Wednesday, January 31, 2018

Rising Health Care Costs to Outpace COLAs?

The Washington Post ran an article looking at the longer-term impact of the increasing costs of health care on any COLAs from SSA. Out-of-pocket health-care costs likely to take half of Social Security income by 2030, analysis shows discusses a recent Kaiser Family Foundation which "found out-of-pocket health-care costs for Medicare beneficiaries are likely to take up half of their average Social Security income by 2030."  The KFF report, Medicare Beneficiaries’ Out-of-Pocket Health Care Spending as a Share of Income Now and Projections for the Future was published January 26, 2018. Here is the executive summary

Medicare helps pay for the health care needs of 59 million people, including adults ages 65 and over and younger adults with permanent disabilities. Even so, many people on Medicare incur relatively high out-of-pocket costs for their health care, including premiums, deductibles, cost sharing for Medicare-covered services, as well as spending on services not covered by Medicare, such as long-term services and supports and dental care. The financial burden of health care can be especially large for some beneficiaries, particularly those with modest incomes and significant medical needs. Understanding the magnitude of beneficiaries’ current spending burden, and the extent to which it can be expected to grow over time, relative to income, provides useful context for assessing the implications of potential changes to Medicare or Medicaid that could shift additional costs onto older adults and younger people with Medicare.

In this report, we assess the current and projected out-of-pocket health care spending burden among Medicare beneficiaries using two approaches. First, we analyze average total per capita out-of-pocket health care spending as a share of average per capita Social Security income, building upon the analysis conducted annually by the Medicare Trustees. Second, we estimate the median ratio of total per capita out-of-pocket spending to per capita total income, an approach that addresses the distortion of average estimates by outlier values for spending and income. Under both approaches, we use a broad measure of Medicare beneficiaries’ total out-of-pocket spending that includes spending on health insurance premiums, cost sharing for Medicare-covered services, and costs for services not covered by Medicare, such as dental and long-term care. We present estimates of the out-of-pocket spending burden for Medicare beneficiaries overall, and by demographic, socioeconomic, and health status measures, for 2013 and projections for 2030, in constant 2016 dollars.

A pdf of the report is available here.

January 31, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Retirement, Social Security | Permalink | Comments (1)

Tuesday, January 30, 2018

Want to Live Longer? If You Can Afford It, Retire Early But Do Stuff!

The New York Times ran an article about recent research regarding the correlation between early retirement and longevity.  The Connection Between Retiring Early and Living Longer  looks at a number of studies here and abroad.

That retirement promotes health and prolongs life isn’t obvious. After all, work provides income and, for some, health insurance — both helpful for maintenance of well-being. It also can provide purpose and camaraderie. Evidence is mounting that loneliness and social isolation are linked to illness, cognitive decline and death. One study of American retirees found them less likely to be lonely or depressed.      

For some, retirement doesn't have a healthy impact.  Developing, or continuing, good eating habits and exercise are critical.  "Retirees are more likely to exercise, and those who do are better off for it. One study found retirees get more sleep and spend more time doing household work and gardening — both of which are more active than a desk job. Another study found that better health in retirement may be because of the reduced likelihood of smoking."  Those are all good things, but for many, retirement is outside of their financial ability. "[A]ccording to a recent national survey by the Board of Governors of the Federal Reserve System, many Americans don’t have the resources to retire. About 20 percent of Americans over 44 years old have no retirement savings. Half of Americans are at risk of being unable to maintain their standard of living in retirement. If you want to retire, whether for health benefits or otherwise, you’ll have to start preparing when you’re still young."

January 30, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Other, Retirement | Permalink | Comments (0)

The Challenges Facing Sellers of LTC Policies

My co-blogger buddy, Professor Pearson, recently posted about the costs of  long term care insurance policies. A new article  in Bloomberg View examined the implications of the losses posted by a division within GE for long term care insurance policies, What’s Bad for GE Will Be Worse for America. The article notes the implications of the division's losses beyond the company: "it’s also a harbinger of a much greater challenge for society at large: paying to care for the growing number of Americans who can’t look after themselves." The article notes that increased life expectancies contributed to the problems but it's important to look beyond why a particular company has issues. Instead the article offer that paying for long term care is not a problem to be solved just by the insurance companies.

"By 2050, the U.S. will have almost 90 million people aged 65 and over, and more than half will need long-term care at some point. Yet only a sliver of that group can afford the premiums insurers require. As of 2015, private insurance covered less than 10 percent of U.S. spending on long-term care -- and the private market has been shrinking."

We all know there is no easy answer on what we should do in the US regarding long term care. I thought this paragraph very compelling

The challenge is to design a safety net that will deliver long-term care when it’s needed -- without making people destitute first, yet without burdening taxpayers unduly. This isn’t only a matter of compassion: There’s a strong economic argument as well. The cost of long-term care weighs heavily on the economy, as family members step in to do what the health-care system does not. The lifetime cost to caregivers in forgone wages and other losses has been put at $3 trillion.


January 30, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink

Thursday, January 25, 2018

What Does An Alzheimer's Patient Look Like? She Looks LIke All of Us

Kaiser Health News ran a very interesting story, Postcard From California: Alzheimer’s ‘Looks Like Me, It Looks Like You’. The article opens with the story of an attorney who has early onset Alzheimer's who recounts her experiences as part of a panel discussion.  "Sponsored by Northern California and Northern Nevada Chapter of the Alzheimer’s Association, the event was part of an initiative to highlight the disease’s impact on women, who account for two-thirds of people living with Alzheimer’s and two-thirds of those caring for them... About 630,000 people have Alzheimer’s disease in California, and women in their 60s have a 1 in 6 chance of developing the disease — almost twice as high as the risk of developing breast cancer."  One of the most compelling quotes in this story came from a panelist who said this "'“Alzheimer’s looks like me, it looks like you, it looks like everyone,'" [she] ...  said." The story closes with advice from one of the panelists about the importance of doing what makes one happy.  Good advice.

January 25, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Programs/CLEs | Permalink | Comments (0)

Wednesday, January 24, 2018

What to Do About Unlicensed Care Facilities? The Hawaii Issue

According to reports from Hawaii media, the state has a growing number of unlicensed long-term care facilities for the elderly and disabled.  One critic describes the problem as facilities that have "gone rogue."  I strongly suspect that Hawaii isn't alone on the issue, where providers operate in the shadows of the law, seeking to avoid regulations setting minimum standards, authorizing inspections and implementing other state oversight. Operators push back on regulation, citing the costs of compliance.  Certainly, I've seen issues in my own state of Pennsylvania, where some operators attempt to change their names or identities to avoid whatever is viewed as the latest or most demanding regulations.  I remembering watching as an employee of one long-time, respected provider of "assisted living," chipped those words off the granite sign at the front of the property, part of his boss's effort to avoid Pennsylvania's then "new" regulation of assisted living operations.

Legislators in Hawaii have introduced new legislation in an attempt to plug the oversight holes, but operators are pushing back:

Care home operators, case managers, industry regulators and others filled a conference room Monday at the [Hawaii] Capitol for a tense briefing about the consumer protection, fairness and enforcement issues that these unregulated facilities present.


Rep. John Mizuno, chair of the Health and Human Services Committee, said he and health officials have crafted a bill that they hope cracks down on the problem. “We cannot lose any more kupuna,” he said. “No one else dies. That’s it.” 


The situation has gotten to the point that some health officials are worried that Hawaii’s rapidly aging population may end up with unsafe options for their care. “If the Legislature is unable to stop this trend, more licensed facilities will drop out and this will place more seniors at risk,” said John McDermott, who has served as Hawaii’s long-term care ombudsman since 1998.

By the way, "kupuna" is a Hawaiian word for elders, grandparents or other older persons. For more information, read "Why Hawaii's Unlicensed Elder Care Industry Is Out of Control," by Nathan Eagle," and review HB 1911, which seeks to authorize Hawaii's Department of Health to investigate care facilities reporting to be operating without an appropriate certificate or license.

January 24, 2018 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Housing, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (2)

Tuesday, January 23, 2018

Physician-Assisted Death: Ethical Debates, Professional Challenges, Societal Questions

The Hastings Center has announced an upcoming public workshop on February 12-13, 2018 in Washington, DC.  Physician-Assisted Death: Ethical Debates, Professional Challenges, Societal Questions will explore several topics.  The website explains

What is known about the access to and practice of physician-assisted death in the United States and in other countries? In U.S. jurisdictions where it is legal, who makes use of this provision? What are the experiences of health professionals? Who is vulnerable? These are some of the questions that will be explored at “Physician-Assisted Death: Scanning the Landscape and Potential Approaches, a public workshop organized by the Board on Health Sciences Policy of the National Academies of Science, Engineering, and Medicine. Hastings Center research scholar Nancy Berlinger is on the planning committee for the workshop, which will take place in Washington, D.C., on February 12 and 13.

“Ethicists, clinicians, patients and their families debate whether physician-assisted death ought to be a legal option for patients,” states the National Academies board in explaining the background and objectives of the workshop. “While public opinion is divided, and public policy debates include moral, ethical, and policy considerations, a demand for physician-assisted death still persists among some patients, and the inconsistent legal terrain leaves a number of questions and challenges for health care providers to navigate when presented with these patients.” . . . At the National Academies workshop, [Berlinger] will chair a session on data and lessons from other nations, including Canada, which implemented its PAD provision nationally in 2016. . . .

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

Monday, January 22, 2018

The Importance of Friendship in Later Life & Caregiving

As I type this, it is 5 in the morning and I'm thinking about my "to do" list for the day.  I've already baked cinnamon rolls, the kind my mom likes best.  My list includes talking to my mother's accountant about a problem with W-2 tax forms for 2 of the 4 caregivers who help mom in her home. It includes setting an appointment wih the latest addition to the team, a physical therapist.  I also need to get the forms from my mom's long-term care insurance company, to start the paperwork for an assessment.  And, that leads into another item on my list, stopping at two residential living communities to drop off  "deposits" to hold spots, while my sister and I work towards the possibility -- no, the probability -- of that difficult decision.

As I think about these small tasks, all of which I need to complete before I head to the airport for another red-eye flight between Arizona and Pennsylvania, I'm also thinking about how important friendships are in later life.  Not just my mother's friends, but my own.  Over the weekend, I spent lots of time talking with a long-time friend. We grew up together and used to ride horses.  As I type this blog post, I can see a funny, faded, framed photo on the wall of my childhood bedroom showing the two of us, plus two more friends, competing as a team in a "4s" class, a riding event that probably no longer even exists. We look so serious as we tried to keep our three chestnut horses plus one palomino in step (and from kicking each other). Riding 4s (2)  
Our elder care interests and careers now overlap as she operates a small personal care home, licensed to provide assisted living. We sometimes joke that we started learning about caregiving in 4-H, although back then our charges  were more likely to be critters. How I wish my friend's care center was an option for my mother, but unfortunately it is too far from my sister's home and job to be practical.

Instead, we talked strategies and other options. She had great advice about switching my mother over to electronic cigarettes, to make a transition to a "no smoking home" a bit easier.  Her mother, who's close to my mother's age, is also struggling with staying in her own home.  Ironic, isn't it, that my friend runs one of the best care homes in the city, but her mother won't even visit?  Sort of like the elder law professor whose parents resisted making plans?

But, as my friend said this weekend, caregiving decisions somehow "seem" different when you are talking about your own parent. The same is true for elder law advice. Even as she and I were giving each other "great" advice, we knew it was hard to follow that advice for our own mothers as they resist major changes.   

It was great to have her to talk with this weekend. My friend understood.  

That wasn't the only important friendship over the weekend.  One of my sister's long time friends interrupted a grocery shopping expedition and joined us on a car ride with our mother.  Her lively, funny conversation kept the tone light and upbeat, even as we did our first drive-by with mom, to look at the outside -- just the outside -- of one care center option that is nearby.  That friend, too, is caring for her mother and sometimes it is our turn to join them to create an "evening out "  

Another friend this weekend is the gal who I came to know so well as the director of the wonderful place where my father lived for many months.  She interrupted her "off duty" weekend to talk to me as a friend about choices.

A cherished neighbor and friend of my mother's also texted me early today, to ask about mom's weekend, even as she is juggling duties to help her husband in a rehab facility, where he is recovering from a broken hip.

I heard from a friend in Florida who lives in a terrific CCRC and she always offers a great ear and sage advice (along with lots of good leads for this Blog).

Another friend actually offered to fly out to Arizona to help -- and she lives in the Virgin Islands.  She, too, is helping an aging parent in the states.

I know that when I return to my classrooms in Pennsylvania later this week, individual students will ask, "how did it go?" And they will undoubtedly surprise me with their patience with our interrupted syllabus and make-up classes.  

Friends who understand.  

I could keep typing for a long time to describe our many friends and the important roles we play in each other's lives.  I know -- and hope -- that many of our readers are supported in their caregiving journeys by such wonderful "late-in-life" friendships. Thank you all,


January 22, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Housing | Permalink | Comments (1)

Sunday, January 21, 2018

Dementia Advance Directive?

I read a recent article in the New York Times as part of the New Old Age Series. Paula Span writes  One Day Your Mind May Fade. At Least You’ll Have a Plan. The article is about advance directives for those with dementia as discussed in a recent article published in the Journal of the American Medical Association (JAMA).  The idea of the dementia-specific advance directive is to express your wishes based on the specific "phase" of dementia you may enter in the future.  The website for this directive is here from which the 5-page directive may be downloaded.  The NY Times article describes the directive "In simple language, it maps out the effects of mild, moderate and severe dementia, and asks patients to specify which medical interventions they would want — and not want — at each phase of the illness."

In the JAMA article, the authors make the case that other existing advance directives aren't particularly helpful for those with dementia because of the way it progresses over time with corresponding diminishing cognitive function (a subscription is required to access the article).  The NY Times article notes that "[a]lthough [dementia] is a terminal disease, dementia often intensifies slowly, over many years. The point at which dementia patients can no longer direct their own care isn’t predictable or obvious. ... Moreover, patients’ goals and preferences might well change over time. In the early stage, life may remain enjoyable and rewarding despite memory problems or difficulties with daily tasks."

The dementia-specific directive describes the person's wishes  as "goals of care" and offers four options for each stage of dementia, directing the person to "[s]elect one of the 4 main goals of care listed below to express your wishes. Choose the goal of care that describes what you would want at this stage."  The directive divides dementia into three stages, mild, moderate and severe.

There are already a number of types of advance directives, with recent pushes for POLST and other initiatives such as the Conversation Project.   Then there is the Five Wishes document,  which as been around for a number of years. Attorneys may be incorporating dementia-specific instructions into advance directives already.



January 21, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, January 18, 2018

Patient Dumping-By the Health Care Provider

There's been a lot of buzz after that video surfaced of a hospital patient left at a bus stop just in a hospital gown. NPR ran a follow up story, Why Was A Baltimore Patient Discharged At A Bus Stop In Just A Gown?  The president and CEO of the hospital in a subsequent press conference indicated that the event was isolated and those involved would answer for their actions.  There is a lot we don't know about the story (and some we may never know because of privacy issues). CBS then ran a story from the mother of the patient. In the story Mother calls hospital "callous and heartless" for leaving her daughter in the cold, the mother explains that her daughter, the patient, has mental illness.

How is this different, if at all, than granny dumping, where a family member might abandon an elder relative at the emergency room? I did a quick google search to see if I turned up any recent articles on granny dumping, and didn't really find much, except for this one from a year ago, Japanese people who can't afford elder care are reviving a practice known as 'granny dumping'.

What's your take? Is this not specifically happening much, if at all, in the US any more?


January 18, 2018 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink

Stunning Rate Increases Likely to Continue for Owners of Long-Care Insurance Policies

The Wall Street Journal has an update article this week on the financial  health of the long-term care insurance industry, detailing recent rate increases and reminding us that even with contraction of this specialized market for sellers of new policies, there are still more than 7 million policies affected by the inadequate pricing structure issues.  

Steep rate increases that many policyholders never saw coming are confronting them with an awful choice: Come up with the money to pay more—or walk away from their coverage.


“Never in our wildest imagination did we consider that the company would double the premium,” says Sally Wylie, 67, a retired learning specialist who lives on Vinalhaven Island, Maine.


In the past two years, CNA FinancialCorp. has increased the annual long-term-care insurance bill for Ms. Wylie and her husband by more than 90% to $4,831. They bought the policies in 2008, which promise future benefits of as much as $268,275 per person. The Wylies are bracing for more increases.

Even with the rate increases, companies are looking at losses in anticipation of claims as existing policy holders are now aging into a claims mode. General Electronic Company, has attempted to reassure shareholders about the impact of its LTCI business on profits.  

Only a dozen or so insurers still sell the coverage, down from more than 100. General ElectricCo. said Tuesday it would take a pretax charge of $9.5 billion, mostly because of long-term-care policies sold in the 1980s and 1990s. Since 2007, other companies have taken $10.5 billion in pretax earnings charges to boost reserves for future claims, according to analysts at investment bank Evercore ISI. . . . 


Almost every insurer in the business badly underestimated how many claims would be filed and how long people would draw payments before dying. People are living and keeping their policies much longer than expected. After the financial crisis hit, nine years of ultralow interest rates also left insurers with far lower investment returns than they needed to pay those claims.


Long-term-care insurers barreled into the business even though their actuaries didn’t have a long record of data to draw on when setting prices. Looking back now, some executives say marketing policies on a “level premium” basis also left insurers with a disastrously slim margin of error.


“We never should have done it, and the regulators never should have allowed it,” Thomas McInerney, president and chief executive ofGenworth FinancialInc. since 2013, says of the pricing strategy. “That’s crazy.”

For more of this detailed article, see  Millions Brought Insurance to Cover Retirement Health Costs.  Now They Face an Awful Choice.  Our thanks to University of Illinois Law Professor Dick Kaplan and New York attorney Karen Miller for bringing this article to our attention.  


January 18, 2018 in Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Property Management, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Tuesday, January 16, 2018

Oh Those Boomers: Reaping the Impact of Loud Music

Those Boomers (or should I say, more accurately, we boomers). We invented lots of things (if you ask us) including rock 'n roll and now we are experiencing hearing loss. It was only a matter of time.... after years of playing all that rock music so loudly (of course our parents warned us), we are reaping the after effects-hearing loss (this is a tongue in cheek statement, BTW). Baby boomers destroyed their hearing. Biotech is trying to fix it 

opens with these paragraphs

Baby boomers grew up with music blasting from dorm room turntables, car stereos, and arenas where the sound of a band at full throttle could rival the roar of a jet engine. Volume became an act of generational defiance. As rocker Ted Nugent put it: “If it’s too loud, you’re too old.” ... Turns out, it was too loud. Millions of boomers are now grappling with hearing loss — some of it caused by turning the volume to 11 — prompting companies to develop treatments that improve upon the expensive and often limited-value hearing aids and surgical implants that have been around for decades.

Intrigued. Find yourself amongst those who maybe played your music at "11"?  Want to read more?  The Boston Globe also an the article.  The article looks at the frequency (no pun intended, honestly) of hearing loss and it's a lot, the treatments being researched, and more. And before you go off to tell your children to turn down the volume on their music, the article notes noise isn't the only reason for hearing loss. Some of it is genetic and another is age related. Technology plays a role as well, with one expert noting the impact of leaf blowers and ear buds.  Different devices and developing drugs are being studied as an option for those with hearing loss.

January 16, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other, Science | Permalink | Comments (1)

Choice and Customer Service in Senior Living

My sister and I have been interviewing locations for several weeks as possible residential settings for our mother, especially as she is no longer able to handle the stairs in her two-story home, but feels trapped by not being able to choose on her own where to walk.  We know that the best way to approach this task is in small doses, and to do it before there is an emergency that limits choices.  This is actually our second go-round, as we also did this with Mom when we were looking at a place for Dad almost 5  years ago.  But we have been very struck by the changes in the marketplace in just that short period of time:

  1. There are many new options, both large and small, that have come into being in just the last five or fewer years.  We have looked at "classic" versions of continuing care communities, as well as what I would call "ala carte" pricing options for communities that offer a wide range of care alternatives, but each for a separate, escalating price and with no assurances of a placement. We've looked at both modest settings and high end "assisted living centers" that are so new the paint has not quite dried. But most of all, what we have found ourselves focusing on are smaller group homes, licensed under that state's law for "assisted living," and under that law the care includes almost all necessary care, other than certain so-called skilled services (such as catheters, feeding tubes, or I.V. hydration).  We liked the small group setting because they often were in a neighborhood that would make our mother feel at home, while still offering a purposeful renovation that included carefully designed toilets, showers and flooring for easier movement.  The price range is stunningly broad between these options, too.
  2. Doctors are not always the best advisors on choices.  We have found that even though our mother has a wonderful primary care doctor, and even though that doctor makes it known that most of his patients are older, he did not seem to be aware that there are group home options.  He kept telling us we'd need a "skilled care nursing home."  But, as Mom has a pretty detailed end-of-live directive that rejects feeding tubes, and similar skilled care interventions, it seems clear to us that we can look at a well-run facility licensed for assisted living that will be able to provide appropriate care through her last days.  
  3. A lot of the smaller places are accessed through what I would call "brokers."  When you do internet research, the odds are that your first contacts will be with some kind of "finder."  Most of these are paid by the facilities, rather than the families conducting the searches.  As such, there is the clear potential for them to steer families to "their" facility clients.  I know from insiders in the industry that the fees are often the equivalent of one month's fee at the chosen location.  While not necessarily a negative, as a good broker is only successful if he or she really knows the available inventory of residential options, the fees are something that can dramatically impact smaller group homes that are operating on a narrower margin.

Additional trends we noticed? We discovered that a small group home that appears to be a  "family" operation,  may actually be part of a chain of homes with a single corporate owner.  On the other hand, at several of the places we visited, we learned the owner had recently purchased another house in the same neighborhood, and was in the process of a second renovation.  Also, as for staffing, we noticed that in certain parts of the city, all of the caregivers were immigrants from the same country, whether Poland or Pakistan or elsewhere.  Another reminder that realistic immigration policies are a key component to senior living. 

Finally, probably our strongest reaction was to differences in what can only be called old fashioned "customer service."  One "famous," established  CCRC completely lost our interest when the person at the front desk never made direct eye contact with us, instead keeping one hand on a cell phone and the other hand on a very dirty "wet wipe" she said she was using to clean surfaces because it was "flu season." It didn't help that we went through three different people to find one who could give us a tour during a scheduled visit (the first two were so new they didn't have knowledge of the full campus.) At the smaller group homes, we definitely noticed when the persons we met with greeted current residents by name as they gave us a tour.  Also, did they know the names of their own staff members  -- and did they introduce us to each other?  When a trip hazard was lying in wait on the floor, did they pick it up -- or merely avoid it?  

In addition to asking about staffing ratios and open visiting hours, we wanted to know about how long each of the staff members we met had worked at the particular place.   Finally, our whole family likes dogs and therefore it was a plus when we found a place that had a "house dog" that the residents clearly loved, but we recognize that not every place can handle the extra work it takes to maintain a pet on site.  

A sad irony is that it is unlikely our mother will live in the same care setting that was so perfect for our father.  That place is an assisted living center with four cottages, purpose built for Alzheimer's care, on a five acre setting.  But it has become clear to us that even though Mom was the one who chose it for Dad, and it is a wonderful place, with people we still love, our mother probably doesn't want it for herself.  In the last few months of our father's residence there before his death, she visited less and less often, and we came to realize she had "already" rejected it for herself.  It wasn't about memories of Dad; rather, it was about what it meant to "also" have the same cognitive impairment.  The director, who has become a good friend of mine, said that is not unusual -- that even successful residential settings are rarely chosen by families for second or third placements because the next loved one can be hypersensitive to the reality of that choice.  Senior care living -- a tough business in which to generate repeat business. 

January 16, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing, State Statutes/Regulations | Permalink | Comments (1)

Monday, January 15, 2018

Regenerative Medicine: The FDA

Stem Cells!  The New England Journal of Medicine published an article on regenerative medicine. Rejuvenating Regenerative Medicine Regulation explains FDA action regarding the regulation of regenerative medicine.

The Food and Drug Administration (FDA) recently made long-awaited progress toward protecting patients from interventions involving human cell- and tissue-based products (HCT/P) of unknown safety and efficacy. By clarifying its position on the handling and therapeutic use of cells, the agency has sent a clear signal that it intends to regulate a broad swath of highly manipulated cellular materials as biologic drugs. This is a welcome development, and complementary action taken at the state level and by professional societies would further promote the interests of patients.

The question of whether using the patient's own stem cells falls under the FDA or medical practice has been one of debate, which are addressed with the issuance of these guidance documents.  The authors see these as a step in the right direction but not the final step. A pdf of the article is available here.

January 15, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Filial Friday on Monday: PA Supreme Court Agrees to Hear Further Appeal of "Reverse" Filial Support Case

Regular readers of this Blog will remember that we have been following the case of Melmark Inc. v. Schutt, wherein a residential facility for disabled children and adults in Pennsylvania, has sought to hold 70+ year-old New Jersey parents liable for approximately 13 months of care the facility provided for their autistic adult son after New Jersey stopped public payments for his support.  The parents were successful at the trial and intermediate courts of appeal in Pennsylvania, arguing that New Jersey, not Pennsylvania law controlled the issue of any filial obligation.  Pennsylvania statutory law imposes liability on certain family members, without regard to age, to cover costs of care provided to "indigent" children or parents, while New Jersey's filial support statute limits obligations for older adults, for "any person 55 years or over," to support for minor children or spouses.  See N.J.S.A. Section 44:1-140(c) (Relatives Chargeable).   The unpaid costs in question totaled more than $200,000, before the Melmark took it upon itself to take the son back to New Jersey, dropping him off at a local hospital.

On December 26, 2017, the Pennsylvania Supreme Court granted the facility's request for further appeal on the following issues:

1. Whether the Superior Court erred as a matter of law in finding that New Jersey’s filial support statute, rather than Pennsylvania’s, applied
in this matter where there is no conflict between the New Jersey statute and Pennsylvania’s statute under the facts of this case?

2. Whether the Superior Court erred in finding that New Jersey has a greater interest in the application of its filial support statute where, inter alia, all of the relevant contacts, with the exception of the residency of Respondents Clarence and Barbara Schutt, are with Pennsylvania; where the Schutts took affirmative actions to keep their highly disabled son in a Pennsylvania nonprofit residential and therapeutic institution, Petitioner Melmark, Inc., with the avowed aim of Melmark funding his care for his “entire life,” including manipulating the Pennsylvania and New Jersey legal systems to prevent his return to New Jersey; and where the Superior Court’s decision results in Melmark being entirely uncompensated for providing an extended period of vital, intensive care for the Schutts’ son?

3. Whether the Superior Court erred in finding that the lower court properly denied relief on Melmark's claims for quantum meruit and unjust enrichment? 

I've been teaching Conflicts of Law for many years and I actually used a variation on this problem for the final exam in my Fall 2017 course.  As was true in the lower courts in the Melmark case, most of my students came to the conclusion that under the forum's choice of law rules, the state with the most substantial relationship to the issue of parental liability for statutory support was the state where the parents and son were residents, here New Jersey.  

My best guess is that the Pennsylvania Supreme Court may go more deeply into  the common law claims for "quantum meruit and unjust enrichment" (which in Pennsylvania are usually treated as alternative names for the same causes of action, sometimes termed "quasi-contract" claims). 

As I've been saying for months now, this is a tough case for everyone.  

January 15, 2018 in Current Affairs, Ethical Issues, Health Care/Long Term Care, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, January 12, 2018

Federal Right to Try Legislation

The New England Journal of Medicine recently published an opinion article, Federal Right-to-Try Legislation — Threatening the FDA’s Public Health Mission. The second paragraph sets out the issues

[T]he FDA created “expanded access” pathways to give desperate patients without other options access to promising products before approval, while still providing oversight. The agency received more than 5000 requests under those pathways between 2010 and 2014.1 But in August 2017, the Senate passed the Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act, which would sharply curtail the FDA’s oversight of access to investigational drugs for patients with life-threatening illnesses.2 Though popular with the public and supported by politicians from both parties, the legislation has been widely criticized by policy experts. In isolation, its impact would probably be limited, since the bill was substantially hollowed out to secure the necessary votes. Nonetheless, the motivation behind the proposed legislation threatens to weaken the FDA’s ability to pursue its public health mission.

The article discusses the bill, the concerns expressed and the countervailing arguments.  The authors conclude "[a]re we prepared to abandon the FDA’s gatekeeping role in favor of unfettered patient autonomy and market forces, risking precisely the problems that prompted Congress to grant the FDA its present authority? The agency has made substantial progress in balancing the needs of desperate patients and the principle that all patients deserve evidence that the benefits of medical products justify their risks. We upset that balance, and diminish the FDA’s public health mission, at our peril."

A pdf of the article is available here.

January 12, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (0)

Thursday, January 11, 2018

ER Visit Signals Underlying Issues?

Kaiser Health News ran a story about how an ER visit may signal underlying, and maybe undiscovered, issues for elders. For Elder Health, Trips To The ER Are Often A Tipping Point explains that "[a]n older person’s trip to the ER often signals a serious health challenge and should serve as a wake-up call for caregivers and relatives."  Based on a study last year, the article reports that statistics bear this out: "[s]ix months after visiting the ER, seniors were 14 percent more likely to have acquired a disability — an inability to independently bathe, dress, climb down a flight of stairs, shop, manage finances or carry a package, for instance — than older adults of the same age, with a similar illness, who didn’t end up in the ER."  This doesn't mean those who visited the ER were always admitted, and in fact, in many instances the converse was true.

The takeaway: Illnesses or injuries that lead to ER visits can initiate “a fairly vulnerable period of time for older persons” and “we should consider new initiatives to address patients’ care needs and challenges after such visits,” said one of the study’s co-authors, Dr. Thomas Gill, a professor of medicine (geriatrics), epidemiology and investigative medicine at Yale University.

The article notes that those needing help with ADLs or IADLs for example, are particularly at risk of having problems after an ER visit.

January 11, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Tuesday, January 9, 2018

MN Concerns SNF Penalty Rollback Affects Efforts to Fight Elder Abuse

We reported recently that the administration has decided to take a step back from the imposition of penalties vs. nursing homes.  The StarTribune ran a story that Minnesota officials have concerns that this step back will harm their efforts to fight elder abuse. U.S. easing of nursing home penalties could imperil Minnesota's crackdown on elder abuse notes that "[t]he federal move also comes as Gov. Mark Dayton has pledged tougher action against elder abuse and has promised improvements to the state’s troubled system for investigating and responding to allegations of maltreatment in senior homes." The article reminds readers of a five-part series that the paper had run back in November of 2017 that focused on the state's handling of elder abuse cases. The series was the catalyst for the Minnesota Governor's creation of "a working group to review state oversight of senior care homes and transferred some enforcement authority from the Health Department to the Department of Human Services, which has more resources." The state's acting Commissioner of health has taken steps to attack the backlog of those elder abuse cases pending investigation by increasing staff and moving away from paper records.   The article also offers some comments from those who support the step back from the use of penalties.


January 9, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

MN Concerns SNF Penalty Rollback Affects Efforts to Fight Elder Abuse

We reported recently that the administration has decided to take a step back from the imposition of penalties vs. nursing homes.  The StarTribune ran a story that Minnesota officials have concerns that this step back will harm their efforts to fight elder abuse. U.S. easing of nursing home penalties could imperil Minnesota's crackdown on elder abuse notes that "[t]he federal move also comes as Gov. Mark Dayton has pledged tougher action against elder abuse and has promised improvements to the state’s troubled system for investigating and responding to allegations of maltreatment in senior homes." The article reminds readers of a five-part series that the paper had run back in November of 2017 that focused on the state's handling of elder abuse cases. The series was the catalyst for the Minnesota Governor's creation of "a working group to review state oversight of senior care homes and transferred some enforcement authority from the Health Department to the Department of Human Services, which has more resources." The state's acting Commissioner of health has taken steps to attack the backlog of those elder abuse cases pending investigation by increasing staff and moving away from paper records.   The article also offers some comments from those who support the step back from the use of penalties.


January 9, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

Monday, January 8, 2018

Florida Nursing Homes and Emergency Generators

Here's an update on this issue in Florida.  The Florida legislature opens its 2018 session on January 9, 2018 and one of the issues on the legislative agenda is whether to legislatively require nursing homes to have generators and enough fuel to power them for a certain length of time during an emergency.  In addition, concerning the Florida administrative agency's proposed rules on requiring emergency generators (the Governor's emergency administrative order was struck by an ALJ): the ALJ has scheduled a hearing over three days (January 17, 19 and 24, 2018).

Although this issue Florida resulted from Hurricane Irma, it's worth watching.  Emergency generators can be important beyond just hurricane-prone states. Consider the recent winter storm Grayson that was described as a "bomb cyclone". The storm resulted in power outages for many, so it's not too far a stretch to recognize that emergency generators could come in handy beyond Florida. Stay warm!

January 8, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (1)

The Challenge of Finding Safe & Effective Pain-Killers for Older Adults

Over the holidays, unfortunately I had the experience of learning more about how older consumers struggle to understand what safe and effective treatments are available.  In this instance, my mother, in her 90s, was experiencing overwhelming back pain.   She has a long-history of osteoporosis (and it runs in the family on the female side, so my sister and I pay particular attention to this issue!) and in the last few weeks without any known "accident," she had begun to find it almost impossible to walk without pain.  She's not the complaining type, and, having been raised by parents who were Christian Scientists, she tends to follow a "mind over matter" approach to this kind of problem.  But, by Sunday last week, it was no longer possible to pretend she wasn't deeply uncomfortable.

We began another health care odyssey.  Some of the steps we had already learned from past "holiday" experiences with my parents, including calling the "non-emergency" 911 number to get an experienced EMT evaluation of her status in the home, and, if necessary, a transport from her home to the emergency room.  Then, recognizing that New Year's Eve is probably not the best night (if such a thing even exists) to spend in the local hospital's ER, we decided to go early in the morning.  

Five hours after our arrival in the ER, we left with a new "LSO" back brace, instructions on how to use it, and prescriptions for a different walker and a new pain medication.  On the latter point, we informed the ER physician of the fact Mom had not done well on narcotic pain relievers in the past ("why are those ants crawling on the walls") but we were told the drug prescribed was like a very strong Ibuprofen, but in a formulation that would not interact with the blood thinner she was on or her pacemaker.

We duly stopped at the pharmacy on the way home, and I signed my life away in order to pick up her prescription as she was unable to walk in to get it herself.  When we got home,  there were two documents in the bag with the prescription, including what I would call a typical "product insert" that looks like a page from the Physician's Desk Reference and a second sheet entitled "Directions for Use."  The top of the instructions warned, "This is a narcotic drug and not recommended for the relief of pain in...."  And then the list of disqualifying conditions included at least 3 of my mother's age-related conditions.  Yikes!  

My sister and I are  not usually intimidated by product inserts, but here the instructions seemed directly at odds with our concerns about narcotics for mom.  Everything we found on the internet only made us more confused and worried.  

By this time it was late on New Year's Eve, her pain was increasing, and we knew we couldn't persuade her to go back to the ER and her primary care physician wasn't on call.  The bottle said "every 6 hours."  The ER physician had orally told us "every 6 to 8 hours," and finally we knew we had no choice -- her pain was real and we started using it at 12 hour intervals, gradually moving down to 8 hour intervals before she seemed to have real relief.  It was another 5 days before her very kind primary care physician could squeeze us in for an appointment to have a more complete conversation -- and the good news is that we are now more comfortable about a longer range plan.

So on the heels of that multi-day experience, I was very interested in an article I spotted for my airplane trip home to Pennsylvania from Arizona. Phoenix Magazine had a detailed feature story in their January 2018 issue on "Pharma Chameleon," reporting on the arrest for fraud and racketeering charges of INSYS  Therapeutics founder, a "billionaire executive" in Phoenix, well-known for his work on painkiller medicines.  The history of this executive has nothing to do with my mother's pain relief medicine, but it was definitely a reminder that the pharmaceutical industry is deeply involved in pursuit of the "next" generation of painkillers.  And, of course, this article contrasts with the recent news that a different drug company is dropping R & D for a dementia drug.  Pain-killers are still "in," and dementia drugs apparently are "out."  

So, I recommend the Phoenix Magazine article!  I was particularly struck by this paragraph:    

In November, Kapoor [the Phoenix-based INSYS executive arrested by the feds] pleaded not guilty to all charges and is currently awaiting trial, along with the six other former executives, who pleaded not guilty last January. All have severed ties with INSYS, which continues to do business. In July, it received FDA approval for a new drug, Syndros, a synthetic form of THC, the psychoactive component found in cannabis, to treat chemotherapy-induced nausea and loss of appetite in AIDS patients. As it did with Subsys, the company is looking into ways to manufacture the drug as a sublingual spray. Under Kapoor, the company donated $500,000 to the effort to defeat the measure to legalize marijuana for recreational use on Arizona’s 2016 general election ballot, paving the way for the synthetic substitute.

January 8, 2018 in Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (1)