bers of uninsured (45 million) or underinsured (80 million), public and private insurance options, regional cost variation, poor public health metrics, and financing for potential solutions while spending 30 percent more per capita than any other industrialized nation on health care.

At $57 billion in 2007 including all payers, home care is only 3 percent of U.S. health care (National Association for Homecare & Hospice, 2009) (see Figure 12-1). And like health care generally, home care is organized into separately funded categories, called silos: home health agencies, hospices, medical equipment, home health aides, pharmacy managers, medical providers, and thousands of private bureaucracies. Two key referral sources, hospitals and nursing homes, are in fiscal and regulatory silos of their own. Thus, financing promotes discontinuous care. Rules that govern the care of people with heavy chronic illness burdens result in an uncoordinated, overly costly, and hazardous delivery system that is far from patient-centered and is known for its failings (Schoen et al., 2008) (see Figure 12-2).

Some financing models, including Medicare Part C, offer opportunities to break down silos using financial risk. However, only 11.4 million people, or about a quarter of Medicare beneficiaries, are in such payment models (Henry J. Kaiser Family Foundation, 2009, 2010). And there are

FIGURE 12-1 Personal health care expenditures, 2006.

FIGURE 12-1 Personal health care expenditures, 2006.

NOTE: SNF = skilled nursing facility.

SOURCE: National Association for Homecare & Hospice (2009).

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