Monday, November 30, 2009
Medicare and Medicaid challenges will make states enforce filial responsibility laws: and they're trickier than one thinks
Al Gore’s spectacular book “Our Choice” on climate change has a chapter on population demographics. Although I discussed that in my review of it yesterday on the Book Review blog, I’ll reiterate here that he referred to the “safety net” to care for the elderly available in western nations. I said there that I thought his coverage was a bit naïve, in that population demographics and economic contraction are going to strain the safety net, and put more responsibility back on families, especially adult children, and especially the childless.
Then consider the Editorial in the Washington Times: “Rationing Grandma’s health care: Democratic plans will exacerbate Medicaid coverage problems,” link here. Actually it’s both Medicaid and Medicare, as reported by CMS, and there specific (and justified) concerns here about gutting the private sector’s Medicare Advantage replacement programs. (Although, later Nov. 30, TV station WJLA reproted that most ot the Medicare Advantage cuts affect more fringe-like benefits for the better off, and that basic M.A. coverage could improve for some people.)
But the most critical point, and one that I’m surprised the Washington Times doesn’t hit harder, is the way responsibility will fall back on families. Almost thirty states have filial responsibility laws (as I covered on this blog starting July 2007), and they will certainly gain attention soon as states find their Medicaid budgets crimped. (To use the president’s pre-inauguration words last January, that can has already been kicked to the dead end of the road.) One can make a partial comparison to the voluntary responsibilities parents have for conceiving children – doing so might make a good high school English theme. It’s different: it’s not chosen, and it's just about "justice" as an individualist views "personal responsibility"; it comes about from being in a community. And it doesn’t happen to everyone, and one can normally use the parents’ funds to meet the needs until they are gone. But there are other subtleties: even if the parent has money and/or long term care insurance, and even given the presence of Medicare and supplementary coverages, the adult child is legally required to make sure that the parent gets the best available care, even at some self-sacrifice. The adult child cannot behave in a manner that could interfere with delivery of care, and that could become a more subtle point than many people realize. In some special situations, the adult child can be expected to prove that he or she is capable of a stream of support even when there are funds.
We will certainly see our idea of “social contract” challenged. And we need the open debate that has been kept out of the limelight, whether because of ignorance or out of fear of consequences, not just for politicians but more many naïve individuals.
Friday, November 27, 2009
The “Deals & Deal makers” page C3 of the Wall Street Journal “Money & Investing” section today (Black Friday, Nov. 27) has an interesting “pension tsunami” story about how pension funds of major public sector employers may be diverting resources to manipulative but “undeserving” middlemen (call them “parasites”).
The story concerns CALPERS, the California Public Employees’ Retirement System, which reportedly continued using the services of two investment counselor firms (sort of the Vernon Albright – “My Little Margie” kind) after their contracts had expired.
The story is by Craig Karmin, is titled “For Calpers, a blunder on pay”, and has link here.
Such practices could gradually put even more strain on PBGC, eventually, and become a political issue.
Attribution link for p.d. Wikipedia picture of Sacramento waterfront. My last transit of the area was in Nov. 1995.
Thursday, November 26, 2009
A note on hospice benefits: Once a patient enters a Medicare-approved hospice program, the Medicare hospice program pays for hospice services and for medical services and prescription drugs related to the condition (for example, heart failure or cancer) that led to the admission. Other medical services related to other conditions not causing the admission would be paid in a conventional way through Medicare, but all care is coordinated through the hospice (with special billing procedures).
Although hospice provides some home care with items like bathing, the patient (and therefore the patient’s family) is still responsible for proving (either in person or by hiring from a home health company) companionship, safety and custodial care, with necessary and appropriate continuity. In states with filial responsibility laws, adult children able to pay can be held responsible for these costs. (However, many hospices offer short respite stays to relieve caregivers or family members.) Hospice services do continue during hospital stays, skilled nursing stays, and can be arranged in assisted living and nursing home settings. (Assisted living facilities cannot themselves provide medical services other that prescription medication management, but the patient or family can bring services in from hospice.)
Tuesday, November 24, 2009
Lester Holt on NBC Nightly News reported on Nov. 24 that Medicare costs vary enormously from one city to another, even in the same state or region. In Miami, Medicare spends about $16000 a year per beneficiary, in nearby Fort Lauderdale (in Broward instead of Dade County), about $9000, and in some parts of Oregon, about $6000. Much of the problem has a lot to do with how hospitals and emergency services are overused, with little consideration about costs.
Monday, November 23, 2009
Robert J. Samuelson has an op-ed on p. A19 of the Nov. 23 Washington Post that indicates that seniors should back off on demanding their tribute in the way of entitlements. The article is titled “Health ‘reform’ that burdens the young,” link here. AARP says that even a 2:1 max on how much seniors can be charged more in premiums is too much; AARP wants a “community rating” which ignores age altogether.
Who stands to gain quickly by making the young pay more? Probably retirees below Medicare-age. More and more companies drop retiree health insurance; an individual premium from BCBS for me would have been $400 a month at age 64; with the employer retiree insurance it was about $180.
Samuelson does agree that insurance companies could or should be banned from discriminating on the basis of pre-existing conditions for “public policy” reasons, but age is not such a category. Working Americans already pay a Medicare tax. Not allowing insurance companies to price by age undermines the entire system, he says. But, for every one of us, youth is mathematically transitory. The only exception seems to be for the vampires in “Twilight”. (Maybe Robert Pattinson will always be 23.)
Sunday, November 22, 2009
Steve Kroft reports. The segment, "The Cost of Dying," (14:06) says that there is something worse than dying, since 100% of us will: it is “dying badly”. Medicare spends $50 billion a year on the last two months of life, more than on the budget for DHS.
In Medicare, we turn the laws of supply and demand upside down. Hospitals have an incentive to admit more patients to pay off bonds. Perverse incentives in our system “are magnified at end of life.”
By law, Medicare cannot reject any treatment based on cost. However, some say that rules should be drawn, based on age and certain medical condition, which might seem like “rationing” but it could be better than “rationing badly.”
Many people are not familiar with end-of-life options, including hospice, living wills, and the like.
European countries with more socialized systems ration what is spent publicly on end-of-life care.
Saturday, November 21, 2009
AARP stands behind most of the provisions in the health care reform bill recently passed by the House. The link (here) is called “Health Reform: Get the Facts: AARP is fighting for you”.
I’ve personally never liked the idea that I have to depend on any organization to “fight for me”, but many people are not in a position to speak publicly for themselves.
Some of the points AARP makes here should be noted. One of them is the closing of the “doughtnut hoe” (that is, “coffee cup handle) in Medicare Part D.
Another is to provide more help for elderly to remain at home. However, that provision provokes a paradox. That means a need for more home care workers, and the need to provide them health insurance at work. That degree of complexity needs to be thought through, given that the demands for eldercare are increasing so steeply with demographics. AARP needs to watch that Hospice funding does not get affected.
Picture: The “Before and after” for Medicare Part D
Tuesday, November 17, 2009
The Health Section of the Washington Post this morning (Tuesday Nov. 17) has a bit story by Elizabeth G. Olson from Kaiser Health News, “The virtual doctor visit: New technology is helping elderly patients and those with chronic diseases monitor their condition from the comfort of home”. The link is here.
We’ve talked about Life Alert and similar products for out-of-town caregivers to monitor elderly parents, but this allows nurses, home health providers, and even caregivers themselves to monitor medical information like blood pressure or oxygen from a distance. One problem is that Medicare may not cover this service unless (sometimes) the client is legally defined as “homebound”, which means that the client cannot normally leave home with a lot of assistance and does not leave home frequently. Of course, the client must be able to comply with the instructions in using the devices, sometimes when alone.
There is a psychological question: does the client feel overwhelmed by the constant monitoring?
Monday, November 16, 2009
The Retirement Living TV Network (link here ) has become available in many communities on Cable. In Arlington VA on Comcast it is Channel 175. It’s motto is “the Second Half of Life Is the Best Half of Life”. (No more final exams!)
On Sunday morning (Nov. 15, 2009) I happened to notice on my Comcast box that a program “The Voice” about caregiving would come on, just as I left for church. I recorded it. Margaux St. Ledgere hosted a forum on the topic.
One guest talked about her experience in an Italian-American family in the 1970s, before the term became accepted. The show said that 45 million Americans are giving unpaid caregiving, and the president has made November 2009 the month to honor them. The show also said that 40% of our nurses come from overseas.
The show provide a high-level discussion of the “powers of attorney”.
Sunday, November 15, 2009
AARP is reporting that dental care may be an important strategy in preserving memory health for seniors, in this piece by Joene Hendry, link here.
Peridontal disease and gingivitis are sometimes associated with a gum infection by the bacterium Porphyromonas gingivalis. Studies have shown that the presence of by levels of antigen for this bacterium are associated with poorer performance on short-term memory loss, and this may be one reason why dentists recommend root planning treatments, to reduce pockets. The bacterium is associated with chronic destructive gum diseases, or deep bone infections that can explode with sudden swelling. It might lead to systemic inflammation that gradually increases the likelihood of stroke or coronary artery disease, or it might even lead to the greater likelihood of brain plaque formation through mechanism not yet understood. Some people may develop immunity to it with time, however. Here is a “citizen’s compendium encyclopedia” reference on the bacterium, with is anaerobic gram-negative and may tend to be resistant to antibiotics (link).
Picture (unrelated): from Baltimore National Aquarium
Saturday, November 14, 2009
The National Institute on Aging, and Alzheimer’s Disease Education & Referral Center has a useful booklet and web page (link) “Home Safety for People with Alzheimer’s Disease.” The paper takes up, with a great deal of flexibility, critical questions like leaving people alone (at least for shorter periods of time) and driving. The paper seems to be a list of voluntary suggestions, not law or administrative policy.
One of the issues will be practicality. In a given home, some suggestions cost much less and probably address a much greater practical risk. These include providing locked medicine cabinets, installing grab bars in bathrooms, using shower seats and extended nozzles, locking away firearms, prohibiting cigarette smoking (if possible), and maintaining smoke and carbon monoxide detectors. If a family member has a hobby area with tools or electronics, it may be a good idea to keep the area locked. If an area of the house is locked when the user is away, it’s a good idea to go the extra mile with electrical safety, including inspecting or replacing outlets or fixtures in old homes, and periodically (like once a year) replacing surge protectors in homes known to have frequent power surges. The instructions also discuss the possibility that the person with AD uses a computer, and should be protected by Internet filters. But a hobbyist will want to make sure that he or she or another responsible person is present when his equipment is used.
There are other private references on this subject, such as this.
Picture: Baltimore harbor (Nov 2009, mine, unrelated).
Thursday, November 12, 2009
The AARP has an interesting article about older Americans and H1N1, by Katharine Greider, link here. The article says that older adults, especially those born before 1950, may well indeed have some antibodies to H1N1 antigen proteins, but if they get a symptomatic infection, they may, as with a study in California, be more likely to die. This report was carried in the National Library of Medicine and may be found here.
On site H1N1 tests produce false negatives in about 1/3 of cases, and over 20% of severe cases never received antiviral medication.
Anecdotally, it does not seem that seniors are taking any undue risk in going to places where younger adults congregate, such as riding on subways or even going to discos. It does not seem that “social distancing” is particularly necessary.
But seniors should not feel complacent just because so much public attention has been placed on H1N1 in the young. It's true that the 1918 Spanish flu disproportionately attacked the young, but that could partly be because of crowding of people in the military. "Social distancing" public health rules were very strict then.
Sunday, November 08, 2009
I thought I would note that CNN today has been carrying advertisements from MetLife for variable annuities, as offering “buffering” of a guaranteed income flow even during market downturns, while increasing in value when the market goes up.
There is a website called “Annuity FYI” (link here.
There are a number of guaranteed benefits available with many contracts. These include Guaranteed Minimum Income Benefits (GIMB’s), Guaranteed Minimum Withdrawal Benefits (GMWB’s), Guaranteed Account Value Benefits (GAV’s) and Lifetime Withdrawal Benefits (LWB’s). These tend to offer some additional protection to retirees (especially female) who could fear that they could outlive their wealth.
Thursday, November 05, 2009
A column in the DC Examiner (p 23) today (Nov. 7) by Kimberly Lankford, from Kiplinger’s Money Power, may help people do their 2010 retirement savings planning. The title of the piece is “How much can I save for retirement in 2010?” with link here.
The lack of formally defined inflation and therefore the lack of a COLA increase in social security benefits for 2010 does not reduce retirement contribution limits in 2010. Roth IRA contributions can continue at the same rate, and for married couples the maximum permissible income goes up slightly. There is also an elimination of an income limit for converting a traditional IRA to a Roth.
Income tax brackets will rise slightly in 2010, and the gift allowance remains intact.
Wednesday, November 04, 2009
Here’s an important tip from USA Today, “Your Money”, Tuesday Nov. 3, in a story by Sandra Block. “You can skip IRA withdrawals this year – or roll one back.” The link is here.
Late last year, Congress waived the minimum IRA withdrawal requirement for those who are 70-1/2 or older, in order to give seniors a chance to recover some value lost in the 2008 financial collapse. If you did take a withdrawal , you may be able to redeposit one withdrawal within a certain time period, as explained in the article. This forbearance does not apply to inherited IRA’s.
The basic IRS publication on IRA’s is here.
There are more details about the mandatory withdrawal and temporary waiver in Publication 590 (PDF), here,p. 3, and then Chapter 1 on p 34.
Tuesday, November 03, 2009
An organization called the National Association for Home Care & Hospice (NAHC) has a secondary political issue advocacy website “We Can Save Home Health” (link) and makes the argument that the current proposals for health care reform would slash Medicare (and probably Medicaid) benefits for home health care for certain seniors and disabled individuals in many circumstances. The website offers staged links for the voter to contact politicians in his or her state.
Of course, in many situations families (or individuals from their own previous savings or provisions previously made by spouses) must pay for home health care services on their own now, as Medicare typically does not care for many of these services, outside of Hospice on the one hand and rehabilitation on the other.
Monday, November 02, 2009
Chris V. Nicholson has a potentially important story about “virtual estates” on p B4 of the New York Times today (Monday Nov 2). The title in print is “Death in an Online Age Raises Issues of Ownership” and online the title is stronger “Virtual Estates Lead to Real-World Headaches,” link here.
The story opens with an anecdote about the disposition of an imaginary island in Second Life, and even discusses the monetary conversion rate to Second Life. But a more practical problem would concern intellectual property: blogs, profiles and ordinary personal websites, as well as Twitter accounts, and, in act, emails, IM’s and text messages.
There is a suggestion that some day people will need to name “digital executors” to have accounts, and that could present a problem if someone has trouble finding someone willing to do it. Or perhaps an ISP could simply delete all the material upon a person’s death if there is no such agreement.