Tuesday, June 12, 2018

Medicare Trustees Release Bleak News on Trust Fund

The Medicare Trustees have released their 2018 annual report, which is chock-full of empirical data.  Reporting on this, the New York Times puts things in perspective with their story:Medicare’s Trust Fund Is Set to Run Out in 8 Years. Social Security, 16. This is less time than was reported  last year, as the story explains:

The Medicare trust fund will be depleted in 2026, the administration said. By contrast, the government said last year that the trust fund would be exhausted in 2029.

In a companion report, federal officials said the Social Security Trust Funds for old-age benefits and disability insurance, taken together, could be depleted in 2034, the same year projected in last year’s report. The fund that helps tens of millions of retirees is expected to be depleted a year earlier than projected last year, while the outlook for the disability trust fund is more favorable.

A good economy doesn't seem to be enough to extend the programs' solvency, according to the article:

The report said the less favorable outlook for Medicare’s hospital trust fund resulted from “adverse changes” in program income and costs. Income to the Medicare fund is expected to be lower than estimated last year because of “lower payroll taxes attributable to lowered wages in 2017 and lower levels of projected gross domestic product,” the Treasury said in a “fact sheet” accompanying the report.

At the same time, it said, outlays from Medicare’s hospital trust fund “are expected to be higher than last year’s estimates due to higher-than-anticipated spending in 2017, legislation that increases hospital spending” and higher payments to private Medicare Advantage plans.

The Trustees report explains why the trust fund's time line has sped up:

The estimated depletion date for the HI trust fund is 2026, 3 years earlier than in last year’s report. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years HI income is projected to be lower than last year’s estimates due to (i) lower payroll taxes attributable to lowered wages for 2017 and lower levels of projected GDP and (ii) lower income from the taxation of Social Security benefits as a result of legislation. HI expenditures are projected to be slightly high er than last year’s estimates, mostly due to higher than expected spending in 2017, legislation that increased hospital spending, and higher Medicare Advantage payments .

The full Trustees' report is available here.

June 12, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Social Security | Permalink | Comments (1)

Monday, June 11, 2018

Aging: "The One Shark We Cannot Escape"

My good friend and colleague, Pennsylvania Elder Law Attorney Linda Anderson, has a thoughtful essay about her personal journey in elder law in a recent issue of  GPSolo,  the ABA journal for solo, small firm, and general practitioners.  Her closing paragraphs address several core issues, comparing her elder law focus with traditional tax and estate planning concerns.  I enjoyed her use of classic lines from the movie Jaws.  

My early work with elder clients or their adult children across a variety of asset levels certainly involved tax and estate planning. But it became clear that serving and protecting these clients demanded more than just good lawyering, that good planning needed “a bigger boat.” It entailed comprehensive knowledge of the Social Security, Medicaid, and VA benefits bureaucracies, close engagement with insurance providers, geriatric care managers, social workers, and other professionals, as well as close monitoring of state and federal regulatory and policy changes and housing and age discrimination laws, among others. The eventual next step for me was completing the requirements to become a certified elder law attorney (CELA).
 
 
Solo or general practice attorneys do not have to become dedicated elder law experts when taking on clients seeking long-term care and funding planning. Take those clients, but be prepared to augment tax and estate planning expertise with a deep dive into areas of elder and special needs law and funding mechanisms. All this is doable, of course, but the biggest difference is in mindset. Attorneys often approach estate and long-term care planning as transactional or episodic--needs arise, documents are drafted or revised, and we and the clients move on. But the nature of the legal work I've touched on above demands a continuing, flexible outlook and a lot of homework. When in doubt, consult with or refer your client to a CELA-qualified attorney. These attorneys are listed in the website for the National Elder Law Foundation (NELF, nelf.org). Another resource for lawyers (who may or may not be CELA-qualified) is the National Academy of Elder Law Attorneys (NAELA, naela.org). Both organizations are excellent sources for information and referrals.
 
 
Finally, as we all learn in time, everything that we've covered here will become very personal for each of us. This may first happen through our parents or siblings as they transition and age, but it's necessarily part of our own futures as well. That's true whether you're a Baby Boomer looking at 70, a Gen Xer thinking that 40 is “old,” or any age in between.
 
 
Aging is the one shark we cannot escape. But as attorneys, we know how to plan and can build our clients' (and our own) “boats” to manage aging as well as possible.
 
The full article is currently behind a paywall on the ABA website. For more of Linda's wise words, it is worth tracking down a copy of An Elder Care Lawyer's Story.  It is in Volume Issue No. 2 (March/April, 2018) of GPSolo.  It is also available on Westlaw, although, of course, that's another paywall.   

 

June 11, 2018 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Legal Practice/Practice Management, Medicaid, Medicare, Property Management, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Friday, June 8, 2018

Filial Friday: Using Cultural Norms to Explore Public Policy on Elder Care

Duke University Law graduate and 2018-19 Bristow Fellow H. Hunter Bruton uses filial support laws in China and contrasting government policies in Japan to explore public policy choices affecting the relative responsibilities of family and government to provide care for aging adults. The author's 2018 article for the University of Minnesota Law Review begins:

This Essay aims to fill that gap by formulating policy recommendations from the lessons of China and Japan--two countries that have taken divergent approaches to facilitating familial and communal eldercare. Conventional wisdom paints cultural portraits with a broad brush: inescapable forces fight against familial and communal eldercare in the West, while Eastern cultures revere the elderly. But cultural ideals and characterizations do not always accord with reality. Similar to the United States, cultural and societal trends in both China and Japan have resisted government efforts to place the eldercare burden on families and communities. This Essay explores how each government’s response has altered eldercare practices and elucidates general principles applicable to the American-eldercare context.

 

Part I begins by defining eldercare and explaining the benefits of familial and communal eldercare. It concludes with a brief survey and analysis of familial and communal eldercare’s past, present, and future in America. With the goal of increasing familial and communal eldercare in mind, this Essay turns towards two differing international examples. Part II scrutinizes China’s solution--mandating familial and communal eldercare to alleviate government costs. Part III analyzes Japan’s approach--institutionalizing encouragement of familial and communal eldercare. Each Part also evaluates American analogs, and possible reform opportunities in the United States. An all-inclusive assessment and comparison would require empirical studies and elaboration beyond this Essay’s scope. Instead of purporting to meet these demands, this Essay intends to chronicle the successes and shortcomings of China and Japan and give American policymakers a better understanding of pertinent considerations in formulating eldercare policy.

For more, read Improving Familial and Communal Eldercare in the United States: Lessons from China and Japan.

June 8, 2018 in Current Affairs, Ethical Issues, Health Care/Long Term Care, International | Permalink | Comments (0)

Thursday, June 7, 2018

Michigan Bar Journal Issue Explores the Intersection of Elder Law and Disability Law

A recent issue of the Michigan Bar Journal offers interesting practitioner perspectives on disability law and elder law issues.  The January 2018 issue includes:  

Introducing the theme of the issue, attorney Christine Caswell writes: 

While there may be a perception that the section focuses on helping clients qualify for public benefits, its mission is actually much broader. Elders and those with  disabilities have many of the same issues as the rest of the population— divorce, consumer problems, bankruptcy, business ownership, and litigation—but these issues are magnified when questions arise concerning competency, the need for ongoing care, and discrimination. Moreover, these different legal areas may conflict when determining what is in the best long-term interests of these clients.

June 7, 2018 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Legal Practice/Practice Management, Medicaid, Medicare, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, June 6, 2018

Doctors' Conversations with Patients About Aid-in-Dying

Earlier this week I posted an update on California's aid-in-dying law.  I was interested in this article published in the New England Journal of Medicine, Beyond Legalization — Dilemmas Physicians Confront Regarding Aid in Dying.

Noting that doctors in jurisdictions where aid-in-dying is lawful are will need to have conversations with patients making the request, the author suggests

Physicians can start by clarifying what patients are asking and why. Some ways in which patients might raise the topic of PAD are listed in the box. Not every question about PAD is a request for assisted suicide. Patients might be seeking information, talking through concerns, expressing distress, or trying to ascertain the physician’s views. To clarify the patient’s motivation, physicians might say, “I’ll be glad to answer that question, but first please tell me what led you to ask.”

The author offers some examples of how patients might raise the issues with their doctors and suggests the next step for doctors is to

explore patients’ concerns and identify and address their palliative care needs, regardless of the physicians’ own views or the legal status of PAD where they practice. Discussions could cover patients’ physical symptoms; psychosocial, existential, and spiritual suffering; hopes and fears; and goals of care. All options for end-of-life care should be discussed, including palliative and hospice care and palliative sedation.

It’s also important for physicians to think through what actions they’re willing to take. Both physicians who support PAD and those who oppose it should try to relieve patients’ multidimensional concerns and distress. After comprehensive palliative care is intensified, 46% of patients who have requested PAD change their minds. (citations omitted).

The author recommends the doctors consider the parameters of when they would participate in medical-aid-in-dying, offering that "perceived loss of autonomy and dignity is now a more common reason for requesting PAD than inadequate pain control." (citation omitted). The author also discusses issues that may occur from a doctor's lack of experience in the area and potential adverse outcomes and counseling families about them. The author also offers some comments for doctors who are opposed to medical aid-in-dying  and concludes with this advice: "[r]esponding to inquiries about PAD is new territory for most physicians. To fulfill their obligations to patients and be true to their own values, physicians should think through how they will respond to the challenges raised by these conversations."

 

June 6, 2018 in Advance Directives/End-of-Life, Consumer Information, Health Care/Long Term Care, Other, State Statutes/Regulations | Permalink | Comments (0)

Dax, France -- a Prototype Village for Residents with Dementia?

From Ben Mulford, a law graduate working at the Iowa Department on Aging, comes an interesting description of a French village designed to give residents who have Alzheimer's Disease as much freedom and normalcy of life as possible, in a safe setting. Map Dax France

Work has begun on France's first "Alzheimer's village” where patients will be given free rein without medication in a purpose-built medieval-style citadel designed to increase their freedom and reduce anxiety. 

 

Residents of the village in Dax, southwestern France, will be able to shop in a small supermarket, go to the hairdressers, local brasserie, library, gym and even a little farm.  They will live in small shared houses designed to reflect their personal tastes and in four districts reminiscent of the southwestern French region between forests and the seashore.

 

While it may sound similar to a typical residential complex, the inhabitants are all men and women suffering from Alzheimer's,  the commonest cause of dementia. . . . 

 

The village is the brainchild of the late Henri Emmanuelli, a former Socialist minister and local MP who launched the project after reading about a Dutch gated model village in Weesp, Netherlands, seen as a pioneering care facility for elderly people with dementia.

 

Residents are confined to the village for their own safety but are allowed to move around freely inside and are watched over by plain-clothed medical staff. The staff don't treat patients, they care for residents, they say.
 
Interesting details include the plans for researchers "cohabiting" with residents, and using a high ratio of live-in carers and volunteers to stage activities.   The article makes the amusing (worrying?) comparison to the plot of The Truman Show, a movie where a key resident, played by Jim Carrey, was living in a fake town.    
 
Will this be cost effective?   The projection is described as "largely funded by the region," and the prediction is it will "only cost patients €66 per day, roughly the same as the rate for a traditional nursing home in France."  
 
I'm a bit skeptical about the "medieval" citadel design as being comforting.  I doubt if residents would be that old.  But, perhaps it would enhance a vacation feel to the location.  I know a resident of a dementia care community, one that follows a village concept on a smaller scale, and when the misting system is operating to cool the exterior porches for all the cottages, she thinks she's at a hotel on the coast of California.  That is a nice alternative to reality -- Arizona in the summertime.  Plus, ambiance of the location is important to attracting and keeping workers, and to make family members and friends feel relaxed and welcome, too.
 
Thank you, Ben, for sharing this interesting piece.  For more, read France Starts Work on Revolutionary 'Alzheimer's Village' Where Patients Roam Almost Free, from The Telegraph

June 6, 2018 in Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Health Care/Long Term Care, Housing, International | Permalink | Comments (0)

Monday, June 4, 2018

More on California's Aid-in-Dying Law

As we previously blogged, after a trial court judge struck the law, the California Attorney General filed an appeal.  According to a recent article in the San Francisco Chronicle, California’s right-to-die law on hold for at least a month.

California’s right-to-die law for terminally ill patients will apparently remain suspended for at least another month after a judge on Wednesday reaffirmed his ruling that the law was illegally considered and passed during a special legislative session on health care.

[The judge] ruled the law invalid May 15 and halted its enforcement last Friday. It had been in effect since June 2016, allowing doctors to prescribe life-ending medication to mentally competent adults who have less than six months to live.

On Wednesday, the nonprofit Compassion & Choices ... asked [the judge] to suspend his ruling and cited its potential impact on two terminally ill patients, one of them an 82-year-old Marin County woman who has already obtained a prescription for life-ending medication. The judge denied the request.

The state attorney general also weighed in, seeking to have the order set asid eon the grounds that "the judge improperly issued a statewide order in a local lawsuit and also should have given his office 10 days, under state law, to file objections to Friday’s order before putting it into effect."  The Judge has set a June 29 hearing.

The article offers this to describe the impact of the order. "Because of the ruling, doctors can no longer prescribe life-ending medication to dying patients, and a patient who had already been provided with the medication would be committing suicide by taking it, with implications for insurance coverage." 

Stay tuned!

June 4, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, May 29, 2018

No Stay During Appeal of California Aid-in-Dying Law

As we reported last week, a trial court judge in California held that the California physician-aid-in-dying law was invalid.  The state appealed, according to an article in the LA Times.  A subsequent article in the New York Times reports that the appellate court declined a stay of the trial court's ruling pending the appeal,  No Stay of Ruling That Tossed California Assisted-Death Law.  "California's 4th District Court of Appeal refused to grant an immediate stay requested by state Attorney General Xavier Becerra. However, the court gave Becerra and other parties time to "show cause" — that is, provide more arguments as to why the court should grant the stay and suspend the lower court ruling.” Since no injunction was entered, the law still is in effect, as noted in the article. The California AG " argued that the measure was legitimately passed and asked [the appellate court] for quick action so that terminally ill people seeking options under the law wouldn't die "an excruciating, painful death" before the issue is finally decided."

Stay tuned.

May 29, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Beware the Befriender - Another Tale, This Time from Brooklyn

A book I co-authored on The Law of Financial Abuse and Exploitation was inspired, sadly, by several cases we had in our Elder Protection Clinic at Dickinson Law in Carlisle Pennsylvania.

In one case, at first the relationship between great niece and great aunt had seemed to friends and neighbors to be loving and protective.  It wasn't until the elder's care needs increased, and it turned out there was no money to pay for care by professionals, that the truth was uncovered.  The aunt's money, close to a million over three years, was gone. 

With the benefit of hindsight, you could see how the exploitation began -- with the younger woman asking for permission to use the elder's accounts for a few improvements and upgrades around the house. Then she stopped asking for permission.  Eventually her spending was for fur coats, jewelry and a luxury car (actually, two). Her aunt no longer could see to review her accounts and there weren't any other relatives to ask questions.  The niece probably didn't count on her aunt living past 100 -- or testifying against her at the criminal trial about the unauthorized spending, when she was 101.   The younger woman tried to justify her behavior, testifying at trial that "she wanted me to have the money. She was going to leave it to me in her will."

Several friends, including Karen Miller, in Florida, sent me copies of another tragic tale, this time from Brooklyn via the New York Times.   I suspect, that in this account of a relationship between an older widow and a local waitress, the younger woman probably told herself her "friend"wanted her to have the money.  She too will be thinking about this in jail.  Read She Found Comfort in a Brooklyn Diner, Then Lost Everything.   

May 29, 2018 in Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Monday, May 28, 2018

NYT: Safety Issues When Guns Are In Elderly Hands

Here's a challenging but potentially important topic for many families on this holiday weekend. 

Becky has a post last week about the importance of doctors asking older patients about guns as a safety risk.  I've posted in the past, here and here,  about related issues, including laws affecting registration of gun ownership when intervivos or testamentary trusts are used as the legal vehicle to pass down weapons to succeeding generations.  

The New York Times continues the conversation with In Elderly Hands, Firearms Can Be Even Deadlier.  From Paula Span's article: 

While older adults make many fewer suicide attempts than younger cohorts, they die more often, in part because they use such lethal methods. Yet health care providers who ask older patients about driving and wandering may not ask about guns.

 

“Safety planning for adults with dementia is something every clinician thinks about, but I don’t think firearms are often on the radar,” said Dr. Donovan Maust, a psychiatrist at the University of Michigan Medical School and co-author of a recent article on guns and dementia in the Annals of Internal Medicine.

 

They should be. At various stages of dementia, people may grow unable to distinguish loved ones from intruders. Their decision-making ability deteriorates. They can become paranoid, depressed, impulsive, agitated or aggressive.

Dr. Maust's co-authored commentary, linked above, is worthy of closer reading.  Perhaps in an attempt to allay the fears of gun owners that dementia is not an automatic disqualifier for gun ownership, the piece suggests that doctors consider the stage of any neurocognitive impairment as part of a multi-party discussion about access:

A diagnosis of cognitive impairment or dementia does not in itself mean that a person should not have access to firearms—the level of cognitive impairment is probably most important. In a recent review, Patel and colleagues proposed using the clinical dementia rating scale to estimate the stage of dementia and the person's ability to safely complete complex tasks, including firearm handling. 

 

For patients with minimal cognitive impairment, approaches could be similar to those related to driving, including acknowledging the emotions involved and allowing the PWD [person with dementia]  to maintain agency in the decision for as long as it is safe. As with an “advance driving directive”, PWDs, their family members, and their health care providers may proactively discuss firearm access and consider setting a “firearm retirement date”. This patient-centered approach may allow an older adult to maintain decisional control and identify trusted family members or providers as future surrogate decision makers. To our knowledge, no one has tested the acceptability or efficacy of this approach.
Did you catch that acronym above, perhaps a new one for many of us?  PWDs? My thanks to colleague Laurel Terry for her early morning reading habits -- and  for sharing the NYT article with us. 

May 28, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Property Management, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Friday, May 25, 2018

Sci Fi Friday: Recommending Short Story "Today I Am Paul"

Of course, I'm supposed to be finishing my exam grading.  Instead, while stopping by my office, I find a copy of a short story from one of my colleagues.  The accompanying note says,"Not even my sci-fi 'escape' is untouched by elder care issues.  Thought you'd get a kick out of this."

And indeed, I do.  I definitely recommend "Today I Am Paul," by Martin L. Shoemaker.  The author draws upon his personal experiences in visiting his mother-in-law in a nursing home to craft a true tale ... with a difference ... as the narrating caregiver is an android.  

While my printed-page-loving self recommends reading the short story, I also found a great podcast of the story being read aloud by Kate Baker and I'm linking it here, from Clarkesworld Magazine.  

I now plan to use this story to introduce my Elder Law course in the autumn.  So much to talk about, including the roles of family, caregivers, technology, fear.....   I suspect my co-blogger Becky Morgan, with her often expressed enthusiasm for tech including driverless cars, will appreciate this story too.  Happy reading or listening for Memorial Day weekend!

Many thanks to Dickinson Law Professor Matthew Lawrence for this unique, caring experience.  

May 25, 2018 in Books, Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Science, Web/Tech | Permalink | Comments (0)

Wednesday, May 23, 2018

Myths & Mistakes About New Medicare Cards: AARP Research Survey

As we all know, CMS has been rolling out the new Medicare cards without SSN on them.  AARP Research conducted a survey about the new cards, and the results are quite interesting.  2018 AARP Survey: Experience and Knowledge of Medicare Card Scams explains:

n March 2018, AARP engaged Alan Newman Research to conduct a national research study among U.S. adults ages 65 and older about their experience and knowledge around the new Medicare cards being issued in April 2018 and potential vulnerability to scams related to the new card and benefits. 

Key findings include the following:

  • Most (76%) U.S. adults ages 65 and older indicate they have not seen, read, or heard much or anything at all about the new Medicare cards (or are not sure).
  • Three in four (75%) Medicare beneficiaries are not sure or are incorrect about the key change with the new cards being new identification number.
  • Nearly two-thirds (63%) of Medicare beneficiaries are unsure or are incorrect in believing that Medicare will charge new beneficiaries a $25 processing fee for the new card. 
  • Over half (56%) are not sure or are wrong in thinking that Medicare will call them to verify their Social Security number before they can receive their new card.
  • At least one in three are extremely/very concerned about being a target of Medicare scam (33%) or victim of identity theft (40%).

A pdf of the survey results is available here.

 

May 23, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Statistics | Permalink | Comments (0)

California AG Files Appeal in From Court Decision Setting Aside Physician-Aided Death Law

Both Becky and I have written about a California trial court's recent ruling that a California's law permitting physician assistance in death was enacted in an unconstitutional manner.  The judge granted a window of five days before the ruling would become effective, to permit any appeal. That appeal has now been filed by the California Attorney General.  From the Los Angeles Times:  

California Atty. Gen. Xavier Becerra on Monday filed an appeal against a judge's recent ruling overturning the state's physician-assisted suicide law. . . . 

 

Becerra's action Monday moves the case to an appeals court, which will decide the future of the law. He also asked that the law stay in place while the matter is further litigated, a request that will most likely be granted, said Kathryn Tucker, an attorney who heads the End of Life Liberty Project at UCSF/UC Hastings Consortium on Law, Science & Health Policy.

As Becky says, stay tuned.  But probably best not to hold your breath while awaiting the next ruling. 

May 23, 2018 in Advance Directives/End-of-Life, Current Affairs, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

A Closer Look at Continuing Care at Home Contracts (Sometimes Known as Continuing Care Without Walls)

As I prepare for some summer writing and speaking projects, I've been taking a closer look at Continuing Care at Home (CCaH), sometimes also called Continuing Care Without Walls.  Pennsylvania was among the early states to license CCaH providers, doing so under the Pennsylvania Department of Insurance's regulatory authority for Continuing Care Retirement Communities (CCRCs).

CCaH is something of a hybrid, contract-based product, sort of a combination of “home care agency” and “long-term care insurance.” The customer makes a prepayment for access to specific services, to be provided in the customer's own home,  The services offered tend to emphasize care coordination; several different types of plans may be offered by a single provider.

From the providers I've reviewed, CCaH contracts typically have an upfront “entry” or membership fee, plus monthly service fees.  In some of the plans there is also cost sharing and deductibles for services.  Overall, the fees, as one would expect, are lower than for traditional CCRCs, but can still be significant.

For example, in a recent report I reviewed, one operation described a series of contracts available.  One contract involved a 90% "refundable" entry fee plan.  In 2012,  a prospective member who qualified at age 88 could expect to pay an entry fee of $147,160, plus monthly service fees ranging from $290 to $584.

In some instances, the company may charge annual fees, rather than a single entry fee plus monthly fees. For example, another Pennsylvania CCaH provider offers "life care plans," "home care plans," and "traditional life care plans."  The first two contracts have annual fees, while the third, "traditional life care plan," is structured with a single upfront entry fee, plus monthly fees of 1% of the entrance fee. 

At that company, for the "life care plan" with annual fees,  a prospective member could select a "life time benefit" of between 1 and 7 years, plus a maximum daily benefit of between $75 per day to $250 per day, with options for a waiting period, cost of living adjustments, and "shared care."  As of April 2016, if a prospective member at age 80 chose a life care plan with a 7 year "maximum life time benefit," no waiting period, no cost of living adjustment and no shared care, he or she could expect to pay annual fees of around $7,880 for a $100 per day benefit -- or up to $15,60o per year for a $200 per day benefit.   Fees would be discounted by 20% for two or more people per household and the benefits and annual fee "may vary based on the member's health status at time of enrollment."  Further, the provider cautions, "though not anticipated, the annual fee for members of life care and home care plans may be adjusted after the fifth anniversary of their continuing care agreement," and any such adjustments would be on a uniform basis for all members in a specific plan.  

In Pennsylvania, all of the current providers of CCaH are connected to or developed by operators of brick and mortar CCRCs, and therefore the CCaH contracts sometimes offer priority admission to the related CCRC if resident care is desired.  I don't think this connection between a CCaH program and a CCRC facility is necessarily required in other states. 

Traditional long-term care insurance has had a troubled history nationally and in Pennsylvania, CCaH providers seem to avoid that history by staying closely tied to the positive reputation of a visible, attractive brick and mortar CCRC.  However, CCaH contracts do not necessarily promise to use the staff or services from the related CCRC, and if so, the CCaH provider may turn to third parties, such as home care agencies, in the search for workers.  The contract terms are key and require careful reading.

Pennsylvania currently licenses five CCaH providers.  The longest operating provider is Friends Life Care at Home, a not-for-profit operation in southeastern Pennsylvania.   It was organized in 1985 and according to registration information at the Pennsylvania Department of Insurance it has approximately 2,500 contracts in existence.   Friends Life Care recently entered into a joint marketing agreement with SpiritTrust Lutheran Life

Continue reading

May 23, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Tuesday, May 22, 2018

Congrats to NAELA

NAELA celebrated its 30th year with its annual conference in New Orleans, LA on May 17-19, 2018. The conference consisted of three tracks: legal tech, advocacy and public benefits.  The well-attended conference packed in a great amount of programming in two and a half days. Speakers included leaders from the field of elder law, consultants, cyber security experts, researchers and more.  NAELA members unable to attend may check the NAELA website for more information.

In addition, Michael Amoruso was sworn in as the next NAELA president by outgoing president Hy Darling.  Congrats NAELA!

(In the interest of full disclosure, I'm a former president of NAELA and co-chair of the planning committee for this conference.)

 

May 22, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Legal Practice/Practice Management, Medicaid, Medicare, Programs/CLEs, Property Management, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Monday, May 21, 2018

California Aid-in-Dying Law Overturned

A number of news outlets reported that a trial court judge has overturned California's aid-in-dying law. As an example, the LA Times reported Riverside judge overturns California's doctor-assisted suicide law. The judge ruled "that the California Legislature violated the law by passing the End of Life Option Act during a special session dedicated to healthcare issues, according to the plaintiffs in the case as well as advocates for the law."  The law, which has been in effect about 6 months, has already been used, according to sources quoted in the article.  "In the first six months California's law was in effect, more than 100 people made use of it to end their lives. Fifty-nine percent of them had cancer, according to state data." Both sides on this issue are quoted in the article. The state attorney general has 5 days from the order's entry to file an appeal.

Stay tuned.

 
 

May 21, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Other, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, May 18, 2018

Doctors Discussing Gun Safety With Elder Patients

Kaiser Health News published a compilation of recent stories about gun safety and one caught my eye: the advantage of doctors discussing gun safety with elder patients. Doctors Should Be Discussing Gun Safety With Aging Patients, Researchers Say.

The reference to the story  from the LA TImes, As more older Americans struggle with dementia, what happens to their guns?seemed particularly on point and the KHN story published the opening from the LA Times article

The man had been a patient for decades, retired now from a career in which firearms were a part of the job. He was enjoying his days hunting, or at the shooting range with friends. But episodes of confusion had led to a suspicion of dementia, and the nights were the worst: At sundown, he became disoriented, anxious and a little paranoid, and had started sleeping with his loaded pistol under the pillow. One night, he pointed it at his wife as she returned from the bathroom. It wasn't clear whether he recognized her, but he was certainly confused — and she was terrified. Thankfully, the incident did not end in disaster.

Regardless of your position on the gun control debate, consider these statistics from the LA Times article

Roughly 1 in 3 adults over 65 in the United States is thought to own a gun. An additional 12% live in a household with someone who does.

As seniors turn 70, their odds of developing Alzheimer's disease in a given year jump from less than 1% (among those 65 to 69) to 2.5% (among those 70 to 74), and keep rising from there. By 2050, the number of older Americans with Alzheimer's is expected to reach 13.8 million.

The article discusses driver safety and draws corollaries to gun safety. The article highlights the lack of response to this issue at the state level:

No federal laws prohibit the purchase or possession of firearms by a person with dementia. Only two states, Hawaii and Texas, explicitly mention dementia or similar conditions in their firearms statutes.

In Hawaii, any person under treatment for "organic brain syndromes" is prohibited from owning a gun. Texas law makes individuals diagnosed with "chronic dementia" ineligible for a license to carry a handgun in public. But it does not limit such a person's right to purchase or possess firearms.

One expert quoted in the article describes this as not an issue of taking away someone's guns but instead a decision that focuses on the person's safety.

May 18, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Thursday, May 17, 2018

When I'm 64...Will I Be Relevant?

We all can sing along to that fabulous Beatles song, When I'm 64. Perhaps the Beatles were prescient, as now Kaiser Health News has published an article about remaining relevant in your life when you are 64 and beyond.... Will We Still Be Relevant ‘When We’re 64’? opens with this description

A gnawing sense of irrelevancy and invisibility suddenly hits many aging adults, as their life roles shift from hands-on parent to empty nester or from workaholic to retiree. Self-worth and identity may suffer as that feeling that you matter starts to fade. Older adults see it in the workplace when younger colleagues seem uninterested in their feedback. Those who just retired might feel a bit unproductive.

The article then segues into a discussion of various recent studies that bears out this fear of becoming irrelevant. Whether it's being important at work or important in your personal life, there is a value to being relevant, or even being needed, even if it's just giving advice to a younger person. "Having purpose and meaning forestalls loneliness, which takes an emotional and physical toll. Studies by ... researchers have found that loneliness is associated with weaker immune systems and poorer physical health."

One group in Austin, Texas (the slogan, "Keep Austin Weird")  took initiative by "finding their purpose with a community created by Aging is Cool, an active-aging company founded just over a year ago." The article discusses this community initiative as well as some other ones across the country, volunteering and continued employment. The article closes with an example for all of us: "96-year-old actress Betty White ... [who] still produces good work and she has a great amount of energy... Her entire package promotes a youthful and optimistic attitude.”

May 17, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other, Science | Permalink | Comments (0)

Tuesday, May 15, 2018

Pennsylvania Considering Changes to Guardianship Laws for 2018 Passage

Pennsylvania has several interesting bills pending that would make significant changes to the laws governing court-appointed guardians for incapacitated adults, and at least one of these could move forward this legislative session.  I've learned to expect late night action from the Pennsylvania legislature once it reconvenes in late May and before it adjourns in late June or early July.  The pending legislation includes:

  • Senate Bill 884 (Printer's No. 1147), with Senator Greenleaf as the lead sponsor, offered as a comprehensive reform package for adult guardianship laws, relying in large part on model legislation, and drafted before the most recent high profile news stories and editorials that involve allegations of improper appointment of a particular fee-paid guardian in a number of guardianships for incapacitated adults on the eastern side of the Commonwealth.  On April 16, 2018 this bill was referred to the Senate Appropriations Committee.  

I've seen recent drafts of proposed amendments to SB 884 that would require alleged incapacitated persons to be represented by a lawyer during the guardianship proceeding, require criminal background checks through the State Police (without creating automatic disqualifications if there is a history of convictions), and would also mandate "certification" for "professional guardians." Professional guardians are defined to include individuals or entities that are appointed to serve 3 or more incapacitated persons.  The responsibility for certification of the professional guardians would be assigned to the Pennsylvania Department of Human Services, although the proposed language would appear to permit the department to accept certification through an outside program such as that offered by the Center for Guardianship Certifications. 

  • House Bill 2247 (Printer's No. 3296), with Representative Gillen as the lead sponsor, and submitted in April 2018 following the high profile articles, would mandate criminal background checks for all current or prospective guardians and provides that courts "shall disqualify a guardian or prospective guardian convicted of an offense classified as a felony under the laws of this Commonwealth or a substantially similar offense under the laws of another jurisdiction."  

While the proposed amendment to S.B. 884 would require criminal background checks for potential guardians, unlike HB 2247, it stops short of banning appointment of individuals who have any particular criminal history. No doubt this decision reflects a 2003 ruling by the Pennsylvania Supreme Court in Nixon v. Commonwealth.  In that case, a per se ban on employment of individuals as long-term care workers if they were convicted of certain crimes was deemed unconstitutional.  Senate Bill 884, even if amended, would give greater discretion to the courts to consider the individual history and the nature of the offense than would HB 2247.

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May 15, 2018 in Cognitive Impairment, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Housing, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (2)

Sunday, May 13, 2018

"Bullying in the Nursing Home" -- Getting Beyond the Headlines

News publication sites affiliated with USA Today and the Associated Press have been running a recent piece on "bullying" among older persons, often with a provocative headline such as "It's like 'Mean Girls,' but everyone is 80": How nursing homes deal with bullies.   The title undoubtedly catches many a reader's eye, simply because of the heightened discussions of bullying at a national level, including Melania Trump's recent announcement of her Be Best platform for younger persons.  The topic isn't actually all that new from a journalism perspective.  Paula Span wrote on "Mean Girls in Assisted Living" for the New York Times in 2011, and the same publication carried a granddaughter's Op Ed on "Mean Girls in the Retirement Home" in 2015.   

On a parallel track, and perhaps more disturbing, are reports of bullying among nurses, a profession normally associated with empathy and caring.  See e.g., "When 'Mean Girls' Wear Scrubs," a 2013 post on DiversityNursing Blog, tracking a several studies and a book.  

More important than the clever headlines, however, are the reports of affirmative efforts to counter the bullying, which at the older end of the spectrum of life, seems to focus on name-calling, gossip, and ostracising behavior, rather than physical intimidation.  From the most recent USA Today writer's article:  

After the cafeteria exiles and karaoke brouhahas, the 30th Street [Senior] Center [in San Francisco]  teamed up with a local nonprofit, the Institute on Aging, to develop an anti-bullying program. All staff members received 18 hours of training that included lessons on what constitutes bullying, causes of the problem and how to manage such conflicts. Seniors were then invited to similar classes, held in English and Spanish, teaching them to alert staff or intervene themselves if they witness bullying. Signs and even place mats around the center now declare it a “Bully Free Zone.”. . . 

 

Robin Bonifas, a social work professor at Arizona State University and author of the book “Bullying Among Older Adults: How to Recognize and Address an Unseen Epidemic,” said existing studies suggest about 1 in 5 seniors encounters bullying. She sees it as an outgrowth of frustrations characteristic in communal settings, as well a reflection of issues unique to getting older. Many elderly see their independence and sense of control disappear and, for some, becoming a bully can feel like regaining some of that lost power.

I think that last line rings true.  I've certainly seen older adults sudden strike a "meaner" demeanor as their freedom is limited by physical  health issues and as their frustrations increase.  But I also think it can be important to assess whether a "mean" trait -- or at least a "meaner" dynamic -- is a reflection of cognitive impairment, such as disinhibition associated with certain types of neurocognitive impairments.   

On an even more worrisome level, is there a danger of misinterpreting fear or irritation as "meanness," perhaps arising from compelled interactions in a congregated living situation?   In one instance, I've seen an older woman who had regularly chose to sit with the same group of 3 other individuals at meals for several weeks, suddenly reject one member of their informal club.  It took careful listening to realize the rejection was actually uneasiness bordering on fear -- on some level not completely rational -- but associated with that targeted individual's tendency to wander at night into others' rooms and thus to lead the "mean girl" to try to keep the other away from her around the clock.  Targeting the "bullying" behavior could be addressing the wrong problem in the latter case.  

Finally, I think there is a danger associated with the admittedly clever tendency to use the "Mean Girls" movie as the analogy for older bullying, thus implying this is only an issue (and problem) associated with women, not men.  As a later paragraph in the most recent article makes clear, bullying behavior among older adults is not "just" about women. But perhaps that is obvious from the larger national news?  

May 13, 2018 in Books, Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Retirement | Permalink | Comments (0)