Kansas & Missouri Estate Planning

Medicaid Misunderstandings Costly

When an elderly person is ready for the nursing home, some families are entirely understanding, in agreement, and financially able. As a result, the transition happens smoothly. Unfortunately, for a far larger number of families and elderly persons, some trip to the hospital will happen in between and may even immediately precipitate the transition to nursing home care.

If that's the case, then there are important hospital and Medicare policies of which you should be forewarned. Enter "observation care" which can make for a big bill upfront and even far bigger ones down the line.

According to a recent article in the Wall Street Journal, and their sources at the Medicare Rights Foundation, the number of "observation hours" has been steadily growing for years. Tragically, such observation hours count as "outpatient services," even if the service lasts for several days (as it sometimes does with the elderly) and Medicare pays for inpatient and outpatients services in entirely different ways.

As you likely know, Medicare Part A pays for inpatient bills, so those are usually taken care of, but Medicare part B is what takes care of outpatient services. And those services can add up to a far greater cost.

It's often vital to know the distinction between the two types of services from the hospital, and yet it's also fairly difficult. Medicare advises to simply ask, but then there are certain documents such as the "Important Message from Medicare" which accompanies inpatient care, but not outpatient. Still, the hospital can switch with little to no notice.

It's actually even more important than the size of the immediate bill. Medicare will only pay for nursing home expenses if the person was admitted inpatient at a hospital for at least three days, excluding the discharge day.

For so many families that's the sole reason why it takes a hospital visit to arrange for the transition to nursing home care in the first place, but if you are put under observation or other so-called "outpatient" care, and without your notice, it can literally mean thousands of dollars out-of-pocket down the line.

Bottom line: It all hinges on hospital practice and Medicare definitions.

Reference: The Wall Street Journal (February 5, 2012) "Check Hospital Tab"

Finding A Nursing Home for Dad... Simple Math Makes It Even More Difficult

Fact of Life: It’s harder to find a bed for a man than for a woman, especially when it comes to a bed in a nursing home.

Finding a nursing home for an ailing loved one, and a good nursing home that is affordable, is already a fairly difficult task. Unfortunately, it's only likely to grow in difficulty as the number of elderly in need of care begins to peak. Unfortunately, too, there are some factors of which you might not be aware. For example, it is disproportionately difficult to find a nursing home for a male patient.

This fact was recently showcased at the New Old Age Blog and I thought it was worth sharing.

What is working against our male elderly loved ones is not much more than "simple math" (and, trust me, I am "math challenged"), with a bit of Medicare policy work at play. From a "numbers" standpoint, women have a longer life span on average. As a result, therefore there are more women in nursing homes. That fact alone has created a bottleneck based on population statistics.

Aside from women ruling the roost in nursing homes, throw in the fact that, under Medicare rules, most rooms in nursing homes are no more than "semi-private" (a delicate euphemism). Bottom line: Co-ed rooms aren't allowed either. Thus, with more women already in such semi-private rooms there are vacancies for which only women can be admitted into a facility. The math is fairly easy to figure out, but it's a strange and unintended consequence nonetheless.

Good news for fellas: If you do make it to a nursing home, then it is a "buyer's market." As the Beach Boys sang in Surf City, there are (at least) "two girls for every boy."

Reference: The New York Times The New Old Age Blog (January 30, 2011) "Fewer Beds For Men Entering Nursing Homes"

Hospice: A Medicare and Medicaid Profit Center?

Healthcare lawsuits involving the various ways the elderly can be taken advantage of turn up in the news on a (seemingly) daily basis these days. Why? Well, partly for political reasons and partly for the sheer number of egregious situations that have been created.

As an informed citizen/taxpayer, it's important to think about and understand the big picture. However, as a family member, it's vitally important to remember them for the sake of your elderly loved ones.

Consider this: A national hospice company improperly cycled patients through nursing homes and hospice with a goal of making as much profit as possible from Medicare, according to a whistleblower lawsuit announced recently.

A new legal battle has begun to churn, as recently reported at Kaiser Health News. Yet another healthcare company is being accused of taking advantage of the elderly and their families to draw the greatest yield from Medicare and Medicaid coffers. Here a large company, operating across several states, is accused of actively recruiting and cycling patients through nursing home and hospice services.

Such companies are compensated by Medicare based on the length of time patients receive care. Medicare picks up the entire nursing home tab for the first 20 days (after that the patient has to contribute), and conversely, if a patient spends too much time in hospice care, Medicare demands their money back since the patient was clearly admitted to end-of-life care under false pretenses.

Here's the rub: If you cycle between nursing home regimens and then jump into hospice care as early as possible (but not too early), Medicare will pick up the entire tab and for the maximum amounts, and that's the issue.

The legal battles, as well as the politics and economics aside, stories like these also demand a certain amount of attention since they could directly impact your family.

If you have a loved one in need of nursing home and/or hospice care, it's important that they find and receive that care… and that they not be abused by an uncaring system.

Reference: Kaiser Health News (January 4, 2012) "Lawsuit Accuses Company of Fraudulently Cycling Patients through Nursing Homes, Hospice Care."

Drug-Managed Dementia Dilemmas

In the modern world, drugs can be either a blessing or a curse. Knowing when and why is as important as what, especially when it comes to prescribing anti-psychotics for elderly nursing home patients.

Fact: Dementia and Alzheimer's can prove to be huge challenges for the healthcare institutions we trust to care for our affected loved ones. Unfortunately, these are challenges many institutions meet with the over-use, abuse or improper use of drugs. The good news is that this problematic trend is being identified and resolved for many families.

As recently reported by the Associated Press, the turn to drugs for nursing home patients with dementia is nothing new. As many family caregivers can attest, dementia has a nasty tendency to disorient patients who may grow paranoid or lash out as a result. The safest way to protect them and others has been through medication to calm them. Of course, under-funded institutions also have a tendency to use drugs to a fault, and many use the wrong drugs, like anti-psychotics. These drugs (with names like Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Invega, and older medications) are designed to help people suffering from schizophrenia or bipolar disorder… and are not approved for dementia patients.

Since 2005, these drugs have been under an FDA warning - they can cause an increased rate of death in dementia patients (due to heart attacks and pneumonia). Nevertheless, as of 2007 (according to a recently released government audit), about one in seven nursing home patients aged 65 or older was prescribed at least one of the drugs and, in about 83% of these cases, the prescription was for off-label use, like treating dementia. Ironically, the use of these drugs can create further confusion for the dementia patient and impair his or her ability to interact normally. Not surprisingly, many dementia patients actually have improved dispositions when they are taken off of these drugs.

While it's hard to estimate just how widespread the problem is today, at least it has been recognized and many institutions are correcting the trend. While the use of drugs is not bad in all cases (since there are patients who are severely disoriented), but certainly not every patient needs them or needs them at full strength. This is just one more concern to bear in mind when you visit your elderly loved one and when choosing the right nursing home for them. Be sure to ask about their protocols and procedures regarding the prescription of drugs for patients with dementia and/or Alzheimer's.

Reference: The Associated Press via ABC News (September 14, 2011) "Push Underway to Cut Drugs for Dementia Patients"

For-Profit Versus Non-Profit Nursing Homes?

As addressed in previous posts, choosing a nursing home for a loved one is no fun for anyone. But, when it has to be done, it has to be done. Sometimes, yesterday. To add one more thing to the one more thing to consider column, is it better to go with a for-profit nursing home or with a non-profit nursing home?

How do you separate the sheep from the goats when it comes to choosing a nursing home? Recently, Reuters collected advice from several experts and specifically addressed the brewing controversy regarding differences between for-profit and non-profit facilities. I think it is worth your read.

The article focuses on the legal battles of a former Florida state-appointed consumer advocate, Brian Lee, and the controversy there. However, the central theme problems with for-profit nursing homes. And, that theme is supported by a recent study by the U.S. Government Accountability Office.

The study indicates that for-profits had more frequent and serious deficiencies than non-profits. Practical problem: For-profit nursing homes make up more than two-thirds of all nursing homes. So, most of us will probably be using a for-profit facility. Nevertheless, to be forewarned is to be fore-armed.

Do your own research. While experts agree that a good starting point is the Medicare website and the ratings there, you still will want to visit the facility and conduct your own fact-finding. Indeed, many say that you should visit at various times, the evening especially, and arrive unannounced. Be sure to make note of cleanliness, accessibility, and whether the residents themselves are happy and aware.

In the end, it is not enough to blindly rely on the referral of a hospital discharge practitioner. They don't know you or your loved one. When making the right choice, whether that is a for-profit or non-profit nursing home, patience and persistence are key... along with some good, old-fashioned horse sense.

Reference: Reuters (August 23, 2011) "For-profit or not: what to consider when choosing a nursing home"

Elder Homeowners - Betwixt And Between

Are you a seasoned citizen, or do you care for someone who is? Perhaps you can relate to this sentiment: "But for these doggone depressed home prices, I'd sell this paid-off home I can't keep up and move into one of those nice everything-included senior housing places." If you can relate, you are not alone.

The housing market is still idling at terribly low levels. That's not news, I know. While many younger families may "want" to move for the additional space, many seniors "need" to move. Both, when you get right down to it, are betwixt and between. The younger folks cannot sell their smaller home to buy the larger homes of the seniors. And, the seniors must get top-dollar for their homes to afford the "nice everything-included senior housing places."

Kaiser Health News recently released an article taking stock of the situation and new reactions from assisted-living and nursing home facilities.

For many seniors, the gameplan had been to use the equity in their home as the investment to keep them afloat in retirement. BA-BOOM. The value in those homes dropped like a rock in 2008. Regardless how much the house may have been worth before the crash, it's tough to sell a house these days. Really tough. To make matters worse, they tend sit on the market for years, or fetch too little money to make the sale feasible. End result: Seniors are waiting much longer before they can enter into a facility. That wait, incidently, isn't good for their finances or health.

But seniors aren't the only ones unhappy with this trend. The facilities themselves aren't happy. In certain facilities in locations hardest hit by the housing bubble, the occupancy rate has dropped as much as 10%. It seems nursing homes and continuing care facilities have been hit the hardest and assisted-living only slightly better.

In the face of such challenges, however, some facilities are working to help ease the transition for seniors. For example, certain facilities have begun incentive programs, ranging from simple real estate education classes to more fluid contracts. The contracts allow the entrance costs of the facility (usually something akin to the cost of a home itself) to be paid whenever the house is sold. One management company, Brookdale Senior Living, has even begun offering to buy houses of senior residents at pre-determined prices, if they do not sell within a designated timeframe.

For you or a loved one it means that there are a number of planning possibilities. For those who are just not ready to leave home, consider in-home care services or perhaps having a younger loved one move in (e.g., many grandchildren are unemployed or underemployed, yet responsible). Still, if a facility is necessary, then be sure to checkout potential options, depending on the facility and where you live.

It might be possible to work with the administration on a creative solution. Remember: Chances are you're not the only one with the problem and they may offer a solution you hadn't considered.

In the end, if you don't ask, the answer is always "no."

Reference:  Kaiser Health News (August 21, 2011) "Housing Bust Derails Some Seniors’ Assisted-Living Care"