Monday, December 14, 2015
Ok, that title was supposed to be somewhat tongue in cheek, but there is some reality to it as well. According to an article in the Wall Street Journal on December 8, 2015, The Fastest-Growing Group of Licensed Drivers: Americans Age 85 and Up, "[n]ew data from the Federal Highway Administration shows people age 60 and above represented almost 26% of all driver’s license holders in 2014, up from 20.6% in 2004. Those younger than 30, on the other hand, make up about 21% of drivers, down slightly from 22% in 2004." Discussing the trend that younger generations are moving away from driving, the article notes
[S]ince 2000, people of every age cohort under 60 have been slowly letting their driver’s licenses lapse or have not been getting them in the first place.
Those 60 and above, meanwhile, are now more likely than before to have a valid driver’s license in their wallet.
People age 85 and up represent the fastest-growing group of licensed drivers, the FHWA said.
The article explains this trend is slow moving and offers reasons for its occurrence, especially costs. The article concludes with a comment that this changing demographic is also changing the highways: "[t]o help older drivers navigate the roads, the agency said it is working on new laminates to make highway signs brighter from further away."
Information about the Federal Highway Administration report is available here. The Administration's Handbook for Designing Roadways for the Aging Population is available here. The 2014 Highway Statistics Report is available here.
Monday, December 7, 2015
Money Magazine's final article in the series on the costs of dementia focuses on the costs in the final stages of the disease. Coping With the Costs of Dementia: The Final Stage discusses the costs and the options for caring for an individual in the final stage of this disease.
In the final stages of dementia, which typically last four to five years, the need for care intensifies. [One's] spouse eventually will require around-the-clock assistance with most activities of daily living. [One's] toughest decision: whether to try to continue caregiving at home or move [one's] loved one to an assisted-living facility or a nursing home. [One] may feel guilty at the prospect of putting someone [one] love[s] in “a home”—that’s common and understandable—but a setting where professionals are providing the intense level of care needed at this point is often the best path, especially if they’re trained in the needs of dementia patients. That said, it’s also the most expensive care option by far.
The article urges caregivers to take proactive action, suggests caregivers pick a nursing home with a memory care unit, get advice on the order in which to spend assets and start planning for the caregiver's own future. "Caring for someone with dementia is emotionally exhausting and financially draining, but it comes with one particular satisfaction: knowing that you’ve done whatever you can to make the last years easier for someone you love."
Sunday, December 6, 2015
Money Magazine's second article on the costs of dementia focuses on the middle stage of dementia. Coping With the Costs of Dementia: The Middle Stage discusses a series of steps for the caregivers and family to take, not only for the present, but in positioning themselves for the final stage of the disease. The article discusses a number of suggestions:
- greater levels of care, including adult day care and respite care and recommends only hiring caregivers with experience in caring for individuals with dementia;
- examine the terms of any long term care insurance policy, if the individual has one;
- if the individual is a veteran, look into VA benefits;
- examine the individual's and family member's investment portfolio; rearranging allocations to more conservative investments may be needed;
- investigate a reverse mortgage;
- caregivers should talk to employers about options; and
- begin to research nursing homes.
December 6, 2015 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (0)
Thursday, December 3, 2015
Money Magazine ran a series on the costs of dealing with dementia. Separating dementia into three stages, early, middle, and late, the series breaks down the costs for each of the stages.
Coping With the Costs of Dementia: The Early Stage looks at both the personal costs as well as the financial costs of copying with the disease in the beginning.
The financial toll can be nearly as large as the personal loss. Over the last five years of life, the average out-of-pocket cost of care for dementia patients totaled $61,500—81% more than for people without dementia—according to a new study in the Annals of Internal Medicine. Nearly half of the dementia patients ended up on Medicaid, the government health care program for impoverished Americans, compared to about 20% of patients suffering from heart disease or cancer.
If you were asked what is the reason for the costs of dementia early on, would you say drugs or treatments? According to the article, if you did, you'd be wrong. "Driving the cost aren’t drugs or treatments, but the years of care necessary to get a person safely through life’s everyday activities. Medicare, the primary health insurance for people 65 and older, doesn’t cover that long-term nonmedical care."
The article discusses the differences between "normal" aging and early signs of Alzheimer's. As far as costs in the early stage of the disease, "which lasts an average of two years, [one's] out-of-pocket costs won’t be burdensome. But [one will] need to plan for more expensive care later on, and move quickly, since [one's] husband, wife, or parent has a limited window to participate in financial decisions and sign any necessary legal documents before cognitive abilities fade."
The article recommends a number of steps to take to prepare, including obtaining the needed documents, appointing agents, talking to a doctor, organizing finances and preparing for Medicaid. Check out the graphic of expenses in the last 5 years of life.
Wednesday, December 2, 2015
The GAO has released another report on Nursing Home Quality. Dated October, 2015, Nursing Home Quality: CMS Should Continue to Improve Data and Oversight is a 52 page report issued by the GAO that "examines (1) the extent to which reported nursing home quality has changed in recent years and the factors that may have affected any observed changes, and (2) how CMS oversight activities have changed in recent years."
The report notes some issues with the data collected as well as some efforts regarding oversight, and in the conclusion the GAO discusses the issues with the data and also
according to CMS officials, the agency faces the challenge of conducting effective oversight of nursing home quality with its limited resources, while meeting all of its oversight requirements. CMS has made modifications to some activities it considered essential to its oversight, without knowing whether the modifications have affected the agency’s ability to assess nursing home quality. Further, some modifications made by CMS regional offices and state survey agencies to their own nursing home oversight activities could adversely affect the CMS central office’s ability to oversee nursing home quality, while other modifications could be effective strategies that could be adopted more widely among regional offices and state survey agencies....
The GAO makes 3 recommendations:
- Establish specific timeframes, including milestones to track progress, for the development and implementation of a standardized survey methodology across all states.
- Establish and implement a clear plan for ongoing auditing to ensure reliability of data self-reported by nursing homes, including payroll-based staffing
- The Administrator of CMS should establish a process for monitoring modifications of essential oversight activities made at the CMS central office, CMS regional office, and state survey agency levels to better understand the effects on nursing home quality oversight.
Monday, November 30, 2015
I have a confession. I've been avoiding writing about Medicaid. It's so complicated it scares me. But, Medicaid can be really important to daughterhood because someday you might have to decide if it's right for your parent. So you have to get smart about it.
She explains the importance of the Medicaid program as a "safety net for when everything falls apart" and after a brief description, moves into a discussion of the 5 misconceptions:
- "Medicaid is a lot like Medicare...
- Medicaid is available to everyone...
- Medicaid Will Take Your Parents' Home...
- Medicaid is a national program that's the same for everyone...
- Medicaid only covers nursing homes...."
With each she offers explanations as to what Medicaid really covers and concludes her post noting
When is Medicaid right for your parent? It depends on so many individual and family circumstances. And, it depends on your state. There are no hard and fast rules. But, if you've been walking down this caregiving road for a long time and you are looking at nursing home care, Medicaid may be necessary to pay for the care. OR, if your parent's money is running out because of expensive care --- even if he or she isn't in a nursing home --- then it could be helpful, especially if there's a good community program in your parent's local area... [a]nd, figuring this program out for your family is not easy. Just remember that it's a crazy complicated hard situation. Not that you are failing.
Note, you can also access her post on her blog here.
Ever received a robocall? Of course you have. Even if you are on the do-not-call list, you still get robocalls. Want to do something about robocalls? Then read the following
Consumers Union issued a report, Dialing Back: How Phone Companies Can End Unwanted Robocalls. Here is an excerpt from the executive summary:
The Do Not Call list, federal law enforcement efforts, and actions by the states have not been enough to protect Americans from the flood of unwanted robocalls that have become rampant in recent years. Hundreds of thousands of people complain each month to the Federal Trade Commission (FTC) about unwanted calls, and it’s estimated consumers lose $350 million a year to phone scams. Thanks to rapid advances in Internet technology, robocallers can make thousands of auto-dialed calls per minute for a relatively low cost. Robocall scammers easily escape detection and punishment by operating overseas or using software to disguise—or spoof—their name and number. The problem is so bad that federal agencies and Congress have been exploring solutions to the unwanted robocall problem.
Technological solutions are necessary to address this problem. A number of leading experts agree that phone companies have the power right now to implement technologies to dramatically reduce robocalls.
Consumers Union surveyed a variety of experts and innovators and found there are at least four proposed and existing robocall filtering technologies that phone companies could pursue to help protect their customers from unwanted robocalls. One solution, the Primus Telemarketing Guard, has been successfully implemented for traditional and broadband phone lines in Canada, which calls into question why similar technologies have not been offered in the United States.
The executive summary reviews call-blocking technologies that phone companies may provide and then offers the following recommendations:
● Phone companies should immediately offer free robocall-filtering services to all of their customers based on latest available technology.
● Phone companies should immediately develop "Do Not Originate" techniques to reduce spoofing by fraudulent callers.
● Phone companies should continue to pursue call authentication strategies as a long-term solution to the spoofing problem
To read more about Consumers Union's efforts to fight robocalls, click here.
Sunday, November 22, 2015
Prior to the Bipartisan Budget Act of 2015 , all indications pointed to a pretty significant increase in the 2016 Part B premiums for Medicare. However, the increase was much less than expected in part because of the compromise in the Budget Bill. The Kaiser Family Foundation released a very helpful issue brief on November 11, 2015, explaining the developments and the impact on beneficiaries. What's in Store for Medicare's Part B Premiums and Deductible in 2016, and Why? explains the premium increase, the hold harmless provision and a $3 repayment surcharge to make up the deficit Part B will incur in 2016 because of the lower premium. ("includes a $3 repayment surcharge, which will be added to monthly premiums over time to cover the cost of the reduced premium rate in 2016.")
The brief explains the hold harmless provision, identifies the categories of beneficiaries who will have to pay the higher premiums (and why) and the amount of premiums paid by higher income beneficiaries. The brief also offers a projection for 2017 and concludes that but for Congressional intervention, "in the face of flat Social Security benefits and rising out-of-pocket costs, many people on Medicare could have greater difficulty affording their medical care costs in the coming year."
Thursday, November 19, 2015
CMS has released the 2016 amounts for deductibles, premiums, and co-pays for Medicare A and B. The Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts are available in the Federal Register here. (The inpatient deductible is $1,288 for 2016). The Part B amounts are available here. Remember because there is no COLA this year, the hold harmless provision keeps the Part B premium the same as last year for many Medicare Beneficiaries. For those not protected by the hold harmless provision, their Part B premiums will be $121.80+ $3. Don't forget that higher income beneficiaries will pay a higher premium, referred to as the income-related monthly adjustment. The higher premium amounts can be found here as well.
Wednesday, November 18, 2015
Living in a Sunbelt state, I know how hot it can get in the summer months. I recently ran across a July 2015 decision from HHS' Departmental Appeals Board (DAB) reviewing the imposition of a "per instance" monetary penalty CMS assessed against an Arizona SNF.
CMS’s allegations in this case are predicated on complaints that portions of Petitioner’s facility – including several residents’ rooms – were uncomfortably hot. Those allegations are supported by the complaints of several residents and by temperature readings taken by a surveyor on July 16, 2014. Readings taken by the surveyor showed portions of some of the residents’ rooms being as hot as 90 degrees Fahrenheit.... Such temperatures plainly exceed what any reasonable person would consider to be "comfortable." On their face they comprise violations of 42 C.F.R. § 483.15(h)(6).
After discussing the ways the surveyor and the SNF measured the temperatures inside the SNF, the ALJ in the opinion notes
The overwhelming evidence is that rooms at Petitioner’s facility were uncomfortably hot due to the failure of the facility’s air conditioning system. Arizona in July is a very hot place. Building interiors in that State that are not adequately air conditioned can become dangerously hot. As Petitioner admits, the air conditioning in its facility had failed to work adequately in July 2014. The failure prompted residents to complain that their rooms had become uncomfortably hot.... The staff took various measures to address the failure of the air conditioning system, including closing curtains in residents’ rooms and conducting random temperature checks....
"The evidence that residents were not comfortable is overwhelming, beginning with these residents’ complaints and further evidenced by the fact that Petitioner’s own staff recognized that there were problems with overheating in the residents’ rooms." The ALJ upheld the penalty.
Coinciding with the presentation yesterday at the National Press Club in Washington, D.C., the journal Health Affairs released a report by Melissa Favreault, Howard Gleckman, and Richard W. Johnson, titled "Financing Long-Term Services And Supports: Options Reflect Trade-Offs For Older Americans And Federal Spending." Noting the history of weak buy-in for existing long-term care insurance products, the authors' study, funded by the SCAN Foundation, AARP and LeadingAge, looks to future alternatives. From the abstract:
To show how policy changes could expand insurance’s role in financing these needs, we modeled several new insurance options. Specifically, we looked at a front-end-only benefit that provides coverage relatively early in the period of disability but caps benefits, a back-end benefit with no lifetime limit, and a combined comprehensive benefit. We modeled mandatory and voluntary versions of each option, and subsidized and unsubsidized versions of each voluntary option. We identified important differences among the alternatives, highlighting relevant trade-offs that policy makers can consider in evaluating proposals. If the primary goal is to significantly increase insurance coverage, the mandatory options would be more successful than the voluntary versions. If the major aim is to reduce Medicaid costs, the comprehensive and back-end mandatory options would be most beneficial.
Tuesday, November 17, 2015
The Washington Post's magazine section runs a Work Advice column by Karla Miller. A recent question was intriguing:
As a longtime colleague of Susan’s, I’ve been asked by her boss to feel out whether she really means to leave the office only if “taken out in an ambulance or a coffin” (the boss’s words). I agree that it is probably time for her to retire (she is financially well off), but I also know she gets great satisfaction from her work. Should I broach the subject with Susan as a caring co-worker?
The response urges caution in participating in the employer's plan, observing bluntly "that smells like a steaming heap of age discrimination."
For the full discussion, See @Work Advice: Putting the Old, Gray Co-Worker Out to Pasture.
Thursday, November 12, 2015
The ABA is offering a webinar on VA Pension: Income Security for Veterans and Their Family. The 90 minute webinar is scheduled for November 17th, 2015 from 1-2:30 p.m. est. The website offers the following description of the webinar
This webinar will cover eligibility of veterans and their dependents for VA pension.
Panelists will discuss how to get the best results for a client looking to obtain a VA pension. Practical pointers on obtaining the highest amount for pension will be discussed, as well as how a client can keep that amount each year. Practice tips on dealing with a VA debt—due to an overpayment issue related to a VA pension—will also be provided. This presentation will give practitioners an understanding of the law and provide practical tips on how to work within the confines of the VA.
To register, click here.
Kudos to my Stetson colleague, Stacey-Rae Simcox, one of the panelists!
Wednesday, November 11, 2015
I was reading a recent article in the New York Times on estimating longevity in the context of the Social Security Trust Fund. Your Kids Will Live Longer Than You Thought ran in the NY Times on November 10, 2015. The article discusses statistics and probabilities, explaining how life expectancies are calculated. Looking at the Social Security projections of life expectancy, the article notes that SSA is likely too conservative in their longevity projections.
The Technical Panel on Assumptions and Methods established by the Social Security Advisory Board, an independent government agency that advises Social Security’s trustees on matters including actuarial assumptions, says Social Security is systematically underestimating future declines in mortality rates, and therefore underestimating the likely life spans of young Americans.
So this is a good news-bad news scenario. Good news for those who get more years of life, bad news for Social Security. "[O]ne quirk of Social Security is that a piece of obvious good news (People will live longer than we thought!) is bad news from the narrow perspective of paying for retirement benefits (The government will have to pay benefits longer!)." So how to handle Social Security's too conservative projections? The Congressional Budget Office "tweaked" them by increasing them.
Tuesday, November 10, 2015
On November 6, 2015 the appellate division of New York's Supreme Court addressed an issue long brewing in some states, whether Continuing Care Retirement Communities (CCRCs) can insist on "private pay" for skilled nursing care despite a resident's "eligibility" for Medicaid under state and federal laws. In Good Shepherd Village at Endwell, Inc. v. Yezzi, the unanimous panel affirmed summary judgment in favor of the CCRC on the payment question.
The decision highlights Congressional DRA action in 2005/6 that amended federal Medicaid law to expressly permit CCRCs to offer contracts that require residents to "spend on their care resources declared for the purposes of admission before applying for medical assistance." The DRA amendment was a response to the industry's lobbying efforts, following a 2004 decision by a Maryland appellate court in Oak Crest Village, Inc. v. Murphy that held such a contractual provision violated the federal Nursing Home Residents' Bill of Rights, viewed as prohibiting nursing homes from conditioning admission on guarantees of private pay.
In the New York case history, the couple apparently signed two separate documents, beginning with a "contract" at the time of their entrance into the CCRC that required them to pay both an entrance fee ($143,850) and "basic monthly fees" of approximately $2,550 to cover the cost of independent living. Any need for skilled nursing care would be assessed "an additional charge." That contract provided that residents could "not transfer assets represented as available" for less than fair market value. When the wife needed skilled care, the couple signed a second document, referred to in the case as an "admission agreement," for treatment in the CCRC's skilled nursing unit. The "admission agreement" reportedly required the Yezzis to "pay for, or arrange to have paid for by Medicaid" all services provided by the CCRC.
Monday, November 9, 2015
Professor Janet Dolgin from Hofstra University has a very good article in the October 2015 issue of ABA's The Health Lawyer on "Reimbursing Clinicians for Advance-Care Planning Consultations: The Saga of a Healthcare Reform Provision." The article offers facts, analysis, historical perspective and opinion about the need to approve payment to health care providers in order for them to be able to engage fully with clients and their families in careful conversations about advance care planning, including end-of-life decisions. The article is concise, but the downside for interested readers is the digital version of the article is currently behind a pay-wall for ABA Health Care Section members only.
To stimulate your interest in tracking down a hard copy, perhaps through your law colleagues or local law libraries, here are a few highlights. Professor Dolgin writes:
Advance care planning is part of good healthcare. Thus, paying clinicians to talk with patients about advance care planning makes sense: it enhances advance care planning and thereby serves to effect good healthcare. "If end-of-life discussions were an experimental drug," writes Atul Gawande in his recent book, Being Mortal, "the FDA would approve it." Yet efforts to provide for reimbursement to clinicians for time and attention given to advance-care-planning conversations with Medicare patients have been stymied since 2009 (at least until quite recently) by the politics of healthcare reform....
Published, peer-reviewed research shows that ACP [Advance Care Planning] leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity....
In July 2015 CMS accepted the recommendation [supported by AARP, the AMA and others identified in the article] and opened the proposal to [pay health care clinicians for such consultations] to a two month-comment period in its proposed physician payment schedule for 2016.... If the proposed rule is accepted by CMS, payments for advance-care planning consultations are slated to begin in early January 2016.
The article demonstrates well the tension between the use of administrative law options to achieve what Congress finds unable or unwilling to address as a matter of Congressional laws. Of course, administrative processes can gore the ox of either side on a politically-charged debate.
Perhaps I am alone in being sad that it takes billing codes approved by insurance providers and CMS to achieve appropriate consultation between health care staff and families about advance decision-making. But Professor Dolgin's article is a realistic explanation for exactly why that "is" necessary.
November 9, 2015 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink
Thursday, November 5, 2015
The U.S. Treasury announced the creation of a new retirement savings vehicle, myRA. According to the blog post announcing this, myRA is a "retirement savings account for individuals looking for a simple, safe, and affordable way to save for their retirement. Over thirty percent of all American households have no retirement savings. myRA provides a way to start saving for retirement."
MyRA is designed for those who don't have an option for a retirement savings plan through their jobs. There are some benefits to myRA:
There’s no cost and no fees to open and maintain an account;
The investment will not lose money;
U.S. Treasury backs the investment;
Account owners choose how much to save ($2, $20, $200 – whatever fits their budget);
If account owners change jobs, the account stays with them; and
Account owners can withdraw the money they put in without tax and penalty.
Tuesday, October 20, 2015
In the last month of life, one in two Medicare beneficiaries visits an emergency department, one in three is admitted to an intensive care unit,and one in five has inpatient surgery. But one of the most sobering facts is that no current policy or practice designed to improve care for millions of dying Americans is backed by a fraction of the evidence that the Food and Drug Administration would require to approve even a relatively innocuous drug.
The article explains why this evidence is important
The public and private sectors are now engaged in an unprecedented array of virtuous efforts to improve end-of-life care. That these efforts are generally not evidence-based is not the fault of the organizations promoting them. It is the responsibility of investigators and research sponsors to identify, develop, and rigorously test interventions so that they can offer guidance as growing political and cultural tolerance increasingly permits implementation of end-of-life care programs. Achieving evidence-based end-of-life care will require at least four key developments — which, fortunately, are now attainable.
The article discusses the four key developments and notes in conclusion "the central challenge is to avoid complacency regarding plausibly useful but non–evidence-based initiatives. Researchers, research sponsors, and large insurers, employers, and health systems can collaborate to advance knowledge about what works best for whom. And the sooner they do so, the better...."
Monday, October 19, 2015
Recently I was reading an issue of The Senior Care Investor, a subscription-based news service that reports on the "World of Senior Care Mergers, Acquisitions, and Finance," and doing so since 1948.
For approximately the last three years, most of the M & A activity has been in assisted living (AL) and memory care (MC). Senior Care Investor reports that CCRCs are "beginning to make a comeback" as the housing market recovers and prospective residents are again able to use equity in their homes to finance transitions into CCRCs. The most recent issue also indicates some development money is returning to the skilled nursing facility market, even as overall M & A activity in senior housing is lower in 2015 than in 2014.
I've been watching quite a bit of activity over the last few years in conversions of nonprofit senior housing operations to "for profit" and there is more evidence of that in the latest report. But the most recent issue (Issue 9, Volume 27) also reports on a "rare for-profit to not-for-profit deal," with a New Mexico-based company, Haverland Care LifeStyle Group, purchasing a new AL/MC community in Oklahoma.
Also, the Senior Care Investor reports on a faith-based, not-for-profit CCRC provider that has decided to sell an entrance fee model (one that's in transition to an "all rental" model) that will offer independent living, AL, MC units and nursing home beds. What happens when senior housing operations are fully "private pay" AND "rental" models AND disconnected from a faith-based organization? Can they maintain their tax-exempt status? In other words, if the public is paying market rates (and thus higher rates based on any market increases) with no promises of future care if the residents run out of money, is that senior housing enterprise still a nonprofit operation entitled to be treated as exempt from federal income taxes?
Wednesday, October 14, 2015
I'm always playing catch-up on my "must read" list, but fortunately, others keep me on task. One such article is Florida State Medicine and Law Professor Marshall Kapp's piece, inspired in part by Hendrik Hartog's 2012 book, Someday All This Will Be Yours.
In For Love, Legacy, Or Pay: Legal and Pecuniary Aspects of Family Caregiving, published by the Springer Journals of Case Management, Professor Kapp begins with this overview and note of caution about legal planning:
Most caregiving and companionship provided by family members and friends to elder individuals in home environments occurs because of the caregiver's feelings of ethical and emotional obligation and attachment. From a legal perspective, though, it might be ill-advised for an informal caregiver to admit to such a motivation.
He advises consideration of personal service or personal service agreements, explaining:
We must reject an analytically attractive and pure, but never really socially realistic, tendency to dichotomize the caregiver experience, recognizing instead that a person may simultaneously be both a family member, with the related emotional and ethical connotations of that label, and a business employee. Morality and materiality are not incompatible. Caregiving can be both an act of love and a marketable commodity bought and sold between non-strangers.
As Professor Kapp points out, if we as a society really wanted to encourage family caregiving without all too vague promises about future inheritances, we could go beyond mere tax credits and "instead use public funds to pay family caregivers directly."