The Secret to Chronic Happiness

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Lady with cookiesBy all rights, Fletcher Hale should not be happy. At 76, the retired trade association manager has endured three heart attacks and eight heart bypass operations. He’s had four stents and a balloon inserted in his heart. He has diabetes, glaucoma, osteoarthritis in both knees and diabetic neuropathy in both legs. He can’t drive. He can’t travel much. He can’t see very well. And his heart condition severely limits his ability to exercise. On a good day, he can walk about 10 yards before needing to rest.

Yet the Brooklandville, Md., resident insists he’s a genuinely happy guy — in part, because he appreciates what he can do. “There’s no question that as age impinges on your life, you do have ‘black dog’ days,” said Hale. “I fight aging every day. But I never, ever give up. You have to work at keeping happy.”

Hale focuses on the things that bring him joy: writing and listening to music and audiobooks. By juggling those pastimes throughout the day — every day — he ultimately feels a sense of contentment. “Every one of those things requires that I use my mind — which is a good thing.”

Geriatric experts agree that Hale has pretty much figured out the right formula. “You have to be willing to accept your new reality — and move forward,” said Dr. Susan Lehmann, director of the geriatric psychiatry day program at Johns Hopkins University School of Medicine. “Aim to have the best life you can at where you are right now.”

Living with chronic disease often complicates life. The majority of adults 65 and over have multiple chronic conditions that contribute to frailty and disability, according to a 2013-14 report from the Centers for Disease Control and Prevention. The percentage of chronic conditions among people 65 and over has increased over time, too. The percentage of people reporting hypertension, asthma, cancer and diabetes was higher in 2013-14 than in 1997-98, reports the CDC.

Chronic conditions can have a devastating impact on both men and women, according to the CDC report. About 57 percent of women and 55 percent of men age 65 and up reported hypertension. Another 54 percent of women and 43 percent of men reported arthritis. And a full 35 percent of men and 25 percent of women reported dealing with heart disease. At the same time, older women were more likely to report clinically relevant depressive symptoms than were older men. In 2014, 15 percent of women 65 and older reported depressive symptoms, compared with 10 percent of men.

Chronic pain, in fact, more frequently leads to depression than does anxiety, said Dr. Kathleen Franco, associate dean at the Cleveland Clinic Lerner College of Medicine. That depression then leads to additional pain and suffering, she said. “So you have an emotional and physical component.”

That’s why Hale clings dearly to his greatest passion: writing. When he retired at 65, his original plan was to travel with his wife, Tracey. His physical limitations curbed those goals, so he circled back to what has brought him the most happiness. He stays engaged in daily news by writing for two blogs — including one at-large column in which he espouses what he calls his “compassionate conservative” values.

Hale also adores reading, even though glaucoma has made it all but impossible. Not one to give up, he uses his Amazon Echo smart speaker to order audiobooks. He loves sitting on his balcony in the sunshine and listening to books like The Guns of August. Similarly, he enjoys streaming both classical and country music, especially the Oak Ridge Boys and the country rock group Alabama.

Hale also has learned to use Alexa, the Echo’s built-in digital assistant, to help with seemingly simple tasks that are difficult with poor eyesight. To tell time, he simply asks Alexa.

Beyond that, he avoids getting trapped in any frustration loops, such as trying to troubleshoot computer issues. During a recent technological tussle, he simply shut down the machine and turned on PBS and Charlie Rose. “Watching that show keeps my mind active,” he said. After taking time to de-stress, he was able to solve the tech issue.

Hale finds some excuse to get out of his house every day. Sometimes he runs an errand. Or he’ll meet a friend for lunch. As a bird lover, he might just sit in a park listening to birds singing. “If I can combine a pleasant venue with the sound of bird symphonies, I’m a happy camper,” he said.

This is Hale’s version of what some experts call “mindfulness.” Mindfulness, which often involves deep, slow breathing that’s aimed at lowering your heart rate and calming you down, can be highly effective on older, ailing people, said Franco. “It’s simple. It doesn’t cost anything. You can do it and no one even knows you’re doing it.”

One other thing often works like magic: helping others. “Once you start giving to others, you tend not to get stuck in your own aches and pains,” said Franco.

Anne McKinley knows this firsthand. Even at 85, she still volunteers for an aging advocacy group and sits on its board of directors.

McKinley copes with the debilitating effects of lifelong scoliosis. She, too, battles glaucoma, and her visual perception difficulties affect her balance. She’s had both knees replaced and more recently needed emergency surgery for an infection she contracted in the hospital following parathyroid surgery, which also affected her vocal cords.

The Evergreen, Colo., resident said that keeping a very positive attitude — and constantly reaching out to family and friends — keeps her content.

“Feeling like I have control of my life is very important,” she said. “The key is not to feel rushed. I can accomplish one thing in a day and feel good about it.”

It’s been a tough road since her husband, Cameron, died four years ago after 59 years of marriage. But with her master’s degree in social work and experience as a social worker, she knew how to utilize social services for older people in her community. That includes one service that performs housekeeping and other chores for a modest fee.

McKinley still visits family in Florida — though she must use a cane or walker to get around. Her grandchildren frequently come to visit, “and we feast whenever they do,” she added, typically on the cookies and pies she loves to bake. Above all, she said, she’s always getting out of the house. She gets her hair cut every week. “It’s my best remaining feature,” she said.

Then, there’s her Siamese cat, Frankie, who joins McKinley every evening at 6 p.m. to watch the evening news while McKinley makes herself a snack and a martini. “My favorite part is the olives,” she said.

And, yes, she expresses how particularly grateful she is for what she has — including a home with a 20-foot-high ceiling on an 18-acre site, where she can look out any window and see the surrounding beauty.

The real key to happiness at every age and stage — particularly old age — is not material things, but gratitude for life’s simple blessings, like laughter among friends or watching a sunset with a loved one, said Lehmann, the Johns Hopkins doctor. “It’s the small things in life that end up mattering most of all.”

Perhaps Think Before You Eat?

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Man carrying full shopping basket in grocery store

Diets designed to boost brain health, targeted largely at older adults, are a new, noteworthy development in the field of nutrition.

The latest version is the Canadian Brain Health Food Guide, created by scientists in Toronto. Another, the MIND diet, comes from experts at Rush University Medical Center in Chicago and Harvard T.H. Chan School of Public Health.

Both diets draw from a growing body of research suggesting that certain nutrients — mostly found in plant-based foods, whole grains, beans, nuts, vegetable oils and fish — help protect cells in the brain while fighting harmful inflammation and oxidation.

Both have yielded preliminary, promising results in observational studies. The Canadian version — similar to the Mediterranean diet but adapted to Western eating habits — is associated with a 36 percent reduction in the risk of developing Alzheimer’s disease. The MIND diet — a hybrid of the Mediterranean diet and the DASH diet (Dietary Approaches to Stop Hypertension) — lowered the risk of Alzheimer’s by 53 percent.

Researchers responsible for both regimens continue to study them further in rigorous clinical trials launched this year.

Still, the diets differ in several respects, reflecting varying interpretations of research regarding nutrition’s impact on the aging brain.

A few examples: The MIND diet recommends two servings of vegetables every day; the Canadian diet recommends five. The Canadian diet suggests that fish or seafood be eaten three times a week; the MIND diet says once is enough.

The MIND diet calls for at least three servings of whole grains a day; the Canadian diet doesn’t make a specific recommendation. The Canadian diet calls for four servings of fruit each day; the MIND diet says that five half-cup portions of berries a week is all that is needed.

Carol Greenwood, a professor of nutrition at the University of Toronto and a key force behind the Canadian diet, and Martha Clare Morris, a nutritional epidemiologist at Rush University Medical Center and originator of the MIND diet, elaborate on research findings about nutrition and aging and their implications for older adults.

Nutrition And The Brain

It’s not yet well understood precisely how nutrition affects the brains of older adults. Most studies to date have been with animals or younger adults.

What is clear: A poor diet can increase the risk of developing hypertension, cardiovascular disease, obesity and diabetes, which in turn can end up compromising an individual’s cognitive function. The corollary: A good diet that reduces the risk of chronic illness is beneficial to the brain.

Also, what people eat appears to have an effect on brain cells and how they function.

“I don’t think we know enough yet to say that nutrients in themselves support neurogenesis (the growth of neurons) and synaptogenesis (the growth of neural connections),” Greenwood said. “But pathways that are needed for these processes can be supported or impaired by someone’s nutritional status.”

Essential Nutrients

“Several nutrients have been shown to have biological mechanisms related to neuropathology in the brain,” Morris said.

On that list is Vitamin E, a powerful antioxidant found in oils, nuts, seeds, whole grains and leafy green vegetables, which is associated with slower cognitive decline, a lower risk of dementia, and reduced accumulation of beta-amyloid proteins — a key culprit in Alzheimer’s disease.

“The brain is a site of great metabolic activity,” Morris said. “It uses an enormous amount of energy and in doing so generates a high level of free radical molecules, which are unstable and destructive. Vitamin E snatches up those free radicals and protects the brain from injury.”

Also on her list is vitamin B12 — found in animal products such as meat, eggs, cheese and fish — and vitamin B9 (folate), found in green leafy vegetables, grains, nuts and beans.

Because aging affects stomach acids that facilitate the absorption of B12, “everyone who gets to middle age should have a doctor check their B12 levels,” Morris said. A deficiency of this vitamin can lead to confusion and memory problems, while folate deficiency is associated with cognitive decline and an increased risk of dementia.

Omega-3 fatty acids found in fish and nut oils, especially DHA (docosahexaenoic acid), are highly concentrated in the brain, where they are incorporated in cell membranes and play a role in the transmission of signals between cells.

“A primary focus has to be maintaining healthy” blood vessels in the brain, Greenwood said. “So, heart health recommendations are similar in many ways to brain health recommendations, with this exception: The brain has higher levels of Omega-3s than any other tissue in the body, making adequate levels even more essential.”

Other studies point to calcium, zinc and vitamins A, C and D as having a positive impact on the brain, though findings are sometimes inconsistent.

Foods To Avoid

For the most part, the Canadian and MIND diets concur on foods to be avoided or limited to once-a-week servings, especially saturated fats found in pastries, sweets, butter, red meat and fried and processed foods.

As for dairy products, “there’s no evidence one way or another. If you like your yogurt, keep eating it,” Morris said. Greenwood adds a caveat: Make sure you consume low-fat dairy products as opposed to whole-fat versions.

Other Helpful Diets

Randomized clinical trials have demonstrated that both the Mediterranean diet and the DASH diet have a positive impact on various aspects of cognition, although neither was created specifically for that purpose.

“At the end of the day, our [Canadian] diet, the MIND diet, the Mediterranean diet and the DASH diet are not that different; they’re all likely to be helpful,” Greenwood said.

The Pattern Counts

Studies promoting the cognitive benefits of drinking tea or eating blueberries have recently garnered the headlines. But a focus on individual foods is misguided, both experts suggested. What matters instead are dietary patterns and how components of various foods interact to promote brain health.

The bottom line: Concentrate on eating an assortment of foods that are good for you. “As long as people are eating a healthful diet, they shouldn’t have to worry about individual nutrients,” Greenwood said.

How The ACA Survival Could Affect You

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Crystal BallMaybe next year will be just another confusing version of the past years? Analysts of the Congressional Budget Office continue to predict how the next new bill might… change federal revenue and spending, the number of people with health coverage, and the overall state of the commercial health insurance market over the next 10 years.

The analysts will do their best to compare their bill projections as they occur based on the assumption that the Affordable Care Act will stay in place.

Of course, the Affordable Care Act has very often worked differently than drafters, implementers and budget analysts expected.

In November 2008, for example, analysts at a PricewaterhouseCoopers think tank predicted that the health system changes the Obama administration had proposed would help cover about 30 million uninsured people at an average cost of $2,500 per individual.

Between 2013 and 2017, the Affordable Care Act Medicaid expansion program, the premium tax credit subsidy program, the cost-sharing reduction subsidy program and the ban on medical underwriting have helped cut the number of uninsured people by 13 million.

The federal government spent about $66 billion on Medicaid expansion support for states in 2016. Milliman [an actuarial firm] estimates the federal government spent about $14 billion on the premium tax credit subsidy program and the cost-sharing reduction subsidy program in 2016. Actual federal Affordable Care Act subsidy spending amounted to $80 billion, for an actual 2016 average of about $6,000 per newly insured individual.

Republicans, over the past several months, have attempted to pass a budget bill that would repeal many Affordable Care Act taxes and penalties, and replace the existing subsidy programs with new state grant and tax credit subsidy programs.

It’s possible that the Republican efforts to change the Affordable Care Act could fade away, and the Affordable Care Act could stay on the books, more or less as is.

Here are two thoughts about how the Affordable Care Act could possibly change life for individuals and employers in 2018, just by continuing to be “the law of the land.”

  1. Knowing the rules in any given market could be more difficult.

One of the guiding principles floating in the air when policymakers were working on health system change proposals from 2000 through 2009 was that by making state insurance rules more uniform it would help reduce compliance costs.

The Affordable Care Act eliminated state-to-state differences in underwriting rules and greatly reduced differences in benefits package rules, but it added new types of differences. Since January 2014, when major Affordable Care Act rules took effect, some states have had state-based Affordable Care Act exchange programs, and some have had exchange programs operated by the U.S. Department of Health and Human Services’ HealthCare.gov system. Some states have helped HHS implement the Affordable Care Act major medical standards rules. Other states have refused to have much, or anything, to do with enforcing the Affordable Care Act standards.

Under the administration of former President Barack Obama, efforts by HHS to ease some Affordable Care Act rules without wrestling rule changes through Congress increased state-to-state differences.

Obama signed the main Affordable Care Act bill into law March 23, 2010. A “grandfathering” provision in the law explicitly let people hold on to individual major medical policies that were in effect on March 23, 2010. However, some consumers said they should also be able to keep any policies they bought between March 23, 2010 and January 1, 2014 [when other laws became effective].

The Centers for Medicare and Medicaid Services, the HHS arm in charge of running the Affordable Care Act commercial health insurance programs, took a sideways approach in handling that controversy.

CMS did not persuade Congress to pass a new law and did not develop a formal regulation.

Instead, in November 2013, CMS issued a memo saying it would refrain from enforcing certain Affordable Care Act standards. CMS said it would look the other way if a state let insurers keep individual policies written from March 23, 2010 to January 1, 2014. The non-enforcement memo gave each state the freedom to do what it wanted about “transitional” policies, which are also known as “grandmothered” policies.

The method CMS used to create individual policy grandmothering set an important precedent: One way to change how the Affordable Care Act works is to let states go their own way.

In other cases, CMS worked with the Internal Revenue Service and the Employee Benefits Security Administration to revise and remove Affordable Care Act rules by issuing different types of “informal guidance,” including memos, rulings on specific proposals, and batches of answers to frequently asked questions.

If the current Affordable Care Act framework stays intact, and the Trump administration tries to operate within that framework as well as it can, Trump’s CMS may end up dealing with Affordable Care Act controversies and operational problems by issuing its own non-enforcement letters, and its own batches of informal guidance that give states more freedom.

Trump’s HHS has already notified states that it wants to make the Affordable Care Act Section 1332 waiver program, which lets states apply to adjust some Affordable Care Act rules, as flexible as possible.

Trump’s CMS has told states that it wants to find ways to defer more to state insurance regulators. CMS has already decided to rely more on state insurance regulators’ efforts to review 2018 rates, instead of conducting its own reviews.

The Trump administration efforts to give states more flexibility could lead to programs and rules that do a better job of meeting local needs.

One possible drawback is that keeping track of what the rules are in each state could become more complicated. 

Another possible drawback is that even knowing what the rules are in any given state could take more effort. The Obama administration, for example, posted important batches of informal guidance in many different formats, on many different websites. Hence, insurance companies, employers and compliance lawyers had to scramble to figure out where to look for guidance. 

  1. Government-run health plan programs could displace ordinary individual major medical coverage in some markets.

Congress has taken so long to enact changes to the current Affordable Care Act framework, or to postpone making major changes, that it has left health insurance and managed care companies almost no time to implement any changes, or even to come up with individual major medical products and rates for 2018 based on the idea that the current framework might stay pretty much the same.

Meanwhile, the HealthCare.gov open enrollment period for 2018 is set to begin November 1, 2017.

The current CMS HealthCare.gov issuer map shows that most people in the United States could be able to buy individual exchange plan coverage from at least one insurance company in November, but the coverage supply appears to be fragile.

Many counties are on track to have just one exchange plan issuer. If issuers dislike what they see happening in Washington, they can opt [and are opting] to pull their 2018 products out of HealthCare.gov.

If Congress leaves the Affordable Care Act intact, and it also approves funding for the cost-sharing reduction subsidy program [a major Affordable Care Act subsidy program for low-income exchange plan buyers] issuers might be able to rush into the 2018 open enrollment period with the products they have already filed with regulators.

On the other hand, if Congress leaves the Affordable Care Act framework intact, but it fails to fund the cost-sharing reduction subsidy program or other stabilization funds, issuers could have trouble adapting to the new market conditions by November 1. Issuers may have no choice but to pull products off the shelves.

 

 

 

 

Many Doctors Say Opioids Are Not The Answer

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Man and family memberPeople who have experienced pain, especially gnawing, chronic pain, know that it affects their happiness, outlook and the ability to function. 

In the past couple of years, the treatment of chronic pain has undergone an earthshaking transformation as opioid addiction continues to claim — and ruin — lives.

Many primary care doctors no longer liberally prescribe opioid painkillers such as oxycodone, fentanyl and hydrocodone for back pain, migraines and other chronic conditions. Instead, they are increasingly turning to alternative medications and non-drug options such as acupuncture and physical therapy.

“Most primary care doctors are afraid to do pain management because of the opioid backlash,” says Michael McClelland, a health care attorney in Rocklin, Calif., and former chief of enforcement for the state Department of Managed Health Care. “Either they don’t prescribe anything, and the patient remains in pain, or they turn them over to pain management specialists so someone else is writing that prescription.”

As a result, McClelland says, “people in genuine pain are going to find it more difficult to get medicine they may well need.”

Anita A., who asked that her full name not be used to protect her family’s privacy, says that happened to her father, Fred, when they moved from Maryland to the Sacramento area in November 2016.

Her father, 78, suffers from back pain that two surgeries did not alleviate. For more than a decade, he took opioid medications under the supervision of pain specialists in Maryland. He has tried “every other medicine,” in addition to acupuncture, nerve block injections and more, but the opioids worked best to control his pain, she says.

“He doesn’t take more than he needs and he’s not seeking to take more,” Anita says.

But in California, two pain specialists declined to see her father, saying his case was too complex. Finally, a primary care physician referred him to a different pain specialist, who saw him in January 2017, three months after starting the quest.

“It’s frustrating,” Anita says. “You get the sense that the medical society is treating everyone as a potential addict.”

A year ago, the Centers for Disease Control and Prevention issued new guidelines for primary care doctors prescribing painkillers for chronic pain, which did not apply to patients receiving active cancer, palliative or end-of-life care. The guidelines recommend doctors to first prescribe non-opioid medications, such as ibuprofen and acetaminophen, and urge non-drug treatments such as physical therapy.

When opioids are used for acute pain, such as that caused by injury, the guidelines suggest doctors prescribe the lowest-effective dose for the shortest-possible time — often three days.

In California, a statewide database known as CURES records opioid prescriptions. Last year, Govenor Jerry Brown signed a bill that requires prescribers to check the database and see if their patients have received these drugs from other doctors.

Opioids are highly addictive, and over time patients need higher dosages to achieve the same pain relief because their bodies develop a tolerance to the drugs.

 

“We don’t have any evidence to support the use of daily opioid therapy beyond about three months for chronic, non-cancer pain,” says Dr. Ramana Naidu, an anesthesiologist and pain management specialist at the University of California, San Francisco. “All of these individuals who have been on opioids for many years  have been doing so without any support from medical literature and science.”

Long-term use also comes with a plethora of possible and unpleasant side effects: constipation, confusion, low testosterone, difficulty urinating, weakened bones and more. And in a counterintuitive twist, opioids can make patients more sensitive to pain.

In some specific circumstances and at a low dosage, opioids can be used over the long term for chronic conditions when “patients have improved quality of life and function, no side effects and no concerns about misuse, abuse or addiction,” Naidu says. But in those cases, he requires his patients to take a “vacation” from opioids every two to four months.

As the Centers for Disease Control and Prevention guidelines recommend, pain specialists are now looking to non-opioid medications plus a variety of non-drug treatments to help patients with chronic pain. These include acupuncture, massage, yoga and visits to pain psychologists.

Penney Cowan, founder and CEO of the American Chronic Pain Association, based in Rocklin, worries that some doctors are not treating their patients as individuals with unique needs. She’s hearing from members whose primary care physicians are simply refusing to refill their opioid prescriptions. 

Liz Helms, president and CEO of the California Chronic Care Coalition, believes some people in chronic pain should be able to get opioids as long as their use is carefully managed by physicians. “That doctor-patient relationship is key to ensuring that someone stays out of pain so they can function,” Helms says. 

Clearly, there is disagreement between some doctors and patients. If a patient finds themselves in the middle and in pain, here are a few suggestions:

First, a patient will need to accept that drugs, especially opioids, are not going to be the cornerstone of pain management and be open to other options, whether it’s alternative medications or other therapies.

“It’s harder work and not the quick fix of opioids, but in the long run, they are better for good health,” says Dr. C.Y. Angie Chen, an assistant clinical professor at Stanford Medical School who specializes in addiction medicine.

Second, it pays to be honest with the doctor and ask questions. If the doctor suggests no more opioids, ask the doctor to explain how he/she plans to decrease the medication.

And if a patient has not yet contacted a pain management specialist, request a referral. Cowan suggests talking with the pharmacist as well. “Pharmacists are the most accessible of all,” she says. “They can provide useful information about medications.”

Take a look at the “Pain Management Tools” section of the American Chronic Pain Association’s website for more resources, or call 800-533-3231. Ask about the support groups the organization sponsors.

Call the California Chronic Care Coalition at 916-444-1985 or visit its My Patient Rights website at www.mypatientrights.org.

Finally, Dr. Chrystina Jeter, clinical instructor of pain medicine at UCLA Health, wants people to know that she and other pain physicians are ready to help, even if a patient does not agree with their decisions to change a treatment plan.

“If I tell a patient they have to taper the opioids or that I can no longer prescribe  opioids, it’s not because I want to cause discomfort or that I do not care,” she says. “My primary job is to keep a patient safe, and I have a lot of evidence now to suggest that the prescribing habits of 10 years ago were not in patients’ best interest in the long run.”

Long-Term Care At Home Without Breaking The Bank

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Couple on bridge

The vast majority of older adults choose to receive long-term care at home and not in nursing homes. But many people forget to make plans for this very important expense.

Nor do they see long-term care insurance as a viable option — because it is expensive and often seen as protection against the cost of only nursing home care.

That should change, some experts contend. If the long-term care insurance industry focused more on helping people cover home-based services, they argue, policies would be more affordable, and potentially appealing.

Long-term care, for most people, is a home care problem. It makes sense to insure people for the likelihood of where care is going to be needed first — which is at home.

Genworth, one of the nation’s leading long-term care insurers, acknowledged that this position is supported by industry claims data.

“Primarily, we are seeing people utilizing home care and a smaller percentage using nursing home care,” said Beth Ludden, Genworth’s senior vice president for long-term care insurance products.

“People think, ‘While I might start out needing care at home, eventually I’ll need to be in a facility,’” Ludden continued. “But that’s not something we see in our data. For the most part, people are able to stay at home for the whole time.”

Currently, more than 6 million older Americans are thought to have a “high need” for long-term care, according to a report from the U.S. Department of Health and Human Services. That’s defined as requiring daily assistance with two activities (eating, bathing, toileting, dressing, continence or transferring from a bed to a chair) that lasts at least 90 days or a need for substantial assistance due to severe cognitive impairment.

About 52 percent of adults reaching age 65 today will need these services — 26 percent for two years or less; 12 percent for two to four years; and 14 percent for more than five years, the HHS report projected.

Yet fewer than 10 percent of older adults have purchased long-term care insurance, which has somewhat declined in popularity as premiums skyrocketed and insurers exited the market over the past decade. Whether the industry can fix its major problem — affordability — remains to be seen.

From a consumer’s perspective, if the goal is covering several years of home-based care, not nursing home care, a person can purchase a less expensive policy without all the bells and whistles that drive up costs.

A 55-year-old couple buying a policy of this kind — say, $4,000 a month in benefits for each person, for a maximum of three years, with a 1 percent compounded annual inflation protection provision — from a major insurance company would pay $2,380.05 a year in premiums. It’s common for policyholders to pay premiums for 10 or 20 years before claiming benefits. Terms are similar in most states.

How much help in the home might this policy provide?

According to 2016 data compiled by Genworth, the average annual cost for care provided by a home health aide was $46,332, compared with $82,128 for a semiprivate room in a nursing home. That translates into $3,861 a month, for 44 hours of home care a week — the equivalent of slightly more than six hours of care, seven days a week.

That might not be enough for seniors with serious, disabling illnesses, but it can provide much-needed relief to unpaid family caregivers who could otherwise be on call nonstop.

What happens if someone ends up needing nursing home care?

People might consider what is known as a “qualified long-term care partnership policy” — a plan available in every state except Alaska, Hawaii, Illinois, Massachusetts, Mississippi, New Mexico, Vermont and Washington, D.C. 

These little-known insurance products are designed to help consumers preserve their assets if they become seriously ill, need nursing home care and seek to become eligible for Medicaid, which pays for nearly half of nursing home costs in the U.S.

To qualify for Medicaid, most states require that an individual have no more than $2,000 in assets; couples are allowed to have up to about $120,000, so that a well spouse does not become impoverished. With a partnership policy, every dollar received in long-term care benefits is exempted from Medicaid’s asset test and protected from seizure by the state.

In other words, if you get $200,000 in benefits from a partnership policy and your state has an asset limit of $2,000 for Medicaid, you can keep $200,000 in assets plus the $2,000 allowed and still meet your state’s asset test.

Partnership policies do not guarantee Medicaid eligibility and a person would still have to meet whatever income standards their state sets for Medicaid. (Many, but not all states, allow people to “spend down” to qualify, using their income to pay for institutional care.)

Alan, 61, of Las Vegas, purchased a partnership policy three years ago because it allows him to retain control of his financial assets, even if he needs caregiver services. Another plus: The policy permits him [if he decides to stay at home] to take a certain amount of the monthly amount and give it to someone he chooses to provide care for him, even if that person is a family member.

There is no reliable national data about how many people with partnership policies end up going on Medicaid to cover nursing home care. Nor is there good data about the number of these policies that have been sold or the benefits paid out to date.

David Guttchen, who directs the Connecticut Partnership for Long-Term Care, the first such program in the country, is skeptical about policies with benefits that will cover only a portion of expected costs. (Four states, including Connecticut, were the first to launch partnership programs and have special rules.)

“A person absolutely needs to know what the average home care and nursing home costs are for their state, to get a sense of what the exposure might be,” he said. “If you don’t buy meaningful benefits, you’re wasting your premium.”

If a person is able to cover a good amount of home care but the policy does not cover nursing home care, some protection is gained, for a while, but a person could still pay an enormous amount out-of-pocket going forward, if Medicaid is not an option.

It’s a gamble because people cannot be sure what kind of care they will need in the future, or for how long, or what the future of Medicaid will offer. Before buying any policy, consult with an elder law attorney and an independent insurance adviser.

Drug Coverage Denied by Medicare and Fighting Back

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Man ConcernedKenneth Buss had taken a blood thinner, for over a year when his mail-order pharmacy refused a request to refill his prescription. He immediately contacted his physician who urged his Medicare plan insurer to approve the medication. 

The request was denied. But Buss, 79, did not let the matter drop. Without coverage, a 90-day supply of Xarelto costs about $1,300 at a local pharmacy — more than 10 times what Buss had been paying.

“That killed me,” said Buss, who remembers phoning his Medicare plan and saying, “Excuse me, are you saying my doctor is wrong and you know better?”

With his physician’s help, this determined Arizona resident persuaded his plan to renew his prescription. But many similarly frustrated older adults are not sure how to appeal Medicare drug plan denials.

“A lot of cases fall through the cracks,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. “People simply do not know exactly how to proceed or they try to go through the process; but it’s complicated, time-consuming and people just give up.”

Concerns about Medicare drug coverage are common: More seniors call the Medicare Rights Center’s national hotline (800-333-4114) about this topic each year than any other Medicare organization.

Here is some essential information about the appeals process:

The Basics

Nearly 41 million Medicare beneficiaries receive drug coverage through stand-alone drug plans or privately run Medicare Advantage plans — Kenneth’s type of coverage.

Some rules apply across the board. Notably, plans must cover substantially all drugs in six categories: HIV/AIDS treatments, antidepressants, antipsychotic medications, anti-convulsive treatments for seizures, immunosuppressive medications and treatments for cancer. In other categories, at least two medications from each class must be offered.

Plans are not allowed to cover such drugs as those for weight loss, coughs and colds, fertility, cosmetic purposes, sexual difficulties and non-prescription medications, among others.

Beyond these generalities, Medicare drug plans have considerable flexibility in choosing which drugs to cover (their formularies), capping the amount filled per prescription (quantity limits), requiring preapproval before a medication is supplied (prior authorization), asking people to try other lower-cost treatments first (step therapy) and assigning medications to different classes with different costs attached (cost-sharing tiers).

A failure to meet any of these requirements may result in a denial. In Buss’ case, his plan requires annual prior authorization of Xarelto. Although his doctor submitted the proper request, as he did in 2016, this time the plan deemed his rationale for prescribing the medication as insufficient.

Persistent Problems

The latest government audit of Medicare’s drug program confirms that plans often impose limits on drug coverage without advance approval from the Centers for Medicare & Medicaid Services (CMS), as required.

Notably, 64 percent of plans applied quantity limits that had not been approved by CMS, while 41 percent improperly dealt with requests for prior authorization or exceptions to plan requirements.

Also, insurance plan representatives were deficient in communicating with members and providers: 70 percent of denial notices did not offer adequate explanations for the actions taken, were incorrect or were written in a manner that was difficult for most people to understand.

About 45 percent of the insurance plans did not reach out to Medicare members or physicians to acquire the necessary additional information to make a coverage decision.

The takeaway for seniors: You must take the initiative in supplying relevant materials. Your chances are best if your physician clearly and comprehensively states, in writing, why you must take a particular medication and the likely harm of not doing so while referring to your particular medical circumstances.

Appeals Process

Seniors tend to think that when they are unable to get a medication at a pharmacy, they have grounds to appeal. But that is not true.

Another step awaits: An individual needs to request a formal “coverage determination” from the Medicare drug plan before the appeals process can start. Included should be an “exceptions request” asking that a plan’s rules be waived so a senior can obtain a medication or pay less for a drug.

Once a coverage determination is issued, there are five steps to the appeals process: a “redetermination” by the drug plan; a “reconsideration” by an independent review entity (MAXIMUS Federal Services serves this purpose across the U.S.); a hearing before an administrative law judge; a review by the Medicare Appeals Council; and a review by a federal district court.

Breakdowns in the process can occur right at the start: Individuals are supposed to get a notice from the pharmacy informing them of their right to appeal when a prescription cannot be filled, but much of the time this does not happen, said Casey Schwarz, senior counsel at the Medicare Rights Center.

Appeals can be processed on an expedited, fast-track timetable or at the standard, slower pace. But even expedited appeals can drag on, as plans and other entities miss decision-making deadlines.

Tips For Seniors

Older adults can become discouraged as they go through the early steps of this process, but “we encourage them not to give up — people are often successful at higher levels of appeal,” Schwarz said.

In 2015, the latest year for which data are available, independent reviewer MAXIMUS reversed drug plan decisions 30 percent of the time. That year, appeals to MAXIMUS climbed 47 percent over 2014 levels.

Some other tips from advocates: Keep careful records of every person you have spoken with and what they told you. Work closely with your physician’s office. Keep a record of any out-of-pocket drug expenses; these can be recovered later if your appeal is successful. Be persistent.

For help, call the Medicare Rights Center national hotline (800-333-4114).

“The complexity is awful, but hang in there if you can,” said Buss, who hopes he will not face similar difficulties when it’s time to renew his Xarelto prescription next year.

 

 

Caregiver ‘Boot Camp” for Dementia Patients

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Boot camp alzheimer caregiversGary Carmona thought he could do it all. He has headed companies and chaired nonprofit boards. But since his wife was diagnosed with dementia, Gary, 77, has felt exceedingly overwhelmed. 

 

 

“I really see myself crashing at times,” he said. “In my mind, I’m saying, ‘You know, I can’t really handle all this.’”

There was the time his wife, Rochelle, wandered outside and fell down. And the time she boiled water and walked away, leaving the burner on.

“I’m always double-, triple-, quadruple-checking everything that she’s around,” he said.

Carmona was among about 25 people who went to a Los Angeles-area adult day care center on a recent Saturday for a daylong “caregiver boot camp.” In the free session, funded in part by the Archstone Foundation, people caring for patients with Alzheimer’s or another form of dementia learned how to manage stress, make their homes safe and handle difficult patient behaviors. They also learned how to keep their loved ones engaged, with card games, crossword puzzles or music.

Doctors and researchers increasingly recognize that caring for people with dementia compromises the physical and mental health of the caregivers. And that, in turn, jeopardizes the well-being of the people in their care. Some studies have shown that the burden on caregivers may increase the likelihood that the loved ones in their charge will be placed in a nursing home.

“People with Alzheimer’s who have stressed caregivers have been shown to have poor outcomes,” said Zaldy Tan, the medical director of the UCLA Alzheimer’s and Dementia Care Program who created the boot camp. “Their caregivers have essentially thrown in the towel.”

People with dementia are also more likely to visit the emergency room and be hospitalized if their caregivers are not prepared for the task, Tan said.

That’s one of the main reasons why UCLA Health and its geriatrics division started its caregiver boot camps in 2015.

UCLA holds four boot camps a year at community and senior centers in Southern California and hopes to expand over the next year to meet the growing need. About 5 million Americans, 1 in 10 people over 65, have Alzheimer’s disease — a number that could balloon to 16 million by 2050, according to the Alzheimer’s Association.

Similar caregiver training programs have taken place in New Jersey, Florida and Virginia.

Tan started the recent session by explaining the progression of dementia, noting that in its later stages people often do not remember their loved ones.

“Do they all reach that stage?” asked one woman, who takes care of her sister.

“They do, if they live long enough,” Tan said. “I know it’s heartbreaking.”

He also warned the group that their actions can inadvertently provoke anxiety or aggression in their loved ones.

“Many times, when you see someone shift from being calm to agitated, happy to angry, typically there’s a trigger,” Tan said. “A trigger is just like a trigger on a gun. Something is pushed and you get a reaction.” He told them that as caregivers they were in the best position to identify and avoid those triggers.

Leon Waxman, who also attended the boot camp, said he tries not to upset his wife, Phyllis. But sometimes she gets angry, as she did the day he dropped her off for day care while he attended the session for caregivers.

Taking care of Phyllis the past few years has been trying, he said. She can still dress herself, but she gets easily confused and can no longer make decisions.

“The hardest part for me is I don’t have my wife anymore,” said Waxman, who has been married to Phyllis for 58 years. “She’s not the same person she was 10 years ago.”

During the boot camp, recreational therapist Peggy Anderson demonstrated a game caregivers could play at home: music bingo. Each square had the name of a song, and she played music.

“What’s this song?” Anderson asked the group.

“Bye blackbird,” one yelled out.

“If you have that one, mark it off,” she said.

Anderson said that even people with dementia can sometimes recognize songs and read their titles. “There’s a lot of good things that come out of this activity — just listening to music, clapping your hands, reminiscing,” she said.

In another room, occupational therapist Julie Manton explained how to prevent people with dementia from falling. She advised the group to ensure their homes have good lighting and bed rails, as examples. She also urged them to remove throw rugs.

Manton warned the participants that their loved ones might wander off and suggested the use of monitoring devices. “The key thing is to know where your loved one is at all times,” she said.

 

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