Medicare has a low administrative rate. Medicare pays roughly 4% to 5% of total expenses for administrative costs. The best run health insurers have slightly higher administrative expense ratios (8% to 10%). Is this a slam dunk that Medicare is inherently more efficient than private insurers? Not neccessarily. I want us to consider the following vignette that I am prepping for a new hire class.
Mayhew Insurance has an extremely good idea how much each hospital in the network should be paid each month for pediatric emergency room visits. Big City Academic Hospital gets 17% of total spend, St. Anthony’s the Forgetful gets 2.3%, East Nowhere Community Medical Center tends to get about 1.5% and North Suburban General usually sees 30 admissions and 1.1% of spend. These numbers will bounce around a little bit, especially at the smaller community hospitals as a run of food poisoning or extremely slippery monkey bars will create local clusters. We expect that. We look for the things that are odd and inexplicable.
A data analyst has been reviewing pediatric ER claims and is noticing a spike for the past three months at North Suburban General for pediatric ER. Instead of 30 plus or minus a few, we are now paying for 45 pediatric ER visits a month. The excess incremental ER utilization is costing $10,000 more per month. The analyst notifies her boss who agrees that this looks odd, and they call the medical management team to figure out what is going on as this is expensive and unexpected.
After a week of data diving and talking with the hospital the following things are noted.
- The incremental ER diagnosis codes are low level, unspecified complaint codes.
- Starting about four months ago, North Suburban General has instituted a policy of given a $10 meal voucher to any adult who stays at the ER for more than 4 hours and $8 meal vouchers for kids.
- Most of the increased utilization is on Tuesday night.
- The cafeteria food is not that bad and if you are selective, you can easily find 150 calories per dollar. You can also find 20 calories per dollar. Tuesday night is burrito night in the cafeteria.
- Most of the increased utilization is coming from a cluster of families where the mothers all once had the same last name.
What is going on here?
Four months ago, a family brought their son in for a broken leg. They received X-rays and had it casted up after about five hours in the ER. The mom, kid and his little sister also got meal vouchers. They asked and were told that any ER visit that lasted more than four hours came with meal vouchers.
The family is food and income unstable. Some times the bank account lasts the month, some times it doesn’t. Some times, the parents are working 40 hour in the week, some times they are working 15 hour per week . An effectively free meal that costs four hours of time at the ER is an effective hack. They started to visit the ER when money was getting tight as the waiting room had a TV and some games for the other siblings, and someone could complain about something. The hack worked, the family was fed for the night. The mother told her sisters, and they embraced the hack.
Mayhew Insurance’s plan to beat the hack was to send a social worker with a large stack of burritos and fajitas to the grandmother’s house for the entire family to have a burrito night on us. The social worker has helped a couple of the families hook up with other sources of aid. The other families were given Mayhew Insurance expense account to order pizza or burritos once a week. The total cost to us for these families is now under $125 per month. In the past six months, there was one ER visit from this family and it was legitimate.
The fundamental problem being presented here is not a medical problem. It is a problem of resources. These families lacked sufficient money to buy food, so they found a way to take care of their families given the constraints that they faced. Our solution is a non-medical solution to avoid massive medical costs…..
This is a vigentte for data analytics, but it is also illustrative of the incompleteness of the administrative cost calculation. Traditional Medicare is a fee for service system. They pay a claim as it comes in. If the sudden utilizers were covered by Medicare, they would be generating multiple $750 to $1,000 claims that Medicare would quickly turn around and pay out for an administrative cost of less than a dollar per claim. This elevated ER utilization would have continued for years. Extremely efficient but this is also extremely wasteful.
Using the simple formula of Non-medical Expenses/(non-medical expenses + medical claims expenses) to calculate the administrative cost ratio, Medicare looks awesome. They are paying a buck per claim and they have a high number of mid-dollar claims. Mayhew Insurance looks extremely inefficient as we’re paying far fewer claims, and solving this problem cost about $4,000 in labor plus another $1,500 per year in pizza/burritos. None of that is considered medical expense. Yet our total medical spend is lower and the people who were going to the ER to get a meal are better off as they are not wasting their Tuesday evenings as well as getting a meal.
Fee for service auto-adjudication is inherently cheaper than any system that involves population management. There is some significant value to both the patient (avoiding needless hospital visits) and the population manager (not paying for needless hospital visits) but to get that value costs money.
I'mNotSureWhoIWantToBeYet
Thank you for this.
Since lots and lots of data are available in lot and lots of areas now, too many “muckrakers” think that putting the numbers in Excel and doing some division is the way to find the “truth”. As your example clearly demonstrates, people who spend their lives working on a problem usually aren’t idiots and they know how to do division as well. Maybe the muckrakers aren’t seeing something new? Maybe there is more going on than shows up by dividing some numbers?
Talking to people who work in the trenches is usually much more illuminating than looking at raw numbers.
Thanks.
Cheers,
Scott.
Central Planning
Analytics can help find all sorts of interesting correlations. I wonder how many companies can actually do the right thing and save money by not screwing their customers, but by actually doing something that benefits everyone.
In your example, would you revisit the status of Burrito Tuesday every year? I’m sure Mayhew Insurance doesn’t want to be providing meals forever. Or ask the social worker if they can now afford meals themselves? Or stop paying for Burrito Tuesday and see if claims at the hospital go back up? Or wait until the hospital doesn’t offer coupons any more?
Richard Mayhew
@Central Planning: I have no idea what the status is on Burrito Tuesday. That was a problem resolution that I spent some time diving into the data after my boss talked to the ER expense analyst boss as a preliminary BS check. I was on the problem long enough to know what the short term solution was. I have no idea what the long term solution is (besides a full employment economy with high wage gains for everyone….)
Cervantes
Oh come on. How many insurance companies would really do this? This is a fantasy. What they actually do is just try to deny claims, usually on bogus grounds.
RSA
And it probably goes without saying that there’s value to everyone else who uses the ER. My anecdote: I’d taken my wife home after brain surgery, and the doctors had underestimated the pain she would be in. At 4:00am I brought her to the ER, and we had to wait in line behind a man with a toothache and a woman asking about prenatal care. Also, it was freezing cold, and the ER was warm.
Thoughtful Today
Uh, yes,
Medicare is significantly more cost efficient than even the most cost effective insurance.
Insurance, even the “good” Goodwill Inc. “non-profit” charades, leach profit out of the health care system and often with obscene costs, sometimes the costs are literally human lives.
japa21
@Cervantes: Actually, it is not a fantasy, and many insurance companies do things just like this. At least those that have the wherewithal to do the initial investigating.
Cervantes
@japa21: I do not believe you. Show me some evidence.
Thoughtful Today
{sigh}
Honest data analytics consistently shows that the predatory leaching done by insurers means less money goes towards health care.
Which is the point, the insurance racket is a racket, fewer paid claims means more money in the insurers pocket.
Remove the insurance racketeers and there would be a huge amount more money available for health care.
Richard Mayhew
@Cervantes: as I indicated in comment three, I’ve been a part of cost avoidance efforts for years. As a side note, it is cheaper to never receive a claim than to deny it.
japa21
@Richard Mayhew: Richard, without trying to whitewash the issues that do show up with insurance companies, it is obvious there are some people who see no good within the insurance industries and believe all insurance companies are evil and do not care about the health of their insureds.
Are there problems? Of course. Even single payer systems have problems and not everybody is happy. But you will never convince some people that insurance companies also can have a positive role to play.
Chyron HR
@Thoughtful Today:
You forgot the part of your fantasy where Obama sends the army to nationalize the hospitals and has all the nurses rounded up and shot.
scav
A strict application of finding a lesser cost solution quickly (which saves cash in itself), that will be agreed to easily (again, see value of speed), avoids litigation (costly) and bad PR (bonus). Sounds entirely logical such instances would pop up. Especially as this example seems to be a limited in scale problem (different circs. if it was systemic).
Rommie
Wow, there are so many topics to potentially pick at here. Lying Cat has already made an appearance. Those People mooching the system again, like they *always* do. Idiot Hospital being idiots by giving the food vouchers. Incompetent Insurance wasting their customer’s money by rewarding bad behavior, instead of using the Invisible Hand to slap Idiot Hospital.
All avoiding the WHY chain of events, of course. But if you put this out there in general Internet land, those points will get debated endlessly (plus some I’m sure I haven’t thought of) and the WHY questions ignored. It’s really quite depressing. SMH.
Thoughtful Today
heh,
Absurdist theater: “Obama sends the army to nationalize the hospitals”…
….
Like the Veterans Affairs Hospitals?
President Clinton appointed managers to the VA that did profoundly good work in increasing health outcomes and satisfaction levels.
President Bush came in and we got the Walter Reed Hospital scandal. President Obama has been marginally better but still took his eye off the ball.
Bill Clinton proved socialist hospitals can be more effective and efficient.
Mnemosyne (tablet)
Well, it would have been nice to actually discuss the topic at hand, but of course that commenter has shown up who has to jump up and down screaming, LOOK AT ME! PAY ATTENTION TO ME! MEMEMEMEME! so I know the conversation is effectively over now anyway. It’s like trying to have a conversation at an otherwise quiet restaurant when a hyperactive toddler is at the next table.
Richard Mayhew
@Rommie: The why is simple — those families do not have enough money to make their monthly nut that includes a reasonable amount of decent food.
Fixing that is “simple” a full employment economy with high productivity gains that go 100% to workers.
Can an insurance company actually do a goddamn thing about that “simple” fix. Nope. So second best solutions — how do we avoid pointless ER utilization — spending $1,500/year to avoid $20,000 to $30,000 worth of pointless expenses is a win.
As far as the hospital, they tweaked their voucher system so that it only applied to level 3/4/5 visits (ie something actually wrong) so someone complaining about feeling lightheaded due to dehydration would not get a voucher. There goes the entire hack angle.
Thoughtful Today
lol
It’s a comment thread … on the internet … about insurance and how it relates to health care.
Insurance corps are the equivalent of leaches ‘bleeding’ the patient.
YMMV and may depend on who’s paying you.
John M. Burt
@Cervantes: I am reminded of a passage in The Amazing Adventures of Kavalier and Klay which describes a group of young writers and artists gathering in an abandoned warehouse to bang out a sixty-four page comic book over a weekend in order to make a printer’s deadline. I found the way it was written very amusing, and read it aloud to another person who told me that it was silly of me to enjoy such a nonsensical, impossible tall tale. I replied that the scene was based on a well-known incident from real life, which I’d read about in multiple histories of comics publishing.
Cervantes
@Richard Mayhew: Maybe so but this is highly exceptional. You are trying to argue that the administrative expenses of the insurance industry in general are justified because they engage in public health and social services. Maybe you do that, but I don’t see Aetna sanding the sidewalks in the winter.
I think it’s nice that you are part of a highly unusual program but trying to tell people that the insurance industry normally does that is simply false.
Richard Mayhew
@Cervantes: I can not speak for other insurers, Japa can speak for his employer. The general point of the post is that different business models have different expense profiles. Medicare is a low cost model because it just pays with minimal analytics. Reducing Waste, Fraud, Abuse ( this is a case of waste and abuse) costs money even as it saves money. Medicare would have spent 30 or 40 dollars total to pay 20,000 in ER claims. Mayhew Insurance spent 5g to avoid paying 20G in claims. Distributing that 5g across a other normal claims makes the admin cost look way worse despite providing better value.
Richard Mayhew
@Chyron HR: that is McLaren… Get your bores and trolls right
wenchacha
This is a great example of an area where public health research could help improve outcomes while saving money at the same time. I can believe that some companies would do this. There are people in this world who value people over profit-at-all-cost.
Sam Dobermann
@Richard I am surprised you have fallen for the “Medicare has a low administrative rate. Medicare pays roughly 4% to 5% of total expenses for administrative costs” myth. That is only true if you only consider the cost of automatically processing claims and disbursing funds and nothing else.
The true administration costs of Medicare have to include the amounts paid on fraudulent claims which amounts to 10% or $200 BILLION per year and all the other expenses of trying to track down and prosecute the fraud. The total – and I don’t know if anyone has been able to quantify it – comes close to 18% – 20%. Other expenses are in looking at the data as Richards firm does to identify trends, needs, differences and of course looking at what works and what doesn’t; best practices or effectiveness measures. Of course, Congress forbid using any of that info to influence what would be paid for.
Remember the hoo hah about the $350 million in the ACA to hire more FBI agents? They were said to be coming to your door if you hadn’t bought your health care insurance yet. Actually no, they were hired to augment the extensive number of agents, both FBI and those in HHS and CMS who were and are working on investigating and prosecuting fraud.
By fraud I don’t mean the petty chiseling of the hungry families gaming the system. I mean outright criminal fraud and theft by those who are responsible for the costs of our health care in the US.
This is mainly done by fake billings by providers. I’ll give evidence in a minute but first one of the reasons this has been able to go on is the various hurdles set up by Congress. For one thing they mandated that all providers be paid in 15 days. That means that most all the money goes out the doors and into the fraudsters pockets before there is any chance to evaluate claims. Second, prior to the ACA anyone could apply and submit claims to Medicare and get paid. Most all private insurers require some sort of contracting which can allow time for what ever investigation is needed. Now with the ACA some limits are being put in place. In fact many improvements in fraud prevention and detection as well as increased penalties for fraud are in the ACA.
As far as the fraud which, remember I said amounted to $200 Billion a year some of the best evidence comes from the DOJ Web site. Here are a sample:
At http://www.justice.gov/opa/pr/national-medicare-fraud-takedown-results-charges-against-243-individuals-approximately-712
Thursday, June 18, 2015
National Medicare Fraud Takedown Results in Charges Against 243 Individuals for Approximately $712 Million in False Billing
Most Defendants Charged and Largest Alleged Loss Amount in Strike Force History
Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced today a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulting in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings. In addition, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of providers using its suspension authority as provided in the Affordable Care Act. This coordinated takedown is the largest in Strike Force history, both in terms of the number of defendants charged and loss amount.
Attorney General Lynch and Secretary Burwell were joined in the announcement by FBI Director James B. Comey, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, Inspector General Daniel R. Levinson of the HHS Office of Inspector General (HHS-OIG) and Deputy Administrator and Director of CMS Center for Program Integrity Shantanu Agrawal, M.D.
The defendants are charged with various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and pharmacy fraud. More than 44 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program overall.
… “The defendants charged include doctors, patient recruiters, home health care providers, pharmacy owners, and others. They billed for equipment that wasn’t provided, for care that wasn’t needed, and for services that weren’t rendered. In the days ahead, the Department of Justice will continue our focus on preventing wrongdoing and prosecuting those whose criminal activity drives up medical costs and jeopardizes a system that our citizens trust with their lives. …
… “This takedown adds to the hundreds of millions we have saved through fraud prevention since the Affordable Care Act was passed.
With increased resources that have allowed the Strike Force to expand and new tools, like enhanced screening and enrollment requirements, tough new rules and sentences for criminals, and advanced predictive modeling technology, we have managed to better find and fight fraud as well as stop it before it starts.”
According to court documents, the defendants participated in alleged schemes to submit claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, Medicare beneficiaries and other co-conspirators allegedly were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed. Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $712 million in fraudulent billing.
…
A few others:
http://www.fbi.gov/houston/press-releases/2015/assistant-administrator-of-riverside-general-hospital-sentenced-to-40-years-in-prison-in-116-million-medicare-fraud-scheme
The former assistant administrator of Riverside General Hospital was sentenced today to 40 years in prison for his role in a $116 million Medicare …
http://www.fbi.gov/chicago/press-releases/2015/administrator-and-biller-of-illinois-physician-group-convicted-in-4.5-million-medicare-fraud-scheme
http://www.fbi.gov/oklahomacity/press-releases/2015/hospice-company-owner-sentenced-to-serve-three-years-in-prison-and-pay-more-than-2.5-million-in-restitution-for-medicare-fraud
http://www.justice.gov/opa/pr/medicare-fraud-strike-force-charges-89-individuals-approximately-223-million-false-billing
But piecemeal prosecution won’t end the problems — however it will help. Sometimes a few very public prosecutions, fines and often prison time makes others in a community take note. The proof is in finding that overall claims to Medicare for the entire area dropped precipitously after a big takedown.
Medicare for all, by what ever cutesy name, is not the answer to our health care problems. It is just a financing mechanism after all. And that is not the biggest problem with our system.
Another huge problem that runs up medical costs which in turn increases either government costs (deficit — your tax dollars wasted) or your insurance premiums raised is over-treatment. If you care about your health care costs and the quality of your care, read Atul Gawande’s Overkill at
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande?intcid=mod-most-popular
He is the most interesting and knowledgeable writer on medical/health care issue today. He is also has a good sense of humor. Any of his articles are great but If you really want to understand what is really wrong with our health care system you need to read this article, Overkill. I can’t praise it enough. Dr Gawande goes over and updates some of his previous articles, particularly The Cost Conundrum which set off a firestorm in McAllen TX with waves that definitely reached DC. It also showed the effects of a few very public fraud settlements and jail time on the practice costs in the entire area
I’d quote some of Gawande’s writing but I’ve probably used up all my electrons for today.
The Sailor
One small insurance company has nothing to do with how most insurance companies work.
The anecdote was about a kid with a broken leg, that’s a serious medical issue.
The plural of anecdote is not anecdata.
And regardless what you believe, the numbers do tell the true story, your company just apparently chose to keep some costs off of the books.
Sam Dobermann
A patient like Sara Monopoli could continue to try chemotherapy and radiation, and go to the hospital when she wished—but also have a hospice team at home focussing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe. A two-year study of this “concurrent care” program found that enrolled patients were much more likely to use hospice: the figure leaped from twenty-six per cent to seventy per cent. That was no surprise, since they weren’t forced to give up anything. The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I.C.U.s dropped by more than two-thirds. Over-all costs fell by almost a quarter.
This was stunning, and puzzling: it wasn’t obvious what made the approach work. Aetna ran a more modest concurrent-care program for a broader group of terminally ill patients. For these patients, the traditional hospice rules applied—in order to qualify for home hospice, they had to give up attempts at curative treatment. But, either way, they received phone calls from palliative-care nurses who offered to check in regularly and help them find services for anything from pain control to making out a living will. For these patients, too, hospice enrollment jumped to seventy per cent, and their use of hospital services dropped sharply. Among elderly patients, use of intensive-care units fell by more than eighty-five per cent. Satisfaction scores went way up. What was going on here? The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking.
Much of what we call health care is social services. That’s why most major hospitals have social workers on staff. And the above described Hospice care is really about half medical care and half social work.
A lot of times a private insurer can try different things more nimbly than a big program often bogged in bureaucracy.
Oh, one more thing: Aetna just raised its minimum pay for every employee to $16 an hour.
Has the Federal Government or its contractors done the same yet?
Sam Dobermann
@Sam Dobermann: Well, I screwed the above post badly. The first paragraph of the quote from Gawande was supposed to be:
In late 2004, executives at Aetna, the insurance company, started an experiment. They knew that only a small percentage of the terminally ill ever halted efforts at curative treatment and enrolled in hospice, and that, when they did, it was usually not until the very end. So Aetna decided to let a group of policyholders with a life expectancy of less than a year receive hospice services without forgoing other treatments.
… A two-year study of this “concurrent care” program found that enrolled patients were much more likely to use hospice: the figure leaped from twenty-six per cent to seventy per cent. That was no surprise, since they weren’t forced to give up anything. The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I.C.U.s dropped by more than two-thirds. Over-all costs fell by almost a quarter.
The 2d paragraph is ok but I’ll recopy to make sense.
This was stunning, and puzzling: it wasn’t obvious what made the approach work. Aetna ran a more modest concurrent-care program for a broader group of terminally ill patients. For these patients, the traditional hospice rules applied—in order to qualify for home hospice, they had to give up attempts at curative treatment. But, either way, they received phone calls from palliative-care nurses who offered to check in regularly and help them find services for anything from pain control to making out a living will. For these patients, too, hospice enrollment jumped to seventy per cent, and their use of hospital services dropped sharply. Among elderly patients, use of intensive-care units fell by more than eighty-five per cent. Satisfaction scores went way up. What was going on here? The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking.
Much of what we call health care is social services. That’s why most major hospitals have social workers on staff. And the above described Hospice care is really about half medical care and half social work.
A lot of times a private insurer can try different things more nimbly than a big program often bogged in bureaucracy.
Oh, one more thing: Aetna just raised its minimum pay for every employee to $16 an hour.
Has the Federal Government or its contractors done the same yet?
Thoughtful Today
[sigh]
Corporate insurers like Aetna, under our insane system, are apparently allowed to create real world experiments with offering hospice care, essentially an Uber death panel.
Authoritarians are fine with that … ’cause … cognitive dissonance….
Thoughtful Today
Imagine…
Richard explaining to your Grandmother, ‘no, sorry, you can’t stay at home with your dignity and immediate support network, it’s just not efficient for our Corporation, off to the Hospice to you!’
Bureaucrat might even get a bonus if that elderly consumer stops being a greater cost than profit altogether…..
Richard Mayhew
@Thoughtful Today: you do knowthat Medicare is experimenting with hospice programs as well because they tend to be kinder, gentler and far less traumatic to the individual and their families ( as well as far cheaper … My aunt died of pancreatic cancer in hospice. She died sitting on a porch listening to birds with a CD on the back ground after spending the afternoon drinking lemonade and bullshitting with some friends. If she was at the hospital, when her blood pressure crashed she would have been rushed to the ICU and put on a ventilator and tubed up for a week before she died. She chose hospice and Medicaid made that choice a dignified one instead of the chaos of a hospital.)
Hospice is often a good choice for people who know they don’t have long to live.
BubbaDave
@Thoughtful Today:
Good God, you’re Sarah Palin after all. Somehow “Aetna let a selection of terminally ill patients enroll in hospice without asking them to forswear curative treatment” turned into “an Uber death panel” after it spent a little time rattling around your skull?
Sam Dobermann
@wenchacha: Plenty of research has been done. We know what treatments are worthless and even harmful to patients. These worthless treatments have been so designated by their appropriate specialty boards. The low cost ones are being dropped but the higher cost ones, well, they are still being done by too many doctors because they generate money for the doctors and hospitals.
Gawande in Overkill bluntly says ” Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”
Patients have to educate themselves. More important they have to question the necessity — and the safety — of the procedures and consider refusing them.
Sam Dobermann
@Thoughtful Today:
“Richard explaining to your Grandmother, ‘no, sorry, you can’t stay at home with your dignity and immediate support network, it’s just not efficient for our Corporation, off to the Hospice to you!’”
Once again you demonstrate you don’t know what you are talking about. Most hospice care occurs while the patient is living at her or his home. A nurse comes in as often as needed to check on the patient to see what see needs or wants or what she can do to make her life easier and more pleasant. They usually supply appropriate medications like a self controlled pain medicine pump and any others. The hospice nurses are available for phone calls at all times.
When Richard says “My aunt died of pancreatic cancer in hospice. She died sitting on a porch listening to birds with a CD on the back ground after spending the afternoon drinking lemonade and bullshitting with some friends.” He means she was at her home, sitting on her porch doing what she choose to do with her friends.
What the hell is wrong with that? Are you against a patient CHOOSING what she wants?
How the hell is that a death panel?
The evidence is in: those patients who accept hospice care and choose NOT to keep taking “treatments” which are likely to fail to improve their situations live longer than those who continue with the full panoply of care. Hospice care is dedicated to making the patient, and their family as comfortable as possible and allow them the dignity of their own choices.
Hospice is never imposed; it is always by a patient’s choice and they can change their mind at any time.