Explaining the U.S. Home Health Care System

Yesterday's post on early hospital discharges has triggered a lot of interesting discussion.  Two questions came up over and over:  why can't we do this more like European countries, who have single-payer systems--and why can't we do this more like our ancestors, who regarded caring for family members as an important part of familial duties?

No one made both arguments, so I'll try to take them one at a time.  On the question of Europe, I do get the impression that European governments provide a lot more automatic in-home care.  But that's all anecdotal--I'm not aware of any really good studies on the matter.  Moreover, the anecdotes I have heard indicate that it's far from uniform: Spanish families are supposed to provide lots of care for sick relatives; Norwegian families, almost none.

We also shouldn't exaggerate the holes in the U.S. safety net.  When they sent my mother home with us, I got a call on the day of discharge from the home health company that was providing the IV antibiotics to walk me through the billing, what we were getting, and how many visits we could expect.  A nurse showed up promptly at seven in the evening to walk me through the process and leave me with all the supplies as well as fairly detailed instructions on how to use them.  Another nurse will be coming by regularly to change surgical dressings and deal with her surgical drain.

Nonetheless, I am under the impression that in at least a few countries, a nurse would be stopping by twice a day to administer the IV and check that everything was okay.  Obviously, that's not the case here.  So why the difference?

Some of it is national priorities.  The longer I've reported on the health care system, the more I've realized that every system has stuff that it spends a lot of money on--presumably, the stuff their culture (or at least, their government) really cares about.  The Japanese have loads of high-tech scanners.  The Netherlands seems to have very extensive home health care services, and a crazy-awesome record against antibiotic resistant bacteria.  America puts almost everyone, including its charity patients, in at least semi-private rooms (the surgical ward my mother was on didn't seem to have anything except private rooms.).  And to judge by local television, those rooms are much nicer than what's available elsewhere--hospital rooms in foreign film always look faintly third world to American eyes.

You can often argue that any of these choices is overdoing it, but to some extent, they're just differences in taste.  A few years back, a friend whose father had open heart surgery in Britain's NHS was on an open ward 8 hours later--and when I expressed shock, a fellow Brit derisively said "Oh, that's right, American hospitals are like hotels."

But that's not the whole explanation, because in fact, we spend about three times the OECD average on home health care.  Most of that probably comes via Medicare or Medicaid.  We're ranked #5 in the OECD.

Part of it is wages, and regulation.  We've had two visiting nurses since my mother came home.  Registered nurses make an average of $65,000 a year, which is far above the U.S. average.  America makes heavy use of occupational licensing, and in health care, those occupations spend a lot of time making sure that less-well-paid professions do not infringe on their turf.  The result is higher health costs.

There's also density.  It is much less expensive to provide in-home services in compact housing clusters than it is in sprawling American subdivisions.

Are home care agencies padding the bills?  Maybe.  But the last time we decided to slash reimbursements because home care services were wildly overpriced, about half of the agencies went out of business.

And if we did cut reimbursements, it's not clear to me that we'd choose to spend the money on more home care services.  We might use it to cut our tax bills, or spend more in other parts of the system.  I'd argue that Americans are probably more likely than many European countries to feel that families should be able to help out--perhaps in part because people tend to have more kids who can provide help.

The conservative question is why we don't provide even more of it.  This post makes that point at length:

I think it's worth remembering that "sickroom care" was once a natural part of homemaking, and families used to have the skills to care for relatives who were suffering from a wide variety of ailments. We're talking about something that is a lost art, not an impossible art. Old homemaking manuals used to have chapters about it (here's one); sometimes even cookbooks would. There was one around the house when I was a child -- heaven knows where it came from -- and I used to read the "sick room" chapter with fascination -- how to clean and sterilize a bedpan and wrap it in a neat package of clean newspaper to keep it read y for use, and the importance of giving the patient as much privacy as possible (even if that is only turning your face casually away) while he or she uses it; how many visitors are appropriate; what to do with infectious garbage; how often to change the sheets; how to avoid bedsores.

Homemaking manuals don't seem to have this chapter anymore.

It seems pretty obvious that when people grow to expect professionals to do the work of caring for the sick, both the recovering and the dying, then that work is no longer seen as the proper expertise of loved ones. Either it is above them (and doctors and professional nurses should do it) or it is below them (and health care techs and janitors should do it).

Maybe one way to lower costs, and improve care at the same time, is to invest in caregiver support rather than hospital stays.

That is basically what is happening with us.  We've had nurses come and show us how to perform tasks, and then we perform them.  And in fact, I'm very glad that we're doing it.  It's a privilege to be able to take care of my mother, after all the years she took care of me.  I think that it's bringing us closer; I certainly hope it will.

But I think there are reasons that families now do less of this.  Dealing with bedpans may be disgusting, but it's basically pretty simple.  Administering an IV through a PICC line is . . . well, the sheet they gave us has 17 steps, which doesn't actually include everything the nurse showed us.  And as I mentioned in the comments of the previous post, I've been terrified that I'd kill my mother with an air embolism.

(Incidentally, thanks to commenter and anaesthesiologist Devilbunny, who set my mind at rest on that score.)

That's comparatively minor to the time they sent my grandfather home from the hospital on a Friday with a promise that the hospice nurse would show up on Monday to help care for him as he was dying of cancer.  When my mother turned on the toaster, that plus the oxygen machine blew a fuse, and she was sure that he'd die before she got the power back on.  That's besides the regular burdens of caring for a semi-comatose patient in terrible pain.  There's more going on with treating today's patients--which means more going wrong.  It's not always that people are unwilling to care for the sick, as much as afraid.

The other obvious reason is that women aren't home any more to provide round-the-clock care.  The needs of sick care are not really compatible with the schedules of a modern industrial economy.  Indeed, the comments complain more one expression of wonder at the way that hospitals blithely assume they can just call you up whenever they're ready and have you show up on a moment's notice to pick up their patient--or set up mid-day follow-up appointments that require someone to take a half a day off of work to drive their non-ambulatory parent to a doctor's visit.

The size (and scatter) of families probably also has something to do with this.  More of the burden falls on one person, until it becomes impossible.

Ultimately, there's never going to be a perfect solution.  There are good reasons for families to have a care-giving roles--and good reasons why that's often difficult.  It's possible that for all the complaints, the current system represents the right set of tradeoffs: we ask families to pitch in when they can, and provide extra help when they can't.

But the nature of such tradeoffs is that some people will always be unhappy about the choices we make.  They'd probably be happier if the tradeoffs were more explicit, but that doesn't mean that the complaints would all go away.