Tuesday, February 5, 2019

How can we keep Gramps and Granny at home?

Most elders would much rather be in their own homes than in hospitals, but our current health care system seems to be organized around hospitals rather than homes. This is not only less desirable but more expensive.
European and other OECD countries spend much less on health care than does the United States but have better health statistics. This is not necessarily an indictment of U.S. hospitals and doctors on quality (though it is on cost), because there are many differences between the U.S. and our western peer countries besides the way our health care system is organized. Europeans on average are more physically active than Americans, walking and bicycling more, and less likely to be overweight or obese. Another very important difference is that while European countries spend much less on health care, they spend more on a variety of social services, including family and child support and housing. Thus, the U.S. spends about 18% of its gross domestic product on health care, while this is 10-12% of GDP in other OECD nations but public spending on social services represents 21% of GDP in other countries and 19.3% in the U.S. To look at this in another way, for every $1 spent in the U.S. on health care, $0.56 is spent on social services while in other OECD countries, for every $1 spent on health care, $1.70 is spent on social services.
How does this difference in spending priorities affect our health outcomes? As noted in prior postings and in Prescription for Bankruptcy, maternal death rates in the U.S. are dramatically worse than in other OECD nations, and infant death rates are worse even though we have many more neonatal intensive care beds. Much of this can be attributed to the very different ways new mothers are treated. In most OECD countries, generous paid maternity leave is the norm, while in the U.S. if it is offered at all, it is likely to be unpaid. This is clearly a reason why half of new mothers in the U.S. do not even keep their six-week postpartum checks.
Two studies published last fall showed how provision of better social services can impact both quality and cost of health care. One, published in JAMA Internal Medicine in October, looked at the impact of community health workers on the health outcomes of a group of low-income veterans cared for at a Philadelphia VA hospital. These elderly veterans had at least two chronic diseases and lived in high poverty census tracts. Not only did the veterans who were visited by community health workers report greater satisfaction with their health and with their care, but they experienced 65% fewer hospital days over the nine months of the study compared with a similar group who did not have these visits.
A study published the same month in Health Affairs looked at how supportive social services supplied to elderly residents of Queens impacted their hospital use. The group studied were residents of subsidized elder housing units who were matched in every way except that one group had access to a variety of in-home services. These included counselling, home safety assessments, wellness and socialization programs and assistance with accessing government programs and in transportation. The group that got these services, compared to a very similar group living nearby without them, had 32% fewer hospitalizations, and when they were hospitalized, went home sooner.
Increasing social support clearly works. How to finance it is problematic. For large agencies that are globally budgeted, such as the VA or the new Medicare Accountable Care Organizations, a good case can be made for them to plunge in and spend the money and expect a good return on their investment. For the nation as a whole, policy makers must be made to understand that investing in these low-tech services may give a bigger bang for the buck than many other ways the money can be spent. Spending money on improved social support will not only make our most vulnerable citizens happier but in the long run it will save money.


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