“Frankly, I Call It Fraud”: A Guest Post on Healthcare [UPDATED]

November 23, 2009 at 3:14 am (Guest Post)

The following was written by a woman whose husband died of a dementia similar to J’s.  It is reproduced here with her permission.

Did anyone see “60 Minutes” tonight where they addressed end-of-life care?  It was quite interesting and certainly appropriate for what many are going through.  They were discussing whether putting people in hospitals when they were at the end of life was more costly, and one woman told of the thousands of dollars worth of bills for her mother, who was terminal with heart and liver failure; yet they did a Pap smear on her, took all kinds of tests, called in a psychiatrist because she was “depressed.”  She told them that she, of course, was depressed because she was dying.

I assume it was a doctor speaking, and one of the things mentioned was that hospitals have to have beds filled and tests given to keep their profit level up.  They also have several doctors “looking after” the patient, mostly so that each can bill separately.

I can certainly relate to that.  When my husband first went to the hospital for a broken bone, he was immediately put on Hydrocodone, even after I told them he didn’t do well on strong pain meds.  Then, they called in a psychiatrist, because he was hallucinating – duh???  [ed:  This is a common feature of “our kind” of dementia — though J mostly doesn’t have it — that can be exacerbated by medications.] Each doctor referred him to another doctor, and at the end of three days, I don’t know how many doctors had supposedly seen him.  Then, he was referred to the rehab hospital, where again, another psychiatrist was called and proceeded to give him several different antipsychotic drugs.  Again, he was referred to several doctors, when all that was supposed to be done was rehab on his injury.

They said that many patients never read their hospital bills, because Medicare of Medicaid is paying for it.  Believe me, every one of his bills was gone over by me, and I was appalled at the cost of things and the number of drugs that he had been prescribed in addition to his Aricept and antidepressant.   I counted the meds they gave him, and between the meds, supplements, etc., he was given 16 different types of pills.  I checked them on the drug interaction site and some of the ones he was taking should not have been used with others, and some it said not to be given to patients with dementia.

The bills from the nursing home were absolutely incomprehensible, and when I would question them, they couldn’t even answer the questions.  If you don’t think there is fraud in the system, just check things out.  While he was on a catheter for several weeks, they still billed for Depends.  I checked them each time I was there, and the package had the same amount in it every day.  When I asked about this, they told me that’s what was allowed.  When he was taken off food and water on the last day of the month, they still ordered his Aricept, Celexa, Seroquel, and other drugs when they knew he was dying and were expecting it any moment.  So, where did those drugs go?  He certainly didn’t receive them.  I could cite many more examples.

I continued to receive notices from Medicare and his secondary carrier for more than two years after his death.  Some were notifications of payment to doctors I didn’t even know he had seen.  One had even moved out of the area.

The hospital where he went now has hospitalists who direct hospital care rather than the patient’s own doctor.  Then, they refer different doctors for each thing.  So, he had psychologist, neurologist, urologist, physical therapist, and I don’t know what all referrals; each one billing separately.  If I recall, they even had a different doctor that billed for his dismissal.
When I figured up all his bills for the approximately last two years of his life, they were nearly $80,000, and that did not include the cost of the nursing home care.

Needless to say, I have a lot of pent-up feelings about the medical profession, and as long as we have greedy doctors, hospitals, and nursing homes, we are going to have fraud.

Have I stirred up a hornet’s nest?

Ed.:  The woman who tells this story says that she doesn’t blame Medicare or Medicaid for this state of affairs (her own experience, as I understand it, was solely with Medicare), but rather “the greedy medical profession,” “including insurance companies, doctors, hospitals, etc.,” and that her specific objection is to the unnecessary overtesting, overtreatment, overmedication, and overbilling, whether due to defensive medicine or profit-seeking.

How should sensible healthcare reform tackle this problem?  It is wasteful, costly, and as often as not, harmful to the patient.

UPDATE: Ed.: I asked my doctor sister to comment.  Here’s what she said:

I don’t know what to say. It’s hard to read about someone’s awful health care experience and be able to say anything meaningful. But the majority of Dr’s aren’t venal and evil or see awful end of life situations such as this as opportunities to make a buck. The hospitals I’m not so sure of.

The way medicine is practiced now is by individual specialists who take care of their little niche and don’t want to be bothered about anything else. Why? Many Dr’s avoid primary care because it’s hard to be the jack of all trades and the master of none.  And the reimbursement sucks. And the paperwork is unconscionable. And more. Plus if you’re a specialist and do procedures you get paid more the more of them you do. Duh. So no one is really taking care of the whole patient, they’re just shoving their tube in their orifice of expertise.

But I also have a serious problem with patients’ expectations. Everyone wants more health and more testing and more access. What happened to common sense?  When a dying demented person is admitted to the hospital the institution takes over to some degree.  The nurses want the patient to be quiet and not too much bother (sorry but it’s true). The Dr’s dread the sad and often angry family who wants their loved one not to suffer and it’s up to us to FIX IT. And it’s not unusual to have several family factions who want different things and we get caught in the middle. Hospitals are terrible places for the dying and one of these health bills will also have provisions for expanding hospice care.

That would be worth a lot.  I can attest that hospice is probably one of the most cost-effective, as well as compassionate, things you could do.  It only kicks in when there is a condition that is incurable and eventually fatal.  Heroic, expensive, and futile efforts are over or have been forsworn.  They will leave no stone unturned when it comes to physical and emotional comfort, but that is mostly low-tech and relatively low-cost.  SAVING is the word.  It won’t save your life, but it can save money and it can save your sanity.  It minimizes both expense and suffering.

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10 Comments

  1. El Pollo Real said,

    According to my RN wife and who works in a major hospital, a fair amount of the over-testing occurs is to avoid malpractice liability. A certain amount of waste occurs because families cannot weigh cost of treatment vs. quality of like.
    I know that in my father’s case, what was lacking was a dedicated professional overseeing the big picture so as to prevent things like yeah, let’s go ahead with that last million-dollar brain surgery, meanwhile the metastasis which ultimately killed him had already appeared as a spot his lung X-ray.

    If we really are to go through with healthcare reform European style, there will be (no must be) a lot more deaths (and births) at home surrounded by friends and loved ones.

  2. amba12 said,

    There’s no question that coordination — having a team approach with some one doctor in charge — is lacking. This is partly due to the way medicine is divided up: organs that are physically adjacent in the same body must be treated by completely different specialists.

    And partly, I think, the problems with our medical system reflect our can-do, never-give-up culture.

    Giving a Pap smear to a woman who’s dying of heart and liver failure, though, is just preposterous. So is billing Depends for someone on a catheter. I also can’t help thinking that drug companies’ aggressive marketing to physicians (and consumers!) is implicated. A lot of older people have problems compounded by overmedication and medication interactions that your own pharmacist could warn you about. (I always read that section of the package insert.) One medicine is given to counteract the “side” effects of another; it becomes a cascade.

    And then there’s the requirement that everybody be chemically cheered up.

  3. amba12 said,

    I’m sorry to hear that your father had to go through that, El Pollo.

  4. amba12 said,

    I happen to think that my 93-year-old uncle, who’d had a foot amputated due to a thrombus in the femoral artery thrown by atrial fibrillation, and was in agony, was unnecessarily tortured by being brought back from pneumonia for a couple of extra weeks, with antibiotics and a ventilator. But that wasn’t the doctors’ decision; it was his son’s.

  5. david said,

    I find characterizations like “the greedy medical profession” stereotypical and unhelpful. The doctors I know — especially the oncologists — are some of the hardest-working, most compassionate people I know. Sure, they’re well compensated. They’re also in the business of trying to save lives. Most doctors I know are not administrators, and none are in the business of jacking up fees and doing unnecessary procedures.

    This isn’t to say that no such doctors exist, or that there isn’t greed in the medical profession. The villainization of an entire profession doesn’t get at the heart of the problem, though (nor, I’m afraid, does the pending legislation), which lies at the intersection of free-market capitalism, government regulation and care for the sick, no matter their means to pay for treatment.

    I got no answers, by the way.

  6. Donna B. said,

    With talk of bills and then an amount, I’m wondering if the $80,000 is the billed amount, the allowed amount, or the amount paid?

    I’m more often appalled at the differences in what the doctors/hospitals charge and what Medicare allows. Often, neither seem reasonable, but it’s more often that the Medicare allowed part is just ridiculous.

  7. PatHMV said,

    The problem is precisely because somebody else is footing the bill. The only way to stop fraud and waste when somebody beside the recipient of the services is footing the bill, is through regulation and audits. The former of those is inefficient and often leads to refusals to provide truly necessary service, while the latter is simply expensive.

    For some services and procedures, the Medicare reimbursement rate is too low. To make up for those deficiencies, providers simply bill for everything that is allowed, because each new procedure is another little bit of money.

    The providers are unresponsive to patients because they’re going to get paid whether the patient/family is satisfied with the service or not. You can’t threaten to withhold payment until they knock off the charges for the unused Depends. Are people like your friend going to waste their time turning the hospital in for Medicare fraud? Of course not. One, she was busy taking care of her husband, not gathering evidence usable in court. Two, the charges may not in fact technically be fraudulent; the regulations may simply be highly inefficient (but might still be more efficient that requiring copious documentation of the number of Depends actually used for each patient). Thus, the billing department could truly not care less about what the patient/family thinks about the bill; it’s not for you, it’s to appease the bureaucratic gods who decide what will and won’t be paid.

    David’s last sentence correctly identifies the heart of the problem. The free market is FAR more effective at reducing these costs than government regulation could ever be. But in order to provide the services which we think our country is rich enough to provide to everybody, the government, or at least third-party payors, must be involved somehow.

  8. Randy said,

    I agree with David. Of all the bills I’ve reviewed over the years, there have been relatively few doubtful items. EPR is probably right about some tests being done for liability reasons but I doubt those are inordinately expensive or frequent. Donna’s question about billed amount vs. allowed and amount actually paid is a good one. I’ve seen billed amounts reduced as much as 70% and marked paid-in-full as a result of Medicare’s allowable schedule.

  9. Stephanie said,

    Not just Medicare- I’ve had private insurance (usually some form of Blue Cross Blue Shield) with the billed amounts reduced 70% b/c of what they will allow- and no payment required by me. That’s part of what makes me crazy about the current system- those without insurance frequently pay more than twice as much for the same service- and usually can least afford it.

  10. Danny said,

    This post turns my stomach–the level of abuse and corruption makes me want to scream. On the other hand, and a propos of nothing here, I will say that my recent five-month hospital ordeal with our son Charlie fills me with nothing but undying gratitude and admiration for the medical profession. True, his hospital bills are nearing two million dollars which seems absolutely insane but the level of care he received was exquisite and included six mind-boggling operations and the daily expertise of dozens of very devoted and caring specialists who literally kept our son alive minute-by-minute. Today Charlie is a roly-poly healthy boy and I love (most) doctors, nurses, and neonatal researchers!

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