Elder Law Prof Blog

LGBTQI Bias in Nursing Homes?

The NY Times ran an article recently focusing on bias against LGBTQI residents of nursing homes. No Rest at Rest Home: Fighting Bias Against Gays and Lesbians starts with telling the story of one resident who ended up filing suit, in which the resident "accuses the housing center and its managers of failing to protect her from hostile residents who have insulted and verbally abused her. The suit says that she has been pushed, shoved and spit on, and that she was injured, including bruises on her arm, a bump on her head and a black eye." As well in the suit the resident alleges that the facility's "management not only of failing to meet its responsibility to stop the harassment but of retaliating against her for complaining about the abuse and seeking to push her out of the facility."

The article calls this suit as having the potential to "set a legal precedent establishing the responsibility of housing providers to actively address discrimination based on gender identity and sexual orientation under the federal Fair Housing Act. The law states that discrimination based on “sex” is prohibited."

The article quotes our friend Eric Carlson from Justice in Aging, as well as a survey they had previously conducted.

A survey of L.G.B.T. adults living in long-term care settings by Justice in Aging, a legal advocacy group, found that a majority believed they would face discrimination from housing staff if they were open about their sexual orientation. The report captured hundreds of stories of problems encountered by L.G.B.T. seniors with housing staff, ranging from harassment to refusals to provide basic services or care.

“You’re in a communal living setting that puts a lot of pressure on people,” says Eric Carlson, directing attorney for Justice in Aging. “Imagine how oppressive it is to have to be guarded about who you are or your family and friends.”

The article discusses another study and the scope of discrimination against LGBTQI elders as well as HUD's work to redress such discrimination.

PBS Special on Elder Abuse

Nashville Public Television ran a story about elder abuse in Aging Matters-Abuse and Exploitation. Here is a summary of the story:

It is estimated that one in ten adults over the age of 60 is a victim.  But the truth is we don’t know for certain how many older adults are suffering from abuse. In the eighth edition of Aging Matters, Nashville Public Television explores the issues behind elder abuse, neglect and exploitation. 

Experts suggest that our understanding of elder abuse lies decades behind that of child abuse and domestic violence. Elder abuse is underreported. It lacks clear legal definition and is complicated by ethical challenges.  The system of response is different depending on where you live.

What are the risk factors, what can we do to protect ourselves and our loved ones, and what is our responsibility to intervene for those in need? The questions are simple, but the answers are not.  Find out more in Aging Matters – Abuse & Exploitation.

The story is accompanied by a panel discussion and includes background resources.

Summary of Nursing Home Regs

The National Consumer Voice For Quality Long-Term Care has released a fact sheet explaining the changes to the Federal Nursing Home Regulations.   The 15 page fact sheet " provides a brief overview of key changes in the sections on Resident Rights; Freedom from Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge that will go into effect in Phase 1. The purpose of the summary is to highlight what is different between the prior rule and the final rule." The fact sheet is organized by sections of the CFR and explains what is amended and what is new./  Print this out and save it. It's invaluable!

 

Medicare Beneficiaries with Physical/Cognitive Impairments and Nursing Home Placement

here.Last month the Commonwealth Fund published an issue brief about the correlation between Medicare beneficiaries with Physical and/or cognitive impariments and the connection to Medicaid and nursing home placements. With all the talk about changes to Medicare and Medicaid, this is a timely topic (but it always is timely), Risks for Nursing Home Placement and Medicaid Entry Among Older Medicare Beneficiaries with Physical or Cognitive Impairment. Here is the abstract:

Issue: More than half of individuals who age into Medicare will experience physical and/or cognitive impairment (PCI) at some point that hinders independent living and requires long-term services and supports. As a result of Medicare’s limits on covered services, Medicare beneficiaries with PCI experience financial burdens and reduced ability to live independently. Goal: Describe the characteristics and health spending of Medicare beneficiaries with PCI and estimate the likelihood of Medicaid entry and long-term nursing home placement. Methods: The Health and Retirement Study 1998–2012 is used to estimate long-term nursing home placement, as well as Medicaid entry. The Medicare Current Beneficiary Survey 2012 provides information on health care spending and utilization. Key findings and conclusions: Almost two-thirds of community-dwelling Medicare beneficiaries with PCI have three or more chronic conditions. More than one-third of those with PCI have incomes less than 200 percent of the federal poverty level but are not covered by Medicaid; almost half spend 10 percent or more of their incomes out-of-pocket on health care. Nineteen percent of individuals with PCI and high out-of-pocket costs entered Medicaid over 14 years, compared to 10 percent without PCI and low out-of-pocket costs.

The brief offers background, data and analysis. For expediency, I've included the conclusion here. I recommend you read the entire brief.

This analysis finds that:

• A third of older adults have PCI in a given year; more than half of adults who age into Medicare will experience PCI over the remainder of their lifetimes. While the majority of older adults with PCI live in the community, they are at high risk for costly, long-term nursing home placement.
• Individuals with PCI often have multiple chronic conditions, resulting in high Medicare expenses and out-of-pocket spending. Those with high out-of-pocket spending as a proportion of income as well as PCI were at greater risk for spending down their resources and entering into Medicaid over a 14-year period, compared to those with PCI but without high out-of-pocket spending.
• The risk for Medicaid entry was greater for those at lower income levels at the beginning of the 14-year period. However, 14 percent of the highest-income group at baseline with high out-of-pocket spending and PCI entered Medicaid by the end of the follow-up period.

Improving financing for home and community-based care would help many beneficiaries with PCI continue to live independently and support families in helping them obtain the care they prefer. Our current health care system, which covers costly institutional services but not social support in the home, distorts the way Americans receive care as they age and die. After people with serious impairment become impoverished and qualify for Medicaid, they are covered for long-term nursing facility care. However, personal care services at home that might have prevented them from needing to turn to Medicaid or enter a nursing home are not covered by Medicare.

Intervening early to prevent nursing home placement and Medicaid enrollment may produce offsetting savings in Medicare and Medicaid. An accompanying brief describes two innovative approaches to providing long-term services and support benefits: a voluntary, supplemental benefit for home and community-based services for Medicare beneficiaries; and an expansion of the Medicaid Community First Choice program for people with incomes up to 200 percent of poverty. Both options show promise of maintaining independent living longer and avoiding costly long-term institutionalization and exhaustion of resources that result in Medicaid enrollment.

(citations omitted).

The brief is also available as a pdf here.

Dementia Down-Good News!!!

We all need a little good news right now.  So this one caught my eye.  Dementia rates have declined amongst elders (yay). Kaiser Health News reported Dementia Rates Decline Sharply Among Senior Citizens citing to a study recently published in the AMA Journal of Internal Medicine. A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012 reports on a drop from 11.6% to 8.8% on the years of the study.

Here's the abstract:

Importance  The aging of the US population is expected to lead to a large increase in the number of adults with dementia, but some recent studies in the United States and other high-income countries suggest that the age-specific risk of dementia may have declined over the past 25 years. Clarifying current and future population trends in dementia prevalence and risk has important implications for patients, families, and government programs.

Objective  To compare the prevalence of dementia in the United States in 2000 and 2012.

Design, Setting, and Participants  We used data from the Health and Retirement Study (HRS), a nationally representative, population-based longitudinal survey of individuals in the United States 65 years or older from the 2000 (n = 10 546) and 2012 (n = 10 511) waves of the HRS.

Main Outcomes and Measures  Dementia was identified in each year using HRS cognitive measures and validated methods for classifying self-respondents, as well as those represented by a proxy. Logistic regression was used to identify socioeconomic and health variables associated with change in dementia prevalence between 2000 and 2012.

Results  The study cohorts had an average age of 75.0 years (95% CI, 74.8-75.2 years) in 2000 and 74.8 years (95% CI, 74.5-75.1 years) in 2012 (P = .24); 58.4% (95% CI, 57.3%-59.4%) of the 2000 cohort was female compared with 56.3% (95% CI, 55.5%-57.0%) of the 2012 cohort (P < .001). Dementia prevalence among those 65 years or older decreased from 11.6% (95% CI, 10.7%-12.7%) in 2000 to 8.8% (95% CI, 8.2%-9.4%) (8.6% with age- and sex-standardization) in 2012 (P < .001). More years of education was associated with a lower risk for dementia, and average years of education increased significantly (from 11.8 years [95% CI, 11.6-11.9 years] to 12.7 years [95% CI, 12.6-12.9 years]; P < .001) between 2000 and 2012. The decline in dementia prevalence occurred even though there was a significant age- and sex-adjusted increase between years in the cardiovascular risk profile (eg, prevalence of hypertension, diabetes, and obesity) among older US adults.

Conclusions and Relevance  The prevalence of dementia in the United States declined significantly between 2000 and 2012. An increase in educational attainment was associated with some of the decline in dementia prevalence, but the full set of social, behavioral, and medical factors contributing to the decline is still uncertain. Continued monitoring of trends in dementia incidence and prevalence will be important for better gauging the full future societal impact of dementia as the number of older adults increases in the decades ahead.

The authors offer these findings from their study "Population brain health seemed to improve between 2000 and 2012; increasing educational attainment and better control of cardiovascular risk factors may have contributed to the improvement, but the full set of social, behavioral, and medical factors contributing to the improvement is still uncertain."

The study is also available for download as a pdf from here.

The Kaiser article offers some perspective about what this drop means: "The number of Americans over age 65 is expected to nearly double by 2050, reaching 84 million, according to the U.S. Census. So even if the percentage of elderly people who develop dementia is smaller than previously estimated, the total number of Americans suffering from the condition will continue to increase, said Keith Fargo, director of scientific programs and outreach, medical and scientific relations at the Alzheimer’s Association."

Articles about the study have appeared in several other news publications, including NPR and the New York Times.

So with the end of the semester, and we are grading exams, just think how good this will be for us in the long run!

Block Grants for Medicaid-How States Might Fare?

We blogged earlier about the discussion regarding switching Medicaid to block grants. The impact of doing so would be far reaching and the Commonwealth Fund released an issue brief, What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?

Here is the abstract from the issue brief:

Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government’s spending on Medicaid, not only for the population covered through the Affordable Care Act’s eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans. Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee. Methods: Review of existing policy proposals and other documents. Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting “per capita caps” would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.

The article provides history, data and discusses strategies. The Brief concludes that the issue, and the resulting outcomes, are not as simple as may be presented.

As the country’s largest insurer, Medicaid is subject to the same cost drivers that affect all providers of health insurance: population growth and demographic trends that increase enrollment, health trends that influence how often people need care and what kind of care they require, and advances in technology that drive up costs, among other factors. But unlike commercial insurers, government-funded Medicaid, in its role as first responder and safety net, is more vulnerable to these trends and to cost increases. For more than 50 years, Medicaid has been rooted in a flexible federal–state partnership, constantly restructured over time to meet current challenges.

Any attempt to restructure federal financing for Medicaid and replace flexibility with strict spending limits—whether in the form of block grants, per capita limits on spending, restrictions on what counts as state expenditures, or a combination of all three—would divorce funding considerations from the real-life needs that have informed federal and state Medicaid policy for half a century. Crucially, a per capita cap would permit population growth to occur. But the limit of lawmakers’ appetite for continued growth in enrollment is unclear. Given how states responded to the relatively mild and temporary funding reductions the federal government enacted in 1981, sweeping changes like those currently under consideration are likely to produce far more substantial fallout.

The 10 page issue brief can be downloaded as a pdf here.

New Handbook-Coordination of Benefits and Medicaid

CMS has released a new handbook, Coordination of Benefits and Third Party Liability (COB/TPL) In Medicaid (2016).  The explanation of the Handbook offers a section "About This Handbook":  "Purpose: The purpose of the Handbook is to provide an overview of COB/TPL policy on a variety of individual subjects... 2. Intended Audience: The Handbook is intended for CMS Central Office (CO) and Regional Office (RO) staff working on COB/TPL issues, state Medicaid agency staff, and all other parties interested in Medicaid COB/TPL policies... 3. Content: The Handbook contains policy guidance on a variety of COB/TPL topics that is current at the time of publication. .."

The manual is available here for download as a pdf.

 

Medicaid Changes, Are Block Grants Being Discussed?

Medicaid block grants...again? Not only is Medicare in the spotlight for revamp, so too is Medicaid.  Kaiser Health News reported this in Millions Could Lose Medicaid Coverage Under Trump Plan. The article explains

One major change endorsed by both Trump and House Speaker Paul Ryan (R-Wis.) would transform Medicaid from an entitlement program into a block grant program.

Here’s the difference. In an entitlement program, coverage is guaranteed for everyone who’s eligible. The federal government’s commitment to help states cover costs is open-ended. The states’ obligation is to cover certain groups of people and to provide specific benefits. Children and pregnant women who meet specific income criteria must be covered, for example.

The article notes that this isn't the first time that block grants for Medicaid has been proposed. "Turning Medicaid into a block grant program has been discussed for more than 25 years, but the idea has always met resistance from some states, health providers, health care advocates and Democrats. Even with a Republican majority in Congress and Trump in the White House, the plan would still face an uphill legislative battle."

And don't forget the statements regarding undoing the Affordable Care Act:

The biggest risk for Medicaid beneficiaries comes from pledges by Trump and other Republicans to repeal the Affordable Care Act, which provided federal funding to states to expand Medicaid eligibility starting in 2014. Thirty-one states and Washington, D.C. did so, adding 15.7 million people to the program, according to the government. About 73 million are now enrolled in Medicaid — about half are children.

The article focuses on some of the other options that may be considered in determining whether to make changes to Medicaid.

All these proposed changes are a lot to take in. So hang on and stay tuned.

Home Sharing for Elders-Mark Your Calendars

AARP is offering a online chat on November 21 from 3-4 p.m. on Home Sharing: A Powerful Option to Help Older Americans Stay in their Homes. The website offers a summary of this upcoming chat:

The vast majority of older adults have told AARP that they want to “age in place” by remaining in their current home and neighborhood. But much of the U.S. housing stock isn’t very aging-friendly (stairs are an example), and millions of older Americans face economic hardships that challenge their ability to afford the costs of safe and suitable housing.

The rise of home sharing — in which people rent space in their residence to a traveler or short-term tenant — is allowing people of all ages (but especially older adults) to literally earn an income from where they live.

Join AARP’s Nancy LeaMond, former Philadelphia Mayor Michael Nutter, Airbnb executive Sarah Bianchi and Gene Sperling, an economist and consultant to Airbnb, for an online discussion and Q&A about the benefits of home sharing for older adults and the new Airbnd report “Home Sharing: A Powerful Option to Help Older Americans Stay in their Homes.”

The accompanying report will be available here starting  November 21.

Deja Vu? Cutting Entitlements?

A colleague yesterday sent me a link to a story about Speaker Ryan's plan to introduce cuts to Medicare (or eliminate it in its current form as we know it).  (Of course, this was after the class where we had just finished covering Medicare).  All I could think was, not again.... By not again, I meant here is another proposal heading to Congress to change (or eliminate) one of the entitlement programs.  We've weathered the proposals to change Social Security (Remember the Commission appointed by President George W. Bush?). Now it's Medicare. 

There is information on Speaker Ryan's website about his plan to change Medicare.  A series of articles have popped up in the last few days as a result of his recent interview appearing on Fox.  In Talking Points Memo, Ryan Plans to Phase Out Medicare in 2017, the transcript of the interview appears. Here's a quote:

What people don't realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, medicaid is in fiscal straits. You have to deal with those issues if you are going to repeal and replace obamacare. Medicare has serious problems [because of] Obamacare. Those are part of our plan.

The article describes his position as a phase-out of Medicare, although current beneficiaries keep Medicare.

Money magazine also ran an article, questioning the Speaker's assertion that Medicare is going broke.  Is Medicare Really Going Broke, Like Paul Ryan Says?

Here’s the thing: Medicare is on an unsustainable spending path, but it’s not going broke. “The idea that we have a crisis is just nonsense,” says Dr. Robert Berenson, a fellow at the Urban Institute, a nonpartisan research organization, and formerly an official at the Centers for Medicare and Medicaid Services. And Obamacare is not the culprit for Medicare’s fiscal woes.

The article notes that his plan proposes 

changes [that] generally fall under the terms “privatization,” or “premium support.” While it remains unclear exactly what this would look like, it may mean giving beneficiaries some sort of fixed dollar amount to buy their own private insurance as an alternative to, or even replacement for, original Medicare... Under this type of system, beneficiaries who choose the lowest-cost coverage will stretch their government subsidy the farthest—which ironically, is how Obamacare works today.

The Washington Post ran an article about it, focusing on whether this is an "opportunity" for the Democrats, Paul Ryan’s plan to phase out Medicare is just what Democrats need. The Washington Post article offers a sobering assessment

If Ryan gets his way, Medicare as a universal insurance program will cease to exist. It will be replaced by “premium support,” or vouchers which seniors will use to buy private insurance. If you can’t afford any of the available plans with what the voucher is worth, tough luck. The whole point is to transfer the expense from Medicare to the seniors themselves. Half a century after Medicare brought health security to America’s seniors, Republicans would snuff it out, leaving some unknown number without any coverage at all and breaking the fundamental promise the government made.

Serious bummer folks.

Save the Date-Institute for Law Teaching and Learning’s Summer 2017 Conference

Mark your calendars for the Institute for Law Teaching & Learning 2017 Summer Conference. The topic is Teaching Cultural Competency and Other Professional Skills Suggested by ABA Standard 302. The conference is scheduled for July 7-8, 2017 at the U. of Arkansas Little Rock Bowen School of Law. Proposals are now being accepted, including specifically on:

addressing the many ways that law schools are establishing learning outcomes related to “other professional skills,” particularly the skills of cultural competency, conflict resolution, collaboration, self-evaluation, and other relational skills. Which, if any, of the outcomes suggested in Standard 302(d) have law schools established for themselves, and why did they select those outcomes?  How are law professors teaching and assessing skills such as cultural competency, conflict resolution, collaboration, and self-evaluation?  Have law schools established outcomes related to professional skills other than those suggested in Standard 302(d)?  If so, what are those skills, and how are professors teaching and assessing them?

Proposals are due by February 1, 2017 and should be sent to Kelly Terry, [email protected]. Proposals are limited to 1 page and must include a title, the presenters names and contact info, a summary of the presentation and the interactive teaching methods to be used.

More information, visit the website or contact Professor Terry. Thanks to Professor Terry for sending us info about this conference.

 

 

2017 Medicare Premiums

CMS announced the 2017 premiums on November 10, 2016. Since the 2017 SSA COLA is so low, the hold harmless provision will kick in for many.  For the Part B premium, most will pay $109.00 because of the "hold harmless" while others will pay $134.  The income adjusted part B premium for higher income beneficiaries starts at $187.50 and tops out at $428.60 for a single person. The 2017 annual Part B deductible will be $183. 

The Part A inpatient hospital deductible for 2017 will be $1,316, and the SNF co-pay for days 21-100 will be $164.50 in 2017. More of the 2017 figures are available here.

AARP Beta Testing CareConnection Website

AARP has announced the beta version of their caregiving website CareConnection. According to the website

CareConnection is a new site aimed at connecting caregivers with information, other caregivers and helpful services. We’re listening firsthand to understand the concerns and challenges facing caregivers today, and we’d like to include you in the design of this site and its offerings. Explore the information, tools and solutions available, and share what works— and what doesn’t—so that we can build the best experience for caregivers like you.

The website lists articles and resources on a variety of topics, will offer a caregiver community that allows a caregiver to connect with other caregivers, provides an "ask-the-expert" free 30 minute consult with UnitedHealth care managers, and "caregiving tips and hacks" ("simple and inexpensive ways to use household items to solve every day problems, such as for those who have limited hand mobility, turning rubber bands into grips for a slippery glass or running a pen through a tennis ball to enhance the grip while writing") that are searchable by topic.

 

What Will President Trump Administration Mean for Seniors?

As I've spent several recent weeks of my sabbatical in Arizona to be closer to my 90+ year old parents, I watched the run up to the election from this Southwestern vantage point, instead of my usual Pennsylvania location.  Not only was I surprised by the result of the Pennsylvania vote, it was a surprise to see Arizona voters -- usually a Republican stronghold with a strong "senior" vote-- struggle with the election choices available to them.  

On November 8, Arizona rejected legalization of recreational marijuana (predictable) and approved a significant increase of minimum wage (a closer call, as the business community in Arizona largely opposed that increase).  Further, Trump had angered some by throwing shade on 80-year-old Senator John McCain's "hero" reputation. In contrast, Trump's seeming alliance with controversial Sheriff Joe Arpaio, despite the later's pending criminal contempt prosecution, gave other Arizonans pause. Ultimately, 84-year-old Arpaio was voted "out" in Arizona (but, it remains to be seen whether he will be "out" of government at the federal level too).   In other words, Arizonans were not voting in support of a "pure" Republican platform.  

My mom, a Democrat but a somewhat reluctant Hillary supporter, was glued to CNN for much of the summer and fall, and she accurately predicted the Trump victory despite the pollsters' and commentators' refusal to acknowledge the frustrations driving the Trump tidal.  She insisted on voting on election day, rather than taking advantage of Arizona's early vote options. 

We know little about how Donald Trump will prioritize and govern once he takes the reins of his very first elected position.  That uncertainty makes many nervous even as it makes others hopeful.  

What will a Trump Administration mean for aging Americans?  Some topics to consider:

• Public Retirement Benefits:  Candidate Trump -- rarely one to get into the details of policy issues -- seemed o make a distinction between age-based benefits, including Social Security retirement and Medicare health insurance coverage, and disability-based benefits.  Congress may seize on the latter.  Trump argued "more jobs, less waste" was a cure for the solvency questions.   On the one hand, he says he would support privatizing "some portion" of Social Security savings or investments to allow individuals to self-invest, while on the other hand rejecting "government" in the role of the retirement"investor." He seems willing to consider means testing for payment of retirement benefits. Here's a link to several utterances of Donald Trump on the topic of Social Security.  
• Health Care for Seniors:  Unlike ObamaCare in general, it will probably be harder for Donald Trump and Congress to displace the fundamentals of Medicare for seniors.  But real cost questions attend health care for seniors.  At what point will Trump be hit with the reality that all of his campaign plans about immigration, walls, foreign trade and infrastructure pale in comparison to the true challenges facing an aging American on health care?  
• Medicaid for Long-Term Care:  Candidate Trump has probably not focused on Medicaid as a source of long-term care financing.  With Republicans controlling the House and Senate, however, will the old "anti-Medicaid planning" forces feel newly energized?
• Consumer Protections for Older Americans:  Candidate Trump will feel the pressure from Republican-controlled Congress to roll back administrative safeguards implemented by President Obama during the last two years. Perhaps here is where seniors may feel the quickest impact from the change in power, including potential rollbacks on consumer protection measures that attempted to bar pre-dispute binding arbitration "agreements" for nursing home residents, implemented fiduciary duty standards for investment advisors, and imposed closer scrutiny on consumer credit companies. Indeed, the most direct threat of the Trump Administration, combined with the Republican Congress, is likely to be to "Elizabeth Warren's Consumer Financial Protection Bureau."  

How this all plays out will be "interesting," won't it?  The points above are about today's generation of seniors.  Perhaps the most important Trump impact will be for "future" seniors, especially if Trump's predicted roll back on environmental protections and his advisors' seeming rejection of climate science hold sway.  

Sixth Annual Conference on Health Law

Save the Date: February 13, 2017, the 6th Annual Health Law Conference at Florida State University. This year's conference is titled Patients as Consumers: The Impact of Health Care Financing & Delivery Developments on Roles, Rights, Relationships & Risks. The program's learning objectives include

• Appreciate the ways in which the role of the individual who is purchasing and receiving health care services is changing from one of passive patient to that of a consumer who is expected to influence, if not determine, his or her own health care

• Understand the legal and ethical ramifications of the individual’s changing role from patient to consumer for the physician and other health care providers with whom the patient/consumer maintains a professional relationship

• Manage the physician’s legal responsibilities and risks associated with the changing professional relationship engendered by expectations that patients will take on a more consumer-like role regarding their own health car

• Identify major developments (e.g., aggressive consolidation of health care insurers and providers into mega-entities, the incentivized development of new coordinated product delivery entities such as Accountable Care Organizations, the proliferation of electronic health records, and replacement—on both mandatory and voluntary bases—of fee-for-service arrangements by various value purchasing strategies such as Pay for Performance (P4P) and bundled payments) in contemporary U.S. health care delivery and financing

Topics include Evidence-based Medicine & Shared Decision-making, Impact of Cost Containment Initiatives on Patient Rights and Provider Liabilities, and Patient Populations at Particular Risk of Not Controlling Their Own Medical Choices.

Registration is free unless seeking CLE credits.  For more information or registration, click here.

 

 

 

 

Older Adults-Confidence About Law Enforcement and Courts?

I recently was called for jury duty. One of the questions asked during voir dire was about jurors' attitudes regarding the prospect of service. That made me think of a study I ran across recently, Measuring Older Adult Confidence in the Courts and Law Enforcement, published in Criminal Justice Policy Review.  The abstract for the article explains

Older adults are an increasingly relevant subpopulation for criminal justice policy but, as yet, are largely neglected in the relevant research. The current research addresses this by reporting on a psychometric evaluation of a measure of older adults’ Confidence in Legal Institutions (CLI). Confirmatory factor analysis (CFA) provided support for the unidimensionality and reliability of the measures. In addition, participants’ CLI was related to cynicism, trust in government, dispositional trust, age, and education, but not income or gender. The results provide support for the measures of confidence in the courts and law enforcement, so we present the scale as a viable tool for researchers and practitioners interested in understanding older adults’ confidence in these institutions. We conclude by discussing the implications of our work on efforts to improve interactions between older adults and legal institutions, and we highlight avenues for further research.

Here is a short excerpt from the conclusion:

Why is it that older, older adults report more confidence in the criminal justice system than younger, older adults? Does this reflect a cohort effect or individual differences? In addition, future research should examine whether these confidence subscales predict willingness to engage or actual engagement in legal activities such as jury service, reporting crimes (as a victim or witness), or initiating litigation as well as they do in more general samples

The full article published in the journal is available here for a fee.  A pre-publication pdf from ResearchGate is available here for free.

 

A Two-Question Quiz on The Timing For Your Retirement

The Wall Street Journal ran an article last month about a study that focused on people's decision-making regarding whether to retire.  Before Retiring, Take This Simple Test reports on study by "Philipp Schreiber and Martin Weber at the University of Mannheim in Germany, [where]  a simple two-question quiz [was developed] that can help predict whether you’ll regret the timing of your own retirement."  Two questions-that's pretty easy, right. Here we go, it won't take you long to answer them:

Question 1: You just learned that you are due a tax refund. If you’d like, you can get the $1,000 refund right away. Alternatively, you can get a $1,100 refund in 10 months. Which do you prefer?

Question 2: You just learned that you are due a tax refund. If you’d like, you can get a $1,000 refund in 18 months. Alternatively, you can get a $1,100 refund in 28 months? Which do you prefer?

How did you answer them? According to the article, "[t]he point of the exercise is to measure the consistency of a person’s time preferences. Someone with consistent time preferences should answer both questions the same way—choosing the early option both times, or the delayed option both times. Such consistency is a requirement for making financial plans that you stick with."  There are folks who don't answer consistently, and that's a red flag, the article explains. Those folks  "exhibit a tendency known as present bias, or hyperbolic discounting. They strongly prefer rewards that arrive right away." As for timing of retirement, the article notes that study shows that those who provided inconsistent answers ultimately regret the timing (too early) of their retirement.

The article suggests some positive applications of the study results. For those of us who participate in savings via payroll deductions, such programs could be improved "if they were personalized according to the results of the two-question quiz. Consider a person who exhibits a strong bias for receiving rewards in the present. Given the likelihood that she’ll be tempted by an early retirement, she might want to be defaulted to a higher savings rate during her working years. This will help her avoid future regret over the timing of her retirement decision, since she will have sufficient savings."  The article goes further, suggesting changes to enrollment in Social Security to minimize buyer's remorse for early retirement (evidently a lot of folks start drawing Social Security at age 62, which we all know results in a permanent reduction in benefits).

The study referenced in the WSJ article is reported in The Influence of Time Preferences on Retirement Timing. The abstract explains

This study analyzes the empirical relation between the decision when to retire and individuals time preferences. Theoretical models predict that hyperbolic discounting leads to dynamic inconsistent retirement timing. Conducting an online survey with more than 3,000 participants, we confirm this prediction. The analysis shows, that time inconsistent participants decrease their planned retirement age with increasing age. The temptation of early retirement seems to become stronger the closer retirement comes. We show that the negative effect of age is between 1.5 and 3 times stronger for participants who can be classified as hyperbolic discounters. In addition, we find that time inconsistent participants actually retire earlier. On average, the most time inconsistent participants retire about 2.2 years earlier. The time inconsistent behavior has severe consequences: Time inconsistent participants are ex post more likely to regret their retirement timing decision. Also, the unplanned early retirement leads to a constant decrease of retirement benefits of about 13%.

The full paper can be downloaded from the SSRN link here.

 

Using Age-Progression Virtual Reality as an Incentive to Save

The Wall Street Journal recently published an article by Maddy Dychtwald, co-founder of Age Wave, on using virtual reality (VR) to help folks save. How Virtual Reality Can Boost Retirement Savings reports on a project and explains how it unfolded

Professor Hal Hershfield of UCLA’s Anderson School of Management partnered with Daniel Goldstein of Microsoft Research, Jeremy Bailenson, director of Stanford’s Virtual Human Interaction Lab, and several other Stanford researchers to see if connecting people with their future selves could affect their willingness to save for that future self. They took photos of college-age research subjects and digitally altered half of them to create virtual avatars at age 65—complete with jowls, bags under the eyes, and gray hair.

Why don't people do a better job of saving for retirement? According to the article, experts think it's psychological to some extent. "When you’re in your 20s and 30s, you can’t even imagine your life at 65 or 95. If you can’t imagine it, chances are you’re not planning for it."

Back tot he project.  Digitally aging the participants wasn't the end of the project. Next the participants were provided with "goggles and sensors and were dropped into virtual reality, where they faced a mirror reflecting either their current self or their future self. As part of the experiment, they were each given $1,000 to spend. They could either buy a gift for someone special, invest in retirement, plan a fun event, or put money into a checking account."

This is getting intriguing. Want to bet what happened? According to the article, "[t]hose research ...  greeted by their aged avatar put more than twice as much money toward retirement as those who saw their contemporaneous selves." The researchers, to double check the results, also showed "some research participants ... the aged avatars of other test subjects to see if that impacted their choices. It didn’t. Only those who saw themselves at retirement age were likely to invest in their future." 

The  WSJ article explains that VR tools are under development "to offer experiential solutions to our nation’s lack of retirement planning... [and] provide a visceral experience that might even immerse [the user] in several different future scenarios, so [the user] can experience, for instance, what it’s like to live with limited funds at 65, 75 or 80."

The article about the study, Increasing Saving Behavior Through Age-Progressed Renderings of the Future Self, is available here.

This is the abstract from the research study article:

Many people fail to save what they need to for retirement (Munnell, Webb, and Golub-Sass 2009). Research on excessive discounting of the future suggests that removing the lure of immediate rewards by pre-committing to decisions, or elaborating the value of future rewards can both make decisions more future-oriented. In this article, we explore a third and complementary route, one that deals not with present and future rewards, but with present and future selves. In line with thinkers who have suggested that people may fail, through a lack of belief or imagination, to identify with their future selves (Parfit 1971; Schelling 1984), we propose that allowing people to interact with age-progressed renderings of themselves will cause them to allocate more resources toward the future. In four studies, participants interacted with realistic computer renderings of their future selves using immersive virtual reality hardware and interactive decision aids. In all cases, those who interacted with virtual future selves exhibited an increased tendency to accept later monetary rewards over immediate ones.

Wow, just wow.  Now, can we get these for our students?

Federal District Court Enjoins Pre-Arbitration Dispute Rule

A federal district court in Mississippi has entered an injunction prohibiting the CMS rule against pre-dispute arbitration from taking effect at the end of  this month.  According to a story on NPR, "[t]he reason for granting the injunction, the court explained in its order, is that it believes the new rule represents "incremental 'creep' of federal agency authority" — in this case the Centers for Medicare & Medicaid Services — 'beyond that envisioned by the U.S. Constitution.'"

The 40 page order is available here.

 

Too Poor to Retire

Our local newspaper, the Tampa Bay Times, recently ran a story about elders who work at low-paying jobs. Although they may wish to retire, they find themselves unable to afford retirement.  For some low-income workers, retirement is only a dream explains that for low-wage workers can't afford to retire. "Studies have found that about one-third of low-wage workers ... say they'll never be able to afford retirement. The problem is particularly acute among minority women... mA 2016 study by the Associated Press-NORC Center for Public Affairs Research found that a quarter of workers 50 or older say they won't retire. Among low-wage workers, earning less than $50,000 a year, it was 33 percent."

Consider the following statistics:

A 2016 report by the nonpartisan research nonprofit National Institute on Retirement Security shows that many black, Hispanic and Asian women have to work past retirement age to be able to afford basic expenses. Women were 80 percent more likely than men to be impoverished.

The research showed that for men ages 70 to 74, about 19 percent of their income comes from wages. For women, it's about 15 percent.

Some low-wage workers will be able to collect Social Security, which will be of some help, but as the story notes, some without legal status won't be able to draw Social Security.  One of the individuals featured in the story is 70 years old and works 6 days a week as the caregiver a 100 year-old person.

So what happens if the low-wage worker falls ill and is unable to continue to work?  Might family step in to help? Are there options?