The Eyes and Ears for Doctors and Hospitals

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Meals ImageDebbie Case held an insulated bag with two packaged meals — a sandwich wrap and fruit for lunch, a burrito and cauliflower for dinner. “You are going to eat well today,” Case told 75-year-old Dave Kelly as she handed him the meals.  Kelly lost his sight about two years ago and reluctantly gave up cooking. 

After putting the food away, Kelly chatted with Case about his experience as a folk musician. As they talked in his living room, Case, CEO of San Diego County’s Meals on Wheels program, glanced around for hazards that could cause Kelly to fall.

Kelly said the homemade meals keep him from eating too much frozen food or take-out. But more than that, he said he appreciates someone coming by to check on him every day.

“Anything could happen,” Kelly said, adding that he worries about falling. “I wouldn’t want to lay around and suffer for days.”

Meals on Wheels is undergoing a dramatic overhaul as government and philanthropic funding fails to keep pace with a rapidly growing elderly population. The increased demand has resulted in lengthy waiting lists and a need to find other sources of funding. And at the same time, for-profit companies such as Mom’s Meals are creating more competition.

Meals on Wheels, which has served seniors for more than 60 years through a network of independent nonprofits, is trying to formalize the health and safety checks its volunteers already conduct during their daily home visits to seniors. Through an ongoing campaign dubbed “More Than a Meal,” the organization hopes to demonstrate that it can play a critical role in the health care system.

“We know we are keeping people out of the hospital,” Case said. “Seven dollars a day is cheaper than $1,300 a day.”

Meals on Wheels America and several of the local programs around the country have launched partnerships with insurers, hospitals and health systems. By reporting to providers any physical or mental changes they observe, volunteers can help improve seniors’ health and reduce unnecessary emergency room visits and nursing home placements, said Ellie Hollander, CEO of Meals on Wheels America.

“It’s a small investment for a big payoff,” Hollander said.

Studies conducted by Brown University researchers have shown that meal deliveries can help elderly people stay out of nursing homes, reduce falls and save states money.

Kali Thomas, an assistant professor at Brown University School of Public Health, estimated that if all states increased the number of older people receiving the meals by 1 percent, they would save more than $100 million. Research also has shown that the daily meal deliveries helped seniors’ mental health and eased their fears of being institutionalized.

Meals on Wheels can be the “eyes and ears” for health providers, especially in the case of seniors who are ill and do not have family nearby, said Thomas, who authored several studies of the organization.

Meals on Wheels has “the potential to capitalize on that,” she said. “They realize they are doing something that is unique and needed in our current health care space.”

Visitors from Meals on Wheels are the only people some seniors see all day. The volunteers get to know them and can quickly recognize problems.

“You notice if they are losing weight, if their house is a mess, if they are talking awkwardly,” said Chris Baca, executive director of Meals on Wheels West in Santa Monica. “Our wellness check is critical and almost as important as the food itself.”

The meal delivery and in-home visits also reduce isolation among residents, said Zia Agha, chief medical officer for West Health, which has organizations that provide and study senior services. Agha said that while numerous high-tech gadgets are available to keep an eye on seniors, they cannot replace a volunteer’s human touch.

Meals on Wheels, Brown University and the West Health Institute recently launched a two-year project in six states to formally build health and safety screenings into daily meal deliveries. The goal is to improve seniors’ health and catch problems early.

“The fact that you don’t have resources to feed yourself or you are so frail you can’t cook is a very big marker that you are going to have high health care utilization,” Agha said. “There is value in targeting these clients through this meal delivery service.”

That’s also what Meals on Wheels America is planning to do in a new partnership with Johns Hopkins Bayview Medical Center and Meals on Wheels of Central Maryland. The project aims to keep seniors at home and reduce their need for costly health services after hospitalization. The idea is to have trained volunteers report red flags and ensure, for example, that patients with congestive heart failure are weighing themselves regularly and eating properly.

Dan Hale, who is leading the project from the hospital, said the meal delivery volunteers can help track patients’ health even months after discharge and keep them from returning to the hospital. “It makes sense financially,” he said.

Funding for Meals on Wheels organizations primarily comes from the federal government, state organizations and donors.

The partnerships with health care organizations and insurers mean additional money for the Los Angeles County programs, said Baca, who heads a countywide association of local Meals on Wheels organizations.

On a recent day in Santa Monica, volunteers showed up just after 10 a.m., loaded up their cars with meals and headed out to deliver them. One of the clients, 58-year old Patrick Ward, receives daily meals at his apartment in Venice.

Ward, who has osteoarthritis and knee problems, said he has fallen numerous times and also had a heart attack this year. He said he can take care of himself pretty well, but his lack of mobility makes cooking difficult.

“It takes one thing out of the day that I don’t have to worry about,” Ward said. “I know they are going to be here every day.”


New Guidelines For Lower Back Ache

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Couple of colorDr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, has some advice for most people with lower back pain: Take two aspirin and please don’t call me in the morning.

The American College of Physicians published updated guidelines that say much the same. In making the new recommendations for the treatment of most people with lower back pain, the group is resisting what many doctors do and changing its previous guidelines, which called for medication as first-line therapy.

Dr. Nitin Damle, president of the group’s board of regents and a practicing internist, said pills, even over-the-counter pain relievers and anti-inflammatories, should not be the first choice. “We need to look at therapies that are nonpharmacological first,” he said. “That is a change.”

The recommendations come as the United States is struggling with an epidemic of opioid addiction that often begins with a simple prescription for ailments like back pain. In recent years, a number of states have enacted measures aimed at curbing prescription painkillers. The problem has also led many doctors around the country to reassess prescribing practices.

The group did not address surgery. Its focus was on noninvasive treatment.

The new guidelines say that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief.

Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said.

In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Oregon, and an author of the new guidelines.

“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”

Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin.

Scans, like an M.R.I. (Magnetic Resonance Imaging), for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain.

Measures that help patients get back to their usual routines can help along the way, as Sommer Kleweno Walley, 43, of Seattle, can attest. Last spring, she slipped on the stairs in her house and fell down hard, on her back.

“After a couple of hours I could barely walk,” she said. “I was in real pain.”

She saw a physical therapist, but the pain persisted. Eleven days later, she showed up at the office of Dr. Christopher J. Standaert, a spine specialist at the University of Washington and Harborview Medical Center. She expected to receive an M.R.I., at least, and maybe a drug for pain.

But Dr. Standaert told her an M.R.I. would not make any difference in her diagnosis or recovery and that the main thing was to keep active. She ended up getting anti-inflammatory medication and doing physical therapy. A few months later, her back stopped hurting.

It is surprising, some experts in back pain say, how often patients are helped by treatments that are not medical, even by a placebo that patients are told at the start is really a placebo.

Dr. Standaert cited a study in which patients with chronic low back pain were offered a placebo, and were told it was a placebo, along with their usual treatment — often an anti-inflammatory drug like ibuprofen or naproxen. Or, the patients remained with their usual treatment alone.

Those taking the placebo reported less pain and disability than those in the control group who did not take the placebo. The placebo effect, although modest, was about the same as the effect in studies testing nonpharmacological treatments for back pain like acupuncture, massage or chiropractic manipulations.

Many people with chronic back pain tend to shut down, avoiding their usual activities, afraid of making things worse, Dr. Standaert said. Helping them is not a matter of prescribing drugs but rather teaching them to set goals and work toward returning to an active life, even if they still have pain.

“They have to believe their life can get better,” Dr. Standaert said. “They have to believe they can get to a better state.”

The question is: Will the new guidelines be adopted?

“Patients are looking for a cure,” said Dr. Steven J. Atlas, a back pain specialist at Massachusetts General Hospital, who wrote an editorial accompanying the article on the new recommendations. “The guidelines are for managing pain.”

Added to the problem are the incentives that push doctors and patients toward medications, scans and injections, Dr. Deyo said. “There is marketing from professional organizations and from industry,” he said. “‘We have the cure. You can expect to be cured. You can expect to be pain free.’”

Medical insurance also contributes to the treatment problem, back experts say, because it does not pay for remedies like mindfulness training or chiropractic manipulations which, Dr. Deyo added, “are not inexpensive.”

Even if doctors want to recommend such treatments, there is no easy referral system, Dr. Atlas said.

“It is much easier at Mass General to get a shot than to get a mind-body or cognitive behavioral therapy,” he added.

Dr. Weinstein has a prescription: “What we need to do is to stop medicalizing symptoms,” he said. Pills are not going to make people better and as for other treatments, he said, “yoga and tai chi, all those things are wonderful, but why not just go back to your normal activities?”

 “I know your back hurts, but go run, be active, instead of taking a pill.”

How Long-Term Care Insurance Has Changed

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couple-in-libraryMany U.S. insurance companies have had challenges, to say the least, with their long-term care insurance product lines in the past decade and still desire how they can find some way to help consumers. 

A Washington-based insurer trade group commissioned a major consumer study by Waltham, Massachusetts-based LifePlans Inc., to look for ways to continue offering Long-Term Care Insurance.

The survey team interviewed 1,326 U.S. consumers who bought LTC insurance policies in 2015; of this number, 225 consumers, who had recently reviewed a policy, decided not to buy coverage; and 800 were randomly picked U.S. residents ages 50 and older.

The team also analyzed a sample of 8,791 LTC insurance policies purchased from seven different insurers.

Researchers compared the results from the 2015 interviews and 2015 policy analyses with the results from similar surveys and LTC insurance policy analyses conducted every five years since 1990.

One thing LifePlans found is broad consumer support for a number of policy proposals that insurers could support in Congress.

Only about one-quarter of the LTC insurance buyers, non-LTC-insurance buyers, and age 50-and-older Americans interviewed said they think the government should pay for long-term care services for all people, according to the LifePlans survey report.

But 86 percent of the LTC insurance buyers, 83 percent of the non-buyers, and 73 percent of the age 50-and-older Americans agreed that LTC insurance premiums should be “fully tax deductible.”

In Washington, one hot topic has been the idea of the government offering a universal catastrophic long-term care benefits program, aimed at people who need two or more years of care. The United Kingdom recently set up a similar public coverage care program for its residents.

LifePlans found that 55 percent preferred the idea of an extended public coverage care system and that 27 percent preferred the idea of the government offering an immediage public coverage care system, which would cover the first few years of care.

LifePlans also came up with information about trends in what LTC insurance policies are really like, what the buyers are like, and what the buyers and active non-buyers are thinking:


Issuers of long-term care insurance policies incorrectly evaluated how many policyholders would keep their policies long enough to file claims, and how long the claims would last. They also miscalculated what low interest rates would do to their investment earnings.

The insurance companies have dealt with the forecasting errors by asking state insurance regulators to approve rate increases.

The LifePlans policy analyses show how the same forces have pushed up the cost of new policies.

In 1990, 59 percent of the LTC insurance policies sold cost less than $1,000 per year, and just 9 percent cost $2,000 or more per year.

In 2015, only 5 percent of the policies sold cost less than $1,000 per year, and 64 percent cost $2,000 or more per year.

The average annual premium increased from $1,071 to $2,727.

Home health care

LTC insurance prices have increased partly because, in some ways, the policy benefits have improved.

The average duration of policy benefits fell to 4 years in 2015, from 5.6 years in 1990.

But the average daily benefit increased to $161, from $72, over that period.

Insurers also added home health care benefits.

Home health care benefits were so rare in 1990 that LifePlans did not track them that year.

In 1995, only 49 percent of the policies analyzed that offered home health benefits could pay for more than two years of care in the home.

The home health care benefit’s richness peaked in 2000; that year, the home health care benefits sold had an average duration of 5.4 years.

But home health care benefits were still better in 2015 than in 1995. In 2015, 79 percent of the policies that offered home health benefits could pay for more than two years of care, and the average home health care benefits duration was four years.

Personal characteristics

The average age of a buyer fell to 60 in 2015, from 68 in 1990. Over that same period, the percentage of purchasers ages 75 and older fell to 1 percent, from 17 percent.

In part because of the age shift, the percentage of buyers who are widowed fell to 7 percent, from 23 percent.

The percentage with a college degree increased to 68 percent, from 33 percent.

Financial characteristics

Between 1990 and 2015, the changes in LTC insurance buyer personal characteristics went hand in hand with changes in financial resources.

The percentage with annual income under $25,000 fell to 4 percent, from 42 percent.

The percentage with less than $75,000 in total liquid assets fell to 13 percent, from 47 percent. 

Buyer motives

LifePlans discovered that the younger, better-educated, higher-income LTC insurance buyers of 2015 had different goals than the 1990 buyers.

In 1990, 30 percent of the buyers wanted to avoid dependence on other relatives, and only 24 percent wanted to protect their assets or leave an estate to heirs.

In 2015, just 13 percent were worried about dependence, and 36 percent were worried about estate protection. 

Non-buyer motives

In spite all of the headlines about long-term care insurance price increases and market withdrawals, high prices may only be about as much of a barrier to today’s LTC insurance sales as they were in 1990.

LifePlans found that 51 percent of non-buyers cited “too costly” as a very important reason for not buying coverage in 2015, but 53-58 percent of the non-buyers also gave “too costly” as a very important reason for not buying coverage from 1990 through 2010.

The popularity of other barriers to buying LTC insurance fell much more dramatically.

In 1990, for example, 36 percent of the non-buyers were very skeptical about whether insurers would pay LTC insurance claims. In 2015, only 13 percent of the non-buyers gave skepticism about payment of claims as a reason for not buying coverage.

LifePlans added a new reason in 2015 for resisting LTC insurance with the uncertainty about whether a policy will cover the types of services a consumer might need. More than half of the consumers say uncertainty about whether a policy will cover the right services is a very important reason not to buy coverage.



If you are thinking about purchasing LTC insurance but have uncertainties, there are better alternatives with a viable solution for reasonable cost and excellent coverage. 

New Nursing Home Rules: Residents Control Their Care

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elderly-with-caregiver-thumbs-upAbout 1.4 million residents of nursing homes across the country now can be more involved in their care under the most wide-ranging revision of federal government rules for such facilities in 25 years.

The changes reflect a shift toward more “person-centered care,” including requirements for speedy care plans, more flexibility and variety in meals and snacks, greater review of a person’s drug regimen, better security, improved grievance procedures and scrutiny of involuntary discharges.

“With proper implementation and enforcement, this could really transform a resident’s experience of a nursing home,” said Robyn Grant, director of public policy and advocacy for the Consumer Voice, a national group that advocates for residents’ rights.

The federal Medicare and Medicaid programs pay for most of the nation’s nursing home care — roughly $75 billion in 2014 — and in return, facilities must comply with government rules. The new regulations, proposed late last year by Health and Human Services Secretary Sylvia Mathews Burwell, take effect in three phases. The first began in November 2016.

They allow residents and their families “to be much more engaged in the design of their care plan and the design of their discharge plans,” said David Gifford, a senior vice president at the American Health Care Association, which represents nearly 12,000 long-term-care facilities.

Grant goes even further, saying the new approach puts “the consumer in the driver’s seat.” Until now, she noted, a person’s care has too often been decided only by the nursing home staff. “And if the resident is lucky, he or she is informed about what that care will entail, what will specifically be done and who will do it.”

HHS reviewed nearly 10,000 comments on its draft proposal before finalizing changes. One controversial measure in the department’s final rule would prohibit nursing homes from requiring residents to agree in advance to have any disputes settled through a privately run arbitration process instead of the court system. The industry association objected, claiming that Medicare officials have authority only to regulate matters related to residents’ health and safety and that an individual’s rights to use arbitration cannot be restricted. The ban is on hold until the association’s lawsuit, to force the government to drop the provision, is decided.

Here are highlights of the requirements now in effect:

Making the nursing home feel more like home: The regulations say that residents are entitled to “alternative meals and snacks … at non-traditional times or outside of scheduled meal times.” Residents can also choose their roommates, which may lead to siblings or same-gender couples being together. And a resident also has “a right to receive visitors of his or her choosing at the time of his or her choosing,” as long as it does not impose on another resident’s rights.

Bolstering grievance procedures: Nursing homes must now appoint an official who will handle complaints and follow a strengthened grievance process. Decisions must be in writing.

Challenging discharges: Residents can no longer be discharged while appealing the discharge. They cannot be discharged for non-payment if they have applied for Medicaid or other insurance, are waiting for a payment decision or appeal a claim denial.

If a nursing home refuses to accept a resident who wants to return from a hospital stay, the resident can appeal the decision. Also, residents who enter the hospital have a right to return to their same room, if it is available.

A state’s long-term-care ombudsman must now get copies of any involuntary discharges so the situation can be reviewed as soon as possible.

Expanding protection from abuse: The definition of abuse now includes financial exploitation. Nursing homes are prohibited from hiring any licensed professional who has received a disciplinary action because of abuse, neglect, mistreatment or financial exploitation of residents.

Ensuring a qualified staff: Consumer groups had urged federal officials to set minimum staffing levels for registered nurses and nursing staff, but the industry had opposed any mandates and none was included in the final rule. Instead, facilities must have enough skilled and competent staff to meet residents’ needs. There are also specific training requirements in caring for residents with dementia and for preventing elder abuse.

“Competency and staffing levels are not mutually exclusive,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. Person-centered care and other improvements “mean nothing if you do not have the staff who knows the residents … and can figure out why Mrs. Smith is screaming.”

Yet, requiring a certain number of nurses could backfire, said Gifford. “It could actually result in some places that are above those ratios by lowering their staffing levels, other places that would increase staffing when it is not necessary, and could be putting their resources into better care to meet the needs of the residents.”


Less Expensive Hearing Aids Over-The- Counter?

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man-talking-on-the-phoneImagine people walking around with stylish ear devices that amplify and clarify sound that connect wirelessly to smart phones, tablets, televisions and digital assistants such as Apple’s Siri or Amazon’s Alexa.

That day is coming, sooner than people may think.

Technology is already moving in this direction, and consumer marketers such as Samsung, Bose Corp., and Panasonic Corp. are reportedly readying new products of this kind.

They will be sold over the counter, to customers who will test their own hearing with cell phone apps or online programs and adjust sound parameters themselves.

The devices “will be widely used by senior people,” just as earbuds are used by younger people today, according to the Hearing Loss Association of America.

The Food and Drug Administration is moving forward. In December 2016 the agency made plans to take the necessary steps to propose a modification in their regulations to create a category of [over-the-counter] hearing aids.

In January 2017, the Federal Trade Commission announced  a major meeting on hearing health care to be held in April 2017. This agency played an important role in ensuring that consumers receive copies of eyeglass prescriptions. For the most part, that does not happen with hearing aids.

Whether agency priorities will change under the new Trump administration is not certain. But technology is developing rapidly under any circumstances.

Older adults with mild to moderate hearing loss, including aging baby boomers, are expected to be a prime market for a new generation of products joining hearing aid and consumer electronics audio technologies.

More than 40 percent of people over the age of 60 have some degree of hearing loss, mostly mild to moderate; that rises to 80 percent of people older than 80.

Yet only 20 percent of those with some degree of impairment use hearing aids because of their high cost (an average $4,700 per pair), the lack of insurance coverage (traditional Medicare does not pay for hearing aids), stigma, denial and difficulty navigating the hearing health system.

Hoping to expand access, the President’s Council of Advisors on Science and Technology came out in favor of low cost, over-the-counter hearing devices in October 2015. The National Academies of Sciences, Engineering, and Medicine seconded that recommendation in a major report on hearing health care published in June 2016.

Both organizations cite a growing body of research and linked hearing loss to cognitive decline, depression, the onset of dementia, falls, poor physical functioning and social isolation. The longer people delay seeking help, research suggests, the more at risk they become.

Several recent developments are of note as consumer electronics companies, hearing aid manufacturers, audiologists, physicians, consumer advocates and regulators prepare for a surge of new hearing devices and changes in the hearing health care system:

Removing Barriers

For 40 years, the FDA has required that adults be examined by a doctor before purchasing a hearing aid or sign a waiver noting that they did not want to take this step. In December 2016, the agency eliminated that requirement for people over the age of 18.

The National Academies of Sciences’ expert panel on hearing health had noted that the rule “provides no clinically meaningful benefit” and could discourage people from seeking care. Instead of seeing a physician, adults signed the waiver 60 to 95 percent of the time.

Still, limits on access to hearing aids exist: All states restrict distribution of these devices to certified audiologists, physicians and device specialists. And some states still require medical evaluations.

Proposed Legislation

Senators Charles Grassley, R-Iowa, and Elizabeth Warren, D-Mass., said in December 2016 that they would soon introduce new legislation endorsing over-the-counter hearing aids, sold without those restrictions.

Currently, six companies control nearly 98 percent of the hearing aid market in the United States, contributing to high prices. Nearly two-thirds of people with severe hearing loss — many of them elderly — report being unable to afford the devices. The cost is generally “bundled” with professional fees for evaluation, fitting and follow-up care.

The American Speech-Language-Hearing Association, an organization representing audiologists and speech-language pathologists, does not believe consumers can adequately self-diagnose hearing problems and opposes over-the-counter devices.

The American Academy of Audiology, which represents more than 12,000 audiologists, believes professionals should evaluate hearing loss but is taking a “wait and see stance” until the FDA proposes a regulatory framework.

Another audiologist group, the Academy of Doctors of Audiology, believes the benefits of expanded access to hearing devices outweigh the risks and supports over-the-counter products.

The senators plan to introduce their legislation, which asks the FDA to issue regulations ensuring the safety and effectiveness of these devices, in this new congressional session.

Creating Standards

One area of considerable confusion is the distinction between hearing aids and personal sound amplification products, known as PSAPs.

This is a wide category of products, ranging from cheap devices that help amplify sound to sophisticated devices that resemble hearing aids in all but their name. In some cases, companies are marketing the exact same device as a hearing aid and a PSAP, sold at different prices.

In 2009, the FDA drew a distinction between PSAPs and hearing aids based on their “intended use.” PSAPs were considered unregulated consumer electronics products for people with normal hearing who wanted to hear more sharply — for instance, during bird watching. Hearing aids were regulated and considered medical devices meant for people with hearing impairment.

But technological advances have brought the two categories closer. And it is well understood that people with hearing loss are using PSAPs as a cheaper alternative to hearing aids.

Going forward, the Academy of Doctors of Audiology, believes higher-end PSAPs will become over-the-counter hearing aids.

In the meantime, the Consumer Technology Association has prepared standards for PSAPs meant to make it easier for consumers to understand what they are buying. The standards, are under review at the American National Standards Institute and could be published as early as February 2017.

The intent is to provide a ‘Good Housekeeping Seal of Approval’ for PSAPs. Currently, there is no easy, standardized way to compare these devices.

When Medicare Does Not Alleviate Enrollment

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Cute couple smilingCindy Hunter received her Medicare card in the mail last Spring and she did not know much about Medicare. She and her husband, retired teachers who live in a Philadelphia suburb, decided she did not need Medicare because she shared her husband’s retiree health insurance plan. 

We were so thankful we had good insurance,” she said. So she sent back the card, telling officials she would keep Medicare Part A, which is free for most older or disabled Americans and covers hospitalization, some nursing home stays and home health care. But she turned down Part B, which covers doctor visits and other outpatient care and comes with a monthly premium charge. A new Medicare card arrived that said she only has Part A.

When Stan Withers left a job at a medical device company to become vice president of a small start-up near Sacramento, California, he took his health insurance with him. Under a federal law known as COBRA, he paid the full cost to continue his coverage from his previous employer. A few years earlier, when he turned 65, he signed up for Medicare’s Part A. With the addition of a COBRA plan, he thought he didn’t need Medicare Part B.

Hunter and Withers now know they were wrong and are stuck with medical bills their insurance will not cover. Hunter called it “an honest mistake” and said there was nothing in the written materials she and her husband received indicating that if they had Medicare Part A, his retiree coverage could not replace Medicare Part B. Withers had no idea he made a bad choice.

Thousands of seniors unwittingly make similar mistakes every year, believing that because they have some type of health insurance, they do not need to worry about signing up for Medicare Part B. Generally, insurance other than that provided by a current employer will not exempt them from Medicare’s strict enrollment requirements. Seniors’ advocates and some members of Congress want to fix the problem, backed by a broad, unlikely group of unions, health insurers, patient organizations, health care providers and even eight former Medicare administrators.

Medicare’s Part B enrollment rules have not changed since the program was created in 1965. Seniors can enroll only when they first become eligible — usually three months before and after the month they turn 65 — or when their job-based insurance ends. If they miss this opportunity, they have to wait until the months of January through March to enroll and then coverage only begins July 1. Most will not be allowed to buy any other health insurance policy during that time.

And if they delay signing up for 12 or more months after becoming eligible, many will be hit with a permanent penalty added to their Part B monthly premium. In 2014, about 750,000 beneficiaries paid late penalties, raising their Part B premiums an average of 29 percent, according to the Congressional Research Service.

“The rules have not changed, but our lives have,” said Joe Baker, president of the Medicare Rights Center, an advocacy group that is leading the effort to update the enrollment process. When Medicare began, the government wanted seniors, especially younger and healthier people, to sign up quickly and so the deadlines and late penalties were incentives to get them in the program.

But these days more seniors work past the Medicare eligibility age, get health insurance through their employer or their spouse’s, or have individual health insurance coverage, Baker said. The problem is not that people are going without insurance. “The confusion that we really see is with how Medicare interacts with other insurance coverage,” he said.

Hunter, 62, became eligible for Medicare earlier than 65 because she gets Social Security disability benefits. She’s receiving two chemotherapy drugs to control ovarian cancer. This fall her oncologist’s office told her there’s “something going on with your insurance,” she recalled. After many calls to her husband’s retiree plan, Social Security, Medicare and even her congressman, she learned that her insurance would only pay a share of the bills for her treatments after deducting the amount the insurer said was Medicare’s responsibility. “But Medicare isn’t paying because I don’t have Part B,” she said. So Hunter is responsible for that portion.

Withers thought the health plan he purchased through his old employer would count as job-based coverage, but COBRA is not a substitute for Medicare Part B, a point no one mentioned when he submitted his paperwork. He should have signed up for Part B when he left his previous job.

“How could there be a rule that no one knows about?” Withers asked.

In addition, the private plan has refused to pay thousands of dollars in medical bills because the company argued that he should have had Part B and those are Medicare’s responsibility.

Confusion over COBRA is just one of many reasons that people miss their opportunity to enroll in Part B. Others think, incorrectly, that getting Veterans Health Administration benefits, job-based health insurance from a company with less than 20 workers, retiree coverage from a former employer, or individual health insurance coverage exempts them from Part B’s lifetime late penalties and waiting periods with no insurance.

To help seniors avoid such mistakes, bipartisan legislation has been introduced in both the House and Senate that would allow people who miss their initial Part B enrollment deadline to sign up in the fall, when millions of seniors already in Medicare are choosing private drug or medical plan changes. Part B coverage would begin the month after they enroll. It would also allow most people who enroll late to apply for retroactive coverage to their initial eligibility date and request a waiver of the late penalties if they can prove they were misled (currently, an exemption may be based only on misinformation from a federal government representative, i.e. Social Security or CMS).

“Because I didn’t ask Social Security and they did not provide any wrong information, there was nothing they could do,” Hunter said. “They said if they had given me the wrong information, they might be able to do something.”

Seniors “should not face penalties or gaps in their Part B coverage simply due to bureaucratic snafu,” said Rep. Patrick Meehan, R-Pa., who co-sponsored the House bill. “I’ve had seniors contact my office and say they simply had no idea of existing deadlines — or that they faced penalties down the road for missing them.”

The legislation also would require Medicare officials to notify all Americans prior to their 65th birthday about signing up for Medicare. Currently, the federal government and some states notify only those 64-year-olds who have health insurance though the Affordable Care Act’s marketplaces.

Although the bill did not see action before the end of the 2016 congressional session, Meehan said he will reintroduce it in 2017.

Getting an official government notice before turning 65 explaining when to sign up for Part B would “absolutely” help, said Withers. “There should be something that tells people what they need to do.”

You’re Not Just ‘Growing Old’ If This Happens To You

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doctor-taking-blood-pressureWhen Dr. Christopher Callahan examines older patients, he often hears a similar refrain. “I’m tired, doctor. It’s hard to get up and about. I’ve been feeling kind of down, but I know I’m getting old and just have to live with it.”

This fatalistic stance relies on widely-held but mistaken assumptions about what constitutes “normal aging.”

In fact, fatigue, weakness and depression, among several other common concerns, aren’t to-be-expected consequences of growing older, said Callahan, director of the Center for Aging Research at Indiana University’s School of Medicine.

Instead, they’re a signal that something is wrong and a medical evaluation is in order.

“People have a perception, promulgated by our culture, that aging equals decline,” said Dr. Jeanne Wei, a geriatrician who directs the Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences.

“That’s just wrong,” Wei said. Many older adults remain in good health for a long time and “we’re lucky to live in an age when many remedies are available.”

Of course, peoples’ bodies do change as they get on in years. But this is a gradual process. If you suddenly find your thinking is cloudy and your memory unreliable, if you’re overcome by dizziness and your balance is out of whack, if you find yourself tossing and turning at night and running urgently to the bathroom, don’t chalk it up to normal aging.

Go see your physician. The earlier you identify and deal with these problems, the better. Here are four common concerns that should spark attention — only a partial list of issues that can arise:

Fatigue. You have no energy. You’re tired all the time.

Don’t underestimate the impact: Chronically weary older adults are at risk of losing their independence and becoming socially isolated.

Nearly one-third of adults age 51 and older experience fatigue, according to a 2010 study in the Journal of the American Geriatrics Society.  (Other estimates are lower.) There are plenty of potential culprits. Medications for blood pressure, sleep problems, pain and gastrointestinal reflux can induce fatigue, as can infections, conditions such as arthritis, an underactive thyroid, poor nutrition and alcohol use.

All can be addressed, doctors say. Perhaps most important is ensuring that older adults remain physically active and don’t become sedentary.

“If someone comes into my office walking at a snail’s pace and tells me ‘I’m old; I’m just slowing down,’ I say no, that isn’t right,” said Dr. Lee Ann Lindquist, a professor of geriatrics at Northwestern University’s Feinberg School of Medicine in Chicago.

“You need to start moving around more, get physical therapy or occupational therapy and push yourself to do just a little bit more every day.”

Appetite loss. You don’t feel like eating and you’ve been losing weight.

This puts you at risk of developing nutritional deficiencies and frailty and raises the prospect of an earlier-than-expected death. Between 15 and 30 percent of older adults are believed to have what’s known as the “anorexia of aging.”

Physical changes associated with aging — notably a reduced sense of vision, taste and smell, which make food attractive — can contribute. So can other conditions: decreased saliva production (a medication-induced problem that affects about one-third of older adults); constipation (affecting up to 40 percent of seniors); depression; social isolation (people don’t like to eat alone); dental problems; illnesses and infections; and medications (which can cause nausea or reduced taste and smell).

If you had a pretty good appetite before and that changed, pay attention, said Dr. Lucy Guerra, director of general internal medicine at the University of South Florida.

Treating dental problems and other conditions, adding spices to food, adjusting medications and sharing meals with others can all make a difference.

Depression. You’re sad, apathetic and irritable for weeks or months at a time.

Depression in later life has profound consequences, compounding the effects of chronic illnesses such as heart disease, leading to disability, affecting cognition and, in extreme cases, resulting in suicide.

A half century ago, it was believed “melancholia” was common in later life and that seniors naturally withdrew from the world as they understood their days were limited, Callahan explained. Now, it’s known this isn’t so. Researchers have shown that older adults tend to be happier than other age groups: only 15 percent have major depression or minor variants.

Late-life depression is typically associated with a serious illness such as diabetes, cancer, arthritis or stroke; deteriorating hearing or vision; and life changes such as retirement or the loss of a spouse. While grief is normal, sadness that doesn’t go away and that’s accompanied by apathy, withdrawal from social activities, disturbed sleep and self-neglect is not, Callahan said.

With treatments such as cognitive behavioral therapy and anti-depressants, 50 to 80 percent of seniors can expect to recover.

Weakness. You can’t rise easily from a chair, screw the top off a jar, or lift a can from the pantry shelf.

You may have sarcopenia — a notable loss of muscle mass and strength that affects about 10 percent of adults over the age of 60. If untreated, sarcopenia will affect your balance, mobility and stamina and raise the risk of falling, becoming frail and losing independence.

Age-related muscle atrophy, which begins when people reach their 40s and accelerates when they’re in their 70s, is part of the problem.  Muscle strength declines even more rapidly — slipping about 15 percent per decade, starting at around age 50.

The solution: exercise, including resistance and strength training exercises and good nutrition, including getting adequate amounts of protein. Other causes of weakness can include inflammation, hormonal changes, infections and problems with the nervous system.

Watch for sudden changes. “If you’re not as strong as you were yesterday, that’s not right,” Wei said. Also, watch for weakness only on one side, especially if it’s accompanied by speech or vision changes.

Taking steps to address weakness doesn’t mean you’ll have the same strength and endurance as when you were in your 20s or 30s. But it may mean doctors catch a serious or preventable problem early on and forestall further decline.

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