Bob CollinsJoseph Andrey, 91, just wanted to go home to die.
The reasons he couldn’t constitute today’s must-read piece in the New York Times that reveals anew that our health care system is broken.
He was stuck in a nursing home. The forces of the health care system — “hospitals, nursing homes, home health agencies, insurance companies, and the shifting crosscurrents of public health care spending” — conspired against Andrey and his daughter.
A hospital released him to a nursing home for rehabilitation. But no rehabilitation was happening. He was only getting worse.
He ended up back in the hospital and, this time, his daughter wanted to honor his wish to go home to die.
But in the health care system, the wishes of a dying patient and his daughter don’t matter.
There’s money to be made. The nursing home gets nearly $700 a day from Medicare.
Home care agencies abruptly dropped or refused high-needs cases like her father’s as unprofitable under changes in the state’s Medicaid program. Hospitals, eager to clear beds, increasingly sent patients to nursing homes. The nursing homes were often too short-staffed to reliably change diapers but still drew premium Medicare rates, ordering hours of physical therapy and other treatment that studies showed was often useless or harmful.
Even hospice was limited. Now mostly for-profit, hospice companies would provide supervision and visits at home a few times a week through Medicare if a doctor certified that Mr. Andrey had only six months to live. The hidden catch: He would lose all Medicaid home care, the daily help he needed to be home at all.
A home-care agency refused to help because he was in an out of the hospital too much and the “girls” — as the office manager for the agency reportedly referred to the aides — couldn’t make any money.
“My father wants to die at home, he knows he’s dying. And here I am proving I’m power of attorney, that I’m guardian, and it means nothing, it falls on deaf ears,” his daughter told the Times in 2013.
Last week, a federal report was issued, confirming what many people in the family’s situation already knew.
For most people, death does not come suddenly, the report points out. With 48 times as many people reaching 85 than a century ago, and triple the number who turn 65, the likely course of death is long and unpredictable. In the new demographic reality, the immediate family is older, too, often literally unable to do the heavy lifting for the long haul.
Yet the system was never engineered to support families through this, and its financial incentives reward harmful transitions among homes, hospitals and nursing homes, said Dr. Joan M. Teno, a gerontologist and one of the report’s authors.
“We have these frail older people moving about in the medical-industrial complex that we’ve constructed,” Dr. Teno said. “It’s all about profit margins. It’s not about caring for people.”
Unable to beat the system and get her father home, his daughter finally signed papers to move her father into a hospice unit inside a hospital.
“Don’t leave me here,” he said.
He was strapped to his bed and given a painkiller. Three days later — last February — he died.
He never went home.
The funeral home director told her the deep pressure ulcers on her father’s body were the worst he had ever seen. The records she obtained showed that in the last year of his life, his care cost at least a million dollars. Was that the best, she wondered, that a million dollars could buy?
“He didn’t die in his bed, and that’s what he wanted,” she said. “I still feel that I let him down.”
