The Health Care System and Older Patients

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Senior man sitting on a wheelchair with caregiverBeing elderly and suffering illness in America frequently means a doctor may not have the opportunity to ask about troublesome concerns dealt with day to day – difficulty walking, dizziness, sleep disturbances, memory lapses and others. 

It means that if a person is hospitalized, they have a good chance of being treated by a physician they have never met not to mention undergoing questionable tests and treatments that might end up compromising their health.

It means that if a person subsequently seeks rehabilitation at a skilled nursing facility, they will encounter another medical team that does not know them or understand their at-home circumstances. Also, a doctor will typically not very often visit.

In her new book, “Old & Sick in America: The Journey Through the Health Care System,” Dr. Muriel Gillick, a professor of population medicine at Harvard Medical School and director of the Program in Aging at Harvard Pilgrim Health Care Institute, delves deeply into these concerns and why they are widespread.

Her answer: a complex set of forces is responsible.  Some examples:

  • Medical training does not make geriatric expertise a priority.
  • Care at bottom-line-oriented hospitals is driven by the availability of sophisticated technology.
  • Drug companies and medical device manufacturers want to see their products adopted widely and offer incentives to ensure this happens.
  • Medicare, the government’s influential health program for seniors, pays more for procedures than for the intensive counseling that older adults and caregivers need.

Gillick offers thoughts about how older adults and their caregivers can navigate this treacherous terrain. 

What perils do older adults encounter as they travel through the health care system? 

The journey usually begins in the doctor’s office. In general, physicians tend to focus on different organ systems. The heart. The lungs. The kidneys. They do not focus so much on conditions that cross various organ systems, so-called geriatric syndromes. Things like falling, becoming confused or dealing with incontinence.

What is advised for people?

Older people are often unwilling to bring these issues to the attention of their doctors. But if a family member is accompanying the patient, they should speak up. In some practices, a nurse practitioner may be more attuned to these issues than the physician. So, it’s a good idea to learn who is ‘good at what’ in the medical office. Another approach is to request a geriatric assessment or consultation that will bring these issues to the forefront.

How do geriatric assessments work?

A geriatric assessment does two major things. It looks at the whole person. And it focuses on that person’s functioning. Can they dress themselves, walk, get to the bathroom? Can they cook meals? Take a bus downtown? Balance their checkbook?

An outpatient geriatric assessment is typically 1½ to two hours and conducted by an interdisciplinary team. A social worker or a mental health professional will ask about the person’s family situation. Are they living alone? Do they have support? A nurse practitioner will look at physical function. And a physician will go over medical concerns and examine the cognitive performance of the individual. Then, the team pulls all these pieces together to assess what is happening with that person.

When someone becomes frail — having consistent difficulty managing things — an assessment of this kind is often a good idea.

What about the hospital environment?

One of the big perils in the hospital is technology, which is also its great virtue.  Technology can improve quality of life and be life-extending. But, sometimes, it creates endless complications.

An example are imaging tests such as CT scans. Physicians hardly think of this as an invasive test. But often one has to administer a dye.  That dye can cause kidney failure in someone with impaired kidney function — something that is common in older adults.

Sometimes there is no real need for scans. An example would be an older person who becomes acutely confused in the hospital, which frequently happens. The appropriate response is to look at what is causing the confusion and take away the offending agent. Often, it’s a medication that was started in the hospital. Or, it’s an infection. But the routine knee-jerk reaction is to do a CT scan to rule out the possibility of a stroke or bleeding in the brain.

For the most part, doctors want to do whatever it takes to diagnose a problem.  For younger patients, this may make sense. But for frail older patients with multiple medical conditions, a cascade of complications can result.

What is sound advice for older patients and their families?

When a test is proposed, ask the doctor “how important is it to pursue this diagnosis” and “how will the results change a procedure?”

It’s also reasonable to say something along the lines of “every time I’ve had a test, it seems like I get into some kind of trouble. So, I really want to know, with this test or this treatment, what kind of trouble I could encounter?”

When someone is hospitalized, sometimes a doctor-patient relationship can be sidelined. Instead, hospitalists provide care. How should people respond?

It’s really important to inform the doctor with a sense of the patient and their needs. Say, a person’s 88-year-old mother is in the hospital, and she has become profoundly confused. The doctor does not know what she was like a week or a month ago. He may assume she has dementia unless he or she hears otherwise. He or she will not understand it might be delirium.

A relative, friend or a caregiver should communicate as someone who can make it easier for the doctor to do his or her job — versus someone who is a nuisance. Build trust, not annoyance.

What about skilled nursing facilities?

Typically, in these settings, contact with doctors is generally minimal after an initial evaluation, though there is a spectrum of how much medical care is needed.

A subset of older adults go to rehabilitation for physical therapy after a joint replacement or a hip fracture. A person is really pretty stable, medically. If they receive good physical therapy and nursing care, it’s probably all right that the doctor is not there much of the time.

But there are also older patients who come to skilled nursing facilities after having had one complication after another in the hospital. These patients can be very fragile, with many medical problems. They are at risk of some new problem in the skilled nursing facility — perhaps an infection — or an exacerbation of one of the problems they already have that has not been resolved.

What is recommended?

When a person arrives at a skilled nursing facility, it’s a new cast of characters. A physician whom a person may fleetingly see including nurses, physical therapists, and aides. If someone is a caregiver, they need to have face-to-face time with the staffers.

Skilled nursing facilities are required within the first week or so to have a care planning meeting with the team. They are to invite patients and their representatives to the meeting. This is a good place to say something along the lines of “My mother has been through a lot, and now that we’ve met and see what you can accomplish, we’d appreciate your best to treat her and not send her back to the hospital.”

People must have trust to make this happen. The family has to trust the medical team. And the team has to trust that the family is not going to become upset. A meeting of this kind has the potential to allow everyone to assess what’s important and the plan going forward.

Aging and Your Best Brain Booster: Good Friends

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Two Senior Women Playing Dominoes At Day Care Centre With Cups Of TeaAsk Edith Smith, a proud 103-year-old, about her friends, and she will give you an earful. There’s Johnetta, 101, who has Alzheimer’s disease and whom Edith has known for over 70 years. 

“I call her every day and just say ‘Hi, how are you doing?’ She never knows, but she says hi back, and I tease her,” Edith says.

There’s Katie, 93, whom Edith met during a long teaching career with the Chicago Public Schools. “Every day we have a good conversation. She’s still driving and lives in her own house, and she tells me what’s going on.”

Then there’s Rhea, 90, whom Edith visits regularly at a retirement facility. And Mary, 95, who does not leave her house anymore, “so I fix her a basket about once a month of jelly and little things I make and send it over by cab.” And fellow residents at Edith’s Chicago senior community, whom she recognizes with a card and a treat on their birthdays.

“I’m a very friendly person,” Edith says, when asked to describe herself.

That may be one reason why this lively centenarian has an extraordinary memory for someone her age, suggests a recent study by researchers at Northwestern University highlighting a notable link between brain health and positive relationships.

For nine years, these experts have been examining “SuperAgers” — men and women over age 80 whose memories are as good — or better — than people 20 to 30 years younger. Every couple of years, the group completes surveys about their lives and they receive a battery of neuropsychological tests, brain scans and a neurological examination, among other evaluations.

“When we started this project, we were not really sure we could find these individuals,” says Emily Rogalski, an associate professor at the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern’s Feinberg School of Medicine.

But find them they did: Thirty-one older men and women with exceptional memories, mostly from Illinois and surrounding states, are currently participating in the project. “Part of the goal is to characterize them — who are they, what are they like,” Rogalski says.

Previous research by the Northwestern group provided tantalizing clues, showing that SuperAgers have distinctive brain features: thicker cortexes, a resistance to age-related atrophy and a larger left anterior cingulate (a part of the brain important to attention and working memory).

But brain structure alone does not fully account for SuperAgers’ unusual mental acuity. “It’s likely there are a number of critical factors that are implicated,” Rogalski says.

For their new study, the researchers asked 31 SuperAgers and 19 cognitively “normal” older adults to fill out a 42-item questionnaire about their psychological well-being. The SuperAgers stood out in one area: the degree to which they reported having satisfying, warm, trusting relationships. (In other areas, such as having a purpose in life or retaining autonomy, they were much like their “normal” peers.)

“Social relationships are really important” to this group and might play a significant role in preserving their cognition, Rogalski says.

That finding is consistent with other research linking positive relationships to a reduced risk of cognitive decline, mild cognitive impairment and dementia. Still, researchers have not examined how SuperAgers sustain these relationships and whether their experiences might include lessons for others.

Edith, one of the SuperAgers, has plenty of thoughts about sustaining relationships. At her retirement community, she’s one of nine people who welcome new residents and help make them feel at home. “I have a smile for everybody,” she says. “I try to learn someone’s name as soon as they arrive, and if I see them it’s ‘Good morning, how do you do?’”

“Many old people tell you the same story over and over,” she says. “And sometimes, all they do is complain and not show any interest in what you have to say. That’s terrible. You have to listen to what people have to say.”

Brian Fenwick, administrator of the Bethany Retirement Community where Edith lives, calls Edith a “leader in the community” and explains that “she’s very involved. She keeps us in line. She notices what’s going on and isn’t afraid to speak out.”

Fifteen years ago, Edith became a caregiver for her husband, who passed away in 2013. “All the time he was ill, I was still doing things for me,” she recalls. “You cannot drop everything and expect to be able to pick it up. You can’t drop your friends and expect them to be there when you’re ready.”

What Edith does every day, she says, is “show people I care.”

William “Bill“ Gurolnick, 86, another SuperAger in the study, realized the value of becoming more demonstrative after he retired from a sales and marketing position in 1999. “Men aren’t usually inclined to talk about their feelings, and I was a keep-things-inside kind of person,” he explained. “But opening up to other people is one of the things I have learned to do.”

With a small group of other men who left the work world behind, Gurolnick helped found a men’s group, Men Enjoying Leisure, which now has nearly 150 members and has spawned four similar groups in the Chicago suburbs.  Every month, the group meets for two hours, including one hour they spend discussing personal issues — divorce, illness, children who can’t find jobs, and more.

“We learn people are not alone with the problems they’re dealing with,” Gurolnick said, adding that a dozen or so of the men have become good friends.

“Bill is the glue that holds the whole group together,” says Buddy Kalish, 80, a member of the group in Northbrook, Ill., a Chicago suburb. “He’s very, very caring — the first one to send out a thank-you note, the first one to send out a notice when there’s been a death in the family.”

Activities are another way of cultivating relationships for Gurolnick. On Mondays, he bikes 20 to 30 miles with more than a dozen older men — many of them from his men’s group — followed by lunch. On Tuesdays, he’s part of a walking group, followed by coffee. On Wednesdays, he goes to the Wenger Jewish Community Center in Northbrook for two hours of water volleyball. On Thursdays, it’s back to the JCC for pickleball, a racquet sport.

“You really get a sense of still being alive,” Gurolnick said, when asked what he takes away from these interactions. “You get a sense of not being alone.”

Without her best friend, Grayce, whom she’s known since high school, and friends who live in her condominium complex, Evelyn Finegan, 88, might have become isolated. Another SuperAger, Evelyn is hard of hearing and has macular degeneration in both eyes, but otherwise is astonishingly healthy.

“It’s very important to keep up with your friends — to pick up the phone and call,” says Evelyn, who talks to Grayce almost daily and chats with four other friends from high school on a regular basis.

Today, the staples of Evelyn’s life are her church; a monthly book club; volunteering at a resale shop in Oak Park, Ill.; socializing with a few people in her building; attending a club of Welsh women; and visiting her daughter, her son-in-law and grandchildren, who live in Oregon, whenever she’s able.

“It’s so nice to spend time with Evelyn,” says her upstairs neighbor, June Witzl, 91, who often drives Evelyn to doctors’ appointments. “She’s very kind and very generous. And she tells you what she believes so you really feel like you know her, instead of wondering what’s on her mind.”

Retiring Earlier Than Planned?

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Couple hiking

At a glance: Stay calm and focus on what you can control. Make sure you have health coverage. Figure out if you are financially ready to retire, and if you are, whether it’s really what you want. 

Whether you had a written retirement plan or not, you probably drew a mental picture of how your retirement would look—and had a general idea when it would begin.

But plans don’t always go according to . . . well, plan. You’re not alone if you find yourself unexpectedly retired. In fact, over 50% of retirees exit the workforce earlier than expected because of unforeseen circumstances: layoffs, buyouts, or a health issue that strikes them or a loved one.

While retirement may have been out of your control, here are a few tips to manage what you can control.

Step #1: Stay calm

You will most likely be feeling a range of emotions that make it difficult to think straight. You may be overwhelmed by worry and stress—and more.

Kevin was suddenly let go from his new job 6 months after moving his family across the country and buying a new house. It was quite a shock. He was angry. He felt betrayed.

Your emotions will take time to process—and that’s okay. While you work through them, do not take any actions in the heat of the moment that you might regret later.

Do you have a cash reserve that can help for a few months and provide separation from those initial emotions? If not, and you feel like you must “do something” to regain control, focus on cutting your spending wherever its the quickest way and as early as possible.

Step #2: Focus on health coverage

If your health coverage remains unaffected—for example, maybe you are covered through a spouse’s plan or you are enrolled in Medicare—you can skip this step. But if your health insurance ended with your employment, insurance coverage is likely your most pressing need.

If you are age 65 or older but have not enrolled in Medicare, you will need to take care of this right away. You technically have 8 months from the date your coverage ended to enroll in Medicare without penalty and having no health insurance is rarely a good idea.

If you are not age 65 yet but you are married or in a domestic partnership, your best option may be to obtain coverage through your partner’s health plan. You generally have 30 days to make this happen outside open enrollment season.

If Medicare and a spouse’s plan are not options, you will need to buy your own insurance. Some options you may want to evaluate include:

  • Insurance through COBRA (Consolidated Omnibus Budget Reconciliation Act). This federal law allows you to stay on your employer’s health care plan for up to 18 months. It can be expensive, but you will have the same coverage you had while working.
  • High-deductible health plan (HDHP). This might be a better option if you are in excellent health—HDHPs generally only cover “catastrophic” health care needs.
  • Plan purchased through your state insurance exchange. Compare the prices with COBRA premiums. Under the Affordable Care Act (ACA), you may be eligible for a subsidy.

If you do need to enroll in an individual plan and it’s outside the open enrollment period, you have 60 days from the day you lose your former coverage.

Step #3: Take stock of your financial situation

Once you take care of your health insurance, you will need to evaluate how much money you have available to spend for the rest of your life—and whether it’s enough.


What do you have?

First, consider any benefits you are due. Depending on the reason for your sudden retirement, you may be eligible for disability payments or unemployment insurance.

If you are at least age 62, you are probably eligible for Social Security, but consider that option carefully. If you are definitely not going to continue working and you have no other income, starting your benefits may make sense. But beginning before your full retirement age will lock you into a lower level of payments for the rest of your life. And if you end up returning to work, your benefits will be reduced until you do reach full retirement age.

For now, simply find out what your benefit amount will be, if needed. Use the Retirement Estimator tool on the Social Security Administration website. Remember to consider what your benefit might be if you took benefits on your spouse’s record.

You will also want to consider any other income sources, like an annuity, a rental property, or pension payments from a previous job. (And don’t forget your spouse’s income, if applicable.) Find out when any annuity or pension payments start and how much you will receive.

If you are at least age 59½, you will also have full access to your retirement savings—money in 401(k)s, 403(b)s, and IRAs. But again, do not tap into these accounts too soon. Your retirement might last longer than you planned, and the longer you leave that money alone to grow, the better.

What do you need?

The other half of the equation is, of course, the money you are actually spending.

Many retirement calculators use a general guideline to estimate how much you need to save for retirement—assuming, for example, you will spend 80% of your pre-retirement money. But that’s only a rule of thumb. Depending on your situation, you might not need that much money.

Here are a few factors to consider:

Now that you are not going to a job every day, will you spend less on transportation? Clothing? Dining out?

Can you downsize your home? Move to an area with a lower cost of living?

Are there services you previously paid someone else that you can now do yourself? Housecleaning, dog walking, landscaping, and home/car maintenance might be expenses you can eliminate.

What other discretionary expenses could you do without?

Once you know how much money you have and how much money you need, you will be able to assess whether your financial situation is dire, iffy, or perfectly fine.

If you’re under age 59½

You might still have options for using your retirement money without penalty, if needed.

If you own a Roth IRA or Roth 401(k) and you’ve had the account for at least 5 years, you can withdraw your contributions without paying penalties or taxes. (This only applies to contributions—you will still owe taxes and penalties on any earnings if you withdraw them before age 59½.)

If you only have traditional retirement accounts, you can access the money through substantially equal periodic payments (SEPPs), a method of withdrawing money that exempts you from early withdrawal penalties. Note that once you start SEPPs, you will need to keep taking withdrawals until age 59½ or for 5 years, whichever is longer.

Step #4: Decide how to move forward

In the best-case scenario, your resources will exceed your expenses and you will not have to worry about working. That’s what happened to Kevin. He and his wife had done a great job saving, they were in a solid financial position and they actually could retire.

In the end, Kevin discovered he still wanted to work, and he found a new position. You may want to consider that, too. There’s a lot to be said for staying busy and continuing to save for the day you do decide to retire.

In an alternative—maybe more likely—scenario, you may not have enough money to live the retirement you envisioned. In that case, you will have to make some choices.

Assuming you are healthy, can you go back to work, even part-time? Do not rule out unconventional options, like working as a freelancer or consultant, teaching at a local community college, or finding occasional gigs through a service like Uber.

And if working is not possible [from a financial perspective] it’s still best, if you can, to keep a steady income stream. However, if this is not an option or you still need more income, try to get by with just Social Security for now and keep growing your retirement money.


Retirement’s Revolving Door

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Tim and Chris Franson.jpg

In his view, Tim Franson utterly failed at retirement. After twenty years as a vice president at Eli Lilly, Franson and his wife, Chris, a real estate agent, thought they were quietly retiring nearly a decade ago. 

For the first month or so, Franson says, he mostly slept. He wasn’t depressed, just mentally and physically exhausted. Then, “I went crazy,” said Franson. “I’m not very good at sitting around.”

He quickly found himself back at work part time after a friend at a small pharmaceutical company asked him for strategic advice. “Things snowballed from there.”

Today, Franson, 66, consults and works about four days a week, while serving on two for-profit boards and two nonprofit boards.

Welcome to the land of the un-retired — people who thought they were leaving the work world only to return because they sorely missed something about it, besides the money. These people in their 50s through 80s retired on pensions or savings — or both — but ultimately woke up to the fact, there’s more to life than watching Florida sunsets.

This “un-retirement” trend continues to build, according to a 2017 Rand Corp. study showing that 39 percent of Americans 65 and older who are currently employed had previously retired. And more than half of those 50 and older who are not working and not searching for work said they would work if the “right opportunity came along,” the study found.

“We have a mistaken image of life, that we go to school, work for 40 years, then say goodbye to colleagues for the last time and embrace the leisure life,” says Chris Farrell, author of “Unretirement: How Baby Boomers Are Changing the Way We Think About Work, Community and the Good Life.” “It hasn’t turned out to be the arc of most people’s lives.”

This is not about older people returning to work because they need the money. This is about older people returning to work because they miss the challenges, the accomplishments and, most importantly, the collegiality.

When retirees are asked what they miss most about pre-retirement life, the number one answer is typically colleagues, says Farrell. “What’s constantly underestimated is that work is really a community. As it turns out, it’s much healthier and more satisfying to work for a bad boss than to sit on the couch and watch TV,” he says.

Franson understands all of this and not that it didn’t make perfect sense for him to retire when he did, at age 58. Lilly offered him a year’s pay and a full pension to take early retirement. Franson had prostate cancer while at Lilly — and though the surgery was successful, he says, “that experience made me sit back and revisit how I wanted to experience my remaining days.” At the time, his children were out of college, and he did not yet have any grandchildren.

Then, life derailed him when his wife, Chris, took ill and died within a few years. Four years ago, he accepted another consulting job in the Indianapolis area to be closer to his children and grandchildren. Franson has no plans to retire from his un-retirement anytime soon.

Laurie Caraway retired in 2013, at age 56, as director of clinical data management at Bristol-Myers Squibb. She picked that age because her father died at 56 before he had a chance to retire from private practice as a surgeon.

Her husband, Scott, a longtime American Airlines pilot, retired along with her. Scott adapted quickly and learned to be a potter. It was summer, and Laura spent the next three to four months biking, swimming and treating retirement like a vacation. Some days, she simply sat on her front porch swing.

Then, the weather changed. The cold autumn reminded Caraway that something had to change in her life. So, she started volunteering in Guilford, Connecticut, with a group that works to uplift academically gifted minority women from disadvantaged communities. That expanded into a part-time, paid position managing the group’s consignment shop.

Caraway was presented with an opportunity to go back — on a short-term contract — to Bristol-Myers Squibb. This encouraged her to send her résumé to Your Encore, a retiree return-to-work program co-created by Lilly, Procter & Gamble and Boeing that matches retirees with employers who need their skills. She landed more contracts to which she can always say “No, thanks” and still have time for yoga class.

“There is life after retirement,” she says. “It’s called work.”

Then, there’s Louise Klaber. She retired at age 65 from a 20-year career in organizational development — but is now working again at age 81.

In 2001, the former New Yorker thought she was living the dream when she arranged to retire in New York City with husband Ralph Walde, a college professor.

September 13 was moving day into their apartment on New York’s Upper West Side. But as the horrific events of 9/11 unfurled, they found they were living in a state of shock. Within weeks, they were both signed up to do volunteer work helping prepare meals for the 9/11 site workers. Their shift: 8 p.m. to 6 a.m., chopping squash, carrots and onions. “It made us feel like we were actually doing something to help,” Klaber says.

The prep kitchen shut down shortly after Thanksgiving, and she found part-time paid work assisting people most severely affected by 9/11 find financial aid, mental health assistance or employment. She then contacted ReServe, a national nonprofit that places retired professionals with public service agencies of all sizes, budgets and missions. ReServe linked Klaber with the New York City Law Department, where she has worked part time ever since as an organizational development counselor. What drives her is not the $10-an-hour pay but the professional camaraderie.

A former marathon runner, Klaber still runs almost daily. That, she says, is an important ingredient for staying healthy — but the work is just as important to her vitality.

When will she finally quit working? “Only God knows,” she says. “I’m having way too much fun.”


Medicare Rules and HSA’s

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Medical symbol with sunriseThe rise of high-deductible employer health plans has created one of the most unpleasant surprises for older employees. 

Anyone on Medicare is no longer allowed to make tax-free contributions to a health savings account (HSA).

In 2003, Congress authorized HSAs as part of the law that also brought Part D drug plans into existence. HSAs are only available to those with a high-deductible health plan.

The beauty of an HSA is that it is funded with pre-tax dollars and its holdings can be invested, like a 401(k). When spent, any earnings on these investments are exempt from income taxes, like a Roth IRA, so long as the expenditures are for qualifying medical expenses. Unlike flexible spending accounts, HSA contributions do not have to be spent by the end of each year but can be carried over indefinitely.

There are minimum deductions needed for a health plan to qualify as high-deductible, and they may change each year. For 2018, plans must have an annual deductible of at least $1,350 if they cover individuals, and $2,700 for families. Further, such plans may not generate out-of-pocket expenses that exceed $6,650 for individual plans and $13,300 for family coverage. These expenses, the IRS says, include plan “deductibles, co-payments, and other amounts, but not premiums.”

The annual maximum on these contributions in 2018 will be $3,450 for HSAs linked to individual insurance plans, and $6,900 for family plans. In addition, $1,000 age-related “catch up” contributions are permitted for those aged 55 or older. This raises the total limits of plan contributions to as much as $8,900. Employers often contribute the rest of these funds. And, contributions to a plan can come from family and friends as well as the insured individuals.

While most HSAs are linked with employer insurance plans, any qualifying high-deductible plan can permit the insured person or family to open an HSA. This includes private health plans through financial institutions. 

Medicare and Social Security enter the HSA picture because Medicare insurance is not a high-deductible health plan. Anyone with Medicare, or coverage from other health plans that do not offer qualifying high deductibles, may not contribute to an HSA. A person can continue to use any assets within an existing HSA account.

Most common questions:

Why does receiving Social Security prohibit a person from contributing to an HSA?

The law requires anyone aged 65 or older who is receiving any type of Social Security benefit to also be enrolled in premium-free Medicare Part A, which covers hospital expenses. This triggers the Medicare-related ban on HSA contributions. Historically, enrolling in Medicare Part A was a very good thing. It can be used as secondary insurance for people covered by employer health plans with no premiums. The rise of high-deductible health plans can make Medicare Part A a dubious benefit. Unfortunately, the only way to reject Medicare Part A is to withdraw from receiving Social Security benefits.

Why does Medicare Part A take effect six months before an individual’s requested effective date? And, how does a person know when to stop HSA contributions?

The earliest that a non-disabled person can enroll in Medicare is age 65. If enrolling in Medicare within six months prior to turning 65, Medicare Part A will start on the first of the month when turning 65. If enrolling in Medicare after turning 65, a person is entitled to as many as six months of retroactive benefits, but in no case can the effective date be earlier than when turning 65.

Historically, people were better off with these retroactive benefit dates. Clearly, that may not be the case when it conflicts with an HSA. 

People who claim Social Security benefits before they turn 65 are too young to qualify for Medicare Part A. Claiming Social Security does not always interfere with an HSA – only if a person is 65 or older.

If a person knows they are going to become ineligible for HSA contributions during a calendar year, can they “front load” that year’s allowable contributions before becoming ineligible?

No. It’s important to remember that contributions to an HSA are calculated monthly. For example, if someone with family coverage had $6,900 in allowable HSA contributions, the rules “credit” one-twelfth of that amount each month, or $575.

Normally, it would not matter if the person made all those contributions in January, for example, because the rules assume they would qualify for HSA contributions for the entire year. But if they became ineligible in July, they would only be able to contribute $3,450 (six $575 monthly contributions).

What happens to any excess contributions?

They need to be removed from the HSA and treated as taxable income on the annual tax return. These rules are explained, albeit not always clearly, in IRS Publication 969

What happens to the employer’s contributions?

The employer has made a commitment to contribute, for example, $1,500 for the year to the employee’s HSA. It is legal for the employer to contribute a full annual contribution. In this example, for a period of six months, the employee’s allowed contributions would be $1,950 in addition to the employer’s $1,500 contribution.

It is the responsibility of the employee to make sure there are no excess contributions. If there are, it’s the responsibility of the employee to correct it before filing that year’s tax return. If the employer does not have knowledge of the employee becoming ineligible for additional HSA contributions, there is no reason why the employer’s contribution should terminate.

What if a person has family coverage and one family member becomes ineligible?

If one spouse becomes ineligible, the full amount of that year’s family HSA contributions normally can be made by the eligible spouse. The $6,900 can be contributed in any way the couple prefers. If the ineligible spouse was making a $1,000 catch-up contribution, this would no longer be allowed.

One important requirement is that if the employee is the person who begins Medicare and becomes ineligible, the spouse must have established their own HSA in order to complete the couple’s allowable contributions.

Is there was a family HSA for people with family health coverage?

There are no joint HSAs. Each spouse must have their own HSA if they wish to make tax-free contributions. This most often happens where the non-employee spouse wishes to make an age-related catch-up contribution of $1,000. That contribution can only be placed in their HSA account. Employers usually do not create such accounts, so the non-employer spouse needs to work with a financial firm to establish the account. There are ongoing efforts to revise HSA laws and eliminate the need for non-employee spouses to create separate HSAs for their catch-up contributions.

If an employer offers only the high-deductible plan, what can a person do if they are ineligible for an HSA?

If a person wants employer health insurance, they will need to accept the likelihood that out-of-pocket expenses could be substantial without HSA funds.

People with Medicare Part A should take a close look at whether it makes sense for them to reject their employer’s health plan and, instead, purchase Medicare Part B and other Medicare coverage, including a Medicare Part D drug plan with an optional Medigap supplement plan or a Medicare Advantage plan. 

If ineligible, how does this affect income taxes?

If a person has made excess contributions and can withdraw them by the time income taxes are due, there will not be a penalty due to the IRS. Otherwise, the penalty is 6 percent.

What tax forms should be used?

Form 8889 is used for reporting your annual HSA activity. Form 5329 is used to report excess contributions. If using a tax preparer, work with them on how to file these forms.



Former Hospitals Get A New Life

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Hollenbeck TerraceWhen Juana Monroy moved into Hollenbeck Terrace in 2015, she learned that the senior apartment building was once a hospital that had appeared in dozens of movies and television shows. Then she began hearing rumors that the old Linda Vista Community Hospital building was haunted. “I was a little scared,” says Monroy, 60.

But she hasn’t seen a ghost yet, and now she loves living in a building with such history. “It’s gorgeous,” she says.

Across the country, hospitals that have closed their doors are coming back to life in various ways: affordable senior housing in Los Angeles, luxurious multimillion-dollar condominiums in New York’s Greenwich Village, a historical hotel in Santa Fe, New Mexico. In the Capitol Hill neighborhood of Washington, D.C., a hospital that opened in 1905 to care for the poor was remodeled and reopened in 2017 with 139 apartment units, a rooftop deck and an indoor dog wash.

Such conversions can pull at the heartstrings of communities in which residents often have an emotional attachment to hospitals where family members were born, cured or died. Nevertheless, the changeovers can also be welcome, particularly when hospitals have been closed leaving their buildings empty and dilapidated.

Closing a hospital and converting it to another use is not exactly like renovating just any old building, says Jeff Goldsmith, a health industry consultant in Charlottesville, Virginia. “A hospital in a lot of places defines a community — that’s why it’s so difficult to close them,” Goldsmith says.

The trend of converting hospitals to condos and apartments comes as real estate values have soared in many U.S. cities, and demand for inpatient hospital care is on the decline. Surgery and other health services are being moved increasingly to freestanding outpatient centers, and the average number of days patients stay in hospitals has dropped significantly.

Against this backdrop, the hospital industry is consolidating, and many institutions are shutting their doors. The number of hospitals in the U.S. has declined by 21 percent over the past four decades, from 7,156 in 1975 to 5,627 in 2014, according to the latest federal data.

In addition, many older hospitals are too outmoded to be renovated for today’s medical needs, which include large operating room suites and private rooms.

Real estate investors say the location of many older hospitals — often in city centers near rail and bus lines — makes them attractive for redevelopment. The buildings, with their wide hallways and high ceilings, are often easy to remake as apartments.

Some of the changes have elicited controversy, however — particularly in New York, where many hospitals have been converted to residential housing in recent years.

St. Vincent’s Transformation

St. Vincent’s hospital in New York, which traditionally cared for the poor and treated survivors of the Titanic’s sinking in 1912, the first AIDS patients in the 1980s and victims of the 9/11 terrorist attacks in 2001, went bankrupt and closed seven years ago. Developer Rudin Management bought it for $260 million and transformed it into a high-end condo complex, which opened in 2014. In early 2017, former Starbucks CEO Howard Schultz reportedly bought one of the condos for $40 million. The shift from a place that cared for the poor to a home for the wealthy, upset many residents in Greenwich Village.

Jen van Meer, an assistant professor at the Parsons School for Design in New York, who lives four blocks from the former St. Vincent’s, says people in her neighborhood were sorry to see the hospital close for more than just sentimental reasons. Because today, if a person is having a cardiac arrest, the nearest hospital is almost an hour drive by car or 20 minutes in an ambulance across the city.

St. Vincent’s is one of at least 10 former hospitals in New York City that have been turned into residential housing over the past 20 years.

Spurring Development

In some circumstances, a conversion provides a much needed lift for the community. New York Cancer Hospital, which opened on Central Park West in 1887 and closed in 1976, was an abandoned and partially burned-out hulk by the time it was restored as a condo complex in 2005. Developer MCL Companies paid $24 million for the property, branded 455 Central Park West.

“The building itself is fantastic and a landmark in every sense of the word,” says Alex Herrera, director of technical services at the New York Landmarks Conservancy. He notes that it has retained some of its original 19th-century architecture.

Repurposing hospitals does not come without friction, however.

Nicky Cymrot, president of the Capitol Hill Community Foundation in Washington, D.C., a neighborhood group, says that when Specialty Hospital Capitol Hill sold off a little-used 100,000-square-foot wing of its facility to developers who planned to build apartments, neighbors weighed in with concerns about aesthetics and traffic. But the builders of 700 Constitution — the hospital-turned-apartment house a few blocks from the U.S. Capitol — preserved the old architecture, which pleased residents.

The renovation cost $40 million and took nearly nearly five years to complete in part because of delays in building an underground parking garage. At 700 Constitution, one-bedroom apartments rent for nearly $2,600 per month.

It’s not the first hospital in the district to make such a conversion. Columbia Hospital for Women which had delivered more than 250,000 babies since it opened shortly after the Civil War, closed in 2002 and reopened in 2006 as condos with a rooftop swimming pool in the city’s fashionable West End. 

Some former hospitals are used for purposes other than housing. In San Diego, Point Loma’s Cabrillo Hospital closed in 2007 and was transformed into a language school nine years later, providing economic stimulus for nearby businesses.

In Santa Fe, New Mexico, St. Vincent Hospital moved into a new facility in 1977 and the old structure downtown was reborn as a state office building. Later, it was abandoned and locals listed it as one of the spookiest places in town. In 2014, the building reopened yet again as the 141-room Drury Plaza Hotel.

‘A Building With Tremendous History’

Linda Vista Community Hospital, which overlooks a park in L.A.’s Boyle Heights neighborhood, opened in 1905 to serve railroad employees. Budget problems and declining patient rolls led to its closure 86 years later, and the abandoned six-story building fell into disrepair.

But the empty patient rooms, discarded medical equipment and aging corridors soon attracted film crews, who shot scenes for movies such as “Pearl Harbor” and “Outbreak.” The hospital also attracted trespassers looking for ghosts and groups such as the Boyle Heights Paranormal Project. The property was purchased and redeveloped by Amcal Multi-Housing Inc. in 2011.

The company turned patient rooms into affordable senior apartments and renovated everything from the intensive care unit to the medical library. Amcal retained many of the building’s original features, including mailboxes, dumbwaiters, windows and stainless-steel doors.

“They really rescued a building with tremendous history … while providing really needed low-income senior housing,” says Linda Dishman, CEO of the Los Angeles Conservancy, a group dedicated to preserving and revitalizing historic structures. “It is such an iconic building in the neighborhood.”

Shedding New Light On Hospice Care

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Woman and caregiverEarlier this year, Kathy’s 86-year-old mother was hospitalized in Colorado after a fall. As she rushed to her side, Kathy asked for a consultation with a palliative care nurse.

“I wanted someone to make sure my mother was on the right medications,” Kathy said.

For all her expertise — Kathy Brandt advises end-of-life organizations across the country — she was taken aback when the nurse suggested hospice care for her mother, who has advanced chronic obstructive pulmonary disease, kidney disease and a rapid, irregular heartbeat.

“I was amazed — really?” Kathy said, struggling with shock.

It’s a common reaction. Although hospices now serve more than 1.4 million people a year, this specialized type of care, meant for people with six months or less to live, continues to evoke resistance, fear and misunderstanding.

“The biggest misperception about hospice is that it’s ‘brink-of-death care,’” says Patricia Mehnert, a longtime hospice nurse and interim chief executive officer of TRU Community Care, the first hospice in Colorado.

In fact, hospice care often makes a considerable difference for those with months to live. “When someone is further out from death, we can really focus on enhancing their quality of life,” says Rachel Behrendt, senior vice president of Hospice of the Valley, which serves the Phoenix metropolitan area.

New research confirms that hospice patients report better pain control, more satisfaction with their care and fewer deaths in the hospital or intensive care units than other people with a similar short life expectancy.

What should seniors and their families, the largest users of hospice care, expect? It’s fairly well understood that patients forgo curative therapies in favor of comfort care when they enter hospice. Here are additional features:

Four Levels Of Care

Hospice providers are required to offer routine care in patients’ homes (this includes seniors who reside in assisted living or nursing homes); continuous care at home for people with out-of-control symptoms such as pain or breathing problems; inpatient respite for families that need a break from caring for a loved one; and general inpatient care for medical crises that cannot be handled in any other setting.

With continuous care, a nurse must be on-site in the home for at least eight hours a day, helping to bring symptoms under control. Usually, this will happen in one to three days. Respite care has a maximum limit of five days.

Some hospices have their own general inpatient facilities and “it’s a common misconception that patients are sent to inpatient hospice to die,” says Jean Cohn, clinical manager at Montgomery Hospice’s inpatient facility, Casey House. “In fact, we’re frequently fine-tuning patients’ regimens in inpatient hospice and sending them back home.”

Intermittent Care At Home

Routine care at home is by far the most common service, accounting for about 94 percent of hospice care, according to the latest report from the National Hospice and Palliative Care Organization.

While services vary depending on a patient’s needs, home care typically involves at least one weekly visit from a nurse and a couple of visits from aides for up to 90 minutes. Also, a volunteer may visit, if a patient and family so choose, and social workers and chaplains are available to address practical and spiritual concerns.

Hospices will provide all medications needed to address the underlying illness that is expected to cause the patient’s death, as well as medical equipment such as hospital beds, commodes, wheelchairs, walkers and oxygen. Typically, there is no charge for such gear, although a copay of up to $5 per prescription is allowed.

What families and patients often do not realize: Hospice staff will not be in the home every day, around the clock. “Many people think that hospice will be there all the time, but it does not work that way,” Brandt says. “The family is still the front line for providing day-to-day care.”

In assisted living, patients or their families may have to hire nursing assistants or companions to provide supplemental care, since hands-on help is limited. In nursing homes, aides may visit less often, since more hands-on help is available on-site.

Self-Referrals Are Allowed

Anyone can ask for a consultation with a hospice. “We get many self-referrals, as well as referrals from family and friends,” says Behrendt of Hospice of the Valley. Usually, a nurse will visit and do a preliminary assessment to determine if a person would qualify for hospice services.

To be admitted, two physicians — the patient’s primary care physician and the hospice physician — need to certify that the person’s life expectancy is six months or less, based on the anticipated trajectory of the patient’s underlying illness. And re-certification will be required at regular intervals.

A Person Can Choose Their Physician

A person has a right to keep their primary care physician or they can choose to have a hospice physician be in charge of their medical care.

At JourneyCare, the largest hospice in Illinois, “we prefer that the patient retains their primary care physician because that physician knows them best,” says Dr. Mark Grzeskowiak, vice president of medical services.

These arrangements require close collaboration. For instance, if a nurse observes that a patient with heart failure is experiencing increased shortness of breath, JourneyCare staff will get in touch with that patient’s primary care physician. The physician is responsible for altering the treatment plan; the hospice is responsible for implementing that plan and giving clear instructions to the patient and family.

Concerns About Medications

“There’s a misconception that a person is going to be medicated to a highly sedated state in hospice,” says Dr. Christopher Kerr, chief executive officer and chief medical officer for Hospice Buffalo Inc. in upstate New York. “The reality of our primary goal is to increase quality wakefulness. Managing these medications is an art and we’re highly experienced.”

Family caregivers are on the front line since they are responsible for administering pain medications such as morphine. “Absolutely, there’s a great deal of fear and anxiety around all the issues associated with giving medications,” says Cohn of Montgomery Hospice. “We try to reassure caregivers that the doses we start with are very small, monitor how the patient reacts, and go deliberately slow.”

Because most hospice stays are short — the median length is only 17 days — and because the diversion of painkillers from people’s homes is a risk, doctors have begun writing prescriptions for a week or two at a time, says Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization. If concerns exist, hospices can have a lockbox for medications sent to the home.

Discharges Are Possible

Estimating when someone is going to die is an art, not a science, and each year hundreds of thousands of hospice patients live longer than doctors anticipate.

If physicians can document continued decline in these patients — for instance, worsening pain or a noticeable advance in their underlying illness — they might be able to re-certify them for ongoing hospice care. But if the patient is considered stable, they will be discharged, various experts say.

In 2015, nearly 17 percent of hospice patients were so-called live discharges, according to a report from the Medicare Payment Advisory Commission. Two days before a discharge, hospices are required to give the patient or family members a Notice of Medicare Non-Coverage. Expedited appeals of discharge decisions can be lodged with a Medicare quality improvement organization.

There are no regulatory requirements governing what hospices should do to facilitate live discharges. Some hospices will spend weeks helping patients make arrangements to receive medications, medical equipment and ongoing care from other sources. Others offer minimal assistance.

At The Very End

Almost 1 in 8 hospice patients do not get visits from professional staff during their last two days of life, according to a study published in JAMA Internal Medicine last year. And this can leave families without needed support.

Some hospices have responded by creating programs specifically for people who have a very short time left to live. “We’ve put together a special team for people who are expected to live 10 days or less because that requires a different kind of management,” says Ann Mitchell, chief executive officer of Montgomery Hospice. “Instead of a nurse for every 15 patients, a nurse on this team will have five to six patients and a social worker is available seven days a week.”

“One-third of our patients are here for less than seven days and often we receive them in a crisis,” says Kerr of Hospice Buffalo. “We’ve had to re-purpose our services to address the urgency and complexity of these patients’ needs and that means we have to be ever more present.” Across the board, Hospice Buffalo requires that patients be seen within 24 hours of an expected death.

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