Fighting to Honor a Father’s Last Wish: To Die at Home
nytimes.com
nytimes.com
We spend more to keep people alive, often in misery, in the last two years of their lives than we often do in the two decades preceding it. Quality of life doesn’t have an ICD9/10 code, though.
I’ve pushed back at doctors and nurses, similarly, who have discharged patients to home, having blithely signed the form that “patient requires transport in fully-equipped ALS (advanced life support) ambulance” (and the bill that goes with it), when the patient is able to walk without assistance, has no complaints or pain, and is generally and hemodynamically stable.
It’s obnoxious.
Cabulance. Even a BLS ambulance for sicker patients.
But an ALS ambulance (and the resulting bill between $2-3000), with ventilators, cardiac drugs, etc., for a patient who is comfortable as described, and has no history of respiratory or cardiac issues goes beyond overkill.
The actual form has lines as follows: "Bed confinement defines the patient as being (1) unable to get out of bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair", "condition must be of sufficient severity that going by means other than this would be hazardous to the patient's health or wellbeing" (and I'd argue that other than for end-of-life care or similar, if you require an ALS transport to go home, perhaps you're too sick to be going home).
That really crosses the line of reasonability to borderline fraud.
This story is really, really glossing over what is happening in home health hospice as a whole. For profit hospice organizations are crippling the non profit organizations by taking all the cheap and easy patients offering them slightly better services than the non profits, while dumping all the expensive and unprofitable patients on the non profits who typically try to take every patient regardless of their ability to pay, regardless of Medicaid and Medicare. These non profits are being killed off one by one because of it.
Yet another example of finance style arbitrage damaging the lives of Americans.
I personally don't even care all that much which route we take, since I think the improvement in either case would be extreme. Unfortunately, both are equally unlikely, because of two-party "democracy".
But the status quo is unsustainable.
Oh wait. That will killing American Doctor's job (which is any ways AMC is doing so effectively) and reduce their salaries.
Clearly USA as a society prefers that the the Hospital Staff's salary, Insurance Company's profits and Medical equipment vendor's profits as more important than "public health care".
This is an excellent potential solution. If you've been to Thailand, India, and Mexico, they all have pretty good healthcare available for a cost that poor, working class families in the U.S. could afford out-of-pocket.
But whereas having cheap software programmers is clearly a god-given right in the U.S., having affordable healthcare is not.
First, some people don't have any money, because they are mentally ill, homeless, or both. But our current system doesn't really do a good job of caring for these people, so perhaps that doesn't matter.
Second, while I agree that doctors are overpaid, the cost of living in America is substantially higher than in Thailand, India, or Mexico. You will have to pay the doctors more than you would in those countries. You will have to pay staff more as well. You will have to pay more for virtually everything. While working class families could afford health care in India out-of-pocket, it seems possible that those families could not afford the same health care in the U.S., assuming everyone involved is paid the same cost-of-living-adjusted salary.
Third, it's hard to provide good care if you can only give patients drugs that are out of patent. India and Thailand avoid this by refusing to recognize certain patents or granting compulsory licenses so that the drugs can be made affordable (not sure about Mexico). If the U.S. did this, it would get sanctioned by the WTO and the American pharmaceutical industry would cease to exist. Poorer countries profit from richer countries' investment in drug development, but if no one develops the drugs then everyone suffers.
What countries with well-functioning healthcare systems don't have a base-layer single risk pool under a government system? Of course, almost all of these systems allow supplemental and/or optional private care, but they are still single-payer insurance systems.
"Medicare will pay premium rates for up to 100 days of services in a nursing home to rehabilitate patients. While such efforts can be beneficial, government investigations and lawsuits document a pattern of excessive or fraudulent orders for such services, often just before death."
What use is a single-payer system that stays hostage to whatever political party is in charge in Congress, subject to lobbying from corporate and other special interests, and mostly toothless to fight fraud?
Having that much paying power concentrated in a single entity controlled by politicians makes it even more of a target for corruption.
Home Health Agencies are not the same as Hospice agencies (the article seems to use the terms interchangeably). As far as I'm concerned, nonprofit/for profit in hospice is really just tax status. All Medicare certified hospices agencies follow the same guidelines, bill the same payor, and are paid the same rate. The Medicare Conditions of Participation say you must take patients regardless of their ability to pay (you can't just try, all providers must and it's why you see it printed on their brochures).
Hospice is a service business and differences are found in quality of care.
As for Medicaid, I really only know about Arizona. Since at least 2001 Arizona has approved hospice care for Medicaid (AHCCCS) patients in hospice and in July 2009 started stalling on payment. In January 2010 they made the decision to retroactively eliminate Hospice services as of July 2009. All Hospice providers who cared for patients July 2009-Jan 2010 were now told the accounts would not be paid. This has lead to some providers avoiding contracting with AHCCCS and thus impacted AHCCS patients access to care when they don't qualify for the Medicare benefit. Of course the patients can still contact any local Medicare hospice and seek charity care regardless of their ability to pay.
"unprofitable patients on the non profits who typically try to take every patient regardless of their ability to pay"
* can people be denied hospice care based on ability to pay?
* why wouldn't someone in that position go through non-profit institutions first?
It seems to be changing a little, slowly, but as this article seems to demonstrate there will be a huge amount of push back from a for profit industry. And once you die the checks stop so I don't see an incentive for them to do better.
Please thank your mother for everything that she does for her patients and thank you for sharing.
They handled his final days treating him with kindness, respect, and dignity. I have no complaints.
By doing so he formed close bonds with doctors and discharge planners who would turn to him when no one else was willing to take a patient. These relationships led to a lot of referrals and he grew his territory to one of the strongest.
The company was later bought and new management enforced much harsher oversight on patient profitability metrics. Needless to say, he quit. Certainly something needs to change.
What I mean: This man wanted to go home. For some reason, he could not. Was it because he was physically prevented from going home? Was it because, if he went home, insurance and/or govt. assistance would be made unavailable, and so with the policies that were in place, he could not afford to go home? Or was it something else?