"Why can't you just die?"--Two-Face to Batman

NYT:

Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.

The charges are assessed retrospectively, so in most cases the money has long since been spent on salaries, medicine and supplies. After absorbing huge assessments for several years, often by borrowing at high rates, a number of hospice providers are bracing for a new round that they fear may shut their doors.

The problem? Medical care works. No one could have foreseen that, apparently:

In the early days of the Medicare hospice benefit, which was designed for those with less than six months to live, nearly all patients were cancer victims, who tended to die relatively quickly and predictably once curative efforts were abandoned.
....
Medicare’s coverage of hospice, which began in 1983, has become one of the fastest growing components of the government’s fastest growing entitlement. Spending nearly tripled from 2000 to 2005, to $8.2 billion, and nearly 40 percent of Medicare recipients now use the service.

To be eligible, patients must be certified by two doctors as having six months or less to live, assuming their illness runs a normal course. They must agree not to bill Medicare for curative procedures related to their diagnosis.

Or maybe it's the idea that doctors can predict the future. Actually, it's the fact that, in 1983, most patients were cancer patients, and they didn't live long. Now it's Alzheimer's patients, who live much longer. And hospice care doesn't mean relocation to a facility; it means care for patients in their homes, palliative care to make their last years comfortable. But when they insist on stretching out those last years as long as possible, well....something has to be done.

I know! Let's demand a refund! This is the Wal-Mart model for healthcare:

In the Wall Street Journal today (subscription required), Vanessa Furhmans wraps subrogation inside a very moving human story. Deborah Shank, a Wal-Mart worker, faced $470,000 in medical bills after getting hit by a truck. Wal-Mart's health plan paid the bills without any hitches. Shank sued the truck company. But it only had limited liability insurance. The settlement Shank won ended up in a trust to care for her now that she's confined to a nursing home.

Wal-Mart, out $470,000, then sued Shank to recover the money it had spent. The retailer won and left her with nothing to pay for ongoing care, beyond what's paid for by government programs (Medicare, Medicaid). As the legal fight escalated Shank's son died in Iraq. While Wal-Mart appears to have a legal right to the money--as even Shank's husband concedes--the nasty situation does not necessarily paint a picture of a benevolent employer.

And I found that story on Forbes.com. When even the WSJ and Forbes think you're evil, well....

And in case you're wondering: no, this isn't a matter of an evil Bush Administration. It predates Bush by 3 years:

In 1998, Congress removed limits on the number of days that an individual could receive Medicare hospice coverage, a move that encouraged physicians to refer terminal patients.

But lawmakers did not remove a cap on the aggregate amount that hospice providers could be reimbursed each year, a measure designed to contain the program’s cost. A hospice’s total annual reimbursement cannot exceed the product of the number of patients it serves and a per-patient allowance set by the government each year ($21,410 in 2007).

It's money that matters, you know....