Over the past few years, much has been made about reform of our health care system. What the general population and most politicians don’t understand is that our system, as it exists now, is not so much a well-­organized structure of interconnected and interrelated parts, but a haphazard and loose association of multiple parties with differing agendas.

If you toss aside the secondary political gain associated with reform, there seem to be two main motivations for change. One is to provide affordable insurance coverage for more people, and the other is to control costs. One could argue that both of these goals cannot be accomplished simultaneously; yet they are both laudable goals.

As a younger man, when money became tight at my house, the solution was usually to work more. Now I opt for the spend-less solution. Unfortunately for the taxpayers, the spend-less solution is never given much consideration by the government, and it almost always opts for the work-more approach.

The big problem is that government does not work in the sense that it creates a good or service that can be sold for a profit—unless somehow one could capture all that hot air. So when the “work-more” solution is applied in government, it means they must raise revenue—usually through raising taxes.

The folly of this approach, as Margaret Thatcher observed, is that eventually you run out of other people’s money. Given the size of the deficit, it’s fair to say that we are already there.

Spending can be reduced without limiting meaningful care. There is enough waste and stupidity in the system to save a whole lot of money without declining bypass for everyone over 70. If this conversation can proceed without the Republicans railing about death panels and such, we might actually get to a solution.

It is generally agreed that the elderly are overrepresented in health care costs. When most people hear this the usual response is, “Duh.” Another piece of information that gets tossed around is that a huge amount of money is spent in the last year of life. Estimates vary and the exact number is not helpful for this discussion, because we usually can’t predict when someone’s last year of life will be.

I purchased new tires for my wife’s aging SUV this fall. I have the expectation that the vehicle can be driven safely for another 50,000 miles. If the engine unexpectedly fails this winter, the tire purchase will turn out to be a bad decision.

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.

Most of the nursing home patients I encounter seem to be in limbo. Their family doctors usually stop following them in the ECF, and they are followed from a distance by the doctors at the facility. So, at the time when these patients need more regular monitoring and coordination of care, nobody is really paying attention.

Much of this would change quickly if the government did two things.

First, every ECF should have an NP or PA who sees patients on a regular basis and takes care of the issues that can be handled there. The government should reimburse reasonable charges for this. Smaller ECFs could share staff. These practitioners could head off problems by monitoring conditions such as UTIs,

G-tube issues, medication problems, and bedsores, which often turn into bigger problems when ignored.

Second, the nursing homes need to take some ownership of the problem. The doctor at the ECF should be required to approve and certify every ambulance trip. Pointless trips should be charged back to the ECF. All of a sudden, the ECFs will take a closer look at who needs to come to the ED. The reflex response of “Send him to the ER” will change, and the doctor will ask questions and think of reasonable alternatives before ordering the $200-per-mile horizontal limo ride.

If one ambulance trip per day per nursing home were prevented, it would save more than $5 billion annually. That would move us farther from the point of having to deny care.

And that point is coming.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.