Sick To Death > Chapter 5 > Reforms to Implement Right Away!

Reforms to Implement Right Away!

How could we start the process of reform? I think rapid reform depends on pursuing an array of attention-getting small endeavors that could create a movement and investing in important longer-term efforts to build the evidence and shape the agenda. All of these activities would focus around creating a political force, broad clinical capability, and sustainable financing.

Short-term consciousness-raising is urgently needed and readily available, for example:

Medicare should propose to pay half of a patient's second hospitalization for the same serious chronic disease within a year, if the first hospitalization did not include any advance care planning. Just getting Medicare leadership to discuss this idea would probably trigger its salutary effects.
Medicare should pay a 20 percent differential to the advantage of physicians who regularly provide continuity care for patients with serious chronic illness. This could be part of the current interest in "paying for performance."
Public policies could start supporting family and paid caregivers - give them respite care, financial support, and health insurance. Again, just forcing the discussion into the public arena might galvanize support.
Family caregivers should have a radio show, input into political campaigns, and organizations advocating for their issues.
Medicare should initiate a set of demonstration projects that target those sick enough to die.

Building the evidence that can shape reform so that changes actually move health care toward efficient and effective strategies will require some longer-term perspectives:

Direct the Centers for Disease Control and Prevention and the National Institute on Aging to develop an epidemiology of the last part of life and then to map trends over time and variations across jurisdictions.
Direct research at the National Institutes of Health toward relief and prevention of symptoms.
Test out the effects of alternative strategies for income support, incentive alignment, and community control in services for serious chronic illness.
Test out innovations in organizing nursing and clinical services.

Some of these require congressional action, leadership in federal executive agencies, or innovation by organized health-care delivery systems. Of course, if there were strong incentive to have those parties paying attention and addressing issues, we would already be moving along much more adeptly. Making small changes does matter, not only for improving care but also for forming the political will to make more substantial and enduring changes.