Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'.
While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility.
They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken.
The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.
Elderly Americans experience about 29 million falls per year, which costs Medicare $31 billion. At about $1,000 per fall that seems quite reasonable. 27,000 older Americans die from falls each year. In an institutional setting like a nursing home, the rate of death per fall is even higher.
$700,000 for two people in assisted living for eight years is about $43,000 per year. That's not unreasonable for the cost of assisted care plus medical expenses.
A facility generating large numbers of fall investigations that don't lead to ongoing medical care seems like it would be pretty easy (potential) fraud to go after though.
29,000,000 / 27,000 = ~1,074 falls per death. ~At 1,000$ per fall that's ~1,000,000$ per death which seems reasonable on average.
However, medical expenses are top heavy. Some of those falls probably cost 200,000+$ because they cause long term medial issues. If a faculty is spending ~1,000+$ on an a median fall their average is going to be much higher than that. Which is a sign they really are providing unnecessary procedures.
Since Medicare is largely funded by payroll taxes, would you say that this is a wealth transfer from non-healthcare industry workers to the various participants in "the chain" of the healthcare industry?
This is what horrifies a lot of us (British) about the NHS being further privatised. You create perverse incentives, beyond just providing the healthcare required.
As I understand these things... Medicare is single payer and NHS is single payer & single provider. Which would make the British NHS more akin to USA's Veteran's Administration.
FWIW: I advocate single payer (Medicare for All), but not single (sole) provider.
We have two family members in an assisted car facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount.
Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay, but even for those with significant assets, there are "perfectly legal" tax dodges that can be set up for $XX,XXX so that Medicaid pays the $XXX,XXX bills while the family inherits the $X,XXX,XXX estate. And if you pay the lawyers a little more, they can probably even figure out how to avoid paying capital gains on the distributed assets if they are below $10 million.
I don't see much hope for the insurance reform in the US until we can get end-of-life costs under control. I don't if "Ponzi" is quite the right term, but it's definitely a system rife with fraud.
House of God is indeed an interesting book and a good read. I read it during second year of my residency, and it is incredibly sad how the stuff that is talked about in the book has gotten worse in some ways, though better in others.
I'm actively against the "bowel run" mentality. I do my best to avoid even the CYA test ordering, though I'm not in the ED where this can be the most rife. I see first hand the "ponzi scheme" (though IMO it is not the correct term) of the system and I chose to go into primary care because I actively want to fix this in any way I can, and being a specialist was not the way I thought would be best to do this.
Sivers.org has got reviews and cliff notes for quite a lot of HN's favorite books, if you're interested. They're actually such good summaries of the books that a lot of the time I just read his synopsis and skip the book.
> And if you pay the lawyers a little more, they can probably even figure out how to avoid paying capital gains on the distributed assets if they are below $10 million.
Capital gains costs bases are currently "stepped up" during the estate transfer. No need to pay anything to lawyers. If your estate is below $10.5M (or thereabouts, I forget what the exact number is since it's now inflation adjusted), you won't be liable for any of that capital gains, nor will you owe any estate tax since you're within the exemption.
Yes, but I think the trickiness is combining this with the combination of revocable and irrevocable trusts that "protects" the assets from Medicare. Although it's possible that in the case I'm aware of, it's NY state and city rules that required the additional layers. My main point is that the current system is designed so that it can be gamed by those with the money to pay the lawyers, and the lawyers have enough influence to keep the system broken such that they continue to benefit.
Despite this, do read "House of God" --- it's a terrifying and eye-opening book!
Ah I see. There are a variety of irrevocable trusts that move assets to a separate legal identity from the original owner of the assets (ex: charitable grantor trusts that are used by the Waltons often). This would reduce the size of the estate for both estate tax and medicare purposes.
In the past, transferring assets to such a trust entailed gift tax, but since the estate tax and lifetime gift tax exemption are now bundled together, you can basically "use" the estate tax exemption to fund this irrevocable trust "for free". As a result your personal assets plummet, you name your heirt the beneficiaries of the irrevocable trust, and you (the parent) can take advantage of medicare fully as you describe.
The drawback to this strategy is that you do lose real flexibility in controlling your assets. Also, the legality of this widespread practice is definitely in a gray zone and carries future legal risk. Transferring a significant portion of one's assets to such a complex instrument is definitely not advised.
This isn't much the case anymore from my experience. A generation ago I recall it being general knowledge that if a loved one had to go into the nursing home you would bankrupt and have medicaid pay. A relative tried that this recently and is close to destitute as a result.
While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility.
They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken.
The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.