Saturday, October 31, 2009

WSJ criticizes "pay-to-play torts" and state pension funds

The Wall Street Journal, on Saturday Oct. 31, has an editorial that helps shed some light on what is wrong with our pension system. It is titled “Pay-to-Play Torts: pension middlemen get investigated; lawyers get a pass”, link here.

The editorial criticizes the practice of law firms making campaign contributions in order to get selected to represent state employee pension funds in widespread securities litigation.

The concern spreads beyond the financial stability of the pension “tsunami” often discussed here before. It goes to the way public policy is influenced by special interests, whose members often no longer have the legal freedom to speak just for themselves in public.

Thursday, October 29, 2009

Home oxygen therapy is often used

Can people with heart or lung problems use oxygen at home? Yes, and there are a number of references on the subject. Here is one.

Use is often intermittent (for short periods, maybe when sleeping), or it may sometimes be continuous. It may result in the need for 24 hour caregiving assistance, or it may not. Certain safety precautions must be followed, such as making sure that all electrical outlets are constructed with three prongs. Compressed oxygen containers do not need electrical power, but liquid oxygen (familiar in high school chemistry class) does.

Here’s a good guide from CIGNA, an insurance company (a bad word in Michael Moore’s world). Blood gas studies are done first to determine the level of need. Often the need is relatively minimal. Often people have oxygen in hospitals or rehab stays but do not need it at home.

Wikimedia picture of home liquid oxygen canisters. Note the condensation ice on the canisters.

Wednesday, October 28, 2009

Married couples can game social security in sophisticated ways (Claim now, stop, claim more later)

Newsweek, on Oct. 26, 2009, published an interesting perspective by Linda Stern, “Gaming Social Security: Increasingly sophisticated retirees are figuring out how to get the most out of the system,” web URL link here.

We’ve talked here about the strategy of returning social security benefits collected if you get a good job again and then restarting at age 70-1/2 at a much higher benefit, as computed by SSA by actuarial formulas based on life expectancy (as is the case with life insurance company annuities). The break-even point is said to be low, with postponing retirement paying off if you live past 78 (especially more likely for women).

Single income married couples (where the wife was a stay-at-home mom and/or [for whatever reason] didn’t earn nearly as much – not always a sequitir, to be sure!! – maybe there was a stay-at-home dad!) may benefit from a cagey strategy. The non-earning spouse claims at 62, and the “breadwinner” (time for Henry Hyde’s “Mom and Pop manifesto” to be sure) waits as long as possible, whereupon the spouse drops the benefits and the earning spouse claims a spousal benefit on his account. This is your “family wage” scenario.

Then there is the “yuppie” scenario, of approximately equal incomes (so 80s sounding, isn’t it!). The lower earning spouse claims at 62 ("the protective social security application"), the other spouse claims (her) spousal benefit at full retirement age, and (his) own slightly later with delayed retirement credits.

People may start hiring financial planners just to game social security.

The article also mentions that some people claim social security early out of fear that it will get cut drastically later during a political binge of “shared sacrifice” (like the dreaded idea of “means testing”). As Obama said, we can’t kick these cans down the road forever. Sometimes claiming social security early can put someone in a higher tax bracket, according to rules on how social security income is taxed (up to 85% in conjunction with other income in some circumstances).

Tuesday, October 27, 2009

Lifespan Respite Care Act funding, and other things

Doing some research this morning, I see that HR 3248, the Lifespan Respite Care Act of 2006, did actually become law during the 109th Congress, under former president Bush, with link here.

But according to a USA Today article by Mindy Fetterman back on June 27, 2007 it hadn’t been funded. It aimed at providing certain kinds of help to people who gave up their jobs to provide unpaid care to elderly parents or other relatives, with link here. For example, social security benefits for the caregiver could be based on the highest years of earnings, caregivers could place their loved ones in publicly supported respite care centers, and caregivers could claim tax credits. Back then the AARP reported $2400 out of pocket expenses experienced on average by family caregivers.

ABC ran a similar story by Fetterman on June 27 2007, “Becoming ‘parent of your parent’ can become an emotionally wrenching process”, link here.

I’m not “for sure” where all this funding stands now, but I’m surprised that I don’t hear more about it in the health care debate. Many of the stories concern parents who themselves are nearing poverty. Sometimes, parents, especially elderly women, have been left well provided for but want personal attention from their own family members rather than hired care. Other times, some people use the need for care to manipulate spouses emotionally.

Is it “selfish” to nudge the parent toward a retirement home? What if the adult child then remains in the parent’s home and looks after it. Should the child “charge” for services and pay market rent at the same time? There’s not much that’s easy to find online about this, beyond IRS Publication 527 (link; see Section 5 especially). It would seem that if the parent comes home occasionally to enjoy the home or yard, that’s personal use (which means they can’t claim depreciation or expenses against any rent that the adult child pays). I would think that the adult child should pay market rent for the space that he or she actually would use (like that of a typical apartment) if the caregiving need had not occurred. But I can find little or nothing written about this online.

Here’s a CNN Money story that may provide a little insight.

Monday, October 26, 2009

AARP Medicare-RX sends out prescription drug change notices for 2010

Recently the AARP MedicareRx plans for Part D Medicare prescription drug coverage (in my case, through United Health Care) sent out 3-part packages to its members. The first document was an Annual Notice of Changes for 2010 (calculated for the subscriber’s location); the second was an Evidence of Coverage booklet, and the third was a 2010 Abridged Formulary, a partial list of covered drugs.

Premiums went up about 6.8%; for me, the coverage (in Virginia) went from $38.20 to $40.80. The copay for some tier 2 drugs went up; but for some tier 3 drugs it came down.

The Coverage Gap, or Doughtnut Hole, was the range $2700 to $4350 in 2009. In 2010, it is $2830 to $4550.

Beneficiaries can pay for their coverage by check, by automatic withdrawal, or (most often) by deduction from their social security checks.

Saturday, October 24, 2009

CMS mails "Medicare & You" booklets; but 2010 premiums were not available at press time

The Centers for Medicare & Medicaid Services (CMS) have mailed the 2010 booklets “Medicare & You” to Medicare beneficiaries.

Ironically, not all the 2010 premium information was available when the booklet was printed. The web link for 2010 premiums is here. Contrary to what has been reported in the media, the Part B premiums for many, perhaps most Medicare beneficiaries, do not increase above $96.40 in 2010, but some people will have to pay $110.50. Read the link for details.

Medicare has a “Fighting Fraud” program that in some cases will pay beneficiaries up to $1000 for properly reporting fraud attempts (on p. 97 of the booklet).

The booklet points out some Part B preventive services which are covered 80% (with supplementary insurance often covering the rest). Some of the services are innovative, such as abdominal aortic aneurysm screening, bone mass measurement, colonoscopy, EKG (static, a new benefit), glaucoma, and diabetes

Friday, October 23, 2009

Maybe, physical immortality really will become possible

On Wednesday, Oct. 21, 2009, Gabriella Boston wrote a lead story in the “Plugged In” section of The Washington Times, “Why stop at 100: Life spans may expand dramatically”, link here. The story starts by recapitulation the recent Lancet story that babies born today have a greater than 50-50 chance of reaching 100.

The article goes on to explore the idea that lifestyle changes and molecular surgery might eventually make immortality on this planet possible – which means to me, your soul will never go through an Event Horizon to find out what is in the next parallel universe (Heaven). Contemplate the idea that we would have to remain employed forever, and stop social security and pensions. Should we have children? In an immortal society, I’m not sure that depopulation, as Phillip Longman writes about it, is a risk. Would we have a world of permanently perfect people, clones of a 20-year-old Clark Kent? It seems that a world that is fixed on its own presence loses all sense of perspective for the future. But at least we would have a direct incentive to protect the planet; we would be around to see the results of our pillage otherwise.

Barbara Walters had run an ABC special “Live to Be 150” in the spring of 2008, and PBS has run some specials on longevity. Walters is up in years herself, and still glamorous.

The old Omni Magazine had suggested that people’s brains be downloaded and saved permanently on computers back in the 1990s. We don’t really need bodies, do we. Imagine digital copies of yourself, with only the copy protection of the DMCA.


Thursday, October 22, 2009

Pacemakers and electronic devices (microwaves, etc.)

Sometimes heart patients, especially elderly patients, do receive pacemakers. In less common cases, even young people get them (as in a Sanjay Gupta CNN report). The question that may come up, even for other household members, is do electronic devices, especially microwaves, jeopardize the operation of the pacemaker?

In general the reassuring answer is no, they do not. Modern pacemakers are well shielded. Patients should be careful about some specific situations: working on automobile ignition systems, welding systems, being very near high tension power lines, and the like.

The American Heart Association has a reference here.

The Arrhythmia Association has a link here.

Wednesday, October 21, 2009

Seniors may have mandatory copayments on Medigap claims by 2015

Milt Freudenheim, in a column on p A22 called “Prescriptions: Making sense of the health care debate: A plan for higher payments,” link here. The issue is Medicare Supplemental insurance, often called “Medigap” (link) The Senate Finance Committee is suggesting that seniors make copayments on Medigap claims by 2015. The mandatory copayments woukd apply to all doctor’s visits under Medigap, to discourage overuse of services by some seniors, who are comforted by the “first dollar” coverage of most services under Medigap, with a net result of increased expenses to Medicare.

Caregivers are often quick to take seniors to doctors at the slightest problem, believing that it is their obligation to do so.

Tuesday, October 20, 2009

Some people question whether elders should be placed in nursing homes or other facilities at all; the personal responsibility of family?

There is a website called “Associated Content” that has a number of cross-referenced articles by Shalanda Jenkins, from back in July 2007, “Is your loved one really safe in a nursing home: things to know in search of the perfect nursing home and care facility?” link (website url) here. On the right frame of the page there are links to related articles about elder abuse and nursing home abuse. In the body of this article Jenkins writes “Studies show that when you participate in the emotional healing of a dementia or alheizmer patient, they are more inclined to more communication of some aspect if they know that they have someone close to them in reach. Better they are taken care of at home with a screened, skilled home nurse than being in a nursing facitlity under responsibility of an aide who has eight other people to look after, one of which requires more attention than your loved one..” Home health care, for 24 x 7 , may be more expensive than nursing home care and certainly more than assisted living.

She encourages family members to look very closely at any care facility, and seems to suggest that at some level care really cannot be bought or outsourced. She also writes, anecdotally without naming any institutions (and I do not identify them on my blogs either), that when she worked as a CAN (certified nursing assistant), that in some facilities, people would say that certain patients could be neglected because no “family” looked in on them. This is certainly an egregious attitude from employees of an institution, but it might grow worse with demographics.

Here is a nice reference on choosing between a nursing home and an assisted living center, from October 2008, here. Assisted living facilities are not allowed to give medical treatment, although they can dispense (and keep accurate track of) medications from a pharmacy (and must, for most patients, especially those with any cognitive impairment at all), and charge separately for the service.

Sunday, October 18, 2009

Can seniors with disabilities safely fly "alone"?

How do airlines handle the travel of seniors with disabilities, including “cognitive disabilities”?

Southwest Airlines has a typical policy, stated here.

Airlines will allow people who bring seniors to airports to get “Escort passes” to accompany the customer all the way through boarding (including going through security at many airports). Most airlines say that they cannot attend to personal needs once the customer is on the aircraft. For example, the customer should be able to comply with seat belt regulations and be able to walk unaided in the cabin to the lavatory. In many cases, flights with stops or especially with connections should be avoided. Airlines do offer preboarding and wheelchair service. Generally they will not verify the identity of people meeting the customer on the other end.

Some literature on the web says that the simulated higher altitude is bad for heart patients or patients with early dementia, but doctors seem to permit it.

But an article by Ed Perkins discusses an Adult Assistance Program at Northwest Airlines, that offers complete supervision for an extra $50 each way (link here). This sounds like a good idea for all airlines.

It is probably surprising for many people to learn that people with considerable cognitive disability, as measured by tests, are allowed to fly as well as to drive (previous post, Aug. 17, 2009). But a physician, and a professional who has worked with the patient, should be consulted for permission. Lists of symptoms for various stages listed in diagnostic criteria often don't match the reality of the individual person.

Thursday, October 15, 2009

Medicare Advantage programs face more criticism during health care reform debate

The Washington Post has a front page story Thursday Oct. 15 “Hidden costs of Medicare Advantage,” Plans’ free perks are subsidized by government,” by Philip Rucker, link here. Some of the perks, like gym memberships, would not seem to belong to a program that the government subsidizes. Medicare Advantage was developed as a replacement for Medicare, which sometimes offers a better deal to relatively healthy, active seniors, but does not work well in certain situations.

I have been approached, during “retirement”, to be interested in selling this product; but I do not want to peddle products to others and to manipulate others into buying things that may not be in their best interest.

Medicare Advantage plans are likely to increase premiums and reduce benefits because of the indirect “burden” placed on them as part of “paying for” health care reform.

The media is also repeating the story this morning that seniors will not get a social security increase in 2010 because of the lack of formally defined price index increases.

Tuesday, October 13, 2009

Time Mag. article proposes replacing 401(k) system with "forced savings + insurance"

Well, everyone ought to peruse the Time Magazine (Oct. 19, 2009, p. 28) article by Stephen Gandel, “Why it’s time to retire the 401(k): Last year’s market wipeout showed the vulnerability of the popular retirement-savings accounts. But the data are telling us that even in the long run, consumers need better options”, link here.

The article discusses the life of an Occidental mechanic, and then goes on to give examples of how people turned out financially if they retired before 2008 compared to during 2008, during the meltdown and “Bailout” crisis.

Companies began to freeze their defined benefit pension plans in the 1990s, in lieu of matching 401(k) contributions. Gandel calls this a con job. Toward the end, Gandel, toward the end of his piece, talks about the idea of wedding savings with insurance. One reason for this is that a huge factor in determining your nest egg is when you retire, and you might be forced to “retire” in a corporate downsizing following a traumatic event like 9/11 (that’s what happened to me), or the 2008 financial crisis. Gandel wants an insurance against this kind of unpredictable “systemic” risk.

The ERISA Industry Committee (ERIC) proposes paying a premium (6%) to a retirement insurance provider, with the end result of a guaranteed “pension” paycheck. But one wonders how insurance carriers of products like this would weather financial hurricanes like than in 2008. Here is a typical link from ERIC, title “ERIC's New Benefit Platform Featured in GAO Report on Alternative Approaches to Current U.S. Pension System”, Sept. 1, 2009.

Monday, October 12, 2009

Are more readers taking note of filial responsibility laws? A particular issue for LGBT?

Recently, I got an appreciative comment on the July 12, 2007 (two years ago) entry about filial responsibility laws (in almost 30 states) in this blog, and I suspect that the visitor might actually have intended to place it on the July 7 2007 entry, where there is a detailed comment by another visitor. I had just added a comment to the July 7 entry about some subtlety as to what these laws may mean, with respect to the Virginia statute. I really appreciate these comments about a legal issue that the mainstream media seems to be missing completely, or perhaps deliberately avoiding to prevent a firestorm. Perhaps the recent case in New York, where Brooke Astor’s son (himself elderly) was convicted of embezzlement and commingling have drawn some sudden issue to the problem, as there were some media reports (not necessarily correct) that Astor was neglected sometimes. (Ironically, I don't think New York State has a filial responsibility law.)

The public’s impression is that these laws deal with the Medicaid giveback period, which the federal government bumped up to six years back in 2006, and that’s true; but they are also used as “poor laws” requiring adult children to support indigent parents (a concept that might be even more applicable before retirement age when social security can kick in, although poor people draw less social security; but the possibility of tapping social security disability benefits should not be overlooked in some cases).

Actually, some of them require even more: that the adult child or children make sure that care is arranged for disabled parents, even when the parents have sufficient resources. Adult children should not behave in a manner that disrupts the delivery of care, and should prove that they can support themselves and their own families without commingling. Even when the parents have resources, they may resist outsourced help and want adult children who were themselves childless or only children may find the demands for emotional loyalty disturbing. Some comments have suggested that this not “fair”, but that depends on how one looks at things; in a community of generally free people, not everything can turn out to be perfectly “fair”. The growing eldercare dilemma will make us rethink "family responsibility" and raise the question as to whether responsibility for parents (as in the Ten Commandments, quite literally) is fundamental the way responsibility for one's own kids is.

Indeed, in our individualistic value system, we emphasize the personal responsibility that goes with one’s own choices (raising children one has sired, and not having children until one is “ready” economically as well as emotionally); Dr. Phil covers the latter all the time. But, with the rapidly increasing life spans and sudden increase in Alzheimer’s disease (in people who no longer die “naturally” of heart disease and stroke), the genesis of responsibility for others surely goes beyond the control of one’s “choices”. Indeed, the eldercare issue could bring back the old-fashioned idea that children are in some sense “economic assets”. The pro-natalist crowd of writers like Phillip Longman, Paul Mero and Allan Carlson will dance in the streets. Maybe this is part of what Rick Warren means when he says “It’s not about you.”

None of this means one does not love one’s parents and family; but our individualistic values assume that everyone should be able to define the course of his own life and define his own dreams. President Obama said so Saturday night when addressing the Human Rights Campaign, but did not go so far as to say explicitly that the demographics of elder care can change the lives of LGBT people disproportionately. He did mention the importance of the health care debate in the larger sense, probably as including elder care: but filial responsibility deals with custodial care issues not generally covered by Medicare, and long term care insurance is only now coming onto the scene as a strategy to address it. I did hear a remark tangential to eldercare obligations Sunday at the National Equality March rally.

The media ought to start to cover this issue promptly, and start quizzing the politicians. Right now, it’s up to the bloggers, and their visitors who post comments.

Sunday, October 11, 2009

Pension funds are caught in the middle

David Cho has a major story in the Sunday Oct. 11 Washington Post’s “Consequences of the Crisis” style, “Steep loses pose crisis for pensions: two bad choices for funds: cut benefits or take greater risks to rebuild assets”, link here.

There is an email list around called “pension tsunami”, and indeed public employee and union pension funds are in a bind: workers have been promised certain defined benefit pensions, that cannot be sustained in the “casino like” money factory that Michael Moore described in his recent movie (“Capitalism: A Love Story”), so either they make sacrifices, or there are more huge taxpayer bailouts down the road, primarily of the Pension Benefit Guaranty Corporation. Right now, the PBGC does guarantee most benefits up to a maximum amount, as has been explained before on this blog.

Thursday, October 08, 2009

Stay in those 401(k) plans, please

Take a good look at today’s (Oct. 8) “The Color of Money” column in the Washington Post by Michelle Singletary, titled “The forecast is sunny if you weather the 401(k) storm,” link here.

Singletary discusses an EBRI-ICI (Employee Benefits Research Institute/Investment Company Institute) report, showing that over 2003-2008, balances rose over 7%, even with the horrible year in 2008, where balances dropped markedly. That report appears to be at this link.

401(k) plans are intended to work over the long haul. If you’re young and can put anything away at all, you should, and keep the strategy of dollar cost averaging. When stock prices are depressed, you buy more shares.

Wednesday, October 07, 2009

Family caregivers and prevention of medication errors: what is written about this problem?

I took a look online at the subject of family caregiving and the potential for medication errors, and the best lay reference that I found was on Stan Cohen’s “Maturity Matters” with a Wordpress article, “Safe medication and aging: 6 challenges to overcome medication errors,” link here.

He concentrates mainly on “low tech” solutions like pillboxes, large labels, and other delivery systems, and making pills easier to swallow (many non-prescription multi-vitamins are huge!) One big help would be a system that inventories by weight the number of pills that remain, so that a caregiver can know at any time if a correct dose has been maintained. Mechanical systems might be needed to keep medication locked up. Some medications (like Coumadin) require constant blood monitoring, and the numbers from such tests (INR’s) can be erratic under the best of circumstances.

But the president is right: physicians, especially those caring for the elderly, need an automated system for tracking what medications other physicians have prescribed. There is no reason why a company like EDS, Perot or IBM could not develop and install such a secure system within the privacy requirements of HIPAA. Unpaid family caregivers should not be grilled into second questioning physicians, although some physicians sometimes may be under pressure from drug manufacturers to over prescribe.

A promising innovation may be the CapsulCard (as trademarked) (link).

Not much shows up on the potential legal liability for non-professionals for medication errors, but it clearly may be comforting to some caregivers to see medication administration done by nursing professionals in a controlled setting. Assisted living centers typically charge over $300 a month to manage medication, so the responsibility is not trivial. This is definitely an issue to address in our health care policy debate.

Sunday, October 04, 2009

Nursing homes could close due to federal, state budget cuts in Medicare, Medicaid, related to health care reform; more "filial responsibility"?

Cuts in Medicare and Medicaid funding associated with health care reform, compounded by state budget cuts and deep “Wall Street caused” recession will soon seriously impact nursing homes, according to the American Health Care Association and other health care experts. The AP story by Dave Collins appeared on Yahoo! today, link here. In fact, the AHCA has an “SOS” or “Save our Seniors” logo on its website, with an article, “Ask Congress to stop proposals that further cut nursing home care” link here.
A number of nursing homes have laid off employees, in an economy that generally needs more “person-to-person” workers, although it does not pay them well. Nursing home closures have already occurred because of Medicare rate cuts (which would apply mainly to skilled or SNF care), as well as state Medicaid cuts.

Many closures occurred in New England, and California a nursing home that serves former entertainment industry workers was closing because of financial losses.

Is this a question of lobbying groups crying wolf? Probably not. Demographics and economics are on a collision course. Families are likely to have to take care of their own much more in the future, as the infrastructure to outsource care to institutions and even home services could get overwhelmed. States would be likely to enforce their filial responsibility laws much more rigorously than before, and the whole notion of intergenerational “social contract” would need to be rethought, bringing in the childless.

Nevertheless, saner analytical heads are looking at this problem. The Lewin Group (I worked for its predecessor in 1988-1989) has a “Demographic and Service Need Projections for the Aging Population: 2020–2030 – A Projection Model for the Baby Boomers of San Mateo County”; for details go to this link.

I wonder how many people in Congress are connecting the dots on this one.

Saturday, October 03, 2009

People born today in US and Europe should reach 100

The Lancet has published a Danish study indicating that half of all people born in developed countries today will live to be 100.

The Lancet study was not available yet, but a related article in improving prevention of neurological diseases in the aged appears here.

In the spring of 2008, Barbara Walters on ABC, as well as PBS, aired specials on longevity, discussed here on the TV blog.

Conservatives will point out the dangers of “demographic winter” with a whole extra generation added to lifespans. Certainly this means that people must stay healthy and able to work longer, and employers must want to employ them, up to age 80 perhaps. It may have implications for our “social contract” and notions of family responsibility (including filial responsibility laws), even for the childless, both financially and emotionally. But some of the arguments can cut both ways.

Here’s a good piece by “benbest” on “Is longevity entirely hereditary?” (link).

Friday, October 02, 2009

Michael Moore, ABC go after corporate "dead peasant" life insurance policies on workers

On Friday, Oct. 2, ABC Good Morning America examined a claim in Michael Moore’s “Capitalism: A Love Story” that employers often buy “dead peasant” life insurance policies (it’s not “dead pheasant”) on employees, and collect in the event of the employee’s death.

It is considered ethically legitimate for companies to buy “key person” life insurance policies, as on executives, since they have an obvious insurable interest. But these policies have been taken out of ordinary rank-and-file employees and can remain in effect even after the employees leave or are laid off. The report said, “no one is harmed”, but there is obviously a “conflict of interest” and maybe a temptation.

Moore says there are tax incentives for this practice.

The ABC story is called “Is your employer betting on your death” and has the formal title “Are 'Dead Peasant' Life Insurance Policies Fair?: Corporations Often Take Out These Policies on Lower-Level Employees”, by Claire Shipman and Chris Strathmann, with link here.

Wall Street goes on to securitize these products.

I see that Moore had discussed this problem on ABC's "The View" Sept. 25.