Tuesday, February 14, 2017
We reported previously that DC had passed an aid-in-dying bill but that there were those in Congress who expressed an intent to overturn it. But it's not just the DC scenario that has advocates concerned. Kaiser Health News ran an article, Aid-In-Dying Advocates, Disheartened By Supreme Court Pick, Brace For New Fight. The article, part of KHN's morning briefing, summaries articles from other publications about Judge Gorsuch's book and his position on aid-in-dying. Click here to access those articles.
While we're on the subject, also check out this article from KHN on Aid-in-Dying Laws Don’t Guarantee That Patients Can Choose To Die, discussing patient access in those states with aid-in-dying laws (we'd previously discussed this in an article from the Denver Post).
I have had several law students take advantage of summer internships available through the David Berg Center for Law and Aging in New York City and they always report it was a great experience. The window is now open for applications for summer 2017. Here are the details:
The David Berg Center for Law and Aging is seeking select students for its Summer 2017 internship program. The David Berg Center for Law and Aging focuses on a wide range of legal and policy issues affecting the older adult population and victims of elder abuse and exploitation. Interns will be offered the unique opportunity to work at the nation’s first elder abuse shelter, The Harry and Jeanette Weinberg Center for Elder Abuse Prevention at the Hebrew Home at Riverdale. Located in the Riverdale section of the Bronx, New York, on 17 acres of the Hudson River, the comprehensive elder abuse center provides an emergency residential shelter as well as psychosocial, health care and legal advocacy and community-based services for victims of elder abuse. Under the direct supervision of the Weinberg Center’s Assistant Director and General Counsel, students will be exposed to legal practice in New York City and Westchester County. Students may have the opportunity to work collaboratively with Weinberg Center partners such as the New York State Attorney General’s Office, the New York City Police Department, District Attorneys’ Offices and Family Justice Centers. Interns will complete substantive research and writing on the different legal and policy issues impacting the older adult population and victims of elder abuse. Past issues have included questions surrounding legal capacity, guardianship, powers of attorney, Medicaid eligibility, copyright, and right to privacy. The interns will gain case management skills and potential courtroom exposure through drafting petitions for guardianship, family court orders of protection and housing court matters. The interns will also have the opportunity to participate in multidisciplinary conferences, meetings of the American Bar Association Senior Lawyer’s Division’s Elder Abuse Task Force and other community outreach and training events. Dormitory style affordable housing at the College of Mount Saint Vincent is available.
Interested students should send a resume, cover letter and writing sample to Deirdre Lok. Her email address is available on the Center's website here.
Monday, February 13, 2017
Late last month the Congressional Research Service published the following: The Elder Justice Act: Background and Issues for Congress. Here is an excerpt from the executive summary
Elder abuse is a complex issue that often requires a multifaceted policy response that combines public health interventions, social services programs, and criminal law enforcement for abusive behavior. To address this complexity, the Elder Justice Act was enacted on March 23, 2010 as part of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). The act attempt s to provide a coordinated federal response by emphasizing various public health and social service approaches to the prevention, detection, and treatment of elder abuse. The Elder Justice Act also represents Congress’s first attempt at comprehensive legislation to address abuse, neglect, and exploitation of the elderly at the federal level.
To date, most activities and programs authorized under the Elder Justice Act have not received federal funding through the annual appropriations process. For the first time, Congress appropriated $4 million for a new Elder Justice Initiative in FY2015 and $8 million in FY2016. However, the authorizations of appropriations for most provisions under the act expired on September 30, 2014. Despite the lack of discretionary appropriations prior to FY2015, some elder justice activities have received funding from mandatory funding appropriated through the ACA Prevention and Public Health Fund (PPHF). As a result of this limited federal funding, the federal government has not substantially developed and expanded its role in addressing the prevention, detection, and treatment of elder abuse.
For FY2012, the Secretary of the Department of Health and Human Services (HHS) transferred $6.0 million to the Administration for Community Living (ACL) from the PPHF for new grants to states and tribes to test elder abuse prevention strategies. Funded projects included using forensic accountants to prevent elder financial exploitation, increasing medication adherence to prevent elder self-neglect, and developing screening tools to identify elder abuse. For FY2013, $2.0 million was transferred to ACL from the PPHF for elder justice activities, which funded development of the National Adult Protective Services Data Reporting System Project. No PPHF funds were transferred to ACL for elder justice activities for FY2014 or subsequent fiscal years.
For FY2017, the President’s budget request included $10.0 million in discretionary funding for Elder Justice/Adult Protective Services (APS) that would be used to fund APS, research, and evaluation activities. The 2017 budget request did not specify an intended transfer of funding from the PPHF for elder justice activities. For FY2017, the Senate Appropriations Committee recommended $10.0 million for the Elder Justice Initiative in its FY2017 Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) appropriations bill. The House Appropriations Committee recommended $8.0 million in its FY2017 LHHS appropriations bill. Neither House nor Senate floor consideration of the bill occurred in the 114th Congress. Since the start of the fiscal year (October 1, 2016), funding for LHHS programs and activities has been provided by two continuing resolutions (CR; P.L. 114-223 and P.L. 114-254). The second FY2017 CR provides continuing appropriations for LHHS appropriations through April 28, 2017, or until full-year appropriations are enacted.
The report offers some observations for Congress as well as some concluding thoughts:
The Elder Justice Act represents one set of policies that exist in the broader context of domestic social policy to address the complex issue that is elder abuse. That is, as a federal legislative response, the Elder Justice Act may best serve as a catalyst for further federal coordination and action that can bring about greater public awareness and attention to the needs of a growing, and potentially vulnerable, aging population. According to GAO, the Elder Justice Act "provides a vehicle for setting national priorities and establishing a comprehensive, multidisciplinary elder justice system in this country."44 Such a response touches on a range of domestic policy programs and issues that are not specific to one congressional committee’s jurisdiction or area of expertise. Furthermore, congressional oversight into federal administration, implementation, and related activities must rely on different committees of jurisdiction as well as the experience of select committees such as the Senate Special Committee on Aging....
Mark your calendars. The Supreme Court is hearing oral arguments on February 22, 2017 in the case of Kindred Nursing Centers Limited Partnership, dba Winchester Centre for Health and Rehabilitation, nka Fountain Circle Health and Rehabilitation, et al., Petitioners v. Janis E. Clark, et al., docket # 16-32.
The Federal Arbitration Act (FAA) provides that arbitration agreements "shall be valid, irrevocable, and enforceable, save upon such grounds as exist at law or in equity for the revocation of any contract." 9 U.S.C. § 2 (emphasis added). That provision requires states to "place  arbitration contracts 'on equal footing with all other contracts."' DIRECTV, Inc. v. Imburgia, 136 S. Ct. 463, 468 (2015) (quoting Buckeye Check Cashing, Inc. v. Cardegna, 546 U.S. 440, 443 (2006)).
The Supreme Court of Kentucky here refused to enforce the parties' arbitration agreements because it held that the attorneys-in-fact who signed those agreements lacked authority to enter into arbitration agreements-despite broad powers of attorney, including the power to make "contracts"-because those agreements waive a "divine God-given right" to a jury trial. App., infra, 43a. The court concluded that only an express mention of arbitration agreements in the power of attorney permits an attorney-in-fact to bind her principal to an arbitration agreement (Ibid.), even though Kentucky law does not require such an express mention of any other type of contract.
The question presented is:
Whether the FAA preempts a state-law contract rule that singles out arbitration by requiring a power of attorney to expressly refer to arbitration agreements before the attorney-in-fact can bind her principal to an arbitration agreement.
Friday, February 10, 2017
When I first saw the news stories of the French cyclist who had set a cycling record for sixty minutes, I wasn't particularly impressed -- that is, until I realized that Mr. Robert Marchand is now age 105 and he's trying to break his own record of almost 17 miles per hour, set when he was 103. Turns out this is part of a much larger story about fitness in aging. From the New York Times:
At the age of 105, the French amateur cyclist and world-record holder Robert Marchand is more aerobically fit than most 50-year-olds — and appears to be getting even fitter as he ages, according to a revelatory new study of his physiology.
The study, which appeared in December in the Journal of Applied Physiology, may help to rewrite scientific expectations of how our bodies age and what is possible for any of us athletically, no matter how old we are.
For more, read Lessons on Aging Well, From a 105 Year-Old Cyclist. Inspiration for your own weekend workout, perhaps!
Thursday, February 9, 2017
We've all heard the saying, laughter is the best medicine. Kaiser Health News recently ran the story, Laughing Until You Die: Humor May Be Antidote For Pain Of Death For Patients, Survivors which focuses on the benefits of laughter.
An aging generation of boomers, the oldest of whom are now 70, grew up to the background sounds of TV laugh tracks and are accustomed to laughing at things that might not always seem so funny. There’s even a non-profit organization funded by donors, conference revenue and membership dues, whose mission is simply reminding people that laughter is a core ingredient of all facets of life — even end of life.
The article provides several anecdotes from folks who live with this laughter philosophy and even mentions the Association for Applied and Therapeutic Humor. The article cites advice from the association "Make certain that you know the ailing person very well before using humor with them." Exactly what type of humor should be used? According to the article, "[f]or some folks, the process of dying comes with less stress when it’s something of a laughing matter. Not a yuk-yuk laughing matter. But, at its simplest, a willingness to occasionally make light of the peculiarities — if not absurdities — that often go hand-in-hand with end-of-life situations."
Wednesday, February 8, 2017
Justice in Aging has released two new issue briefs concerning the new nursing home regs. One is on involuntary transfers and discharges and is available here. The other is on unnecessary medications and antipsychotic meds, and is available here. The briefs were done with the Center for Medicare Advocacy and the National Consumer Voice for Quality Long-Term Care.
Here's the executives summary for the transfer/discharge brief
The involuntary transfer/discharge regulations have changed, but not dramatically. Facilities still can force a transfer/discharge only under one of six specified circumstances, and a resident continues to have the right to contest a proposed transfer/discharge in an administrative hearing. The revised regulations narrow the facility’s ability to base a transfer/discharge on a supposed inability to meet the resident’s needs, by requiring increased documentation by the resident’s physician. The regulations also limit transfer/discharge for nonpayment, by stating that nonpayment has not occurred as long as Medicaid or another third-party payor is considering a claim for the time period in question. All transfer/discharge notices must be sent to the resident, resident representative(s), and (in a new requirement) the Long-Term Care Ombudsman program. The revised regulations now explicitly state that a facility cannot discharge a resident while an appeal is pending.
Here's the executive summary for the medications brief:
Regulations about unnecessary drugs and antipsychotic drugs have been moved from the quality of care section to the pharmacy services section. Some provisions have been moved but not otherwise changed: these include protection from unnecessary medications, requirements for gradual dose reductions, and the use of behavioral interventions in order to discontinue drugs, "unless clinically contraindicated." In addition, the pharmacy services regulation includes a new discussion of a broader category of psychotropic drugs, along with new controls over "as needed" (PRN) psychotropic drugs. The revised regulations also expand requirements for drug regimen reviews.
These and the first brief in the series are available here.
Tuesday, February 7, 2017
We've blogged on a number of occasions about the use of tech to provide services and support to elders, for various reasons. The American Society on Aging will have a series of sessions that deals with how tech is affecting, impacting, or facilitating aging at their annual Aging in America conference. Searching the sessions listings by the keyword "technology" brings up a significant number of sessions. An email I received highlighting the tech sessions included this list of sessions
- NEST CG Program: Co-design of Environments, Services and Technologies With an Aging Population
- Improving Health and Wellness of Seniors Using Wearable Technology
- Co-Designing Environments: The Way Forward
- On Participation: Co-Design of Services
- 21st Century Digital Communities: Technology that Supports Aging Needs
- An Innovative Model of Technology Strategies That Promote Aging in Place in Low-Income Housing Settings
- Building a Community-Based Sustainable Telehealth Intervention Program for Seniors
- Quantifying the Positive Effects of Music and Memory iPods and iPads for Dementia Care
- Policy to Practice: Assistive Technology and Aging
- Addressing Social Isolation Through Technology
- Gadgets or Godsends: How to Understand and Leverage Digital Technologies to Help Seniors
- Technology and a Multigenerational Staff
- The Impact of Senior-Friendly Websites
- Access: Innovative Mobility Options for Seniors
- Integrated eTechnology: Eldercare for the 21st Century
- Innovative Design Applications for Creating Living Environments for All Ages and Abilities
- ABCs of In-Home Technology for Post-Acute Patients
- Mobile Technology and Aging: How Seniors Are Keeping Up and Connecting
- New Technologies Supporting Creation and Sharing in Art Therapy With Older Adults
- Technology in the Life of the Caregiver
- Using Technology in Long-Term Care
- Medication Reconciliation Using a Mobile On-Demand Virtual Pharmacist
- Technology Solutions to Collect and Analyze Data Outside Hospital Walls
- Your Digital Mission: How Social Technology Can Advance Your Organization's Service
- Developing a One-Call, One-Click Transportation System
- Age-Friendly Efforts 2.0
- Technology for Social Change
If you are at the conference and attend any of these tech sessions, let us know.
Robert Fleming sent out some info on a listserv about a series of videos his firm has created and placed on You Tube to educate clients about specific substantive areas of law as well as answers to practical questions. That got me thinking about the value of such a service to clients and how you could even have a video on what to expect when you go to your lawyer's office for the first time. I wondered if any of our readers also have videos on You Tube (or on your firm's webpage) along these lines. Let us know?
BTW, the Fleming and Curti videos are just the first batch in a series. If you want to be kept apprised of new videos, you can subscribe to the Fleming and Curti You Tube channel (click on the red subscribe button-mine is on the top right hand of the screen).
Monday, February 6, 2017
Have you ever spent the night in a nursing home or dementia care center? How about for a week?
While on my sabbatical in Arizona I had the recent opportunity to spend several nights and many daytime hours in a care center. Quite simply, the experience deepened my respect and appreciation for the roles played by professional caregivers at all levels.
The facility in question is a nonprofit center, licensed for assisted living, and devoted exclusively to dementia care without restraints, the very definition of "mission driven" care. Set in a five acre campus, it is what I would call a "green house model" community (or more precisely, an Arizona Model Dementia Specific Assisted Living Project), with a maximum of twelve residents per cottage. It isn't a fancy place, but it is inviting, with a circular path between the four cottages that encourages people to sit under the trees, mingle and chat. Many residents are admitted on "private pay" status, but the center is also Medicaid certified.
Three shifts per day of CNAs (certified nursing assistants), usually at least two per cottage for each shift, provide the bulk of the personal care, cleaning, and meal service for the residents. The CNAs rotate shifts between the four cottages over the course of a single work week, sharing the workload of more challenging residents. There is also a small staff at the administrative level, including an executive director (who is working on her PhD thesis in her rare, spare time) and two LPNs, and there is regular input from both an MD and a very experienced Nurse Practitioner (who also has a PhD). A jack-of-all trades-building-maintenance-man, an up-beat program planner, plus two expert cooks round out the staff. I was on a nodding acquaintance with many of these people as a result of regular visits for close to three years, but my most recent ten days of "living in" gave me profound new appreciation.
The news media, for understandable reasons perhaps, tends to focus on tragedies and bad experiences in long-term care. Lawyers also tend to do the same, although for other reasons. At a recent legal conference, an experienced attorney who represents families in tort suits against nursing homes told me that in his experience, there are "no good nursing homes," only "less bad" ones.
Frankly, my experience, not just recently, but over 30+ years, is that there are very good care centers available. And the quality of living can be better than in the ol' homestead. It does take time to choose the right center for a loved one, and not every place will work for every person. I suspect the differences depend on how well any center identifies and supports its chosen mission of care. The attitude at the top affects the attitude of every employee.
To start at the executive director level, I learned this week that an awning that magically appeared one hot summer day to shade the favorite bench of one resident came from the director's own home. The attractive, sail-like canvas was adjusted "just so" between a building and a tree to provide maximum protection without making the often restless resident feel trapped.
Regular readers of the Elder Law Prof Blog may have guessed. That sun-worshiping resident was my father, a retired judge. He liked to hold court on that bench.
Another resident would often accompany the maintenance man on his daily rounds -- carrying a tool or pushing a cart. That probably slowed the maintenance man down. But I never heard a complaint. On "tough days" for that resident, when he wasn't tracking enough to safely accompany the maintenance man, that same employee would gently and kindly guide him by the shoulder back to his cottage.
One woman, who did not speak English, liked to dance. At the regular planned musical events, I would see even the shyest CNAs allow this woman to draw them onto the stage to join the entertainers with happy feet. My sister joined her in dancing too.
Another resident, who became one of my favorites, sadly had aphasia, making it hard for him to find words to express himself. Instead, he howled. I listened mornings and nights as those hard-working CNAs would correctly interpret his happy howls -- or his sad howls -- or his "I don't want a shower" howls, without losing patience.
This staff includes people born and raised in the U.S., including several from tribal lands. But there is always a shortage of CNAs. This particular staff also includes men and women who are immigrants from foreign lands: Mexico, several countries in Africa, the Middle East, eastern Europe, India, Indonesia, and the Philippines. Many of the caregivers, working 40 hours or more per week, were also caring for disabled relatives in Arizona, or were sending money "home" to support other family members in need. One caregiver, a permanent U.S. resident, is considering the tough question of whether to return to the country of birth in order to join a spouse currently detained and facing deportation for illegal entry. Their children, born in the U.S., would become strangers in that foreign land.
The workers at my father's assisted living center are part of a United Nations of Caregiving.
Sunday, February 5, 2017
As mentioned in a recent post, the observation status case was headed back to court. The February 2, 2017 opinion resulted in a favorable decision requiring corrective action. The Center for Medicare Advocacy released the following Court Orders Corrective Action Plan for Government's Noncompliance with Settlement in Jimmo v. Burwell explaining that the judge has "ordered the Secretary of Health & Human Services to carry out a Corrective Action Plan to remedy the Department’s noncompliance with the Settlement." What's included in this corrective action plan?
The judge ruled that the Corrective Action Plan will include a new CMS webpage dedicated to Jimmo, a published Corrective Statement disavowing the improvement standard, a posting of Frequently Asked Questions (FAQs), and new training for contractors making coverage decisions. In addition, and significantly, the Court largely adopted the Corrective Statement drafted by plaintiffs, and ordered the Secretary to conduct a new National Call to explain the correct policy.
The opinion is available here. Great job CMA! (in the interest of full disclosure, I'm on the CMA board)
Thursday, February 2, 2017
We've heard that Speaker Ryan has a plan to change Medicare, but that the President had made campaign promises about preserving it. So, have an opinion? Should it remain unchanged? Should it be changed? Here's your chance to make your voice heard. AARP is organizing a "thunderclap" campaign, asking those with an opinion share it with the President by Twitter, Tumblr or Facebook and they will all be posted on the same day, February 21, 2017. The website has more information about the specifics on how this works. Don't want to wait until then to make your opinion known? AARP also has a site for folks to contact Congress that makes it about as simple as can be with a prepared message for those who want Congress to support Medicare . (If you think Medicare should be changed, you may not be able to change the AARP standard message and you will need to email your elected representatives)
Wednesday, February 1, 2017
Several years ago CMS entered into a settlement in litigation that has become known as the Jimmo case. CMS agreed that the improvement standard wasn't in fact a standard for determining further Medicare therapy coverage and all was good, or so it seemed. Yet, now we learn it's not, according to a recent story in Kaiser Health News. Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute explains
Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.
So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.
The settlement was supposed to be the end of the matter, and instead of the improvement standard, Medicare was to make the decision as follows, "not ... on the 'potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.'” So in August of last year, the judge ordered the parties to get together to "improve" Medicare's educational initiative for those who deal with the claims and staff hotlines, as well as the ALJs. The parties reached an impasse, so it's back to court.
Tuesday, January 31, 2017
The New York Times ran an article about the use of robots for elders. Seniors Welcome New, Battery-Powered Friends explains retirement communities are among the leaders of testing out new technologies. "Early adopters ... are on the front lines of testing new technologies that some experts say are set to upend a few of the constants of retirement. Eager not to be left behind, retirement communities are increasingly serving as testing grounds that vet winners and losers."
Here is something that I thought particularly interesting regarding technology development pointed out in this article. "Some technologists see the most promise in the social dimensions. For too long, technology has been chasing problems rather than trying to delight human beings, said Joseph Coughlin, director of the AgeLab at the Massachusetts Institute of Technology. “Where are the devices that help us learn and expand our horizons?” he said."
The article explores the advantages of robot companions with some of those designed specifically for neophytes of technology. For example, one company has developed a robot that requires little tech expertise to use, and the robot "is connected to Wi-Fi and operated remotely. In its next iteration, the company is working on training the robot to pick up objects... [The company's] robots will be offered by a consumer health firm ... to retirement communities and people aging in place. The yearly cost is about 20 percent of the cost, on average, of hiring full-time caregivers...." The article explores the role of elders in testing tech products and the value of the feedback that they give.
I love technology "stuff" and can't wait for the next new shiny thing. But, I am concerned if we begin to rely on technology solely as the means of providing caregiving. I can't wait to have my own personal robot, but will it give good hugs?
Monday, January 30, 2017
The Denver Post ran an article recently that some Colorado hospitals are opting out of the new aid-in-dying law. About 30 hospitals opting out of Colorado’s medical aid-in-dying law, Three major health systems have announced they will not participate explains that
Up to 30 Colorado hospitals are opting out of the state’s new medical aid-in-dying law, either fully or in part, but whether that means the doctors they employ are banned from writing life-ending prescriptions is a controversy that could wind up in court.
At this point, terminally ill Coloradans who want to end their lives under the law will need to find out whether their physicians are allowed to participate.
The article explains that whether the ban applies to doctors for those hospitals depends on the hospital. For example, one hospital group has said that the doctors could "talk to their patients about aid in dying and can write life-ending prescriptions in a hospital. But hospital pharmacies will not fill those prescriptions and patients are not allowed to take their own lives in the hospital, which health officials figure is an unlikely request anyway." The proponents of the law take a different view on whether the ban prevents the doctors from writing the prescriptions, but indicate litigation may be needed to decide the matter.
The article explains the provision of the law
The law says a hospital may prohibit an employed or contracted physician from writing a prescription for someone “who intends to use the aid-in-dying medication on the facility’s premises.” It also makes clear that a healthcare provider can choose whether to participate in medical aid in dying and that the provider must transfer the patient’s medical records to a new health care provider if requested.
With the different interpretation of the law, it may be that litigation will be necessary to figure this out. Stay tuned.
Sunday, January 29, 2017
There is a lot of buzz about changes to programs that impact elders and none of us knows what the end results will be. The Leadership Council on Aging Organizations has designated Tuesday (January 31) and Wednesday (February 1) as call your Senators and Representatives days. Here is the information from the American Society on Aging:
The Leadership Council of Aging Organizations (LCAO), of which ASA is a member, is organizing call-in days next Tuesday and Wednesday, January 31 and February 1. This is an opportunity for you to contact your Senators and Representatives to let them know of your concerns about preserving these major programs. To participate, dial 866-426-2631. You’ll hear a brief overview of the issues, and then be asked to enter your zip code to be connected with your legislators.
ASA offers some tips on talking points, available here.
Thursday, January 26, 2017
The Young Invincibles recently released a report that looks at the financial health of the Millennials. The Financial Health of Young America "compares the financial health of young Americans in 1989 compared to today’s young adults to reveal major declines across five key factors – income, assets, net wealth, home ownership and retirement savings. In summary, Boomers had higher incomes, owned more homes, and had twice the net assets that Millennials have today."
In addition, the report notes the following key findings:
Millennials have earned a net wealth half that of Boomers at the same age.
Young adult workers today earn $10,000 less than young adults in 1989, a decline of 20 percent.
Education attainment still an individual’s best pathway to financial security.
When Boomers were young adults, they owned twice the amount of assets as young adults.
Disturbing racial inequality persists and grows. Young African Americans’ median wealth declined by a third since 1989.
Student debt blunts some of education’s benefits.
The report makes various recommendations in the following categories: skills, education, income, employment benefits, housing policies, improving the ability to save and gain wealth, and improve portable retirement choices. This is the first of several reports. The full report runs 30 pages and is available here.
From the Los Angeles Times, there is this interesting account from the antitrust lawsuit examining the proposed merger of Aetna and Humana health organizations:
Aetna claimed this summer that it was pulling out of all but four of the 15 states where it was providing Obamacare individual insurance because of a business decision — it was simply losing too much money on the Obamacare exchanges.
Now a federal judge has ruled that that was a rank falsehood. In fact, says Judge John D. Bates, Aetna made its decision at least partially in response to a federal antitrust lawsuit blocking its proposed $37-billion merger with Humana. Aetna threatened federal officials with the pullout before the lawsuit was filed, and followed through on its threat once it was filed. Bates made the observations in the course of a ruling he issued Monday blocking the merger.
Aetna executives had moved heaven and earth to conceal their decision-making process from the court, in part by discussing the matter on the phone rather than in emails, and by shielding what did get put in writing with the cloak of attorney-client privilege, a practice Bates found came close to “malfeasance.”
Wednesday, January 25, 2017
The Denver Post ran an AP story a few weeks ago about Americans retiring abroad. Growing number of Americans are retiring outside the U.S. highlights the increase in the number of Americans who decide to retire and live abroad. "The number grew 17 percent between 2010 and 2015 and is expected to increase over the next 10 years as more baby boomers retire... Just under 400,000 American retirees are now living abroad, according to the Social Security Administration. The countries they have chosen most often: Canada, Japan, Mexico, Germany and the United Kingdom." The article references a lower cost of living or cheaper health care as a reason some Americans choose to retire to other countries. Climate may also be a factor. It would be an interesting exercise for students to list the issues and considerations when clients decide to retire to another country. Anyone want to assign this as a project?
The winter issue of Columbia University's Magazine has an article on Your Beautiful Brain: Dispatches from the Frontiers of Neuroscience. I was particularly interested in the account of Nobel Prize-winning Professor Eric Kandel's 50+ years of research that began by looking at Aplysia -- a "blobby mollusk with protruding feelers that resemble rabbit ears" -- thus contributing to the mollusk's nickname, the "sea hare."
Clearly to Professor Kandel, the mollusks' brains were beautiful, not least because their comparatively large neural structures provided an accessible way to study more complex structures such as the human brain. Dr. Kandel, now 87, admits that "hunches" have played a role in his research.
From Columbia Magazine:
Today, as neuroscientists worldwide pursue remedies for Alzheimer’s and age-related memory loss, Kandel’s half century of findings are considered indispensable. Substantive therapies for Alzheimer’s in particular are “poised for success,” says Jessell, a colleague of Kandel’s for thirty-five years. “We’re on the cusp of making a difference.” But accompanying that claim is a caveat; the fledgling remedies are not panaceas. “We’re not necessarily talking about curing the disease,” he says. “But we are talking about slowing the symptomatic progression of the disease so significantly that lifestyles are improved in a dramatic way. If in ten years we have not made significant progress, if we are not slowing the progression of Alzheimer’s, then we have to look very seriously at ourselves and ask, ‘What went wrong?’”
Breakthroughs could happen sooner, however. Some of the Alzheimer’s medications available now “probably work,” says Kandel, except for one obstacle: “By the time patients see a physician, they’ve had the disease for ten years. They’ve lost so many nerve cells, there’s nothing you can do for them.” Possibly, with earlier detection, “those same drugs might be effective.” That’s not a certainty, insists Kandel, only a “hunch.”
Professor Kandel has also explored the biological differences between "ordinary" age-related memory loss and Alzheimer's Disease.
Years ago, Kandel had another hunch — that age-related memory loss was not just early-stage Alzheimer’s, as many neuroscientists believed, but an altogether separate disease. After all, not everyone gets Alzheimer’s, but “practically everyone,” says Kandel, loses some aspects of memory as they get older. And MRI images of patients with age-related memory loss, as demonstrated by CUMC neurology professor Scott Small ’92PS, have revealed defects in a brain region different from those of the early-stage Alzheimer’s patients.
Kandel also knew mice didn’t get Alzheimer’s. He wondered if they got age-related memory loss. If they did, that would be another sign the disorders were different. His lab soon demonstrated that mice, which typically have a two-year lifespan, do exhibit a significant decrease in memory at twelve months. With that revelation, Kandel and others deduced Alzheimer’s and age-related memory loss are distinct, unconnected diseases.
Then Kandel’s lab (again, with assistance from Small) discovered that RbAp48 — a protein abundant in mice and men — was a central chemical cog in regulating memory loss. A deficit of RbAp48 apparently accelerates the decline. Knocking out RbAp48, even in a young mouse brain, produces age-related memory loss. But restoring RbAp48 to an old mouse brain reverses it.
Now what may be the eureka moment — this from Gerard Karsenty, chairman of CUMC’s department of genetics and development: bones release a hormone called osteocalcin. And Kandel later found that osteocalcin, upon release, increases the level of RbAp48.
“So give osteocalcin to an old mouse, and boom! Age-related memory loss goes away.”
The same may prove true in humans. A pill or injectable could work, says Kandel: “Osteocalcin in a form people can take is something very doable and not very far away.” In less than a decade, age-related memory loss might be treatable. “This,” he says, “is the hope.”
For more on beautiful brains, read the full article on Columbia University's website.