Thursday, April 24, 2008

Surgically implanted heart pumps can create ethical dilemmas at different levels

Rob Stein has an important front page story today in The Washington Post, April 24, 2008, “Heart Pump Creates Life-Death Ethical Dilemmas,” link here The story concerns the surgically implanted heart pump, which is sometimes a bridge treatment until a heart transplant is found, or is sometimes an end treatment, possibly in conjunction with or after coronary bypass surgery, to add some years of life. The devices have external batteries, microprocessors and wiring leading into the body cavity to control the pump. The treatment has mixed results, working well for some patients but causing serious complications (infections, clots, strokes) and deterioration in others. It appears that in some cases the surgery should not be done unless other family members are willing to be supportive of a possibly risky, disruptive and uncertain surgery.

Here is a typical article from the American Heart Association, “Smaller heart pump bridges time to transplant for more women” from 11/04/2007, link here. It seems that many of the operations are done earlier, in the 50s and 60s. It isn’t clear how well the operation can work repeatedly in later decades.

The Post story considers the ethical dilemmas, in cases where patients want the pumps turned off in end-of-life situations. There is a risk that some people could live very long times with very poor quality and in extreme dependence, when in some cases they might have been more self-sufficient (even with shorter final life spans) without surgery.

When I was a "buddy" in the 1980s for the Dallas Oak Lawn Counseling Center AIDS Project, we would hear talk of patients' "letting go." That talk went away as the medications got better and victims, relatively young, not only survived much longer but went back to work and no longer needed daily services.

But, for the elderly, medicine has gotten much better at prolonging life than at prolonging vigor.

Sunday, April 20, 2008

AARP/United Healthcare appear to offer reasonablly priced supplementary Medicare coverage to those turning 65

Saturday I received a mailing from the AARP which explains the Medicare Supplement plans available to AARP members. It offers a variety of plans, cafeteria style, with monthly premiums from $60 to $120 (with some lower premiums during early enrollment discount periods) from United Healthcare. Some plans offer skilled nursing care (not long term care) and even foreign travel coinsurance.

The plans seems to be guaranteed issue (without pre-existing condition exclusions) if one has turned 65 or enrolled in Part B in the past six months. One cannot have any other coinsurance programs.

As noted before (in November on the blog) Medicare coverage has many limitations, particularly in Part B, and so some deductible ($1024 in the first 60 days, $256 a day or $512 a day in days 61-90 and then after 90 until Lifetime Reserve Days are met, in Part A, as well). The supplemental plan usually covers all but the $1024. Some supplemental plans pay the $1024 deductible. On Part B it pays most of the $20 copy (after the $135 deductible).

As a whole, the plan looks more affordable that I would have expected.

Sunday, April 13, 2008

Eldercare: adult children face the "pay your dues" rule

In the Sunday (April 13, 2008) Business Section, p F1, The Washington Post today runs a hard-hitting column by Michelle Singletary (in “The Color of Money” series) “Pay Your Dues When Your Parents Age,” link here. The column continues on p 3 with the secondary heading “Looking Out for Mom and Dad.” The author appears on National Public Radio on Tuesdays at here.

The heart of her essay appears near the beginning, “… my pastor recently suggested that adult children should set aside money in their budgets to take care of their elderly parents.”

She tries to make light of it, telling us about a fast-food place conversation with her own three kids, and concludes with “I may joke with my kids about taking care of my husband and me in our old age, but we are very serious about making sure they can if they have to.”

First, I love her “pay your dues” phrase. I have an essay on my main site “pay your bills and pay your dues” that seems to tie into this, here. That dates back to 2004 and I nuance what I say there differently today. “Pay your dues” is one of the most popular search arguments appearing on the Urchin reports on my site. I know people are more worried about this than the politicians will admit.

The columnist goes into the challenges posed by the financial world today. Adult children may well have their hands full with their own needs, with unemployment, upside-down mortgages, gasoline prices, their own health issues, and all the familiar economic problems. Most of all, they may be overwhelmed with the financial and personal responsibility of raising their own kids (hence the new term "sandwich generation"). The “individualistic” culture of today does not make this too easy, and often views these difficulties as the results of the parents’ “choices.”

But that’s part of the rub. Some people (me included) didn’t have any children. Some people were only kids (no siblings – me again). Of course, it doesn’t take much to see how this argument applies to many LGBT people.

There has been some talk recently in right wing circles of “demographic winter” (a book review here goes into that). Although that line of thinking is concerned with international political consequences of demographics that may affect Europe even more than the United States, there is still a big demographic shift going on here. As a whole, middle class (and above) people have fewer kids (and the increased social acceptability of LGBT lives is a factor), while people live longer. (It should be born in mind that the average life span is also rising because of lower infant mortality; there have always been some people who live a full century or more.) That would be great if all the elderly were like those select centenarians on Barbara Walters 's recent special “Live to Be 150,” but in fact many people, especially women, are living for years in frail and disabled condition in old age when they would have passed away soon earlier. Part of the problem is that medicine can keep people alive longer, and physicians feel pressured to prolong life for its own sake. At the same time, lifestyle changes (diet – “underfeeding – that fast food trip again!” -- and exercise) have not protected the current elderly as much as they may for future generations of elderly. The result is that adults who have never had their own children can be faced with long periods of eldercare, not so much (or not only) the financial issues but also the issues of emotional connectivity with elders who do not understand today’s individualistic culture. Think about the 50s movie “Marty”. In earlier eras, the unmarried (especially women) were expected to hang close to home to care for aging blood relatives (not always parents) but typically they did not live as long because medicine could not prolong their lives then. I cover some television programs on aging (including Barbara Walters as well as PBS’s “Caring for your Parents”) on my TV blog, April 2008, between April 1 and April 9, here.

The eldercare issue also challenges our ages old equivalence between sexuality and responsibility for others. It’s no longer true that responsibility to provide for someone else besides oneself occurs because of an act of (heterosexual) sexual intercourse conceiving a child. One can exist without the other, “in either direction.” In fact, it never really was true, That confounds the way we think about “public morality.”

The workplace also figures into this. In the United States, we do have a mandatory provision for unpaid family leave, which would cover eldercare (parents) as well as child care and maternity / paternity. In many European countries there is mandatory paid leave, and we’ve never figured out how they make it work. (And the Euro is doing a lot better than the dollar now, as even the Fed notices.) But, at a psychological level, going to bat for parents in the workplace is testy for someone who did not have his own children.

One legal fact that most columnists miss is that around 28 states have “filial responsibility laws” or “poor laws” which can compel adult children to provide for indigent parents (who would otherwise use Medicaid, even when there is no pre-inheritance look back). On this blog, my coverage of that issue appears with the label below.

Long term care insurance is, of course, relates to this discussion. But one problem is that long term care insurance does not always kick in when it needs to. If people are expected to save for possibly mandatory eldercare responsibilities, maybe there should exist pre-tax accounts for this purpose built into our tax policy. Another problem is that Medicare far from covers all elder medical expenses (the famous "doughnut hole" in Part D).

All three major presidential candidates are missing the boat on this issue.

Sunday, April 06, 2008

Going from employer/retiree health insurance to Medicare

The media reports that some seniors, especially when moving, have trouble finding physicians who will accept them as Medicare patients. Many physicians, especially specialists, do not like settling for government ceilings on their reimbursement. This seems especially interesting inasmuch as Medicare is rapidly exploding and becoming threatened with insolvency.

One problem is life-prolonging treatments, that extend life spans but don’t increase vigor, increasing the need for consumption of Medicare services.

A Washington Post story “Financial Futures: On Medicare and Scorned by Docs” by Martha M. Hamilton today April 6, 2008 in the Washington Post, Business, p F01, link here,
relates the difficulties encountered by a woman moving from the DC area to Raleigh, NC.

Persons with already established physicians (especially with those provided by corporate health plans or private retirement plans before age 65 – mine is ING, for example) typically have little trouble keeping their physicians.

I guess I’ll find out soon. I find myself postponing hernia surgery until the month Medicare starts for me, because the out-of-pocket costs should be so much lower. I actually need to do the calculations yet. (It had better not incarcerate or strangulate before then, or I’m in big trouble.) I’ll have a Part B premium, but my corporate plan converts to a prescription-drug only plan, which I’m not sure will make sense given the premium for it.

The major presidential candidates (Hillary Clinton, especially) talk relatively little about Medicare compare to the health care issues for working people.

Tuesday, April 01, 2008

Private LTD insurers encourage claimants to make "fake" Social Security disability applications

The disability program, which the Social Security System administers, is overloaded with fake applications, as a result of demands by private insurers that claimants on long term disability policies apply for DI, too. Now Social Security disability is normally payable only to those who are totally disabled and unable to work in any job at all, often people who are terminally ill. In the 1980s, it was common for people with AIDS to apply for it.

There is a lawsuit against some companies brought by whistleblowers, who may have worked for the companies.

The story appears on the front page of the New York Times, April 1, “Insurers Faulted as Overloading Social Security; Whistle-blower suits; Disability filings called dubious—defense from companies,” by Mary Williams Walsh, in the Business Section online, link here.

Most of the time the DI claims to SS are denied, and the applicants never had a chance of qualifying. They are encouraged to apply because insurance companies can improve their bottom line by delaying payments. The workload is slowing down claims from legitimate SSI applicants, who often wait for over a year for claims to pay, when some may not have survived. The issue would not affect claimants who are old enough (and have enough qualifying quarters) to apply for regular retirement benefits.

Various law firms advertise the ability to fight for SSI benefits.

The disability portion of social security is projected to go broke by 2026, sixteen years before the more familiar retirement portion.

The POMS reference for Social Security DI is here.

Generally, to received DIB a worker must have worked long enough to be fully qualified for social security, and must have worked “recently.” There are some complications.

The program should not be confused with SSI, which is a “welfare program” but not an “entitlement” (which retirement and DI both are, as “supposedly” financed by FICA taxes) managed by Social Security but not funded by it.