We had one in hospice recently (Anne’s dad passed away last night after suffering a stroke last week), so I found the following about end-of-life care both timely and interesting. For those without an immediate need or connection, maybe file it away under “when the time comes.” Of course, what you get out of a story often depends on what you bring to it, so you may want to take it all with a grain of salt. But for me the takeaway here is this: Even the best, most humane impulses can be corrupted when unregulated capitalism is allowed to take root and grow unfettered. Your results may vary. But in any case, in this as with so much else in life, caveat emptor (buyer beware).
New Yorker subscribers can get the full scoop, here. Everyone else, let me know and I will be happy to send it to you free-of-charge. Not even Medicare gives you that good of a deal.
A teaser.
It might be counterintuitive to run an enterprise that is wholly dependent on clients who aren’t long for this world, but companies in the hospice business can expect some of the biggest returns for the least amount of effort of any sector in American health care. Medicare pays providers a set rate per patient per day regardless of how much help they deliver. Since most hospice care takes place at home and nurses aren’t required to visit more than twice a month, it’s not difficult to keep overhead low and to outsource the bulk of the labor to unpaid family members — assuming that willing family members are at hand.
Up to a point, the way Medicare has designed the hospice benefit rewards providers for recruiting patients who aren’t imminently dying. Long hospice stays translate into larger margins, and stable patients require fewer expensive medications and supplies than those in the final throes of illness. Although two doctors must initially certify that a patient is terminally ill, s/he can be recertified as such again and again.
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The philosophy of hospice was imported to the United States in the 1960s by Dame Cicely Saunders, an English doctor and social worker who’d grown appalled by the “wretched habits of big, busy hospitals where everyone tiptoes past the bed, and the dying soon learn to pretend to be asleep….”
Forty years on, half of all Americans die in hospice care. Most of these deaths take place at home. When done right, the program allows people to experience as little pain as possible and to spend meaningful time with their loved ones. Nurses stop by to manage symptoms. Aides assist with bathing, medications, and housekeeping. Social workers help families over bureaucratic hurdles. Clergy offer what comfort they can, and bereavement counsellors provide support in the aftermath.
This year, I spoke about hospice with more than a hundred and fifty patients, families, hospice employees, regulators, attorneys, fraud investigators, and end-of-life researchers, and all of them praised its vital mission. But many were concerned about how easy money and a lack of regulation had given rise to an industry rife with exploitation. In the decades since Saunders and her followers spread her radical concept across the country, hospice has evolved from a constellation of charities, mostly reliant on volunteers, into a twenty-two-billion-dollar juggernaut funded almost entirely by taxpayers.
Let me say that again.
“A 22-billion-dollar juggernaut.”
“Funded almost entirely by taxpayers.”
Caveat emptor, indeed.