Friday, July 29, 2016
My good friend (and former New York Administrative Law Judge) Karen Miller recently had successful hip replacement surgery and I was happily amused when I realized she wasn't home two hours before she was already corresponding with me about the latest hot topics in "aging." Karen is a great example of an "active mind!"
Her latest communications focused on a topic I'd also been discussing recently with Stephen Maag, Esq., Director of Residential Communities for LeadingAge. Steve had mentioned that one of the challenges facing senior living across the board was attracting an appropriately trained and stable work force.
Karen pointed out to me that her CCRC (or, to use the latest label, Life Plan Community) in Florida was looking into partnering with a local high school and community college to provide financial support to students as well as site-based training in senior living. For example, Certified Nursing Assistants or CNAs may often think of hospitals or "nursing homes" as primary employers, but Karen pointed out that active senior living communities may offer far more attractive opportunities for employment, while still needing workers, such as CNAs, with specialized skills .
Karen pointed me to an article about a similar collaborative program in Maryland already under operation:
Thanks to a partnership with Ingleside at King Farm, a not-for-profit continuing care retirement community (CCRC) in Rockville, Maryland, students get first-hand experience in senior living and caregiving while residents enjoy participating in their education. And the partnership proves mutually beneficial, providing the CCRC access to a well-trained labor supply.
“Having a program like this exposes the younger generation to the health care field,” Adaeze Ikeotuonye, Ingleside at King Farm’s health care administrator, tells SHN. “Not many people in high school are necessarily thinking of working in the senior living industry, but bringing them in at such a young age and letting them see what the career possibilities are—that mixes up the dynamics.”
For more about creative partnerships to deal with caregiver shortages, read Senior Housing News' "CCRC Helps Forge High School-to-Senior Living Career Path."
Thanks to Karen for this link and best wishes for continued rapid recovery.
Thursday, July 28, 2016
Kaiser Family Foundation (KFF) published 10 Essential Facts About Medicare and Prescription Drug Spending on July 7, 2016. Here are some of the 10 facts, in no particular order.
- "Medicare accounts for a growing share of the nation’s prescription drug spending: 29% in 2014 compared to 18% in 2006, the first year of the Part D benefit."
- "Prescription drugs accounted for $97 billion in Medicare spending in 2014, nearly 16% of all Medicare spending that year."
- "Medicare Part D prescription drug spending – both total and per capita – is projected to grow more rapidly in the next decade than it did in the previous decade."
- "As a result of the Affordable Care Act (ACA), Medicare beneficiaries are now paying less than the full cost of their drugs when they reach the coverage gap (aka, the “doughnut hole”) and will pay only 25% by 2020 for both brand-name and generic drugs."
- "High and rising drug costs are a concern for the public, and many leading proposals to reduce costs for all patients – including Medicare beneficiaries – enjoy broad support."
To read all 10 facts and review the corresponding charts and explanations, click here.
This week my in-basket sported the latest copy of the Family Law Quarterly and it is a strong lineup of symposium authors writing on a range of issues connected to late-in-life marital woes. The articles in the Spring 2016 issue include:
- The Challenging Phenomenon of Gray Divorces, by Paula G. Kirby & Laura S. Leopardi
- Representing the Elderly Client or the Client with Diminished Capacity, by Robert B. Fleming
- The Battle for the Biggest Assets: Dissolution of the Military Marriage and Postdivorce Considerations for Aging Clients, by Brentley Tanner
- Residence Roulette in the Jurisdictional Jungle: Where to Divide the Military Pension, by Mark E. Sullivan
- Family Support, Garnishment and Military Retired Pay, also by Mark E. Sullivan
- Premarital Agreements for Seniors, by Peter M. Walzer & Jennifer M. Riemer, and
- Financial Abuse of the Dependent Elder: A Lawyer's Ethical Obligations, by Jeanne M. Hannah
In my review of the articles, I would have liked to see more discussion of the potential expectations of the couple about payment of their respective long-term care costs, especially as a party's carefully signed premarital agreement may prove to be irrelevant to the state's analysis of eligibility for Medicaid to cover long-term care. In most states, authorities insist on counting assets of both halves of the couple, without regard to any premarital agreement. This is where "elder law" attorneys can be of help to traditional "family law" attorneys in planning. Compare this Elder Law Answers' discussion of "Five Myths About Medicaid's Long-Term Care Coverage."
Wednesday, July 27, 2016
If your answer is no, you don't know a doctor who specializes in geriatric medicine, then take heart, you aren't alone. One would think, with the sheer number of baby boomers aging away, that there would be a number of doctors specializing in geriatric medicine. Kaiser Health Network (KHN) and West Virginia Public Broadcasting ran a story on July 13, 2016 about the lack of geriatricians. Few Young Doctors Are Training To Care For U.S. Elderly reports that West Virginia is 3rd in the country with a sizeable elder population, but only has 36 geriatricians practicing in West Virginia. It's not just West Virginia, though, who needs more geriatricians. "The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older."
The lack of geriatricians is not due to the lack of training programs in the U.S. "The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled." Why is this, you ask? According to the story, one reason may be the cost of a medical education and "they think that they need to get into something without the fellowship year where they can start getting paid for their work." An audio of the story is also available here.
Georgetown University's American Criminal Law Review recently hosted a symposium on health care fraud and one of the articles to come out of that program is by University of Alabama Law School Adjunct Professor James F. Barger, Jr. His article uses the 2013 criminal case of U.S. v. Kolodesh, which resulted in a "guilty verdict on all thirty five counts," to examine "the general trend of Medicare Hospice fraud enforcement actions." The author reports:
The vast majority of False Claims Act hospice cases in which the United States has intervened have settled in favor of the United States without consideration by a jury, and every criminal hospice fraud prosecution by the United States to date has resulted in a guilty plea or a conviction by jury. Every such case—whether civil or criminal—was initiated by a whistleblower under the public-private partnership of the False Claims Act.
The FCA’s whistleblower provisions have been highly effective at detecting fraud and recovering misappropriated Medicare dollars, but deterrence and prevention remain unattained goals.
The calculated business decision to settle False Claims Act allegations has proven over time to have a neutral-to-positive effect on corporate profitability in the hospice sector. For-profit hospice giants such as SouthernCare and Odyssey, who have paid eight figure settlements, have rebounded quickly and actually gained position over their competitors.....
Nevertheless, while the whistleblower provisions of the False Claims Act have proven extremely effective at discovering hospice fraud and at recovering at least some of the lost Medicare funds, alone the statute has demonstrated very little deterrent effect. Outside of a legislative overhaul of the Medicare Hospice Benefit, the only effective deterrent scheme will be for enforcement officials to supplement their use of the civil False Claims Act with traditional criminal fraud statutes. For this to work, however, criminal penalties must be imposed not only on the relatively small-scale players, like Matthew Kolodesh and Home Care Hospice, but also on the mega hospice companies and their executives and owners.
For more, read "Life, Death and Medicare Fraud: The Corruption of Hospice and What the Private Public Partnership Under the Federal False Claims Act is Doing About It," published in the 2016 issue of the American Criminal Law Review.
Tuesday, July 26, 2016
My friend and colleague, Professor Mark Bauer sent me this recent article (thank you!) Can car-centric suburbs adjust to aging Baby Boomers? We want to age in place, but neither or houses, or their locations, are always designed for us to do that.
In fact, the American suburbs, built for returning GIs and their burgeoning families, are already aging. In 1950, only 7.4 percent of suburban residents were 65 and older. By 2014, it was 14.5 percent. It will rise dramatically in the coming decades, with the graying of 75.4 million baby boomers mostly living in suburbia.
But car-centric suburban neighborhoods with multilevel homes and scarce sidewalks are a poor match for people who can’t climb stairs or drive a car.
“Most [boomers] are in a state of denial about what really is possible and what’s reasonable for them as they age,” said John Feather, a gerontologist and the CEO of Grantmakers in Aging, a national association of foundations for seniors.
Staying put is not without costs, and not just for retrofitting the house to make it accessible. Instead, the article notes, "[r]etirees who want to stay in the suburbs will have to cover the rising costs of property taxes and utilities, and they may have to shell out big sums to retrofit their homes if they become frail or disabled. One study found that it can cost $800 to $1,200 to widen a doorway to accommodate a wheelchair, $1,600 to $3,200 for a ramp, and up to $12,000 for a stair lift. Major remodeling, such as adding first-floor bedrooms or bathrooms, can cost much more."
Then of course, there is the issue of transportation. Out in the suburbs, we may not be able to walk to the stores and services we need, and some of us may no longer be able to drive. Transportation is critical and we all know about Americans' love of automobiles. So, what's the answer?
Even if a suburb has a regional transit system, the routes are often limited and geared to help commuters get to and from work in the city. The nearest bus or train stop may be miles from the subdivisions where aging boomers live. And while the Americans with Disabilities Act requires most public transit systems to provide pickup “paratransit” for people with disabilities who are unable to use regular bus or train services, that applies only to people who meet certain criteria.
One alternative is transportation services overseen by a federally funded network of local agencies that offer services and support to older adults to help them age at home and in the community. In many regions, these Area Agencies on Aging contract with local providers that offer door-to-door van services to older adults who qualify. But those programs, often geared to taking seniors to medical appointments and grocery stores, usually offer little flexibility and require clients to make reservations.
The article examines whether such an option will work for Boomers and what local governments need to do to prepare for this demographic change in suburbia. Of course, some elders choose to move to communities that provide the services and amenities they want and the article discusses these briefly.
But what about transportation? Doesn't that remain the elephant in the room? So, off on a tangent...I read another article this morning about Uber selling passes in NY for ride-sharing. Lyft is partnering with GM so drivers can rent cars. Are we going to see ride-sharing services as an option (or solution) for elders who have had to give up driving? But will this only be an option for those elders who can afford ride-sharing services? I'm still hopeful about self-driving cars....
The Washington Post published an interesting article reporting on the recent Alzheimer's Association International Conference in Toronto. According to the article,
Two studies looked at how complex work and social engagement counteract the effects of unhealthy diet and cerebrovascular disease on cognition. One found that while a “Western” diet (characterized by red and processed meats, white bread, potatoes, pre-packaged foods, and sweets) is associated with cognitive decline, people who ate such food could offset the negative effects and experienced less cognitive decline if they also had a mentally stimulating lifestyle.
Occupations that afforded the highest levels of protections included lawyer, teacher, social worker, engineer and doctor; the fewest protections were seen among people who held jobs such as laborer, cashier, grocery shelf stocker, and machine operator.
“You can never totally forget about the importance of a good diet, but in terms of your risk of dementia, you are better able to accommodate some of the brain damage that is associated with consuming this kind of (unhealthy) diet,” said Matthew Parrott, a post-doctoral fellow at the Rotman Research Institute in Toronto, who presented the study.
In another study, researchers found that people with increased white matter hyperintensities (WMHs) – white spots that appear on brain scans and are commonly associated with Alzheimer’s and cognitive decline – were able to better tolerate WMH-related damage if they worked primarily with other people rather than with things or data.
For more of the intriguing findings, read "Complex Jobs and Social Ties Appear to Help Ward Off Alzheimer's, New Research Shows."
Monday, July 25, 2016
The answer might surprise you. It turns out that the older the person, the less the person spends Kaiser Family Foundation reports in a recently released Medicare data note. Medicare Spending at the End of Life: A Snapshot of Beneficiaries Who Died in 2014 and the Cost of Their Care was published July 14, 2016.
Of the 2.6 million people who died in the U.S. in 2014, 2.1 million, or eight out of 10, were people on Medicare, making Medicare the largest insurer of medical care provided at the end of life. Spending on Medicare beneficiaries in their last year of life accounts for about 25% of total Medicare spending on beneficiaries age 65 or older. The fact that a disproportionate share of Medicare spending goes to beneficiaries at the end of life is not surprising given that many have serious illnesses or multiple chronic conditions and often use costly services, including inpatient hospitalizations, post-acute care, and hospice, in the year leading up to their death. (footnotes omitted)
The authors examine the data on a number of points, with explanations and corresponding charts. Among their findings
Our analysis shows that Medicare per capita spending for beneficiaries in traditional Medicare who died at some point in 2014 was substantially higher than for those who lived the entire year, as might be expected. It also shows that Medicare per capita spending among beneficiaries over age 65 who die in a given year declines steadily with age. Per capita spending for inpatient services is lower among decedents in their eighties, nineties, and older than for decedents in their late sixties and seventies, while spending is higher for hospice care among older decedents. These results suggest that providers, patients, and their families may be inclined to be more aggressive in treating younger seniors compared to older seniors, perhaps because there is a greater expectation for positive outcomes among those with a longer life expectancy, even those who are seriously ill.
In addition, we find that total spending on people who die in a given year accounts for a relatively small and declining share of traditional Medicare spending. This reduction is likely due to a combination of factors, including: growth in the number of traditional Medicare beneficiaries overall as the baby boom generation ages on to Medicare, which means a younger, healthier beneficiary population, on average; gains in life expectancy, which means beneficiaries are living longer and dying at older ages; lower average per capita spending on older decedents compared to younger decedents; slower growth in the rate of annual per capita spending for decedents than survivors, and a slight decline between 2000 and 2014 in the share of beneficiaries in traditional Medicare who died at some point in each year.
The report is also available as a pdf here.
Last week, Lancaster Pennsylvania was host to the 19th Annual Elder Law Institute, co-sponsored by the Pennsylvania Bar Institute and the Pennsylvania Bar Association's Elder Law Section. As the image of the two, fat volumes of course materials demonstrates, there was a lot of content for participants to digest. More than 400 professionals attended,not counting walk-ins. (And yes, the course materials will be available for purchase eventually, from the PBI catalog here.)
I had the privilege of welcoming two new speakers to the Pennsylvania conference, Stephen J. Maag, J.D., Director of Residential Communities for LeadingAge and Brad C. Breeding, President of My LifeSite. Both speakers addressed options available for senior living, and focused on trends affecting Continuing Care Retirement Communities (CCRCs), now also known as Life Plan Communities.
Steve noted that with close to 2,000 communities across the nation identifying under the CCRC or Life Plan label, a majority are "still" nonprofit, especially in so-called "Type A" operations, but that there is clearly a trend in the direction of change to "for profit" ownership or management. Communities are coping with what he termed "unprecedented" change on many fronts, including changing consumer demographics, the impact of health care reform, and use of technology that can affect or delay timing of decisions to move into a Life Plan Community.
Brad outlined the development of his company as a site for comparative information for consumers considering CCRC or Life Plan communities. The company has a data bank with detailed, comparative information on over 400 communities, offering consumers a fee-paid option of getting side-by-side statistics on contract options, pricing, services available and more. But he also said that collecting the information is not easy, as some state regulators, including Pennsylvania, do not "share" information in a transparent way. Remember Medicare.gov's Nursing Home Compare? Brad's company is working to provide consumers with comparative information beyond that narrow focus on skilled nursing care. One of the hot topics Brad identified is the extent to which consumers can use "long-term care insurance" in the CCRC setting, and we all discussed whether such insurance should be paying a pro-rata share of entrance fees, especially in Type A life-care contracts.
My special thanks to Steve and Brad for traveling from D.C. and North Carolina, respectively, to share their knowledge and predictions.
Sunday, July 24, 2016
Stetson Law Elder Law LL.M. alum and president of NELF, Amos Goodall, sent me the link to his most recent article. Retirement account planning can greatly benefit descendants.
The article opens
Many folks have large retirement accounts. According to the Investment Company Institute 2016 Yearbook, in 2015, members of 60 percent of U.S. households had invested $24 trillion in retirement market assets, including individual retirement accounts, 401(k)s, 403(b)s, simple IRAs and others. This article discusses IRAs, and someone with any others should consult legal and financial advisers. In fact, every general rule stated in this article is subject to exceptions, and there may also be specific situations where these rules should be purposefully ignored. This article should be considered as simply a guide for asking questions of your adviser, rather than a road map for do-it-yourself action.
Congratulations Amos and thanks for bringing the article to our attention!
Thursday, July 21, 2016
The National Academy of Medicine (NAM) held a meeting in late May, 2016 to update progress since the release of the major report on Dying in America. NAM "hosted “Assessing Progress in End-of-Life and Serious Illness Care,” a private working meeting for stakeholders to assess progress since the September 2014 release of Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." The meeting recap is available here. The recap includes transcripts of remarks and discussions as well as slides if used by presenters. The focus of the day was on 5 topics that included "(1) delivery of person-centered, family-oriented care; (2) clinician-patient communication and advance care planning; (3) professional education and engagement; (4) policies and payment systems; and (5) public education and engagement." After breakout sessions,"participants generated 3-5 top priority action items in each area .... [which] will inform the strategic planning of a new Roundtable on Quality Care for People with Serious Illness at the National Academies of Sciences, Engineering, and Medicine (the Academies)."
Wednesday, July 20, 2016
I wanted to make sure you didn't miss these developments.
First, Colorado voters in November may see a ballot initiative on physician-aided dying. Proponents are collecting signatures according to an article in the Denver Post, Right-to-die initiative headed for Colorado’s November ballot. It's not a slam-dunk however. The article notes that there is opposition to the proponents efforts to place the initiative on the ballot. Proposed legislation failed previously. Stay tuned.
Second, in case you missed it, on June 30, 2016, the New Mexico Supreme Court issued its ruling in Morris v. Brandenburg, a physician-aided dying case that has been making its way through the appeals process. The court held "we decline to hold that there is an absolute and fundamental constitutional right to a physician’s aid in dying and conclude that Section 30-2-4 is not unconstitutional on its face or as applied to Petitioners in this case." The court relied heavily on the U.S. Supreme Court opinion in Washington v. Glucksberg and found no specific reasons under the NM Constitution to depart from that precedent since physician-aided dying is not a fundamental right. Here's an excerpt from the opinion:
New Mexico, like the rest of the nation, has historically sought to deter suicides and to punish those who assist with suicide, with limited exceptions in the HCDA and the Pain Relief Act. However, these exceptions occurred as a result of debates in the legislative and executive branches of government, and only because of carefully drafted definitions and safeguards, which incidentally are consistent with the safeguards urged by Petitioners. Numerous examples of such definitions and safeguards exist in the UHCDA. In addition to those previously identified in paragraph 35 of this opinion, the following reflect other safeguards relevant to our analysis... These and other provisions of the UHCDA further many of the government interests recognized by the Glucksberg Court as unquestionably legitimate, and which made Washington’s ban on physician aid in dying reasonably related to their promotion and protection…Indeed, if such exceptions and carve-outs to the historical national public policy of deterring suicide properly exist, they are certainly borne of the legislature and not the judiciary.
A summary of the opinion appeared in the July 13, 2016 eBulletin (full disclosure-I'm one of the editors).
Tuesday, July 19, 2016
Registration is now open for Stetson's 18th annual National Conference on Special Needs Planning and Special Needs Trusts (full disclosure-I'm the conference chair). The program is scheduled for October 18-20. October 18th has 2 pre-conferences, one on tax issues and one on pooled SNTs. The National Conference starts on October 19th with general sessions on both mornings and break-out sessions in the afternoons. Afternoon sessions offer 3 tracks: basics, administration and advanced. For more information, click here. Registration information is here.
Monday, July 18, 2016
We were all saddened at the news of Coach Pat Summit's death from early-onset Alzheimer's at the age of 64. I found this article in the Washington Post so moving that I wanted to share it with you. You should read it and encourage your students to read it as well. Pat Summitt’s last great gift was sharing her fight with Alzheimer’s is more than just a tribute to Coach Summitt. It's also a call-out on how we treat people with cognitive decline and how we need to improve our actions. Here's an excerpt from the article:
Pat was just one of four people I know with dementia, and from what I’ve seen, across the board, Alzheimer’s care is a national scandal in our midst, yet few are willing to address it, because it’s just too distressing.
When a friend or family member is diagnosed, this is what you quickly learn: Once-brilliant people who still have vast reserves of brain cells are discounted, forced into retirement, and many are warehoused in facilities where the food is patently awful and the most meaningful activity is bingo. And we wonder why they decline so swiftly. Their care is infantilizing and schedule-oriented, with full-grown adults fed at 6 and forced to bed at 8, and when they can’t communicate as they used to we lack the imagination to try to find other ways to reach them, so their pain or discomfort often goes unaddressed, leading to interactions that, as Stettinius says, “exhaust, frustrate, and deplete everyone involved.” Creative new forms of care that can enhance quality of life — art, poetry, music and animal therapies for Alzheimer’s patients — are the rare exception. Ignorance about the disease is the rule. We give lip service to preserving dignity but devote precious little thought to the fact that the quickest way to rob someone of that dignity is to tell them what time to go to bed.
Use this in class for a discussion on how to support an individual's autonomy and how we can do better for people with Alzheimer's.
Sunday, July 17, 2016
Do alarms lead nurses in SNFs to interact less with residents? Do the alarms help prevent falls? According to a New York Times article from July 2, 2016, there is a movement away from "things" to help with falls and toward an emphasis on human care. Nursing Homes Phasing Out Alarms to Reduce Falls explains there is "a nationwide movement to phase out personal alarms and other long-used fall prevention measures in favor of more proactive, attentive care. Without alarms, nurses have to better learn residents' routines and accommodate their needs before they try to stand up and do it themselves." Over time prevention moved from restraints to alarms, floor mats, etc. and now prevention is moving from those to personal attention. This change is based on " a growing body of evidence indicates alarms and other measures, such as fall mats and lowered beds, do little to prevent falls and can instead contribute to falls by startling residents, creating an uneven floor surface and instilling complacency in staff."
According to the article there are those who are still using alarms and it will take some time for the change to be more widespread. As one expert noted in the article, using an alarm doesn't prevent a fall. "Going alarm-free isn't yet possible for every nursing home, but it's generally becoming a best practice as nursing facilities work to create the most home-like setting for people who live there, according to John Sauer, executive director of LeadingAge Wisconsin, a network of nonprofit long-term care organizations." As one expert noted in the article, using an alarm doesn't prevent a fall.
It seems that more personal care will be a great thing-but will the facilities have enough staff to help residents? We'll have to wait and see...
Thursday, July 14, 2016
My local paper ran a story recently about a vulnerable adult who was neglected to death. 66-year-old Gulfport woman dead after police say she was neglected by caretakers reports that "[t]he caretakers told police they moved out of the apartment eight to 10 days before the woman's death. That left her alone, police said, with little ability to care for herself." A follow up story, Gulfport police: 66-year-old woman left to die in squalor and heat, reports that the caregivers went back daily to check on her, saw her getting worse, but took no action to help her. Both caregivers were jailed and "facing a felony charge of abuse or neglect of an aged or disabled person."
Wednesday, July 13, 2016
Good news for consumers! The Federal Trade Commission (FTC) announced on June 27, 2016 that the telemarketing sales rule (TSR) prohibitions went into effect in June.
The changes to the TSR will stop telemarketers from dipping directly into consumers’ bank accounts through checks and payment orders that have been remotely created by the telemarketer or seller. Since they’re remotely created, they’re never actually signed by the account holder – and that makes it easy for telemarketers and sellers to dip directly into consumers’ bank accounts. And it’s then hard to reverse the transactions with consumers’ banks (again, a reason why con artists love using these methods).
In addition, with the updated rule in place, telemarketers now can’t get payments through traditional cash-to-cash money transfers – the type provided by companies like MoneyGram and Western Union. Scammers use these cash transfers as a quick, anonymous, and irrevocable way to get money from consumers. Once the seller picks up the transfer, the money is gone.
The TSR changes also prohibit telemarketers from accepting as payment cash reload PIN numbers. That means no requests for payment by using MoneyPak, Vanilla Reload, or Reloadit packs, used to add funds to existing prepaid cards. Because scammers use the cash reload PIN numbers to apply the funds to their own prepaid debit cards – and disappear with the money. Except not anymore, under the updated TSR.
Good news all around for consumers! More information for businesses about complying with the TSR is available here. Thanks to blog reader Mike Polk for alerting me to this update!
Tuesday, July 12, 2016
Stetson Law (full disclosure-my school) offers a new webinar on Tuesday July 19 at noon edt. This first Hot Topics in Elder Law webinar covers the subject of nursing home resident discharge. The Right or Wrong Way? Involuntary Discharge of Nursing Home Residents is a 90 minute webinar. Here is a description about the webinar
A recent AP story suggested that "Nursing homes are increasingly evicting their most challenging residents." Nursing home owners assert that the homes are following the discharge rules and more importantly protecting vulnerable adults from violent residents. This interactive debate will feature advocates from both sides of the issue.
Moderated by Professor Roberta K. Flowers, the debate will feature Eric Carlson, directing attorney of Justice in Aging in Los Angeles, California, and Sheila Nicholson, who specializes in nursing home defense and is a partner at Quintairos, Prieto, Wood & Boyer P.A., in Tampa, Florida.
Registration information is available here.
Monday, July 11, 2016
JAMA Internal Medicine ran an article about a study concerning quality of care in end of life, looking specifically at the illnesses. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses was published on June 26, 2016. According to the abstract, "[e]fforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses." The authors wanted "[t]o compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses." The study offers several findings, including:
In a large national cohort of nearly all patients dying in VA inpatient facilities, we observed important differences in the end-of-life care received by individuals with different illnesses. Overall, we found that diagnosis was significantly associated with the quality of end-of-life care as measured both by family surveys and by several established measures of quality of end-of-life care. Patients with end-organ failure and frailty generally received lower-quality end-of-life care than did patients with cancer or dementia. (citations omitted).
After discussing their findings, the authors conclude
While there is room for improvement in end-of-life care across all diagnoses, family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty. This quality advantage was mediated by palliative care consultation, do-not-resuscitate orders, and setting of death. Increasing access to palliative care and increasing the rates of goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the quality of end-of-life care for Americans dying with these conditions.
The article is free and is available here.
Sunday, July 10, 2016
In early June, the Urban Institute released a brief that examines whether Catastrophic Insurance Improve Financing for Long-Term Services and Supports. The abstract explains
A catastrophic insurance program could improve the way long-term services and supports are financed. The program would require enrollees who need care to wait a few years before they could collect benefits, but then it would provide those benefits as long as necessary. Our modeling results show that such a program could reduce Medicaid spending and provide financial relief to hard-pressed states. It could also reduce out-of-pocket spending for families facing catastrophic costs and fund new services and supports. By setting aside funds to cover future spending, a catastrophic insurance program could also raise national saving.
As we well know, paying for long-term care is a challenge for many. As the authors note, "[c]urrently, most people with LTSS needs rely mostly on unpaid family caregivers for assistance. If they need more help, they generally pay out of pocket until they exhaust their financial resources and then turn to Medicaid. New financing approaches could combine public insurance for catastrophic LTSS costs with initiatives to promote private long-term care coverage for other expenses. Our projections suggest that these options could significantly reduce Medicaid spending and provide better financial protection for older people who develop LTSS needs."
Looking at the ways long-term care is financed by many, the authors consider whether an insurance model might be the answer
New LTSS insurance programs could provide better financial protection to people with disabilities; improve the care they receive; and reduce Medicaid costs, which are creating financial problems for many state governments. By setting aside funds today to cover future LTSS spending, new insurance programs could raise national saving. And they could provide families with stronger incentives to save by reducing reliance on Medicaid, which discourages saving because it only pays benefits to people with virtually no wealth outside of their home. The effectiveness of any new insurance program, of course, depends on its particular features, such as eligibility requirements, the size of the daily benefit, and the financing mechanism.
The authors examine a few models to gauge their workability and conclude
An LTSS catastrophic insurance program that requires enrollees with LTSS needs to wait a few years before collecting benefits but then extends those benefits as long as necessary could substantially improve the way LTSS needs are financed in the United States. Such a program could reduce Medicaid spending, providing financial relief to hard-pressed states. It would also reduce out-of-pocket spending for families facing catastrophic costs and fund new services for older adults with LTSS needs, although these impacts would be somewhat smaller than those from a similar-sized program that provided front-end, but time-limited, benefits. By setting aside funds today to cover future LTSS spending, a new catastrophic insurance program could raise national saving. And it could provide families with stronger incentives to save by reducing reliance on Medicaid, which discourages saving because it only pays benefits to people with virtually no wealth outside of their home.
Program details need further analysis. We modeled only a few options, and alternative designs could have different effects. For example, a new insurance program could provide larger daily benefits, which would reduce Medicaid and out-of-pocket spending more than the plan we modeled but would also require more funding. Or new programs could require enrollees to wait even longer to receive benefits than the program we modeled, which would offset less Medicaid and out-of-pocket spending but cost less. Our research is only the first step in the analysis required to design new LTSS financing programs, but it illustrates the potential power of our simulation tool in demonstrating how new options can interact with existing programs.