Thursday, January 23, 2020

The Limits of Hospice Home Care?

Kaiser Health News ran a story about hospice for individuals dying at home and the role of families. Patients Want A ‘Good Death’ At Home, But Hospice Care Can Badly Strain Families explains how Hospice home care works:

Hospice allows a patient deemed to have fewer than six months to live to change the focus of their medical care — from the goal of curing disease to a new goal of using treatments and medicines to maintain comfort and quality of life. It is a form of palliative care, which also focuses on pain management, but can be provided while a patient continues to seek a cure or receive treatments to prolong life.

But the Hospice folks don't do all of the caregiving, with "many family caregivers [responsible for] most of the physical work to [the family, with one daughter noting] that during the final weeks of her mother’s life, she felt more like a tired nurse than a devoted daughter."

Acknowledging that more and more folks want to die at home, the article notes the tasks that fall to family members caring for the person in the final days of life.  "Hospice agencies primarily serve in an advisory role and from a distance, even in the final, intense days when family caregivers, or home nurses they’ve hired, must continually adjust morphine doses or deal with typical end-of-life symptoms, such as bleeding or breathing trouble. Those decisive moments can be scary for the family... "said one expert.  From personal experience, I can confirm that this happens and it is scary. We were lucky-one of our family  was a nurse. I'm not sure how we would have gotten through the process without her. But not everyone has their own family medical professional.

Here's the thing.  The person needs 24 hours care but that may not be something Hospice will provide because "hands-on help is scarce. According to Medicare, hospice benefits can include home health aides and homemaker services. But in practice, that in-person help is often limited to a couple of baths a week. Medicare data reveals that, on average, a nurse or aide is only in the patient’s home 30 minutes, or so, per day."

The article looks at the costs and Medicare coverage rates, Hospice residences and nursing home care.  There's something of a Catch-22 happening.  "As researchers in the field look to the future, they are calling for more palliative care, not less — and, at the same time, they are advocating for more support for the spouses, family members and friends tasked with caring for the patient."  As one expert noted, there's a real need "to expand — in general — our approach to supporting caregivers, [pointing out] that some countries outside the U.S. pay for a wider range and longer duration of home health services."

 

 

January 23, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Tuesday, January 21, 2020

Medicare Part D Donut Hole-Gone or Not?

The New York Times an an article scrutinizing the status of the Part D coverage gap (a/k/a the Donut Hole), in Medicare’s Part D Doughnut Hole Has Closed! Mostly. Sorta.

The donut hole  was weird and unlike other types of insurance and as the article explains, "“designed that way because Congress had a self-imposed budget target,” said Tricia Neuman, who directs the Medicare policy program at the Kaiser Family Foundation.... In order to afford a low deductible, catastrophic coverage and protection for those with low incomes, lawmakers agreed to the doughnut hole. But what other kind of insurance works like that?"

The Affordable Care Act (ACA) contained a provision that gradually closed  the donut hole. "The final reduction, for generic drugs, slid into place on Jan. 1. Now, supposedly, there is no coverage gap. Federal regulations require that your plan (most Medicare beneficiaries can choose from nearly 30) average 25 percent cost-sharing for any drug."  But remember closing the donut hole is not the same as reducing the cost of prescription drugs.

There's still remaining weirdness with the Part D program, as the article highlights:

  • This year, after meeting the $435 deductible, you generally pay a flat price for each covered drug during the so-called initial coverage period. Different plans assign drugs to different tiers for which you pay specified amounts.

But once your total drug expenditures hit $4,020, you’re responsible for 25 percent of the plan’s negotiated cost per drug — not a gap, exactly, but a shift.

If you were paying $45 for a prescription that costs $200, your share is now $50 — not a major change. But for a $500 drug, you’ll owe $125 until you reach the catastrophic threshold.

 . .
  • It will now take longer to climb out of the not-exactly-a-hole.

Last year, you qualified for catastrophic coverage when your out-of-pocket expenditures reached $5,100.

This year, you don’t qualify until they hit $6,350, a big jump. The Affordable Care Act had maintained a lower threshold; this year, that provision ended.

Once there, your co-payment is a flat $3.60 to $8.95, or 5 percent of the drug’s cost, whichever is higher. (Not lower.)

  • Part D has never capped out-of-pocket costs, even when you reach the supposedly safe shore of catastrophic coverage. Your 5 percent co-payment lasts the rest of the year.

. . .

All of this takes place against the backdrop of rising drug prices generally. From 2015 to 2017, more than a million Medicare beneficiaries each year passed the threshold for catastrophic coverage — more than twice the number when Part D began, according to a Kaiser Family Foundation analysis.

Oh and choosing the right Part D program is complicated.  The article notes that Congressional action is needed to reduce the drug prices. And what if the ACA is repealed??

January 21, 2020 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink

Monday, January 20, 2020

Dispute Resolution Issue on Eldercaring Coordination

The latest issue of the magazine for the Association of Conflict Resolution is devoted to eldercaring coordination. Twelve articles make up the issue. Check it out!

 

January 20, 2020 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care, Other | Permalink | Comments (0)

Indiana House Bill 1020 on Physician Aid-in-Dying

Indiana House Bill 1020, which was recently introduced recently, if passed, would legalize physician aid-in-dying in Indiana effective July 1, 2020. Here's the synopsis

End of life options. Allows individuals with a terminal illness who meet certain requirements to make a request to an attending physician for medication that the individual may self-administer to end the individual's life. Specifies requirements a physician must meet in order to prescribe the medication to a patient. Prohibits an insurer from denying payment of benefits under a life insurance policy based upon a suicide clause in the life insurance policy if the death of the insured individual is the result of medical aid in dying. Establishes a Level 1 felony if a person: (1) without authorization of the patient, willfully alters, forges, conceals, or destroys a request for medication or a rescission of a request for medication with the intent or effect of causing the individual's death; or (2) knowingly or intentionally coerces or exerts undue influence on an individual to request medication to end the individual's life or to destroy a rescission of a request for medication to end the individual's life.

The bill includes a sample form for requesting the medication, found in proposed  IC 16-36-7 I, sec. 3(e).

Stay tuned.

 

January 20, 2020 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Legal Practice/Practice Management, State Statutes/Regulations | Permalink

Friday, January 10, 2020

PACE Program and Adult Day Care

Kaiser Health News (KHN) recently published a story about a PACE program, Government-Funded Day Care Helps Keep Seniors Out Of Nursing Homes And Hospitals.

The services provided by PACE, a national program primarily funded by Medicaid and Medicare, are intended to keep people 55 and older who need nursing home levels of care at home as long as possible and out of the hospital.

The program is more important than ever as baby boomers age, its proponents say.

“The rapidly growing senior population in California and across the country will put enormous strain on our current fragmented, and often inefficient, health care delivery system,” said Tim Lash, president of Gary and Mary West PACE. California officials consider PACE an integral part of the state’s strategy to upgrade care for aging residents.

Consider the cost-savings to states with PACE programs, as well as the number of folks, typically dual eligibles, who participate. According to the story,

The National PACE Association said data it collected for 2019 shows seniors enrolled in PACE cost states 13% less on average than the cost of caring for them through other Medicaid-funded services, including nursing homes.

. . .

PACE participants who do not receive government medical benefits can pay out of their own pockets. At Gary and Mary West, the tab ranges from $7,000 to $10,000 a month, depending on the level of care.

Nationally, 50,000 enrollees participate in PACE programs at over 260 centers in 31 states. In California, PACE serves nearly 9,000 vulnerable seniors at 47 locations.

PACE provides the same services as under Medicare and Medicaid, and use of team from various disciplines to provide care. Patients often have chronic conditions and  almost 2/3 of them have some level of cognitive difficulty.

Check it out.

 PACE enrollees commonly have conditions such as vascular disease, diabetes, congestive heart failure, depression and bipolar disorder.

January 10, 2020 in Cognitive Impairment, Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Other | Permalink | Comments (0)

Wednesday, January 8, 2020

Report from 2020 AALS Annual Meeting Section on Aging and the Law

For the last few years, I've found myself with conflicts during semester breaks that interfered with attending the AALS Annual Meeting.  So I was especially happy this year to attend and catch up with long-time and new friends, especially those who work in fields relevant to elder law.  

The annual meeting kicked off for me with a Joint Session hosted by the Sections on Aging and the the Law, Civil Rights, Family & Juvenile Law, Employee Benefits & Executive Compensation, and Immigration Law.  The collaborative event offered lots of interesting "Emerging Issues in Elder Law," with speakers including:

Mark Bauer, Stetson Law, who spoke about recent enforcement efforts to combat elder exploitation, and pointed to a lingering weakness associated with banks that make SARS reports that never go beyond the regulatory body, and therefore never reach first responders, such as local police.  He talked about support for a state-wide effort in Florida to improve police reports to make it easier to identify abusers who target older persons.  He also called for better record-keeping for sales of gift cards, as these have become the number 1 method that telephone scammers get older adults to send them money.  

Wendy Parmet, Northeastern University School of Law, who focused on the impact of immigration laws and policies on the health of older adults, including attempts by the current administration to change the definition of "public charge" to include anyone who could receive any public benefits whatsoever,  thereby expanding the the pool of inadmissible immigrants and further restricting eligibility for legal permanent residency.  She traced the impacts of such policies on older adults once eligible for family reunification, on older citizens overall, and on a nation that once took pride in providing help to immigrants who were "tired and poor."

Jalila Jefferson-Bullock, Duquesne Law, who talked about how some states are not applying sentencing reforms to elderly offenders, even though such inmates statistically are at the least risk of reoffending and, at 19% of the total prison population, are often generating care costs that are unsustainable.  I learned, sadly, that my own state of Pennsylvania is one of the states that is not yet making significant progress on sentencing reforms for older adults.

Rachel Lopez, Drexel University Law, who is director of Drexel's Stern Community Lawyering Clinic, carried forward the theme of needed prison reforms for older inmates, reporting the latest events that follow the Graterford Think Tank Prison Project in Pennsylvania, and making the sobering observation that the most effective argument may not be one that sounds in human rights or human dignity, but the demonstration that return to the community for aging and ill residents saves the state money.  

Naomi Cahn, George Washington Law, who is also the incoming chair for the AALS Section on Law and Aging, presented facts and figures on "gray divorce," especially with respect to financial impacts on women.  She urged a de-coupling of Social Security benefits from marriage (or perhaps marriage longevity requirements), arguing that Social Security credits should be available for time spent as caregivers.  

Browne Lewis, Cleveland-Marshall College of Law, pointed to the emerging issue of "reproductive rights" for older individuals, identifying jurisdictions that restrict women's access to assisted reproductive technologies (ART) including placing age or time restrictions on use of banked or stored eggs.

For faculty members who would like to be part of next year's Law and Aging program at the 2021 AALS Annual meeting in San Francisco, contact Naomi Cahn with your topics and interest.  

January 8, 2020 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, International, Retirement, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Tuesday, January 7, 2020

Catching Up on Some News

Two articles, updating us on two topics important to all of us.

First, statistics. We know women statistically live longer than men,and a recent data report from Pew updates us that this still is true and in many instances women are younger than their husbands.  That it means that late in life, many women will be alone. Globally, women are younger than their male partners, more likely to age alone tells us that "[t]he pattern of spousal age gaps – and the fact that women tend to live at least a few years longer than men – helps explain another universal theme: Across the world, women are about twice as likely as men to age alone. One-in-five women ages 60 and older live in a solo household (20%), compared with one-in-ten men (11%)."  The report looks at religion and geography to measure the extent of this trend. "Rates of living alone over the age of 60 are tied to many factors, including cultural norms, economic development, levels of education and life expectancy. In countries where governments offer fewer retirement benefits or other support systems for older adults, families may face a greater responsibility to provide care."

The next article is from Sunday's New York Times, on the continuing shortage of geriatricians.Older People Need Geriatricians. Where Will They Come From?  notes the long-term shortage of geriatricians and explains their importance, using one real-life example to "spotlight the rising need for geriatricians. These doctors not only monitor and coordinate treatment for the many ailments, disabilities and medications their patients contend with, but also help them determine what’s most important for their well-being and quality of life." There's very little progress on closing this gap, according to the article. "An analysis published in 2018 showed that over 16 years, through academic year 2017-18, the number of graduate fellowship programs that train geriatricians, underwritten by Medicare, increased to 210 from 182. That represents virtually no growth when adjusted for the rising United States population."

The article explains why there aren't more doctors going into the field, including the economics realities.  One measure to address the shortage is cross-training.

Medical associations representing cardiologists and oncologists have begun focusing on older patients...

Health systems are adopting age-friendly approaches, like specialized emergency rooms. The American College of Surgeons’ new verification program sets standards hospitals should meet to improve results for older patients.

Last month the Senate Committee on Health, Education, Labor and Pensions voted to reauthorize a $41 million program that educates health professionals in geriatrics; it awaits a floor vote. A companion bill has already passed the House of Representatives.

Health professionals increasingly recognize that if they’re not in pediatrics, they will be seeing lots of seniors, whatever their specialty. A 2016 American Medical Association survey, for example, found that close to 40 percent of patients treated by internists and general surgeons were Medicare beneficiaries.

Pay attention to these issues. They will affect all of us either directly or through a family member.

 

January 7, 2020 in Consumer Information, Current Affairs, Health Care/Long Term Care, International, Other, Statistics | Permalink | Comments (0)

Monday, January 6, 2020

Guest Blog on The Greying of HIV of America

I had blogged previously about meeting with two professors from the School of Social Work at the U. of Missouri.  One, Dr. Erin Robinson, was kind enough to write the following blog on this important topic.

The Greying of HIV in America

By: Dr. Erin L. Robinson, MSW, MPH

Assistant Professor, University of Missouri School of Social Work

Email: robinsonel@missouri.edu

My name is Dr. Erin Robinson and much of my research focused on older adults, sexual health, and the prevention of HIV. I get a lot of questions about my research, including the need for such research, therefore I am going to share some information with you about the ‘greying of HIV’ in the United States. Over the past decade, older adults have been one of the fastest growing population groups affected by HIV/AIDS in the United States. Currently, 17% of all new HIV infections in the U.S. occur among people ages 50 years and older. This age group also accounts for nearly half of all people currently living with HIV. While the routes of HIV transmission in older adults is similar to that of their younger counterparts, there are some unique factors that contribute to the ‘greying of HIV’ in the U.S. Below are some interesting facts:

Facts about HIV and Aging:

  • Older men are disproportionately impacted by HIV, however rates of older heterosexual women becoming newly infected are rapidly growing. This has led to specialized prevention interventions for older, heterosexual women.
  • Older African American and Hispanic men and women are disproportionately impacted by HIV.
  • 60% of all older adults living with HIV are virally suppressed, which means they have no risk of sexually transmitting the disease to others.
  • Older adults are more likely to be diagnosed when HIV is further along in the disease progression (i.e. late-stage HIV). This means treatment options may not be as effective and mortality rates increase. Many of the symptoms for HIV can be similar for other illnesses, therefore if an older person does not test for HIV then they (and their healthcare provider) may attribute the symptoms to other causes.
  • HIV can cause dementia-like symptoms, this is called HIV-associated neurocognitive disorders (HAND), AIDS dementia complex, or HIV-associated dementia. However, those symptoms can be reversed with proper HIV medications.
  • Over the past few years, new HIV infections have decreased among the aging population. This is due, in part, to tailored prevention interventions among public health officials. However, we still have progress to make in order to curb the disparities.

Why are we seeing this ‘greying of HIV’ in the U.S.?

  • Historically, older adults today have higher divorce rates than previous generations. This means older adults are engaging in new romantic relationships at higher rates as well.
  • Our older generation today has lived through major historic events that have helped shape their outlook on themselves, their relationships, and their sexuality. This includes the industrial revolution, the 2nd wave of the women’s rights era, the Civil rights movement, the sexual revolution, the gay rights movement, and others.
  • Older adults are healthier now than ever before, allowing them to experience sexually satisfying relationships later in life. Over the past 20 years, erectile dysfunction medications have also enabled men to engage in sexual relationships well into their later years.
  • After women have reached menopause and can no longer get pregnant, we see lower levels of condom use. This is true for both committed relationships and new sexual encounters with a casual partner.
  • Older adults do not perceive themselves to be at risk for STIs and HIV, therefore are less cautious in avoiding transmission.
  • A lot of stigma exists around older adults and their sexuality. Many people like to believe that older adults do not engage in sex. Therefore, this creates an environment where older adults feel like they have to hide or deny their sexuality, which exacerbates STI and HIV infection and diagnosis rates.
  • Healthcare providers have a difficult time talking to their older patients about their sexual health and HIV. In fact, when there is an age differential and a gender differential between the provider and the older patient, providers report being uncomfortable prompting such conversations. Providers also report that time is a big barrier in initiating such conversations, especially when their older patient has other health concerns.

Source: https://www.cdc.gov/hiv/group/age/olderamericans/index.html

 

January 6, 2020 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other, Statistics | Permalink | Comments (0)

Thursday, December 19, 2019

Recent Survey on Needs of Older Adults in Tampa Bay Area, Florida

The Area Agency on Aging for Pinellas-Pasco (Florida) along with the Pinellas Community Foundation  did a Community Assessment Survey of Older Adults  (CASOA):

The Community Assessment Survey of Older Adults, or CASOA, is a printed survey that was sent to 10,000 randomly selected households across every Pinellas and Pasco zip code in which at least one resident was known to be aged 60 and over. The Pinellas Community Foundation and the Area Agency on Aging of Pasco-Pinellas joined forces to conduct this comprehensive needs assessment of the area’s aging community.

The survey, which is available here offers key findings in 9 categories:

Overall Community explores how older residents view the community overall, how connected they feel to the community and overall feelings of safety, as well as how likely residents areto recommend and remain in the community.

. . .

Health and Wellness Of all the attributes of aging, health poses the greatest risk and the biggest opportunity for communities to ensure the independence and contributions of their aging populations. Health and wellness, for the purposes of this study, included not only physical and mental health, but issues of independent living and health care.

. . .

Housing  The movement in America towards designing more “livable” communities those with mixed-use neighborhoods, higher-density development, increased connections, shared community spaces and more human-scale design will become a necessity for communities to age successfully.

 . . .

    Outdoor Spaces and Building Generally, communities that have planned for older adults tend to emphasize access --access to parks, green spaces, buildings, and places where the public wants to gather. Accessibility of public places in a community has a major effect on older residents’ quality of life, allowing them to remain mobile, access services, participate in productive activities and engage socially.

. . .

Transportation and Streets Mobility access increases the likelihood that seniors will be engaged with the community and the economy. Because the US is currently highly reliant on automobiles, older drivers may become concerned with their dependency on others for transportation because they can become isolated without their motorized mobility. Those that reside in livable communities where they can reach their destinations easily and comfortably on foot or in public transportation are more likely to remain engaged in their communities and to demonstrate signs of successful aging.

. . .

Social Participation, Inclusion and Education Opportunities. A “community” is often greater than the sum of its parts, and having a sense of community entails not only a sense of membership and belonging, but also feelings of emotional and physical safety, trust in the other members of the community and a shared history.

. . .

Volunteer and Civic Engagement Productivity is the touchstone of a thriving old age. This section of the report examines the extent of older adults’ engagement in the Pasco-Pinellascommunity as determined by their time spent attending or viewing civic meetings, volunteering or providing help to others.

. . .

Job Opportunities People in the U.S. are working longer and retiring at an older age than they did 20 years ago. Of all developed countries, the U.S. has the highest labor force participationof adults age 65 and older. Older adults are postponing retirement for a variety of reasons: improved health, to benefit from delayed pension plans, to accumulate additional wealth, and because the knowledge worker economy is less physically demanding than jobs in the economy of 20 years ago. Some experts believe that older workers will become an untapped resource for economic stability when Baby Boomers begin retiring.

. . .

Community Information Sometimes residents of any age fail to take advantage of services offered by a community just because they are not aware of the opportunities. The educationof a large community of older adults is not simple, but when more residents are made aware of attractive, useful and well-designed programs, increasing numbers of residents will benefit from becoming participants.

. . .

The summary of the results are available here.

 

December 19, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Other, Statistics | Permalink | Comments (0)

Monday, December 16, 2019

New Resource on Hoarding Disorders

The National Center on Law & Elder Rights released a new FAQ on hoarding disorders. Frequently Asked Questions: Hoarding Disorders and Older Adult discusses several important FAQs including how to differentiate between hoarding and clutter or being unorganized, how hoarding is different than collecting, available tools to identify potential hoarding disorders, what to do when hoarding is a factor in the person’s eviction, therapies for treating hording, resources and more. Corresponding PowerPoint slides from a legal training webinar are available here.  Accompanying materials on self-neglect can be accessed here with the link to the webinar recording here.

December 16, 2019 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care, Programs/CLEs, State Statutes/Regulations, Webinars | Permalink | Comments (0)

Friday, December 13, 2019

More on Caregiving

A couple of recent articles are worth mentioning.  First, the New York Times ran an article about millennial caregivers, For Millennials Making Their Way, a Detour: To Caregiving.

For baby boomers who fretted about every aspect of their children’s lives, here’s another worry for the list: Their children may become their caregivers while also handling the pressures of young adulthood. One-fourth of the 40 million caregivers in the United States are millennials, ranging from their early 20s to late 30s, according to a report by the AARP Public Policy Institute.

These caregivers are members of what an expert on aging ,.. calls the panini generation: “They are feeling the heat, and they are feeling pressed.”

As the article notes, for millennial caregivers the timing comes at the beginning of their careers, rather than in their late middle age or older, as it has for previous generations. Think about the financial implications for the millennials, not only for the present, but also for their futures. A look at some statistics helps crystallize the issues.

A change in family structure is one reason for the large number of millennial caregivers.... “Boomers had their kids at a later stage of their life than their own parents, and they had fewer children to provide the care....”

Also, many boomers are divorced and single, leaving caregiving to their children rather than to a spouse....And those younger caregivers are more likely than older caregivers to be men, according to a SCAN-financed poll by The Associated Press-NORC Center for Public Affairs Research.

Younger caregivers spend an average of 21 hours a week on those tasks, usually for a parent, grandparent or close friend, according to AARP. And more than half perform such difficult jobs as helping someone bathe or use the toilet and preparing injections.

Next, frequent contributor and reader of this blog, Professor Naomi Cahn, provided me with a link to a caregiving article she recently had published. Thanksgiving for Caregiving provides some data about caregivers and those who need care, and then offers some tips for caregivers on work/life/caregiving balance.

December 13, 2019 in Cognitive Impairment, Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Thursday, December 12, 2019

Are Physicians and Attorneys Speaking the Same Language When Talking About Competency or Capacity?

One of the most frequent search phrases that brings internet users to our Elder Law Prof Blog is the phrase "competency vs. capacity."  The search leads readers to a post from 2006 that summarizes an article written by two experienced psychiatrists, Phillip J. Resnick and Renee Sorrentino, originally published in December 2005 in Psychiatric Times. The article -- and often our blog post -- is frequently quoted or cited for the following passage:

This [clinical] consultation request reflects a common misconception regarding the issue of competence.  Competence is a legal state, not a medical one.  Competence refers to the degree of mental soundness necessary to make decisions about a specific issue or to carry out a specific act.  All adults are presume to be competent unless adjudicated otherwise by a court.  Incompetence is defined by one's functional deficits (e.g., due to mental illness, mental retardation or other mental condition), which are judged to be sufficiently great that the person cannot meet the demands of a specific decision-making situation, weighed in light of its potential consequences. . . . Only a court can make a determination of incompetence.

 

In contrast, psychiatric consultants can and should opine about a patient's capacity to make an informed decision or judgment.  Capacity is defined as an individual's ability to make an informed decision.   Any licensed physician may make a determination about capacity.  Forensic psychiatrists, however, are especially suited to assess a person's mental status and its potential for interfering with specific areas of functioning.  An individual who lacks capacity to make an informed decision or give consent may need to be referred for a competency hearing or need to have a guardian appointed.  The psychiatric consultation results in an opinion regarding whether such actions are indicated. 

 

Moreover, competence is issue specific.  Some physicians who misconstrue competence to be a global, black or white issue will ask psychiatric consultants for a broad consultation on whether the patient is competent or not.  The response of the psychiatric consultant should be, "Competent for what?" Poster 12.11.19 Cardozo Maimonides   

 

An additional challenge, however, is that in the years since that particular article was written, there has been a strong movement in law to dispense almost entirely with the "incompetent" label for legal purposes, especially when we are talking about the individual's ability to make informed decisions, whether for health care or other matters in life.  The incompetent label is viewed as unnecessarily and inappropriately stigmatizing.  The legal trend is to focus on capacity evaluations.  This trend also rejects global incompetency labels, and is often tied to an evaluation of function for specific tasks.  Perhaps the two professions are moving in the same direction when concerns are identified about cognition, focusing on an evaluation of the individual's "capacity for what?"   

Earlier this week, I was part of a fascinating discussion with a panel that included Dr. Samuel Hammerman, who wears many professional hats including that of a practicing pulmonary and critical care physician; Dr. Charles J. Duffy, a professor of neurology with deep professional interest in dementia; and Rabbi Ron Muroff, who set exactly the right tone for compassionate discussion.  Okay -- we all admitted our introduction sounded like the start of a joke about walking into a bar.....

We took up this topic of "capacity" or "competence" in response to two cases drawn from real life, where patients with serious physical health concerns also have compromised cognition and are rejecting admission or treatment at a hospital. Our audience, members of the Cardozo Society (lawyers) and the Maimonides Society (health care professionals) of the Jewish Federation of Greater Harrisburg, were very engaged and of enormous help in the discussion.  I walked out of the room energized and ready to get back to a long-planned article updating this topic (as soon as I find that elusive commodity, time!).  

December 12, 2019 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases | Permalink | Comments (1)

Caregiving Technology and Reliability

I read last week about a technology problem with a diabetes monitor, A glitch in diabetes monitors serves as a cautionary tale for health tech. Although primarily about this particular device, the article observes that the reliability on this kind of health tech means it's too important for it to malfunction.  Some of the things my students and I always discuss in the context of using technology for aging in place is the reliability of the technology, informed consent to its use, privacy of data collected and the cyber security of those companies that store the data.  As this article illustrates, when we rely on technology to keep people safe, we need the technology to be reliable. It's early days yet as far as the use of technology to age in place and how well it will function over the long haul.

The Task Force on Research & Development for Technology to Support Aging Adults Committee on Technology  of the National Science & Technology Council issued a report, Emerging Technologies to Support an Aging Population.   Section VIII of the report, Cross-Cutting Themes. addresses these issues and others, including system dependability, privacy and security, times when the systems are unavailable, vulnerabilities, and more. 

These are issues that lead to a robust class discussion, and even a few good topics for students' scholarly papers.

 

 

 

December 12, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Web/Tech | Permalink | Comments (0)

Tuesday, December 10, 2019

Updates from Missouri

I was in Missouri last week for a couple of days and had a chance to visit with some great people. First, I had the privilege to meet Dr. Erin Robinson and Dr. Clark Peters from the School of Social Work at Mizzou.   The work they are doing in gerontological social work is quite interesting. At some point our conversation segued into the role of technology in caregiving for older adults, and Dr. Robinson shared with me the research and activities of the Mizzou Center for Eldercare & Rehabilitation Technology, whose "mission is to create technology for proactive healthcare that helps older adults and people of all ages and needs to lead healthier, more independent lives."   We also talked about the University's foray into housing for elders, known as TigerPlace. which is a partnership between Americare and the Mizzou Sinclair School of Nursing.

On Friday, I attended day two of the winter symposium of the Missouri Chapter of NAELA (MoNAELA), The two day program had a robust agenda of general sessions and two tracks, advanced and basics. These folks are a great bunch of people who are quite knowledgeable and caring.

 

 

December 10, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Programs/CLEs, Science, Web/Tech | Permalink

Monday, December 9, 2019

Medicare Mistakes Need Do-Over?

Last week Kaiser Health News reported on mistakes on the Medicare website, which may have causes probelms for beneficiaries chosing their plans during open enrollment. Website Errors Raise Calls For Medicare To Be Flexible With Seniors’ Enrollment explains the extent of the problem.

The overhauled Plan Finder debuted at the end of August, and 2020 plan information was added in October. Over the past three months, Plan Finder problems reported to CMS by the National Association of Insurance Commissioners, the National Association of Health Underwriters, and state and national consumer advocates included inaccurate details about prices, covered drugs and dosages, and difficulty sorting and saving search results, among other things.

CMS made almost daily corrections and fixes to the website, which is the only tool that can compare dozens of private drug and medical plans ― each with different pharmacy networks, covered drugs and drug prices. The website provides information for more than 60 million people with Medicare and their families, as well as state Medicare counselors and the representatives who answer the 800-MEDICARE help line.

Unsurprisingly, the article notes that some folks signed up before corrections were made, which may not become apparent to them until they use the plan in 2020.  Which leads me to my next point.

Sen. Bob Casey of Pennsylvania, the senior Democrat on [the Senate Special Committee on Aging], also said Medicare needs to reach out so people know they can request a “special enrollment period” if they discover next year they made a wrong choice due to inaccurate Plan Finder information.

“People with Medicare must be aware that this reprieve exists and should not have to jump through hoops to qualify,” he said. The administration should “use all means necessary” to let beneficiaries know about their options for a special enrollment period.

Fifteen Senate Democrats, led by Casey, sent a letter  Thursday to Medicare Administrator Seema Verma asking the agency to “widely publicize the existing SEP for people who were misled by information” in the Medicare Plan Finder and to make switching plans easy.

The Associated Press reported on that at the end of last week. Senators urge Medicare to allow seniors a drug plan do-over:

 

In its statement Friday, Medicare said it wants to ensure that seniors “are confident in their decisions and happy in the coverage they choose.”

Medicare said it’s always had the ability to grant do-overs, “but this year we’re doubling down on ensuring that choosing their Medicare coverage is a simple and painless experience for beneficiaries.”

Medicare officials told AP that if seniors had problems with the plan finder and were unhappy with the outcome, they could call 1-800-MEDICARE and request to make a switch.

Agency officials said beneficiaries don’t need to use any technical language, only explain what their issue is to the call center representative. No documentation or screen shots will be required.

Stay tuned. This may not be over.

December 9, 2019 in Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Web/Tech | Permalink | Comments (0)

Tuesday, December 3, 2019

Stories About Alzheimer's

Two recent stories about Alzheimer's caught my eye, and I wanted to share them with you here.  The day after Thanksgiving, the Today Show ran a story, Caregiver for Alzheimer's Patient Shares Family's Struggles. The caregiver wife tells the story of their lives and the financial impact when her husband, a lawyer, was diagnosed at age 61 with early onset Alzheimer's. The summary describes the story, "Millions of Americans selflessly care for loved ones with Alzheimer’s disease and one family is opening up about their struggles on TODAY. Many people are calling for a nationwide program for caregivers, reports special anchor Maria Shriver." Senator Amy Klobuchar appears in the story, as her dad has Alzheimer's. The story mentions pending bills in Congress, including the Alzheimer's Caregivers Support Act. The link to the 3:22 minute video is available here.

The second story, an opinion piece in the New York Times, The Unending Indignities of Alzheimer’s   aired December 1, 2020. It highlights the obstacles family members face in trying to find the necessary care for the individual with Alzheimer's....

But while his family, and his physician, agree on the need for more advanced care, his health insurers do not. Medicare does not generally cover long-term nursing home care. Medicaid does, but only when it deems those services “medically necessary” — and that determination is made by insurance agents, not by the patient’s doctors. The state of New Jersey, where my parents live, recently switched to a managed care system for its elderly Medicaid recipients. Instead of paying directly for the care that this patient population needs, the state pays a fixed per-person amount to a string of private companies, who in turn manage the needs of patients like my father. On paper, these companies cover the full range of required offerings: nursing homes, assisted-living facilities and a suite of in-home support services. In practice, they do what most insurance companies seem to do: obfuscate and evade and force you to beg.

The author writes how the family is piecing together the care the best they can.  She writes "[t]he real problem is not my father’s level of functionality; it’s the lack of available Medicaid beds and the absurdly high cost of any meaningful alternative. For example, there’s a lovely assisted-living facility just two miles from my parents’ apartment. But it costs $8,000 a month, on average, and does not accept my father’s insurance."

BTW, know someone who is a caregiver? Even though National Caregivers' Month (November) is behind us, thank a caregiver.

December 3, 2019 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Monday, December 2, 2019

Elder Law Issues as Part of Candidate Platforms

Although our semester has ended, my students are still paying attention to the elder law issues in the news, including those issues that are being mentioned as part of the presidential candidates' platforms. During the semester, we talk abut news stories regarding elder law issues or elders.  We may have started with a discussion of Medicare for All, but we soon moved beyond that onto other issues.  Most recently, a student send me a link to a YouTube video about the importance of long-term care, put out by one of the Democratic candidates for President (it's important right now to state that I'm not focusing on politics or a particular candidate, but that candidates are realizing the importance of issues affecting elders in the U.S.). In this video, the 102 year old, Dorothy, has run out of money for her care. Even though it's ultimately an endorsement about a specific candidate, the points made in the video are important and are faced by so many older Americans. 

Thanks Jenna for sending this to me and good luck on your exams!

December 2, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (0)

Monday, November 25, 2019

The Cost of Caregiving-Emotionally and Financially-for Caregivers

With Thanksgiving just two days away, I thought we should remember to give thanks to caregivers and to reflect on implications of what that means. This perspectives piece from the Washington Post from a few weeks ago is worth reading In  My family faces an impossible choice: caring for our mom, or building our future the author writes from personal experience about her mother's need for care. Consider this information the author offers:

Sixty percent of people caring for adult relatives or friends also have full- or part-time jobs, according to the AARP’s Public Policy Institute. More than half of caregivers report a decline in exercise , poor diet and not seeing their doctor as needed. Chronic stress in caregivers has been shown to increase the risk of high blood pressure and heart disease . Compared with their peers, elderly individuals who serve as overburdened caregivers are 1.6 times more likely to die within four years. Only 13 percent of caregivers are between the ages of 18 and 29, according to Gallup-Healthways, so fewer studies exist on the effects on younger people. From my own experience, I can say that I routinely missed meals and sleep during my adolescence, and that I strove to hide my exhaustion, weight loss and social isolation from the people around me.

The author also writes about the financial impact that caregiving may have on the caregivers:

Caregiving fuels generational poverty, disproportionately affecting millennials and women who take on that role in their families. ...  Millennial caregivers are more likely than previous generations to be passed over for promotions, forced to reduce their job responsibilities or fired, according to the TransAmerica Institute. Just a few years of caregiving early in life creates cumulative financial setbacks for women, making them less likely to have retirement savings and more likely to require government assistance. A 50-year-old woman earning $40,000 a year who leaves the workforce to care for a family member for five years loses 11 percent of her potential lifetime earnings ($256,753), according to the Center for American Progress. If she does the same at 25, she loses 20 percent of her lifetime earnings ($679,000). When women become caregivers, they also become 2.5 times more likely to live in poverty.

The author reflects on existing caregiving support programs, and mentions a new law from Washington that provides "a publicly funded long-term-care benefit... [of] $100 a day, with a lifetime cap of $36,500, to pay for services including caregiving, meal delivery and nursing home fees."  The state expects to save an enormous amount of Medicaid money as a result of this new benefit.

Know any family caregivers? Right now, thank them for doing this and ask them what help they need.

 

 

November 25, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicaid | Permalink | Comments (0)

Sunday, November 24, 2019

2020 Medicare Premiums Released by CMS

In case you missed this, a couple of weeks ago CMS released the Medicare premium and deductibles amounts for 2020.

Here are some of the more important numbers for 2020  from the CMS notice:

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,408 in 2020, an increase of $44 from $1,364 in 2019. ...  In 2020, beneficiaries must pay a coinsurance amount of $352 per day for the 61st through 90th day of a hospitalization ($341 in 2019) in a benefit period and $704 per day for lifetime reserve days ($682 in 2019). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $176.00 in 2020 ($170.50 in 2019).

As for Part B, "[t]he standard monthly premium for Medicare Part B enrollees will be $144.60 for 2020, an increase of $9.10 from $135.50 in 2019. The annual deductible for all Medicare Part B beneficiaries is $198 in 2020, an increase of $13 from the annual deductible of $185 in 2019."

The release also includes the 2020 Part B monthly premium adjusted amounts for higher-income beneficiaries.

 

November 24, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Tuesday, November 19, 2019

Issue Brief on Medicare Part D

The Kaiser Family Foundation has released its November, 2019 issue brief, focused on the costs of Medicare Part D.  Medicare Part D: A First Look at Prescription Drug Plans in 2020 offers these key findings

  • The average Medicare beneficiary will have a choice of 28 PDPs in 2020, one more PDP option than in 2019, and six more than in 2017, a 29% increase.A total of 948 PDPs will be offered in the 34 PDP regions in 2020(plus another 11 PDPs in the territories),an increase of 202 PDPs since 2017.
  • PDP premiums will vary widely across plans in2020, as in previous years(Figure 1). Among the 20 PDPs available nationwide, average premiums will range sixfold from a low of $13 per month for Humana Walmart Value Rx Plan to a high of $83 per month for Express Scripts Medicare Choice
  • Two-thirds of Part D enrollees without low-income subsidies (9.0 million enrollees) will see their monthly premium increase in 2020 if they stay in their same plan, while one-third (4.3 million) face premium decreases. As an example, the 1.9million enrollees without low-income subsidies in the Humana Walmart Rx Plan, the third most popular PDP in 2019,will see their monthly premium double in 2020, from $28 to $57, unless they switch plans.This is due to plan changes and consolidations, with Humana consolidating two of its DPs (Humana Walmart Rx and Humana Enhanced) into one PDP or 2020 and renaming it Humana Premier Rx, with a $57 monthly premium.
  • The estimated national average monthly PDP premium for 2020 is projected to increase by 7% to $42.05, weighted by September 2019enrollment. The actual average premium in 2020 may be lower if current enrollees switch to, and new enrollees choose, lower-premium plans during open enrollment.
  • In 2020, all PDPs will have a benefit design with five or six tiers for covered generic, brand-name, and specialty drugs,and cost sharing other than the standard 25% coinsurance, similar to 2019. More than eight in 10 PDPs (86%) will charge a deductible, with most PDPs charging the standard deductible of $435 in 2020.
  • Among all PDPs, median cost sharing is $0 for preferred generics and just $3 for generics, but$42 for preferred brands and 38% coinsurance for non-preferred drugs(the maximum allowed is 50%), plus 25% for specialty drugs (the maximum allowed is 33%).
  • Medicare beneficiaries receiving the Low-Income Subsidy (LIS) will have a choice of seven premium-free PDPs in 2020, on average, one more than in 2019. In 2020, nearly 20% of all LIS PDP enrollees who are eligible for premium-free Part D coverage(1.3 million LIS enrollees) will pay Part D premiums averaging $18 per month unless they switch or are reassigned by CMS to premium-free plans.

The full issue brief is available here.

November 19, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)