(Note: This article is from the Health Politics archives) By Mike Magee, MD Some 40 years ago, I recall visiting General Electrics’ “Carousel of Progress” at the World’s Fair in New York. The attraction, now housed at Disney World in Florida, documented the changes in the technology and social structure of the American home over five or six decades, ultimately creating a vision of the future, a case for progress. I think the time has come to build something similar for health care. This “Carousel of Progress” would provide a vision of the past, present and future for something far more important than refrigerators and toasters – our nation’s health. At the core of this carousel would be a vision that’s just within our reach – something that will change health care as we now know it. I’m talking about the concept of home-centered health, in which technology, advanced information systems and a new, more team-oriented medical approach would make it possible for more health care to take place in the home than we ever imagined possible. A key role in this scenario is a home health manager to link the patient with the physician. In fact, the home health manager will certainly help make home-centered health a reality in the coming years. What are some of the issues that designers of this “Carousel of Progress” will need to consider as they try to capture our health care movement from 1960 to 1980 to 2000 to 2020? First is aging. Fifty percent of current 60 year olds have a parent alive, and by 2050 there will be more than 1 million Americans over age 100. This means that the four- and five-generation family, not the three-generation family, will be the norm. 1 Second is health consumerism. In the past 25 years, we have moved from paternalistic health care doctor says/patient does – to partnership models. Educational empowerment and direct consumer engagement are increasingly the rule. As patients are placed at clinical and financial risk for their decisions, physicians are restructuring to create both clinical and educational teams, with patients themselves as team members. 2 Third is the Internet, a critical technologic advance that has ended the age of information segregation. The general public is rapidly absorbing the scientific lexicon, a basic knowledge of organ function, and regularly updated theories regarding causes, diagnoses, and treatments of diseases. Patients are pursuing their own research, double-checking facts, and connecting with other patients with similar conditions. Those few physicians who have created nurse-led virtual education teams have found rapid enrollment of their patients, seeking knowledge, guidance, emotional support, and encouragement. 3 Fourth, the caregiver revolution. One quarter of American households have elder caregivers in place. Eighty-five percent of these caregivers are family members -- the vast majority being third-generation women. To manage these roles, the caregivers are rapidly growing in the understanding of the seven major chronic diseases; the mechanics of Medicare and Medicaid reimbursement; basic health law; and the hiring and management of additional help if they can afford it. These caregivers are also learning how to stretch and prioritize resources; define and personalize quality of life; and avoid unnecessary doctors’ office visits and hospitalization. As third-generation home health managers gain knowledge and confidence caring for fourth- and fifth-generation family members, they are slowly realizing that the strategies and tactics mastered could apply equally well downstream to the benefit of themselves and the younger generations below. 4 Fifth is the shifting health care value proposition. Americans are attempting to move from reactive intervention to proactive prevention, and this changes the playing field for everyone – hospitals, doctors’ offices, health insurers, and pharmaceutical and medical device companies alike. It implies healthy behaviors, early diagnosis, regular screenings, knowing your numbers, effective long-term treatments with excellent adherence, and a personalized, information- and relationship-rich support system that is equitable and just. It suggests that to be valued in our future health care system, each player, in addition to his or her traditional unique contributions, will also need to be engaged in educational and behavioral modification to claim insider status. 5,6,7 With these in mind, the health care “Carousel of Progress” has been created. Now, we’re circling counter-clockwise and the last set appears. Ten realities have been skillfully integrated into this calm and well-organized vision of a healthy home: - A home health manager, previously the informal family caregiver, has been designated for each extended family.
- Health insurance covers nearly all Americans, and a medical information highway has been constructed primarily around the patient, with caregivers integrated in, rather than the other way around.
- The majority of prevention, behavioral modification, monitoring and treatment of chronic diseases now takes place at home.
- Physician-led, nurse-directed virtual health networks of home health managers provide a community-based, 24/7, educational and emotional support team.
- Health care insurance premiums for families have just gone down due to expert performance of the home health manager, as reflected in outcome measures of family members.
- Basic diagnostics, including blood work, imaging, vital signs, and therapeutics are performed by the home health manager and transmitted electronically to the physician-led, nurse-directed educational network, which provides feedback, coaching, and treatment options as necessary.
- Sophisticated behavioral modification tools, age adjusted for each generation, are present and utilized, funded in part by diagnostic and therapeutic companies who have benefited from expansion of insurance coverage and health markets as early diagnosis and prevention has taken hold.
- Physician office capacity has grown, as most care does not require a visit. Physician reimbursement has increased in acknowledgement of their roles in managing clinical and educational teams and multigenerational complexity. Nursing school enrollment is up as the critical role as educational director of home health manager networks has become a major magnet for the profession.
- Family nutrition is carefully planned and executed; activity levels of all five generations are up; weight is down; cognition is up; mental and physical wellbeing are also up.
- Hospitals continue to right size – they’re more specialized and safer, with better outcomes. And scientific advances have allowed early diagnosis and more effective treatment, making the need for hospitalization increasingly rare.
Is this all a far-fetched scenario? Not really. Many of these elements are well within the reach of an integrated and progressive vision for tomorrow’s health.
References
1. Alliance for Aging Research. Medical Never-Never Land: Ten Reasons Why America is Not Ready for the Coming Age Boom. 2002.
2. Magee M. The Best Medicine. New York:St. Martin’s Press;2001.
3. Nash D. Connecting with the New Health Care Consumer. New York:McGraw-Hill;2001.
4. Shalala D. The United States Special Committee on Aging. Long Term Care for the 21st Century: A Common Sense Proposal to Support Family Caregivers. Testimony before the United States Special Committee on Aging: March 23, 1999.
5. Robinson JC. From managed care to consumer health insurance: the fall and rise of Aetna. Health Aff (Millwood). 2004;23:43-55.
6. Robinson JC. Reinvention of health insurance in the consumer era. JAMA. 2004;291:1880-1886.
7. Arno PS, Levine C, Memmott MM. The economic value of informal caregiving. Health Aff (Millwood). 1999;18:182-188. |
