An anonymous death

These events were recounted to me by my wife, a county social worker.  For obvious reasons, I cannot use any real names, either of the persons or the specific institutions involved.  To avoid talking and thinking about a real person as an abstraction – which is precisely the sad circumstance I would like to decry – I will call the subject of this story Charlie.

Charlie was an old man in poor health.  A retired auto worker, he was not a rich man – but he was not a poor man either.  Charlie was, among many other things he may have been in his life, a Medicare recipient.  A little more than a month ago he went to his local hospital with an acute shortness of breath.  The diagnosis was a collapsed lung.

A collapsed lung is a serious condition but, in itself, it is by no means a death sentence.  In Charlie’s case the lung required periodic drainage, among other things, but given attention and reasonable care his prospects for recovery were good.  Charlie was in his seventies and had various other medical problems, but nothing about his state of health was immediately terminal.  He might have been expected to live some number of years with whatever quality of life he could manage for himself – the same sort of expectations you or I might have as living, breathing human beings.

I can only imagine that forty or fifty years ago Charlie could have expected a moderately long hospital stay, during which he would have rested, had his condition attended to at intervals by nurses in small white hats, and by the end of which he would have probably gotten better.  He would not have expected to have been bankrupted in the process – Medicare or no Medicare.  Things have changed.  In the last forty years we have invented new techniques and new diagnostic equipment, but you cannot stay in a hospital for weeks or days anymore unless you happen to be very very rich or very very comatose.  Thus, after a relatively short interlude of adequate care, Charlie was gently booted out the door.

Until very recently, a hospital that could no longer profitably treat a Medicare recipient’s serious but unresolved condition passed him or her on to the second line of defense – a long term care facility, usually a nursing home.  There, Medicare would pay the person’s expenses for the first 30 days.  This was not enough for everyone, but it was something.  It might have gotten Charlie over the hump.  A funny thing has happened lately though – a little bureaucratic fine point with enormous consequences – as the result of the passing of the Affordable Care Act.  Medicare still covers the thirty days of long term care if a person is admitted to a hospital in the normal way.  However, Medicare doesn’t cover this long term care if you are admitted for observation instead of being admitted normally.  Medicare now also pays a hospital more if it admits a patient for observation than would be paid if the patient were admitted normally.  In medical terms, there is no distinction between the two kinds of admission.  Patients get the same care in the hospital regardless of their admission status.  It is purely a bureaucratic distinction, channeling a person in one direction or another.  Hospitals are businesses and their administrators know a deal when they see one.  Charlie was admitted for observation – so no long term care for him.

Charlie was instead ushered gently to the third line of defense – home healthcare.  One cannot send a person home while they are still seriously ill, not without the promise that a home healthcare worker will come around from time to time to try to finish the work that the hospital didn’t do.  Charlie was given a choice of home healthcare providers, and he picked one he had experience with from a prior illness.  Unfortunately, the provider Charlie picked was not the one the Federal authorities preferred.  Again, hospitals get reimbursed for referring patients to a particular provider, and not to others.  A little competition might be nice to keep home healthcare agencies on their toes, but it is bureaucratically easier for both the hospital and the government to only deal with one.  Thus, somewhere in the bowels of the hospitals administrative apparatus Charlie’s unprofitable and inefficient request got shuffled to the bottom of someone’s in-box.  Charlie sat at home – wheezing and waiting.

Finally some concerned bystander to Charlie’s suffering contacted my wife – the last line of defense.  County social workers have rather limited resources to work with.  In general, they investigate – then wheedle, cajole, and bluff more powerful institutions into producing better outcomes.  My wife sorted out what had happened, and extracted a promise from someone at the hospital to complete the unprofitable paperwork to set up services with the provider Charlie wanted.  My wife is not empowered to hold a gun to anybody’s head, nor does she want to be.

In the end, no paperwork was sent – and no one came.  Four days after the hospital promised to resolve the issue, Charlie’s collapsed lung filled to capacity with fluid.  He died of a heart attack, brought on by the accumulated strain, while sitting on his toilet.  A dignified death under the watchful eye of the caring institutions of his society.

We may bicker and haggle about who ought to be doing what – about whether this public policy or that one is the more moral or humane.  Perhaps, as individual human beings, we should spend a little less time trying to be maximally high-minded and a little more time being at least minimally decent.  Everyone involved in this process got a good outcome – except for Charlie.  The people at the hospital didn’t lose any money doing things they couldn’t bill for, and neither did they suffer the embarrassment of having a patient expire on their premises.  The Federal government was a financial winner too, saving money which it will no doubt spend – in its nearly infinite compassion – on someone else the anonymous bureaucrats decide to bestow it on.  The system functioned as designed.  It did everything perfectly – except deliver healthcare.  And let’s not kid ourselves that Charlie’s miserable fate was the product of peculiar circumstances that, you understand, just happen now and then.  Charlie died as the result of policies that people put in place.  Policies that remain in place.  Whether those policies were the result of malice, incompetence, or mere indifference makes very little difference to the outcome.  Any way you look at it – a man is dead.