A New Decade Resolution: 50% of Care to the Home by 2020

Eric Dishman

I’m not usually one for New Year’s resolutions. Either they are so small in scope so as not to rise to the level of “resolution” status or so big that they will take far more than one year to accomplish. And besides, I don’t like disappointing myself during the first week or two of January when I have already failed to eat less chocolate, use the treadmill every morning, or to “be nicer to everyone.” But maybe a new decade resolution makes more sense.

This time of year all the news shows have their “year in review” segments: a fast-edited cacophony of the year’s celebrity scandals, political headlines, media controversies, and, of course, a few new gadgets thrown in all to signify (in their opinion) what was important the prior year. And there is even more chatter when we turn the calendar page to a new decade. Far too many news cycles have already been spent on what to call the decade of 2000 to 2010, with many calling them the “aught” years, the “nameless decade,” or even the “lost decade”–the “naught” years–with the sense that the stock market crash, housing crash, and recession have left us with no gains over the past 10 years.

I don’t know what to call the last decade–and I think it’s ridiculous to think of that time as useless just because our financial wealth didn’t grow–but, regardless, it’s time to look forward. It’s time to move forward. My new decade’s resolution is to do everything in my power to make the next ten years be the decade of care innovation–in particular, to move care into the home and community. If healthcare reform is about anything other than insurance reform (please!), it has to be about care delivery reform. We have to transform how we conceive of care, whose responsibility it is, when we intervene, who is trained to deliver care, and where and how it is practiced. It’s not just a matter of writing a check differently for healthcare–it’s a matter of doing health differently with the money we’ve got.

The good news is that there are many elements in these bills–that rarely make the headlines–that open the door to a decade of care innovation. Covering tens of millions more Americans who were previously un- or under-insured will in itself force innovation as the current system has to find creative ways to deliver more services to more people but without significant increases in money or staff. Very few health plans really know how to be an effective “accountable care organization,” but already a small few of the “old plans” are aggressively reinventing themselves to try be at the forefront of that change. “Care coordination” is going to be novel for many nurse and physician practices–they will have to innovate how they do care on a daily basis. Payment reform–through “bundled payments” and “preventive care incentives”–will create new market dynamics that reward and demand new ways of delivering care that few of us can see or understand at this point. And with care innovation programs and comparative effectiveness studies coming from almost every government agency–the CMS Innovation Center, the Office of the National Coordinator, the Department of Health & Human Services, the National Institutes of Health–it is clear that the next decade, if successful, will begin the transformation of a healthcare system that has changed very little over the past 150 years.The bad news is that neither Congress nor the White House have managed to capture the public’s imagination about the upside of healthcare reform–about the promise of a decade of care innovation. I’ve said many times that government leaders have missed a real opportunity to excite and ignite the country about reinventing our healthcare system with new industries, jobs, technologies, and care models. (Perhaps we should call this reform debate the “lost debate” or the “naught debate.”) They’ve focused so much on headline-grabbing controversies (the public option, abortion, Cadillac plans), the sausage-making process of legislation (filibusters, late night Christmas eve votes, ping pong strategies, reconciliation) in a climate of hyper-partisan self-preservation that the majority of the public as a whole has soured on the idea of healthcare reform in the polls, even though almost every individual yearns for many of the major elements in the bills.

It’s not too late. Congress and the White House can still set out a bold, innovative vision for where healthcare reform will take us. In fact, they probably need to as they try to get this bill finished soon, possibly even before the State of the Union address by President Obama in the coming weeks. I’ll offer the same advice to the President that I tried–but utterly failed through every friend, colleague, and channel I could find in D.C.–to get to him back in September when he gave his healthcare speech to Congress.

The President should make a New Decade Resolution, declaring 2010 to 2020 the decade of care innovation. In fact, he should set out an audacious, going-to-the-moon goal of moving 50% of care that is done today in institutions such as hospitals, clinics, and nursing homes to the home and community by 2020. Instead of investing in more high-tech infrastructure to “fix” us in a medical institution once we’ve already become diseased or injured, we should be investing in infrastructure that helps us to prevent disease and injury, to be more proactive about our own health and wellness, to shift diagnostic capacities into the home and community, and to enlist family and friends in care coordination to offload those overburdened institutional systems and settings.

Having a bold 2020 vision that uses American innovation to shift care to the home and community–and responsibility for wellness to the patient and their care network–will go a long way towards getting the American public excited about the reforms we need to make. Imagine if 10 years from now, those news retrospectives could be looking back at this decade as the time in which we truly gave every American great healthcare, in which we allowed people to age gracefully in their own homes instead of institutions, in which we turned the tide on chronic disease by focusing on prevention and behavior change, in which we personalized medicine to individuals, and in which we invented entirely new kinds of care models, care workers, and locations of care to diversify services for the wide range of health and wellness needs that we, as humans, have always had.

And as with most resolutions, while we may not achieve every aspect of every commitment we make to ourselves, it is far better to have a positive vision and a discernible direction to go in…than to remain mired in the medical morass and the unsustainable status quo that we find ourselves in during this historical moment. And who knows, perhaps in a decade committed to real care innovation, we may surprise ourselves and exceed all expectations.