in American society. These
are people on whom we spend a large percentage of our health care dollars without much to show
for it, either in terms of standard health care outcomes or quality of life.
Many of them have advanced illness. Many have multiple chronic diseases plus
functional impairment plus extensive social needs. They’ve gotten the attention
of people like David Blumenthal, who published an article called “Caring for High-Need, High-Cost Patients—An Urgent Priority” in the New England Journal in
September and another article in JAMA sounding a similar call to action a few weeks
later. They are the focus of the Coalition to Transform Advanced Illness, which
produced a white paper mapping out a strategy for care and which just held a
National Summit on Advanced Illness Care. Everyone defines the relevant
population slightly differently and everyone makes somewhat different proposals
for moving forward. One of the most creative is an idea that has been tried in
England with good results.
This
model gives high need patients a personal health care budget. The budget is
determined by negotiation between the patient and the health care team. It
“relies on a goal-setting and care-planning process in which patients and
health care teams consider medical and social needs.” The budget allows payment
for home supports and for technology that facilitates their remaining at home. It
includes coverage for unusual and somewhat controversial non-medical needs such as a garden
shed for someone with dementia so he could stay home because he had something
to keep him occupied—the alternative was for him to become agitated and restless and quite likely require sedation and/or institutionalization.
Interestingly, the budgets exclude access to primary care and hospital care,
which are uncapped. Studies to date have found the system cost effective and
associated with enhanced quality of life for the participants.
The
result is not entirely surprising in light of the pioneering work done by
Elizabeth Bradley and Lauren Taylor, popularized in a NY Times article in 2011
(and recently the subject of a book, The American Health Care Paradox.) What
these researchers found was that though the US spends as much as 50% more than
other developed countries on acute hospital care, imaging studies, lab tests,
and other standard medical care, it spends much less than most other OECD
countries on social services including old age pensions, disability, family
support, and housing. If you combine the expenditures on both health and social
services to give the true per capita spending in each country (with the amounts
adjusted for GDP), it becomes clear why American health outcomes are so often
inferior to those achieved in other countries: our total per capita spending is actually less than that of similar countries. The US
over-invests in medical care and under-invests in social services.
A
personal health budget that allows individuals to buy social services and other
not strictly medical items that have the potential to enhance the coordination
of care—a smart phone or a laptop, for example—is a way to compensate for
America’s weakness. It fits into the prevailing ethos of individual control and
of having “skin in the game.”
If dressed up in sufficiently
capitalistic sounding language, the proposal might even pass muster in a
Republican-controlled federal government. It could finally transform care for the sickest, most vulnerable patients in the US health care system--and save money, too.
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