The same situation applies to humans. It’s difficult to predict death, so certain expenses can only be evaluated retrospectively to determine if they were “worth it.”

While we can’t predict when people will die, we certainly have a good idea of where they go when they are approaching death: one of the nation’s more than 15,000 nursing homes. (There aren’t that many Burger Kings.) Extraordinary amounts of money are spent on these patients. Some of this is well spent, and some of it is just money tossed on the raging inferno of government waste.

In emergency medicine, we have a front row seat to this enormous bonfire. We are so close that the soles of my shoes melted last week when the extended care facility (ECF) sent someone for a PICC at 11 p.m. to get a med that could be given IM.

Every emergency physician can readily bring to mind several examples of colossal waste every week. The usual scenario is that the patient arrives needing their INR checked, G-tube repositioned, or Foley catheter replaced. We quickly take care of the issue (sometimes while the patient is still on the ambulance stretcher), pat the patient on the head, and send them back. The government ends up spending $1,500 on a $100 problem.

Why is it that they will freely pay all this money (half of it for a fancy cab ride), but not pay a reasonable amount of money for a doctor—or, better yet, a physician’s assistant or nurse practitioner—to just do it right at the nursing home?

The reasons are threefold. First, government never has been, nor do I expect it ever to be, a good steward of our money. There is little incentive for the paper pushers involved to go the extra mile to ensure that dollars are spent judiciously.

Second, there is no disincentive for ECFs to stop being wasteful. Right now, it is easy for them to just call the ambulance and ship the patient off so the problem will belong to someone else. If the ECF must devote staff time to something the hospital could do for them, their bottom line is better if they ship the patient to the ED. Third, there is no incentive for the patient’s physician to come to the ECF to take care of the problem, because the reimbursement is poor or nonexistent.