Healthcare, health policy, cognitive science. , and the path to Universal Healthcare..
In Texas Hospitals, You Don’t Get to Decide to End Care | Houston Press: 2016
[Full disclosure – I don’t know if this has been changed at this time.]
“In Texas it doesn’t matter what instructions you’ve previously given or what your relatives say: If you’re in critical condition, you’re dependent on machines to survive and hospital officials decide it’s time to pull the plug, you will die. And it’s completely legal.”
Large multi-agency, multi-state hospices are fast become the primary source of end-of-life care in the U.S.
According to a new study, chains cared for nearly half of all hospice patients in 2011, a dramatic increase from a decade before when small organizations (mostly non-profits) provided three-quarters of all care. And my own review of their financial reports suggests the biggest chains have grown even more since 2011.
The paper, authored by David Stevenson of Vanderbilt University and Jesse Dalton, David Grabowksi, and Haiden Huskamp of Harvard Medical School, was published in the January issue of Health Affairs (firewall). The authors did not look at the relative quality of care at any of these facilities. Nor did they calculate how long patients remained in hospice care at the chains. But they shed valuable light on how the business of end-of-life care is changing.
Hospice care is overwhelmingly funded by Medicare. And payment rates are generous enough that for-profits have long made inroads into this care model. The new study shows that, like many in the medical care industry, hospices are scrambling to consolidate so they can benefit from the economies of scale and marketing advantages of being big. Publicly-traded companies are responding to investor demands for increasing revenues.
Small non-profits still served more patients than for-profit chains in 2011, but Stevenson and colleagues found their share has been shrinking rapidly. In 2000, they cared for about 53 percent of enrollees. By 2011, they were caring for only about 37 percent. Over the same period, the for-profit chains’ share of enrollees grew from about one-quarter to nearly half. Non-profit chains accounted for roughly another 10 percent.
in 2000, a typical for-profit chain operated 5.6 agencies with 2,300 enrollees. By 2011, those firms owned an average of seven agencies with an average roster of 2,700 Medicare patients, according to the study. By contrast, a typical mom-and-pop for-profit cared for only one-tenth as many people–about 220.
In some cases, corporate hospices are not just growing, they are getting huge. The paper reports that in 2011, the five largest for-profit chains owned 283 agencies with 190,000 patients. But the biggest players have grown even more since.
In spite of their soul-destroying socialism, the Brits engage in a civil, constructive debate over an emotionally charged subject. So that’s how it’s done…
Last month, a spellbinding 10-hour debate to legalize physician-assisted dying took place in Britain’s House of Lords. Since Americans are unfamiliar with this legislative body, it bears mention that most peers in the upper house of Parliament have been appointed for life for their experience in public service or for their outstanding level of achievement in a given field. Accordingly, many of the bills introduced are not shackled by political constraints, as is the case in the U.S. Congress, but instead address urgent social issues that warrant and receive thoughtful consideration.
Assisted suicide debate in United Kingdom: House of Lords on death with dignity.
Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, “Why can’t I do more for this person I love so much?”
Opting to try all forms of medical treatment and procedures to assuage this guilt is also emotional life insurance: When their loved one does die, family members can tell themselves, “We did everything we could for Mom.” In my experience, this is a stronger inclination than the equally valid (and perhaps more honest) admission that “we sure put Dad through the wringer those last few months.”
At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We’ve committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: “I am so glad I don’t have to hurt old people any more.”
Our unrealistic views of death, through a doctor’s eyes – The Washington Post
An op-ed I wrote about the difficulty of navigating the hospice benefit in these days of increased scrutiny…
There are those who continue to pose the question: If hospice is meant to be end-of-life care, why do some patients get “discharged?”
The answer is two-fold. One reason is ever-changing patients and illnesses.
A growing percentage of hospice patients have illnesses with outcomes that are hard to predict. In the past, cancer was the dominant hospice diagnosis. Now, the portion of hospice patients with cancer — one of the more-predictable diseases — has declined. Today, non-cancer diagnoses (such as dementia or heart disease) account for more than 63 percent of hospice admissions, according to the National Hospice and Palliative Care Organization.
The other reason for discharge is simply that reputable hospice organizations are paying close attention to the new rules. Most hospices are more careful than ever about the patients they admit and the patients they keep in their care.
Good piece about the dilemma faced by all hospices – is this patient going to die within 6 months?
One can sympathize with hospice organizations caught in this squeeze. Determining which patients will likely die within six months has always been difficult, especially with conditions like heart disease or dementia, whose trajectories can be unpredictable. To avoid being penalized if they guess wrong, hospices are taking no chances.
At least, that’s true of hospices operating according to the regulations and honoring the movement’s historic mission. The Post attributed much of the jump in discharges to the way for-profit hospices have come to dominate the field, enrolling ineligible seniors for long stays to bolster corporate bottom lines, then dumping them to evade Medicare sanctions. (The Times has also reported on growing hospice costs.) Whistleblowers and the Justice Department have sued several large national chains to stop these practices.
But I worry about families who have agonized about the decision and finally called for help, then feel betrayed when hospice withdraws, even though their relatives can regain hospice care when they decline further. They shouldn’t get caught in this crossfire.
Long article about hospice, and the possible abuse of the system by for-profit hospices.
Hospice patients are expected to die: The treatment focuses on providing comfort to the terminally ill, not finding a cure. To enroll a patient, two doctors certify a life expectancy of six months or less.
But over the past decade, the number of “hospice survivors” in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require fewer visits and stay enrolled longer.
The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012, according to a Post analysis of more than 1 million hospice patients’ records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry.
The average length of a stay in hospice care also jumped substantially over that time, in California and nationally, according to the analysis. Profit per patient quintupled, to $1,975, California records show.
This vast growth took place as the hospice “movement,” once led by religious and community organizations, was evolving into a $17 billion industry dominated by for-profit companies. Much of that is paid for by the U.S. government — roughly $15 billion of industry revenue came from Medicare last year.
At AseraCare, for example, one of the nation’s largest for-profit chains, hospice patients kept on living. About 78 percent of patients who enrolled at the Mobile, Ala., branch left the hospice’s care alive, according to company figures. As many as 59 percent of patients left the AseraCare branch in nearby Foley, Ala., alive. And at the one in Monroeville, 48 percent were discharged from the hospice alive.
An account of cancer care in France.
When my dad began to get worse, the home visits started. Nurses came three times a day to give him insulin and check his blood. The doctor made house calls several times a week until my father died on December 1.
The final days were harrowing. The grief was overwhelming. Not speaking French did make everything more difficult. But one good thing was that French healthcare was not just first rate — it was humane. We didn’t have to worry about navigating a complicated maze of insurance and co-payments and doing battle with billing departments.
Every time I sit on hold now with the billing department of my New York doctors and insurance company, I think back to all the things French healthcare got right. The simplicity of that system meant that all our energy could be spent on one thing: caring for my father.
That time was priceless.
There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.
My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.
One night, a friend called to say that my patient was in the hospital. He’d finally gotten so anemic that he couldn’t catch his breath, and the University of Texas Medical Branch (UTMB), where I am a student, took him in. My friend emailed me the results of his CT scans: There was cancer in his kidney, his liver and his lungs. It must have been spreading over the weeks that he’d been coming into St. Vincent’s.
I went to visit him that night. “There’s my doctor!” he called out when he saw me. I sat next to him, and he explained that he was waiting to call his sister until they told him whether or not the cancer was “bad.”
“It might be one of those real treatable kinds of cancers,” he said. I nodded uncomfortably. We talked for a while, and when I left he said, “Well now you know where I am, so you can come visit me.”
I never came back. I was too ashamed, and too early in my training to even recognize why I felt that way. After all, I had done everything I could—what did I have to feel ashamed of?
UTMB sent him to hospice, and he died at home a few months later. I read his obituary in the Galveston County Daily News.
I Watched My Patients Die of Treatable Diseases Because They Were Poor | Alternet
Elder Law: Kin may be held liable for care – Pittsburgh Post-Gazette: In July 2005, the Pennsylvania General Assembly passed the “Filial Support Law,” commonly known as Act 43. As we approach the seven-year anniversary of the re-codification of this law (it previously existed in the Welfare Code from the 1930s and was re-codified in the Domestic Relations Code for modern usage), there have been increasing instances of facilities pursuing family members to pay for care, usually for parents’ care in a long-term care facility.
– Sent using Google Toolbar