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Perspectives

An unresponsive health care system is unaffordable

Insights
In-home alternatives to facility-based care can alleviate cost and quality concerns for our elderly and vulnerable populations.
Roughly seven months into the pandemic, the contours of a post-COVID world are beginning to take shape. Companies across the world are rethinking supply chains and big, costly office footprints. On the individual level, consumption patterns have shifted and mask-wearing is now the norm. And in health care, the alarmingly high COVID infection and death rates in congregate living facilities have put a spotlight on quality in-home alternatives for our elderly and vulnerable populations. Compounding this last point is a trifecta of budget crunches at the federal, state and local levels, an aging population requiring significantly higher health outlays, and the reality for many seniors of a shortage in their retirement savings that leaves them unable to afford the care they need in their golden years. It doesn't have to be this way. A workable alternative that provides for both budgetary and quality-of-care concerns comes in the way of home- and community-based services. HCBS encompass a wide range of nonmedical support services—from personal care to nonmedical transportation to home-delivered meals—designed to replicate the benefits of facility-based care without leaving one's home or community. Already decades old once the pandemic hit, these services have advanced greatly over the years. Increasing provider sophistication has helped, and the inequities to access revealed by COVID have only strengthened the case for uptake. Moreover, we've seen significant innovation in virtual health technologies and home-based care delivery models. These advancements, along with an acceleration of value-based care trends, have allowed HCBS providers to create greater value and beneficiary satisfaction—all at a materially lower cost than traditional models. A recent example of this progress is the broad adoption of the online delivery of medical care, or telehealth. HCBS have tremendous potential, yet challenges remain. One issue is the lack of provider reimbursement. If we want to realize the potential of home-based care, we need to create the economic incentives to support a sustainable and innovative provider community. We will also need to improve coordination between often competing Medicare and Medicaid programs for individuals who qualify for both programs. Providers and governments are beginning to take heed and tiptoeing into low-cost interventions that work. For example, there has been an increasing emphasis on support for value-based care arrangements, preventive and nonmedical services as well as behavioral health—all of which are major drivers of costs but have been largely ignored until recently. This is welcome and should be explored further. While the data implores policymakers to continue to focus on community-based drivers of health outcomes, the racial inequalities in health care highlighted by COVID-19 provide the moral imperative. The burden of our public health crisis has fallen heavily on the Black and Hispanic communities, of which many of our front-line caregivers come from. As health experts evaluate what worked and what didn't during this crisis, any solution will be incomplete if does not include enhanced access to preventive and sustaining services for these historically disadvantaged areas. Caregiver income support—and the reimbursements that would require—would be helpful, too. The smart money is that in-home care, and the technologies and interventions that supplement it, will advance. Providers and payers will continue to innovate to find cost-effective ways to achieve better outcomes. State and federal policymakers could pave the road ahead by changing the way they reimburse and support these services to improve access and outcomes for everyone. At a minimum, the regulatory flexibility displayed during the pandemic as it relates to the delivery of health care should continue. The time is now for government and private payers to seize the moment and bolster the HCBS ecosystem. We can no longer afford a health care system that fails to respond to market needs in favor of a more expensive and less effective status quo.