Tuesday, October 6, 2015

Gov. Brown Reflecting on "What I Would Want In The Face Of My Own Death"

California Governor Jerry Brown signed the California legislature's "right to die" act on Monday, October 5.  From coverage in the San Diego Union-Tribune:

Gov. Jerry Brown, a lifelong Catholic and former Jesuit seminarian, said he consulted a Catholic bishop, two of his own doctors and friends "who take varied, contradictory and nuanced positions."


"In the end, I was left to reflect on what I would want in the face of my own death," wrote the Democratic governor, who has been treated for prostate cancer and melanoma. "I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill."


Brown's signature on the right-to-die legislation Monday capped an intensely personal debate that dominated much of this year's legislative session and divided lawmakers. Many lawmakers also drew on personal experience to explain their decisions to support or reject legislation making California the fifth state to allow terminally ill patients to use doctor-prescribed drugs to end their lives.

California joins Oregon, Washington, Vermont and Montana in permitting certain assistance in decisions to end one's life

October 6, 2015 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, State Statutes/Regulations | Permalink | Comments (0)

"Over the Hill" as an Evolving History Lesson

We have mentioned Hendrik Hartog's book, Someday All This Will Be Yours: A History of Inheritance and Old Age, (Harvard Press 2012) on this Blog as we did on this post outlining a recent symposium law review with articles inspired by the book.  I've been remiss, however, in not recommending the book directly. 

So let me correct that oversight now.  If you haven't read Princeton Professor Hartog's book, or if (as was true for me for too long) you have allowed the book to sit on your "to read" stack, it's time to get to it.  The book is a treasure of analysis, commentary, legal history, critique and provocation arising from the simple proposition that in many relationships, someone often utters (or thinks they have heard) words to the effect, "when I'm gone, someday, all this will be yours."  The underlying legal question is what happens when no document (such as a will, a trust, or a contract) puts that pledge into writing.

I find much to talk about when reading Hartog's words.  One curious item he describes is a poem, "Over the Hill to the Poor House," published by Will Carleton in 1872.  Hartog explains that the poem is the source for the now common saying "over the hill" to refer to persons of a certain age.  But Hartog points out that the poem's poignancy comes from its all-too-true narrative by one woman about what it can be like to grow old, frail and widowed, even if you have a large family of loving children.

From the closing lines of the poem:

An’ then I went to Thomas, the oldest son I’ve got,
For Thomas’s buildings’d cover the half of an acre lot;
But all the child’rn was on me—I couldn’t stand their sauce—
And Thomas said I needn’t think I was comin’ there to boss.

An’ then I wrote to Rebecca, my girl who lives out West,
And to Isaac, not far from her—some twenty miles at best;
And one of’em said’twas too warm there for any one so old,
And t’other had an opinion the climate was too cold.

So they have shirked and slighted me,an' shifted me about-
So they have well-nigh soured me,an' wore my old heart out;
But still I've borne up pretty well, an' wasn't much put down,
Till Charley went to the poor-master, an' put me on the town.

Over the hill to the poor-house--my chil'rn dear, good-by!
Many a night I've watched you when only God was nigh;
And God 'll judge between us; but I will al'ays pray
That you shall never suffer the half I do to-day.

And for a colorful "sung" version of the poem, with a change in gender for point-of-view, go to Lester Flatt and Earl Scrugg's version of Over the Hills to the Poorhouse

Over 140 years later, we still hear the phrase "over the hill" in less-than-kind contexts, but one hopes the prospects for care and assistance are not quite as grim as described in these verses. 

October 6, 2015 in Books, Estates and Trusts, Ethical Issues, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Monday, October 5, 2015

Webinar on October 6: The "A to Zahner" on Medicaid Annuities

Sorry for the short notice, but on Tuesday, October 6, 2015 from noon to 1 p.m. (Eastern time), the Pennsylvania Bar Institute is hosting a very timely (and cleverly titled) webinar, focusing on the impact of the Third Circuit's recent decision in Zahner on Medicaid planning generally and specifically on the sue of annuities. 

Here is a link to PBI's details on "The A to Zahner on Medicaid Annuities," including how to register.

October 5, 2015 in Current Affairs, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Medicaid, Property Management, Webinars | Permalink

New Illinois Law on "Presumptively Void" Bequests to Non-Family Caregivers Has "Starring" Role

Illinois adopted a new law, Public Act 098-1093, effective on January 1, 2015 that assigns a "presumptively void" status to bequests made to non-family caregivers, if the transfer would take effect upon the death of the cared-for person.  The law applies only to post-effective date bequests that are greater than $20,000 in fair market value.  The statutory presumption can be "overcome if the transferee proves to the court" either:

1. by a preponderance of the evidence that the transferee's share under the transfer instrument is not greater than the share the transferee was entitled to receive under ... a transfer instrument in effect prior to the transferee becoming a caregiver, or


2. by clear and convincing evidence the transfer was not the product of  fraud, duress or undue influence.

The law only applies in civil actions where the transfer is challenged by other beneficiaries or heirs. 

(Fun) Spoiler Alert:  The new law plays a clever "starring role" in the Fall 2015 season premiere of  The Good Wife.  Let's see how many of our law students were watching!

October 5, 2015 in Current Affairs, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Film, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Friday, October 2, 2015

Planning Well For The End of Life (as a Foundation)

I've long been fascinated by the history of Atlantic Philanthropies (AP), starting when I first became aware of the behind-the-scenes role of the founder, Chuck Feeney, in funding extraordinary educational endeavors in Ireland, and, as I soon learned, also funding important social and health advocacy movements around the world.  The end of AP as a multi-million dollar grant-making foundation is near at hand, although not the end of its impact.

Linked here is the latest report from the CEO of AP, Christopher Oechsli, with linked reports on AP's final grants, including its support for a groundbreaking National Dementia Strategy in Ireland.

October 2, 2015 in Current Affairs, Dementia/Alzheimer’s, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, International, Retirement | Permalink | Comments (0)

Thursday, October 1, 2015

Michigan Supreme Court Invites Amicus Briefs From Elder Law & Disability Law Organizations

The Michigan Supreme Court recently invited amicus briefing by Elder Law attorneys and Disability Rights attorneys, in advance of oral argument in an interesting case involving a nursing home resident's claims of false imprisonment by the facility. The legal question of what is sometimes referred to as an "involuntary" admission for care initiated by family members or concerned others acting as "agents" for an unhappy or uncooperative principal, is important and challenging, especially if accompanied by conflicting assessments of mental capacity.

Following the Michigan Court of Appeals' 2014 ruling in  Estate of Roush v. Laurels of Carson City LLC, in September 2015 the Michigan Supreme Court agreed to hear arguments on whether there are genuine issues of material fact on the resident's claim of falsely imprisonment for a period of approximately two weeks.  Ms. Roush alleges the nursing home acted improperly in reliance on her "patient advocate," claiming that she was fully able to make health care decisions for herself, and therefore there were no legally valid grounds for her advocate to trump her wishes. Alternatively, Ms. Roush argued she validly terminated the patient advocate's authority.

In Michigan, individuals may appoint a statutorily-designated "patient advocate," with limited authority as an agent for certain health care decisions.  Michigan law provides at M.C.L.A. Section 700.5506 that: "The [written] patient advocate designation must include a statement that the authority conferred under this section is exercisable only when the patient is unable to participate in medical or mental health treatment decisions...."

The Supreme Court's order identified specific issues for additional briefing by the parties. Further, the court expressly invited the "Elder Law and Disability Rights Section of the State Bar of Michigan. . . to file a brief amicus curiae. Other persons or groups interested in determination of the issues presented in this case may move the Court for permission to file briefs amicus curiae."

October 1, 2015 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Housing, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, September 30, 2015

Do Tontines Have a Valid Role in Modern Retirement Planning?

Jeff Guo, writing for the Washington Postrecently offered a provocative look at "tontines" as a theoretical retirement planning alternative to "annuities." Apparently these are advocated by some modern legal and financial experts:

Economists have long said that the rational thing to do is to buy an annuity. At retirement age, you could pay an insurance company $100,000 in return for some $5,000-6,000 a year in guaranteed payments until you die. But most people don’t do that. For decades, economists have been trying to figure out why....


But there’s also some evidence that people just irrationally dislike annuities. As behavioral economist Richard Thaler wrote in the New York Times: “Rather than viewing an annuity as providing insurance in the event that one lives past 85 or 90, most people seem to consider buying an annuity as a gamble, in which one has to live a certain number of years just to break even.”


Here is where tontines come in.  If people irrationally fear annuities because them seem like a gamble on one's own life, history suggests that they irrationally loved tontines because they see tontines as a gamble on other people's lives.


A simple modern tontine might look like this:  At retirement, you and a bunch of other people each chip in $20,000 to buy a ton of mutual funds or stocks or whatever.  Every year, the group withdraws a predetermined amount and divides it among the remaining survivors.  You might get a bonus one year, for instance, because Frank and Denise died....

 Want to know more?  Read It's Sleazy, It's Totally Illegal, and Yet It Could Become The Future of Retirement.  Hat tip to David Pearson for sharing this story. 

September 30, 2015 in Consumer Information, Crimes, Estates and Trusts, Ethical Issues, Federal Statutes/Regulations, Retirement, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, September 29, 2015

Does LegalZoom Compete with Law Firms? Co-Founder Brian Liu Says "No"

Over the weekend I caught an interview with Brian Liu, co-founder of LegalZoom, broadcast on From Scratch, a radio show about "entrepreneurial life."  The host, Jessica Harris, who has an interesting business background of her own, is a very good interviewer, encouraging guests to explore strengths and weaknesses of their ideas, moving from first inspiration to current goals.  She also asks "work/life balance" questions, often getting candid admissions of the private struggles some have to achieve balance.

I was intrigued with Liu's central premise, that his company does not compete, at least not directly, with law firms for business.  Rather, he believes that the vast majority of clients are drawn to his company precisely because they would never go to a lawyer, whether because of cost, unease about attorneys, or perceptions about value. 

It was also interesting to hear that Legal Zoom's first ten clients, accessing the company's on-line document portal on a Friday night, were seeking "living wills."  That fact tells us a lot about underserved legal and health care needs, doesn't it.  

September 29, 2015 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Legal Practice/Practice Management, Web/Tech | Permalink | Comments (0)

Monday, September 28, 2015

Student Writing Competition on Disability Law: Entries Due by January 15, 2016

Thomas Jefferson School of Law is hosting its second annual student writing competition focusing on disability law.  The Crane Writing Competition, named in honor of a Thomas Jefferson alum, Jameson Crane III, seeks to encourage student scholarship at the intersection of law and medicine, or law and social services.  A central purpose is to further development of legal rights and protections, and improve the lives of those with disabilities.

Who can enter?  The competition is open to currently enrolled law students, medical students and doctoral candidates in related fields, who attend an accredited graduate program of study in the U.S. 

Deadline for entries?  January 15, 2016 (by midnight, Pacific Standard Time) via electronic submission.  For details see the competition website at Thomas Jefferson School of Law: http://www.tjsl.edu/cranewritingcompetition

What will be your topic? The competition accepts papers on a wide range of topics related to disability law, including legal issues arising from employment, government services and programs, public accommodations, education, higher education, housing and health care.  This should integrate well with students currently taking or who have recently completed a seminar course, thus allowing that all important "double value" for good papers.

Prizes include cash ($1,500 to first place; $1,000 for each of two second place winners), plus potential publication.

My thanks to Professor Susan Bisom-Rapp for sharing news of this year's competition.  She is coordinating the competition and you can send questions directly to Susan. 

September 28, 2015 in Cognitive Impairment, Dementia/Alzheimer’s, Discrimination, Ethical Issues, Grant Deadlines/Awards, Health Care/Long Term Care, Housing, Science | Permalink | Comments (0)

Thursday, September 24, 2015

Family Caregivers Show Support for Pennsylvania State Assistance at State Capitol

If you have worked in Elder Law long enough, you have probably received a panicked call from a family caregiver who is unprepared for a loved one to be discharged on short notice from hospital care.

2015-capitol-caregiving-event-tamesha-keelOn September 22, the Pennsylvania Capitol in Harrisburg was crowded with individuals wearing coordinated colors, showing their support for Pennsylvania Caregivers, including family members who are often struggling with financial and practical challenges in caring for frail elders. Here's a link to a CBS-21-TV news report, with eloquent remarks from Tamesha Keel (also pictured left), who has first-hand experience as a stay-at-home caregiver for her own aging mother.  Tamesha recently joined our law school as Director of Career Services.

AARP helped to rally support for House Bill 1329, the Pennsylvania CARE Act.  The acronym, coined as part of a national campaign by AARP to assist family caregivers, stands for Caregiver Advise, Record and Enable Act.  HB 1329  passed the Pennsylvania House in July 2015 and is now pending in the Pennsylvania Senate.

We have written on this Blog before about pending CARE legislation in other states.  A central AARP-supported goal is to achieve better coordination of aftercare, starting with identification of patient-chosen caregivers who should receive notice in advance of any discharge of the patient from the hospital.  Pennsylvania's version of the CARE Act would require hospitals to give both notice and training, either in person or by video, to such caregivers about how to provide appropriate post-discharge care in the home. 

I'd actually like to see a bit more in Pennsylvania. It is unfortunate that the Pennsylvania CARE Act, at least in its current iteration (Printer's Number 1883), does not go further by requiring written notice, delivered at least a minimum number of hours in advance of the actual discharge. AARP's own model act suggests a minimum of 4 hours, consistent with Medicare rules.

Under Federal Law, Medicare-participating hospitals must deliver advance written notice of a discharge plan, and such notice must explain the patient's rights to appeal an inadequate plan or premature discharge. A timely appeal puts a temporary hold on the discharge. See the Center for Medicare Advocacy's (CMA) summary of key provisions of Medicare law on hospital discharges, applicable even if a patient at the Medicare-certified hospital isn't a Medicare-patient. CMA's outline also suggests some weaknesses of the Medicare notice requirement.

AARP's original CARE Act proposals are important and evidence-based, seeking to improve the patient's prospects for post-hospitalization care through better advance planning. At the same time, there's some irony for me in reading the Pennsylvania legislature's required "fiscal impact" report on HR 1329, as it reports a "0" dollar impact.  That may be true from the Pennsylvania government's cost perspective, but for the hospitals, to do it right, whether in person or by video, training is unlikely to be revenue neutral.  I think we need to talk openly about the costs of providing effective education or training to home caregivers.

If passed by the Senate, Pennsylvania's CARE Act would be not become effective for another 12 months.  The bill further provides for evaluation of the effectiveness of the rules on patient outcomes.   

As is so often true, states are constantly juggling the need for reforms to solve identified problems, with the costs of such reforms.  Perhaps the current version of the Pennsylvania bill reflects some compromises among stakeholders. According to this press statement, the Hospital and Health System Association of Pennsylvania supports the current version of AARP's Pennsylvania CARE Act.

September 24, 2015 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations | Permalink | Comments (0)

Monday, September 21, 2015

Wise Words on Cuba, Health Care & Aging

During the last few days, I've been part of a series of conversations (including this podcast from WITF-FM's Smart Talk) about Cuba, with topics magnified by the awareness of Pope Francis visiting in Havana.  I was often asked why I am interested in Cuba, and one person asked if I was "moving away" from a focus on aging.  Actually, my research interests in aging have drawn me to research in Cuba.  Old and Renewed in Cuba 2015

Statistical information on mortality and positive health outcomes in Cuba rival that of so-called "first world" nations. For example, according to World Health Organization reports (WHO 2013), Cuban life expectancy at birth is 77 years for men and 80 years for women. For comparison, WHO reports USA life expectancy at 76 for males and 81 for women.  Costs of health care are quite startling, as Cuba reports $1,828 per capita spending, while the USA reports per capita spending as $9,146.  Of course, one must dig deeper, to look at health care costs as percentages of GDP and other factors, including quality of life in later years.

During an especially vibrant meeting with a group of interested-in-Cuba academics from around central Pennsylvania, I learned from a colleague at Dickinson College in Carlisle, Professor Susan Rose, about a fascinating book tracing the Cuban model for health care to Che Guevara.  It is easy for Americans to focus only on Che as a folk hero (or, for some, anti-hero), remembered for his bearded image and rifle, side-by-side with Fidel and Raul Castro as they fought their way to Havana. Professor Rose recommended to me a 2011 book by her husband Steven Brouwer, Revolutionary Doctors: How Venezuela and Cuba Are Changing the World's Conception of Health Care.  From the book:

Che never lost sight of his original aspiration -- combining the humanitarian mission of medicine with the creation of a just society. When he addressed the Cuban militia on August 19, 1960, a year and a half after the triumph of the revolution, he chose to speak about "Revolutionary Medicine" and the possibility of educating a new kind of doctor....


Since then Cuban medicine and health services have been developed in a number of unique and revolutionary ways, but only now, nearly fifty years later, has Che's dream come to full fruition. Today it is literally true that compesinos, along with the children of impoverished working-class and indigenous communities, are becoming doctors and running, "with unreserved enthusiasm, to help their brothers."  

We had a keynote presentation at Penn State's Dickinson Law by a Penn State-Berks professor, Dr. Belen Rodriguez-Mourelo, who writes with great sensitivity in her book Encounters in Exile about the experience of the Cuban diaspora. (Her photo, demonstrating one of the many contrasts in imagery from Havana, is above.) Belen reminded us of the need for great care in our thinking about Cuba, to avoid treating renewed diplomatic relations as merely opening the doors to a new theme park.  Esas son palabras sabias - wise words.

September 21, 2015 in Current Affairs, Ethical Issues, Health Care/Long Term Care, International | Permalink | Comments (1)

Friday, September 18, 2015

Medicare Criminal Investigation? FBI Raids Home of CEO of Nursing Home Company

As we have frequently reported on this Blog (see e.g., here and here and here), the Obama Administration has been aggressive in pursuit of Medicare and Medicaid claims tied to unlawful reimbursement or kickback claims for companies involved in long-term care.  But even given that history, often tied to whistleblowing by current or former employees, it is unusual to see criminal investigations. Thus recent media reports about the FBI raiding the CEO of American Senior Communities was eye-catching, including this report from the Indianapolis Star:  

A cadre of federal agents raided the Carmel home of an executive of a chain of nursing homes Tuesday morning. But the most important question remains unanswered: Why?

The home is owned by James G. Burkhart, the CEO of American Senior Communities, according to Hamilton County property records. FBI investigators also were at the Southside headquarters of American Senior Communities, at 6900 Gray Road, according to reports.

American Senior Communities manages nearly 100 senior care facilities and is one of the largest nursing home management companies in Indiana. Among those are 60 sites, including skilled nursing facilities and assisted living facilities throughout the state, that the company manages under a contract with Marion County’s public health agency.

According to media reports, American Senior Communities (ASC) issued the following press statement following the raid:

"American Senior Communities’ most important priority is to continue to provide excellent care to our patients and residents. ASC has been contacted by the federal government in connection with an investigation into certain individuals or practices. ASC is fully cooperating with the government and is conducting its own review to ascertain the relevant facts. ASC is in compliance with all federal, state and local laws and regulations and will continue to conduct its business in accordance with the highest standards of integrity." 

Stay tuned...(but don't hold your breath).

September 18, 2015 in Ethical Issues, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Wednesday, September 16, 2015

Ward vs. Incapacitated Person? The Challenges of Labels in Modern Proceedings

Catching up on a bit of reading, I notice that the Uniform Laws Commission has a committee hard at work on drafting proposed revisions to the 1997 Uniform Guardianship and Protective Proceedings Act  (UGPPA).  University of Missouri Law Professor David English is Chair of that committee,  with many good people (and friends) on the working group.

In reviewing their April 2015 Committee Meeting Summary, available here, I was interested to see the following note under the discussion heading about "person-first language:"

Participants engaged in a lively discussion of the desirability of person-first language, and possible person-first terminology.  There was general agreement that the revision should attempt to incorporate person-first language.  For the next meeting, the Reporter [University of Syracuse Law Professor Nina Kohn] will attempt a draft that uses language other than "ward" or "incapacitated" to the extent possible and utilizes person-first language instead (precise wording still to be determined).  The Reporter will also attempt to use a single term that can describe both persons subject to guardianship and those subject to conservatorship.

I've struggled with "labels" in writing and speaking about older adults generally, and incapacitated persons specifically.  It will be interesting to see what the ULC committee recommends on this and even more daunting tasks, including how to better facilitate and promote "person-centered decision-making" and limited guardianships.

September 16, 2015 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Property Management, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, September 15, 2015

Florida to Consider Establishment of "Office of Public and Professional Guardians"

As we have tracked recently on this Blog, in a number of states, including Florida and Nevada, serious questions have been raised about the roles of guardians for disabled and elderly persons, and the extent to which there should be public oversight of guardians, especially "paid" guardians, including public guardians, "professional" guardians or "private" guardians. 

In Florida, newly proposed legislation, Senate Bill 232 (filed in September 2015) would seek to clarify state oversight of all guardians, following on the heels of amendments to Florida state law enacted in mid-2015.  Florida's legislature may take up the latest bill early in 2016, according to media reports.  Key provisions in the bill include:

  • renaming of the current office of "public guardianships," with expanded duties and responsibilities, to create the "Office of and Professional Guardians;"
  • addition of findings about the potential need for a "public guardian" where there is "no willing and responsible family member or friend, other person, bank, or corporation available to serve;"
  • a requirement that "professional" guardians "shall" register with the state;
  • directions to establish a comprehensive system for receipt and state action on complaints made about professional guardians.

From reading SB 232, it seems to me there may be some attempt to appease the concerns about the potential for overregulation of so-called "professional" guardians, as new language in Section 744.2001  requires development and implementation of a new "monitoring tool to ensure compliance of professional guardians with standards" set by the Office, but this "monitoring tool may not include a financial audit " as specified in another section of the law (emphasis added).

Funding will be needed to make expanded oversight effective.

The Sarasota Herald-Tribune has reacted favorably to the latest proposal


September 15, 2015 in Consumer Information, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Property Management, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Monday, September 14, 2015

Commenting on Proposed Medicaid Regs? Comment Period Expanded to October 14

As we have reported earlier on this Blog, CMS is seeking comments on proposed Medicaid rules affecting nursing facilities, including proposals that could affect the use of pre-dispute "arbitration" agreements. Justice in Aging provided the helpful update that the comment period has been extended to October 14, 2015.  In addition, Justice in Aging has provided a link to model or sample comments to use clarify consumer concerns.  

Here is a link to the CMS extension notice.  Here is a link to important information about commenting on key aspects of the proposals, prepared by The National Consumer Voice for Quality Long-Term Care.    

September 14, 2015 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Friday, September 11, 2015

What is the Legal Significance of "Scores" in Mental Status Exams?

In a recent decision in a complicated and long-running guardianship case, an appellate court in Illinois highlights a topic I'm seeing more and more often: How should courts "value" scores given by evaluators on mental status exams, especially when addressing guardianship issues? 

The most recent opinion in Estate of Koenen, issued August 31, 2015, described testimony from multiple witnesses about the mental status of a man in a "plenary guardianship" proceeding.   In two reports, from physicians chosen by the individual, the medical experts opined he was "capable of making his own personal and financial decisions." Another witness, a psychiatrist, was appointed by the court to evaluate the individual's "ability to make personal and financial decisions."  Ultimately, the lower court concluded the individual was unable to manage his affairs.

On appeal, a central issue was the lower court's reliance on the court-appointed expert.  Part of the psychiatrist's testimony was that the man "scored 26 out of 30, at the low end of the normal range" on the Montreal Cognitive Assessment (MOCA)" administered in January 2012, a test that was described by the court as a "twelve-minute test with standardized questions, as well as writing and 'copying' tests."  The psychiatrist also testified that in January 2013 he tested the man again with a score on the MOCA that was "now 22 out of 30 which was 'fully consistent with dementia.'" 

Ultimately, the appellate court affirmed the lower court's decision, noting the extensive use of interviews and other data collection by the court-appointed physician to support the findings of incapacity.  The appellate court seemed interested however, in the actual number scores, taking note that the court-appointed expert discounted scores reported by the individual's preferred physicians on "Folstein or 'mini-mental' examination[s]" on the grounds that the MOCA test was more sensitive "for dementia." 

Reading this challenging case is a reminder of the ABA-APA Handbooks, for attorneys, psychologists, and judges, on assessing capacity of older adults.  The Handbook for Judges describes a host of cognitive and neuropsychological testing tools, although it appears neither the MOCA test or the Folstein test is described.  Is "standardization" of testing for purposes of legal capacity decisions needed? 

September 11, 2015 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Science, State Cases, State Statutes/Regulations | Permalink | Comments (5)

Thursday, September 10, 2015

New York Ethics Opinion Addresses Potential Conflicts in Elder Law Practice

A New York ethics opinion issued July 27, 2015 is a useful reminder of the possibility -- indeed probability -- that law firms well known for specializing in elder law or estate planning may be approached by successive generations of family members, thus creating potential issues of confidentiality (and more). 

In the matter under consideration, involving a small law firm that practiced "primarily in the fields of estate planning and administration, trusts  and elder law," two of the lawyers had a long relationship with a "father," including representation of the father in a contested adult guardianship case. 

Later, a different lawyer in the firm met with a "son" of the father to discuss personal estate planning following a "public seminar" hosted by the firm.  That lawyer did not conduct a "conflict check" before a first meeting, one on-one, with the son.  (One can see how a law firm might be tempted to skip or delay a step in conflict-checking when organizing these kinds of business-generating efforts, a potential not directly addressed in the New York opinion. Would disclaimers or warnings about "client relationships" not forming immediately remedy potential problems -- or perhaps make them even more complicated?)

The law firm, upon discovering the potential for concerns, made the decision not to go forward with representation of the son, and then asked the New York State Bar Association's Committee on Professional Ethics for guidance on whether rules either "required" or "permitted" the law firm to disclose to the father the son's request for representation, or whether the firm was prohibited from further representation of the father.

For the New York ethics committee's interesting analysis,  see New York Ethics Opinion 1067.  For a contrasting "multi-generational" representation problem involving a husband's undisclosed "heir," see A. v. B., decided by the New Jersey Supreme Court in 1999, a case that is a good springboard for discussion of professional responsibilities for attorneys in the course on Wills, Trust & Estates (as I discovered in the Dukeminer/Sitkoff textbook). 

September 10, 2015 in Books, Estates and Trusts, Ethical Issues, Legal Practice/Practice Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, September 9, 2015

Professor Matthew Andres' Civil Remedy for Financial Exploitation Enacted by Illinois Legislature

University of Illinois Matthew AndresWe recently learned of the important role played by Matthew Andres, Director of the Elder Financial Justice Clinic at the University of Illinois School of Law, in convincing the Illinois legislature of the need for a clear civil remedy for seniors and disabled persons who are victims of financial exploitation.  

Earlier this year, the Illinois legislature approved Public Act 99-0272, amending existing law that defined the crime of financial exploitation, to provide a specific civil remedy, one that would no longer be tied to (or require) a criminal prosecution. Effective on January 2, 2016, the new Illinois law provides:

Civil Liability. A civil cause of action exists for financial exploitation of an elderly person or a person with a disability as described in subsection (a) of this Section. A person against whom a civil judgment has been entered for financial exploitation of an elderly person or person with a disability shall be liable to  the victim or to the estate of the victim in damages of treble the amount of the value of the property obtained, plus reasonable attorney fees and court costs.

In a civil action under this subsection, the burden of proof that the defendant committed financial exploitation of an elderly person or a person with a disability as described in subsection (a) of this Section shall be by a preponderance of the evidence. This subsection shall be operative whether or not the defendant has been charged or convicted of the criminal offense as described in subsection (a) of this Section. This subsection (g) shall not limit or affect the right of any person to bring any cause of action or seek any remedy available under the common law, or other applicable law, arising out of the financial exploitation of an elderly person or a person with a disability. 

Professor Andres was the author of a white paper on the need for the changes to prior law, and the resulting bill was supported by AARP.  For more, see the news from the University of Illinois website hereGreat work, Matt!

September 9, 2015 in Consumer Information, Crimes, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, State Statutes/Regulations | Permalink | Comments (1)

Tuesday, September 8, 2015

Deadline 9/14/2015: Comments Due to CMS re "Binding Arbitration" in Nursing Home Admission Agreements

Erica Wood, a director for the ABA Commission on Law and Aging,  writing for the August 2015 issue of the ABA's Bifocal Journal, reminds us that the Centers for Medicare and Medicaid Services (CMS) is seeking comments on proposed changes to rules affecting Long-Term Care Facilities that participate in Medicare and Medicaid programs, including the issue of whether CMS should prohibit "binding" pre-dispute arbitration provisions in nursing home contracts.  The deadline for public comments is 5 p.m., on Monday, September 14, 2015.  Electronic comments, using the file code CMS-2360-P, can be submitted through this portal: http://www.regulations.gov

How do you feel about pre-dispute "agreements" binding consumers, including consumers of long-term care, to arbitration? Your comments to CMS can make a difference! 

I remember my first encounter with "binding" pre-dispute arbitration provisions in care facilities. In the early years of my law school's Elder Protection Clinic, a resident of a nursing home had purportedly "given away" possessions to an aide at nursing home, who promptly sold them on EBay.  The resident was lonely and the "friendship" included the aide taking her out the front door of the facility, via a wheel chair, on little outings, including trips where the resident could visit her beloved house, still full of a life-time of antiques and jewelry.  (The resident might have recovered enough to go home -- although eventually a second stroke intervened.)

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September 8, 2015 in Cognitive Impairment, Consumer Information, Current Affairs, Estates and Trusts, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Property Management | Permalink | Comments (0)

Thursday, September 3, 2015

Third Circuit Rules Medicaid Applicants' Short-Term Annuities Are Not "Resources" Preventing Eligibility

In a long awaited decision on two consolidated cases analyzing coverage for nursing home care, the Third Circuit ruled that "short-term annuities" purchased by the applicants cannot be treated by the state as "available resources" that would delay or prevent Medicaid eligibility.  The 2 to 1 decision by the court in Zahner v. Secretary Pennsylvania Department of Human Services was published September 2, 2015, reversing the decision (linked here) of the Western District of Pennsylvania in January 2014.

The opinion arises out of (1) an almost $85k annuity payable in equal monthly installments of $6,100 for 14 months, that would be used to pay Donna Claypoole's nursing home care "during the period of Medicaid ineligibility that resulted from her large gifts to family members"; and (2) a $53k annuity purchased by Connie Sanner, that would pay $4,499 per month for 12 months, again to cover an ineligibility period created by a large gift to her children. 

The Pennsylvania Department of Human Services (DHS) argued that the transactions were "shams" intended "only to shield resources from the calculation of Medicaid eligibility."  However, the majority of the Third Circuit analyzed the transactions under federal law's "four-part test for determining whether an annuity is included within the safe harbor and thus not counted as a resource," concluding:

Clearly, if Congress intended to limit the safe harbor to annuities lasing two or more years, it would have been the height of simplicity to say so.  We will not judicially amend Transmittal 64 by adding that requirement to the requirements Congress established for safe harbor treatment.  Therefore, Claypoole's and Sanner's 14-and 12-month contracts with ELCO are for a term of years as is required by Transmittal 64.

Further, on the issue of "actuarial soundness," the court ruled:

 [W]e conclude that any attempt to fashion a rule that would create some minimum ratio between duration of annuity and life expectancy would constitute an improper judicial amendment of the applicable statutes and regulations.  It would be an additional requirement to those that Congress has already prescribed and result in very practical difficulties that can best be addressed by policy choices made by elected representatives and their appointees.

The her short dissent, Judge Marjorie Rendell explained she would have affirmed the lower court's ruling in favor of DHS on the "grounds that the annuities ... were not purchased for an investment purpose, but, rather, were purchased in order to qualify for benefits."  In addition, she accepted DHS' argument the annuities were not actuarially sound.

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September 3, 2015 in Current Affairs, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, State Statutes/Regulations | Permalink | Comments (0)