Wednesday, July 29, 2009

Columnist talks about the idea of Medicare rationing in his own family

Jeffrey Weiss has a "Politics Daily" column “Health Care Rationing and my 91-year-old Dad”, in which he see-saws his way through all the questions of medical and personal ethics in deciding how far to go with treatments in repeated hospitalizations for his father, with multiple medical issues.

There’s no conclusion, but rather a recognition that algorithms need flexibility, and decisions probably depend on support of family members.

We have a culture that says it has absolute respect for human life in all cases. It works out one way in the abortion debate (the rights of the mother, too), but at end of life the issues play out in terms of the sacrifices from others required to preserve life. And the sacrifices may themselves be unsustainable, particularly in an individualistic (rather than heavily socialized) society.

We can easily imagine all the arguments

It seems that the health care debate hasn’t really separated out the issues for eldercare, which exist in a system that is already mostly single payer and heavily into “socialized medicine” even though Medicare patients still get to keep their own doctors (sometimes, too many doctors).

Tuesday, July 28, 2009

Legitimate caregiver concerns mean additional tests, additional costs for Medicare; a problem hard to quantify: "agendas with good intentions"

Caregivers may feel pressured to visit more specialists and ask for more tests for loved ones, especially parents, in order to avoid any risk that adult services departments in some states could think they were negligent. That possibility could increase the cost of end-of-life care and increase expenses by Medicare, particularly in a medical environment where formal referrals (often required by private managed care programs of the past, however unpopular with employees) are often not required. 911 calls and emergency service visits, including Medicare expense, could also increase for that reason. But it seems as though there is little formal study of this problem.

However, the Wall Street Journal today has a long story by Ron Winslow and Jacob Goldstein “Cutting repeat hospital trips: simple idea, hard to pull off,” about an initiate at Berkshire Medical Center in western Massachusetts to reduce readmissions, especially of elderly patients with chronic heart, kidney and diabetes problems. The wsj url link is here. The “nursing gestapo” visited homes for dietary and safety problems, telling adult daughters to remove tempting but unhealthful foods from the refrigerator. I wonder, who do they think they are?

The eldercare “crisis” can easily tempt intervention by those with agendas, it seems.
Liz Crenshaw, of NBC Washington, talked loosely today (July 28) about preparing for caring for aging parents as part of financial planning as if it were simple!

Attribution link for Berkshires picture. I hiked in the area on a winter trip while in college in January 1965.

Monday, July 27, 2009

Memory loss diagnosis on older adults may have legal importance for caregivers

Some anecdotal conversations have uncovered the notion that family caregivers must be very careful about parents (or anyone) with a diagnosis of “memory loss” (or “short term memory loss”) anywhere in the medical records. Some people have told me that reckless endangerment laws in some states could make caregivers liable to prosecution for leaving people with mentally documented memory incapacity alone, even for very short periods. The concept is thought to be similar to leaving a child under a certain age home alone or even alone in a car, which has led to prosecutions in some states after some tragedies (as with parents who forgot that the child was in the car).

Memory loss (at any level, not just Alzheimer's as usually defined) is considered a very serious incapacity in disability law in some states (especially if it requires heavily promoted medications), and may not be flexible enough to vary that it varies widely from patient to patient. Some states may have judicial or administrative procedures to establish guardianship or conservatorship, and sill require caregivers without such powers to act as if they had them, a situation that could lead to future litigation.

Of course, the caregiver may not have taken on the responsibility in such a legally clear cut way that occurs when some “chooses” to have or adopt children. Adult social services often interpret laws according to circumstances or political climate, and even if in one state, different counties might implement laws differently. The recent health care public debate may be making the issue more sensitive, but Congress has not really taken on the sustainability problems of our eldercare future.

The availability of home health may become an issue, as may the willingness of the adult to move into assisted living or the ability to afford it (given the loss of home).

While adult children want to help their parents, the speed with which demographics and medical practice has led to an increase in disabled parents with fewer adult children to care for them can produce a public health and social crisis that Congress seems to have overlooked. The president has not yet addressed this aspect of the crisis directly, although I think he probably will soon. Adult children today need to plan for filial responsibility, both financially and in terms of personal attention, well in advance of need, and this particularly applies to singles and the childless (and often the LGBT population).

Memory loss, as the medical world establishes it, may even be partially a cultural problem. Today’s “Smallville” and markedly individualistic world requires mental multi-tasking and heavy use of abstraction that some seniors from past generations were never trained or expected to do; in the past there were more stable and numerous social connections within the extended family (expected from those who did not marry on their own) to maintain a safe and reasonable environment for some elderly, who also did not live as long with some kinds of problems. Some memory loss may actually result from some misused medications; remember that under Medicare physicians still do not have automatic record keeping for cross-checking for drug interactions among different providers. Today’s caregivers deserve better.

Here is a Doctor's Guide story on the reported effectivness of Aricept in some people. The title is "AAGP: Alzheimer’s Drug Aricept (Donepezil) May Delay Need For Nursing Home Placements."

Friday, July 24, 2009

Shingles vaccine recommended for retirees

The Centers for Disease Control does recommend a relatively new vaccine for Shingles for people over 60, and that would include retirees. The commercial name for the Zostavax.

I learned about the vaccine at my first Medicare Physical.

Medically, what happens is that once someone has had chicken pox, the herpes zoster virus goes into hiding in some deep spinal nerve ganglia, and can get reactivated late in life after a person’s immune function declines. The vaccine boosts immunity to reactivation.

People with HIV and T-helper counts below 200 should not get the vaccine.

The CDC link is here.

I tried the CVS Minute Clinic online and got an answer to the effect that CVS does not yet carry the vaccine, but was considering it. I found that a local “compounding” pharmacy, Preston CARE in Arlington VA, would give the vaccine for $68 including $38 copay (on top of AARP Part D) and $30 admin fee.

The vaccination is subcutaneous rather than inter-muscular.

Update: Aug. 2
Safeway stores (at least some) now have signs that they offer the shingles vaccine.

Thursday, July 23, 2009

Law firm explains how lower mortality and longevity contribute to disability

The “Senior Living” section of the northern Virginia “Your Health” magazine has an article “The Overall Effects of Disability” on p 36, Aug. 2009, by Scott B. Elkind, Esq., of Elkind & Shea, the Disability Benefits Law Firm.

The authors point out that an individual has a 72% chance of having some disability before retirement age at some time, and there is a 50% chance that this can last more than three years. Ten years later, such individuals have an overall income reduction of 46%.

I was lucky. My convenience store fall in 1998 resulted in a serious injury (acetabular fracture) and I got worldclass treatment at the University of Minnesota, was back to work in three weeks (when I could well have been in traction), and was paid 100% short term disability by my employer by its insurance plan for that time.

The authors point out that “decreasing mortality” and “increased longevity” will eventually lead to a “crushing societal burden.”

This article does not appear online yet, but the July 2009 article “Disability Dilemma” from the firm is here.

The law firm has a good article on its own site for the newly disabled here.

Wednesday, July 22, 2009

Washington television station reports on early onset Alzheimer's

ABC Affiliate WJLA in Washington DC today, in its 5 PM report, aired a report on early onset Alzheimer’s disease, occurring at 51 in one woman, and 59 in one father. The District of Columbia is expected to have 9000 cases of Alzheimer’s by 2010. Five million Americans have Alzheimer’s now, and the number will be 15 million by 2050.

“If you think a family member has Alzheimer's disease, you're usually right," said Dr. Adam Rosenblatt, a neuropsychiatrist was quoted as saying in the report.

The link for the story, “Initiative Aims to Raise Azlheimer’s Awareness” is here.

The disease is hard on caregivers in a way that AIDS was not in the 1980s. Then, most patients died quickly, or got better for a while, and then returned to “productive life” once antiviral drug treatments became more effective. Drug treatments can slow the progression of Alzheimer’s but so far have not been able to reverse it. Alzeheimer’s may become our largest public health problem.

Tuesday, July 21, 2009

Health care reform could undermine ERISA, with downstream effects

The Wall Street Journal has a challenging editorial today (July 21) “Repealing Erisa: if you like your health plan, you won’t be able to keep it” about how provisions in the health care reform bill would gut many of the provisions of the Employee Retirement Income Security Act of 1974 (ERISA) (Findlaw text here). The web link for the WSJ story is here.

Particularly, it would hinder the ability of employers who self-insure to continue to do so across state lines without a lot of bureaucratic regulation, now avoided by ERISA. In the past, experience has tended to show that self-insured companies often can offer better benefits and even better defined benefit pensions.

The Journal today also has a comprehensive analysis of health care reform on p A16 in the print version. I’ll come back to that soon on the issues blog, but one of the important points is that keeping a mandate on employers (even small ones, with a $250000 payroll floor) is not only anti-competitive (abroad, competing with single payer countries) but could compromise many services to the public that depend on contractors, such as the home health caregiving industry.

It doesn’t sound like Congress has thought too carefully about the potential consequences of what it is about to do.

Sunday, July 19, 2009

Moderate alcohol use might delay dementia in older adults

Today, Sunday July 19, on CNN, Dr. Sanjay Gupta reported a study claiming that adults who had drank alcohol moderately for some years had a 40% less chance of developing some dementia as seniors. Some results have been reported for small caffeine use, too.

Gupta defined moderate alcohol use as one 12 ounce beer a day for women and perhaps two for men.

Small daily consumption of alcohol may reduce coronary artery disease and ischemia, and that might help explain the result. Another possibility could be anti-oxidants in some wines.

CNN also reported on the Cleveland Clinic (which often advertises on ABC with videos) as having lower costs because it pays its physicians salaries rather than charging fee for service.

Friday, July 17, 2009

Should long term care companies be able to access genetic tests for Alzheimer's?

Denise Grady has a story in the Thursday July 16 New York Times “Learning of Risk of Alzheimer’s Seems to Do No Harm”, link here (may require registration). The study was conducted at Boston University and will soon be published in the New England Journal of Medicine.

There is concern over a gene called APOE, for apolipoprotein E, which comprises several types, e2 through e4. The presence of e4 seems to be correlated with a higher occurrence of Alzehimer’s but it is far from definitive, either way.

One important issue is that right now insurance companies can look at genetic tests for long term care insurance, but not for other insurance (also cannot be used for employment). There may well develop political pressure to pass legislation to prevent companies from doing so for LTC as well.

Thursday, July 16, 2009

Social Security spends $700,000 on bash in Phoenix

A Phoenix television station is reporting that the Social Security administration spent $700000 for a management training bash at the Biltmore hotel in Phoenix.

The actual PDF of a letter to the Social Security Administration from the House Ways and Means Committee is here.

The SSA’s reply letter to Congress is here. SSA talks about its "San Francisco Region."

The main media story came from ABC television station KNXV 15 in Phoenix. The story includes a telling video.

Of course, this sounds like a drop in the bucket as to the eventual day of reckoning for the Social Security Trust Fund. It seems like no one under 40 expects it to be there for them.

Attribution link for Wikimedia picture from downtown Phoenix. I last visited Phoenix in May 2000.

Tuesday, July 14, 2009

Adult children should help parents simplify their finances

Mellody Hobson, financial editor on ABC’s Good Morning America, gave adult children advice this morning (July 14). Have a conversation with your parents about finances while they are still well, she said. You may have to approach the topic several times.

She recommended talking to them about direct deposit, automated bill paying, having a will (she didn’t mention write a trust but that is becoming popular), and in many cases considering long term care insurance. Here verb was “simplify.” Good advice could be to take stock certificates and bonds and put them into investment accounts managed by major banks (they are normally protected from the bank’s own health). She said that over 70% of people in the US do not have wills. And 70% of people in assisted living facilities or nursing homes must self-pay. Most people don’t know that Medicare doesn’t normally cover nursing home care, she said (there are exceptions).

The link is called “How to Talk to Your Parents About Money: Get Mellody Hobson's Tips for Discussing Finances With Your Elders” with link here.

Hobson did not mention filial responsibility laws, or so called poor laws, which in 28 states (including California) could force adult children to support indigent parents, and which might be enforced in the future given the financial crisis in many states.

Hobson mentioned the AARP's estate planning link, which is here. I think that it is interesting how the AARP plays devil's advocate with the rapid promotion of living trusts by lawyers, in a piece called "The Truth about Living Trusts", at this link. AARP says that it does not endorse particular trusts or parties selling them. This article is in some contrast to what the media (like Jeffrey Toobin on CNN) has said about trusts (favorably) in view of the Michael Jackson experience.

Sunday, July 12, 2009

Michael Jackson did set a good example for estate planning

Financial columnist Eileen Amrbose has a useful column on p 16 of the Sunday July 12 Baltimore Sun, motivated by the example set by Michael Jackson’s estate. The column has the long title “All the Right Moves? Michael Jackson’s skill as an entertainer was unrivaled, but lessons abound in the King of Pop’s estate planning.” That’s the title in print, but online she is even more explicit. “Michael Jackson wowed audiences with his singing and dancing, but his best performance may have been the handling of his will, which he nearly got perfect.”
The link is here.

Ambrose extracts some practical tips from Michael Jackson’s most public example. One is to be rather public about your intentions. Tell people about it, make more than one copy (yes, keep at least one original in the safe deposit box). She doesn’t say so explicitly, but I think that the idea of a “dead hand” – posthumous expectations of behavior of beneficiaries – would be OK with her. It’s important to be clear and sensible about one’s wishes for custody of one’s children. There have been a few movies and television shows (“Raising Helen”, “Summerland”, “Saving Sarah Cain”) where childless siblings wind up raising the kids and other films about desired behavior (“The Ultimate Gift”). Parents should be sure that the other siblings would be prepared for the task. Or parents might choose other guardians of about their own age whom they know are ready for the task.

The article makes the often overlooked point that wills are supposed to be public but trusts, which have become popular lately and which may have the final say, are generally private. The article also provides some details on contesting wills, where laws vary by state.

Visitors might want to check out the 1968 short story by John Knowles (author of "A Separate Peace"), "The Reading of the Will"; descriptive link here.

Saturday, July 11, 2009

After many mergers, even "fortunate" retirees can find pensions complicated

Retirees with defined benefit pensions from companies that have acquired the companies that they had originally started working for, may find it very difficult to calculate or understand their pension rights from the documents that the “final” companies provide.

Most larger companies try to honor the obligations of the companies that they bought (usually they have to, and usually those items are part of the due diligence before a merger is approved). In some cases, older companies, especially those with specialized customer bases, have pension plans that were more generous than those of the larger (and sometimes more leveraged) acquiring companies. They may have less social security offset, and may offer social security bridges until age 62 instead.

Everyone says now that retirement ages will have to increase, in the heels of an era when companies “bought out” expensive career employees in their 50s and sometimes designed packages that encouraged them to retire earlier, at 62. A large conglomerate may find it is paying pensions that are indeed hodge-podges, with some operations giving formulas that assume associates work until full retirement age and other operations having pushed people out the door early (sometimes because of archaic legal restrictions, for example, not letting pilots fly past 60). And this is true of salaried and management employees, let alone unions.

Its hard to say how all of this plays out in the recent auto industry bankruptcies and restructurings.

There was never a time when it was so important to give individuals control over their own retirement futures. The “conservatives” are right on this one.

Friday, July 10, 2009

AOL lists 20 best retirement locations around the U.S.

AOL walletpop has an article today listing the top twenty retirement communities in the United States. The link is here. They are located all around the country, with some concentration in Florida and California, but one is near Cleveland, and one (the lowest cost) is in Mississippi, John Grisham country. Most of them still have an average home price over $200000, some over $300000, even given recession.

It would be nice to see a walletpop article on senior apartments specifically.

Thursday, July 09, 2009

People should leave clear instructions of their wishes; it's more than just a will

Michelle Singletary has a running column “The Color of Money” in The Washington Post, and today, July 9, on p A15, she has a very practical column, “Don’t Add Confusion to Your Survivors’ Grief”, link here (may require free registration to view content). Here she is talking about a centralized repository of one’s wishes: location of will, life insurance policy (hopefully to help pay for funeral), asses, debts, and the like. She suggests putting the list on on a CD Rom or Flash Drive. Presumably it should be stored in a safe deposit box, with maybe a master copy at home next to the keys for the box. She notes that Michael Jackson's passing in California is causing people to pay attention to their own estate planning.

Earlier on this blog I had talked about trusts and given some links to basic information about their benefits. If you place all your assets in a living trust, don’t forget you will need to notify your auto and property insurance companies to add the trust as the name of the “insured” (they will probably ask for a fax of the deed recording document); in a few states, there have actually occurred some legal battles over the liability of an insurance company when the insured failed to do so, and it could be an issue when the house has a mortgage requiring active insurance.

Thursday, July 02, 2009

Ohio, Texas state pension funds sue over bailout-related bank mergers

More state or public employee pension funds are practicing their fiduciary responsibility to retirees and going after banks caught up in last year’s collapse.

Five funds, including state employee funds in Ohio and Texas, have sued the Bank of America for misleading them about Merrill Lynch before its “forced marriage” with Merrill on Jan 1

The New York Times ran the Reuters story today on p B4. The story follows a story about action taken by Indiana teachers regarding the Chrysler merger in early June. Pension-related litigation could halt many of the complicated arrangements to help financial companies and auto-related companies avoid or come out of bankruptcy. There is a concern that retirees are being “sacrificed” for current employees, and that the PBGC will not completely cover them.

The updated Reuters story is here.

Wednesday, July 01, 2009

Self-paid long term care: compare the options: in-home could be the most expensive

I found another reference on how to choose among long term care options, particularly in “self-pay” situations. The reference is on a site called prosaically “”, and it is here. The title of the article is “How to Choose Between Home Health Care, Assisted Living, and a Nursing Home.” The article aims at US markets, although the costs seem to behave similarly in Canada and Britain. Remember, in general (except in a few countries) purely custodial care is typically not covered except for the indigent (Medicaid in the US); it is generally not covered by Medicare (hospice offers some coverages however).

One particularly important point is that 24-hour-care is likely to be the most expensive option in many cases. That would be particularly the case if one goes through an agency, that would have to send workers out in shifts. If an individual caregiver finds a live-in and does all the legal paperwork (IRS, EIN, immigration, etc) sometimes it could be much less expensive, but doing so may not be all right for many people. In many communities, 24 hour home health could cost close to $200000 a year.

By way of comparison, a nursing home in a similar area may typically cost about $7500 a month, or getting a little under $100000 a year, and an assisted living tends (after purchasing unbundled services with most residents need) in higher cost areas to be about $5000 a month. A recent film about assisted living in Britain found similar numbers, showing active seniors in north London paying about $4000 a month.

Caregivers are always concerned about whether their elders or parents will really get adequate care in these settings.

The best earlier reference that I found for comparison was on this blog Feb. 20, 2008, with the major source the John Hancock Life Insurance Company.