My mother is a hospice nurse and it has given me a viewpoint I don't think I would have ever considered before. Americans (and probably most people) seem to ignore end of life decisions because it is scary, and it can be, but it is important. So incredibly important, to the person leaving this earth to be respected and to the people they leave behind to not have awful experiences like this.
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.
I would add that it's not just end-of-life decisions that we ignore or fear but anything long term or non-acute. Modern medicine is geared towards getting better quickly but there are certain ailments, be it old age, a traumatic brain injury or mental illness, that we're absolutely terrible at dealing with. It's not that people are not willing to put in the years (as is demonstrated by the brave woman in this article) but that the learnings and breakthroughs for long term illnesses takes generations, not years and sadly we're barely at the starting line.
Please thank your mother for everything that she does for her patients and thank you for sharing.
On death and dying, I can't recommend http://www.newyorker.com/magazine/2010/08/02/letting-go-2 enough if you haven't read it before. Things I learned: hospice leads to living longer, better and cheaper; and asking people for advance directives whenever they interact with the healthcare system has a dramatic positive effect.
My father passed away last summer after a long illness. We got all the DNR paperwork done in advance, and made sure all the medical personnel involved had copies. All of them were appreciative of getting the paperwork, and were fully supportive of our decision of comfort care only.
They handled his final days treating him with kindness, respect, and dignity. I have no complaints.
As an EMT/Paramedic, the single best thing I’ve been able to do for patients is take them home (or really, somewhere, ANYwhere other than a hospital or nursing home) to die, in peace, in comfort, and with dignity.
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 to avoid "bounce back" charges and the risk of litigation. I am not disputing your point that it's obnoxious but it's a risk avoidance behavior that the hospital does not have to pay for.
There's reasonable risk mitigation and there's unreasonable.
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.
Pretty much. We are dual service, 911 and IFT. I don't mind the IFT side of things from the patient management experience, especially with chronic patients, but yes.
"Home care agencies abruptly dropped or refused high-needs cases like her father’s as unprofitable"
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.
This is why the bastardized system we have now will never work. We must move to single-payer or fully private health care -- no middle ground.
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".
"Fully private" is not really an option. If you kill Medicaid, you also kill people who can't afford health care. The current system certainly isn't great for the poor either, but it's better than nothing. A single payer system would be better than either, but like you say, it's not going to happen anytime soon.
There are number of ways medicaid can be made completely redundant. Destroy the monopoly of AMC on the number of doctors. Let Indian doctors apply for a cap-free H1B and flock to US to give Americans a better health-care.
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".
>There are number of ways medicaid can be made completely redundant. Destroy the monopoly of AMC on the number of doctors. Let Indian doctors apply for a cap-free H1B and flock to US to give Americans a better 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.
I agree that the impossibility of paying for health care out of pocket in the American health care system, but I don't agree that this would solve the problem.
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.
Because in the absence of a single-payer system, the private portion of this system risk arbitrates all the higher-risk patients to the state-supported insurance and/or medical care, thus bankrupting the government and/or non-profit systems. We see this happen again and again.
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.
Isn't that the whole point of the state from a market economy standpoint? To take care of the things that are unprofitable with compulsion/taxation? You can't bankrupt the government. It's got the power to print money. It can keep going as long as it can do so. It also has the power of legislation. It can regulate prices if it so chooses.
For majority of people in that situation Medicare would apply, and look how single-payer is working for them:
"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.
Do you have any figures to back this statement up? When you say dumping do you mean transferring? Discharging? Revocations? Those events are, and should be, looked at with great scrutiny in compliance surveys.
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.
I see that there is a problem here, but the article seems unduly vague about what it actually is. Could someone explain?
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?
The problem was, insurance was happy to pay $500/a day for nursing home care, but balked at paying anything near that much for home nursing, which he needed to stay at home (since his daughter was a full-time teacher and also probably couldn't lift him, etc).
If the money is owned by the same organisation that gets to spend it, the money is spent wisely. If it costs one fifth to arrange for a daily care at home versus at a nursing home, then that's four fifths saved for something else in the total bill. However, if the one who gets to pay and the one who gets to spend are different parties then both try to optimise from their own perspective and generally end up with contradicting goals.
My brother worked as a sales rep for over 10 years in home health and hospice. He has told me many war stories. Per the article, a lot of companies avoid patients who are short-term (less than a week to live) because the companies stand to lose money. He refused to do this and would regularly take on patients that represented a $10-15K loss.
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.
28 comments
[ 3.1 ms ] story [ 66.1 ms ] threadIt 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.
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?
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?
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.