- The Washington Times - Thursday, August 10, 2000

Rosie DesParois, 87, was a retired nurse facing a death sentence. Doctors said she was terminally ill with advanced breast and endometrial cancer that had spread to her liver. Rather than enter a hospital or nursing home, however, Mrs. DesParois sought care from a Plattsburgh, N.Y., hospice, which allowed her both to live out her remaining days puttering in the garden of her beloved home and to receive some limited medical care there. Visiting hospice staff took advantage of the visits to coax her into taking medicine.Then disaster struck, or so it seemed to the Medicare administrators paying for her hospice care: Mrs. DesParois lived. According to federal regulations dating to the 1980s and enforced by the Health Care Financing Administration (HCFA), hospice patients are limited to six months of coverage. Because Mrs. DesParois' life span had exceeded federal guidelines, in 1997 an agency contractor fired off letters to her and other hospice patients in Plattsburgh stating that they were not eligible for hospice coverage. Further, the contractor demanded reimbursement. Said a horrified relative of one other elderly letter recipient, "Medicare's view seemed to be, 'You're supposed to die, so why don't you?' " The Wall Street Journal reported the controversy in June under the headline, "Hospice's Patients Beat the Odds, So Medicare Decides to Crack Down."In his speech accepting the Republican Party's nomination for president, George W. Bush was sharply critical of Clinton administration officials for failing to take advantage of the nation's economic prosperity to repair programs such as Medicare. "They had their moment," he said. "They have not led. We will." Mr. Bush promised to put the program on firm financial ground although he did not say how and to make prescription drug coverage available to seniors.In fact, for both current and future Medicare recipients, the list of administration accomplishments is as short as it is unsound. Faced with rising spending, the current Medicare program is economically and fiscally unsustainable, Comptroller General of the United States David Walker told Congress in March 1999. President Clinton has sought to add to the burden on the program's aching back. Among other things, he has sought to expand Medicare coverage by allowing persons under 65 to buy into the program at subsidized rates, and he is now trying to add a prescription drug benefit for Medicare recipients. At the same time, he blocked the proposal of a bipartisan panel, co-chaired by Sen. John Breaux, Louisiana Democrat, and Rep. William Thomas, California Republican, to control program costs and to give beneficiaries more choices in coverage.
One way Mr. Clinton has attempted to control the program's fiscal bleeding is to ratchet down reimbursement rates to health care providers treating Medicare recipients. That approach simply makes providers more reluctant to take on new Medicare patients.
A second Clinton administration cost-control measure imposes increasingly complicated regulations on providers to reduce what the media carelessly refer to as waste, fraud and abuse. Not only do the rules mean doctors and hospitals must devote more time to filling out paperwork. They must play a kind of regulatory roulette that can wind up criminalizing good medical practice. Robert Moffitt of the Heritage Foundation cites the case of a California internist trying to negotiate Medicare rules governing colon cancer screens. Said the doctor: "If a doctor orders a stool specimen to test for occult blood which might indicate an early colon cancer is he engaging in good medical practice or criminal behavior?" Answer: It depends. If the patient doesn't have symptoms and the bill is sent to Medicare, it's a criminal offense because these preventive services are not covered benefits.
Thus billing them to Medicare is considered fraud. The absence of intent to cheat Medicare doesn't matter. On the other hand, if a physician waits for colon cancer symptoms to appear before ordering the stool test, he may be putting his patient at risk.
In the case of Mrs. DesParois, Medicare had been under pressure to reduce fraud at hospices since the U.S. Department of Health and Human Services sent out a 1997 warning:
So out went the notices to five Plattsburgh Medicare beneficiaries who had, in effect, lived too long. When the hospice tried to get HCFA to reconsider, the agency responded by seizing the hospice's Medicare payments. In an ensuing court battle between the hospice and the government, a University of Chicago professor advising the hospice explained there was no evidence of fraud there, just dumb luck that a handful of hospice patients had beaten the medical odds against them. The courts eventually agreed. The hospice got its money back, but it was out $80,000 in legal fees.
Still, the Chicago professor couldn't help noticing the perverse incentives the government was enforcing in the case the more quickly patients died at hospices, the happier the feds were. That being the case, Medicare administrators would soon get good news about Mrs. DesParois. Dropped by the unhappy hospice under pressure from HCFA, she was forced to leave her home and enter first a hospital, then a nursing home. There, the Journal reported, she developed gaping bedsores and was in agony. She died soon after. Ironically the nursing home charged Medicare about $150 a day, twice the hospice fee.
At their upcoming political convention, Mr. Gore and his fellow Democrats have an opportunity to explain why such a system is worth sustaining.
E-mail: smithk@twtmail.com

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