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.
"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.
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.
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".
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.
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.
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.
[+] [-] FireBeyond|11 years ago|reply
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.
[+] [-] skmurphy|11 years ago|reply
[+] [-] fubu|11 years ago|reply
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.
[+] [-] 813594|11 years ago|reply
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.
[+] [-] jnbiche|11 years ago|reply
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.
[+] [-] prostoalex|11 years ago|reply
* can people be denied hospice care based on ability to pay?
* why wouldn't someone in that position go through non-profit institutions first?
[+] [-] tn13|11 years ago|reply
"unprofitable patients on the non profits who typically try to take every patient regardless of their ability to pay"
[+] [-] comrh|11 years ago|reply
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.
[+] [-] jianshen|11 years ago|reply
Please thank your mother for everything that she does for her patients and thank you for sharing.
[+] [-] jkestner|11 years ago|reply
[+] [-] WalterBright|11 years ago|reply
They handled his final days treating him with kindness, respect, and dignity. I have no complaints.
[+] [-] tn13|11 years ago|reply
[+] [-] rcarrigan87|11 years ago|reply
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.
[+] [-] ggchappell|11 years ago|reply
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?
[+] [-] jnbiche|11 years ago|reply
[+] [-] yason|11 years ago|reply