Dentistry Advocates Aim for Medicare Benefits

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Dentist Photo

Carolyn Thompson’s tight-lipped smile hides a health care problem the 81-year-old retired nurse cannot afford to correct and that Medicare will not cover.

She needs dentures. Her missing bottom teeth make chewing difficult, so she avoids most of the fresh fruits and foods that provide valuable nutrients. Thompson has not seen a dentist for many years.

“While working I always took care of my teeth, but in the last couple of years have found it difficult to pay for care,” said Thompson.

Thompson’s predicament is common. About 1 in 5 people 65 and older have untreated dental problems. But Medicare rarely covers dental care and fewer than half of elderly Americans see a dentist even once a year — often because they cannot afford to — according to a Johns Hopkins University study published in Health Affairs last year. Just 12 percent of Americans over 65 have dental insurance, that study reported.

Dental benefits were not recognized as a priority when Medicare was enacted in 1965. Back then, nearly half of Americans ages 65-74 had lost their natural teeth; today, 87 percent in that age group still have some or all of their teeth, according to the American Dental Association.

Research shows that untreated dental problems can exacerbate health problems such as diabetes and heart disease, leading to costlier bills for Medicare. That’s why a nonprofit think tank devoted to improving oral health is working toward an audacious goal: Medicare-paid dental care for America’s seniors.

The Santa Fe Group’s objective looks daunting in post-election Washington, where repealing the Affordable Care Act and cutting federal health spending are priorities for both the Trump administration and Congress’ Republican leadership.

Moreover, the costs of expansion would be significant. Such a benefit would likely be heavily used in an aging America whose 65-and-older population is projected to grow at least 30 percent by 2030. Also, while dentures were (and are) relatively inexpensive, newer techniques to preserve natural teeth, such as dental implants, are costly.

The Santa Fe Group’s members include academics, dental industry executives and former government officials. Among the sponsors are Colgate-Palmolive, DentaQuest and Henry Schein.

Santa Fe understands the uphill climb for coverage, but its sights are set on on its strategy to start building public demand for a Medicare dental benefit spearheaded by Dr. Claude Earl Fox, a former senior health official in the Clinton administration.

“We have a long road to go, but we think it’s doable and there will be a growing audience for this,” said Fox, who worked as a professor at both Johns Hopkins and University of Miami medical schools after his career in federal government.

The Johns Hopkins study estimated a dental benefit could cost from $4.4 billion to $16.2 billion a year, depending on what is covered, how much seniors pay out-of-pocket and the level of premium subsidies provided to low-income beneficiaries.

“Most of the talk in Medicare reform is how do we reduce cost rather than expand costs, and adding a dental benefit can make people [on Capitol Hill] very nervous,” said Amber Willink, the study’s lead author and assistant scientist at the Johns Hopkins Bloomberg School of Public Health.

Prescription drugs were the last major benefit Congress added to Medicare. That was in 2006 after more than a decade of pleading from advocates.

Without Medicare to help, seniors have few options to get comprehensive coverage. Private coverage is typically too expensive for many seniors.

Medicare Advantage, private plans that cover about one-third of seniors, sometimes offer a limited dental benefit for additional costs but typically only for a small network of dentists.

“It is important to show a benefit can be structured to save money for Medicare,” Fox said.

Supporting evidence from large studies is limited, however. It is uncertain whether the Congressional Budget Office — the official scorekeeper on federal legislation — would agree with the dental industry’s savings estimates from a Medicare benefit.

Politics aside, some advocates point to firsthand experiences to show that older adults’ health improves with regular dental care.

A retirement community in Alabama, which includes a nursing home and an assisted-living facility, added a dental clinic in 2012. Pneumonia rates dropped soon after, said Lillian Mitchell, a dentist who oversees the office and is the director of geriatric dentistry at the University of Alabama, Birmingham. Mitchell and other faculty oversee dental students who treat patients at the clinic.

“Taking care of oral health affects their overall health by reducing inflammation that has been linked to heart disease, diabetes and other chronic conditions common to the elderly,” Mitchell said.

The clinic’s services cost about half the price of private dentists.

Patients say easy access to the clinic in the building where they live makes a big difference. “This is such a comfort knowing we can go to the dentist without having to leave the facility,” said Peggy Batcheler, 87, a former nursing professor. “We feel so fortunate.”

The Santa Fe Group hopes to draw the American Dental Association, AARP and other seniors’ groups into its campaign for a Medicare dental benefit.

“It is not our No. 1 issue, but it is on top of our conversation list,” said Joseph Crowley, a Cincinnati dentist and president-elect of the American Dental Association. He is very optimistic.

 

Alzheimer’s Patients and Pretend Play

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dollsVivian, 88, holds a baby doll at Sunrise Senior Living in Beverly Hills, California. Some memory care and nursing homes are using a technique called doll therapy to ease anxiety among their residents with dementia.

Sitting beside a neatly made crib, 88-year-old Vivian held up a baby doll dressed in puppy dog pajamas. “Hello gorgeous,” she said, laughing. “You’re so cute.”

Vivian, who has Alzheimer’s disease, lives on a secure memory floor of a home for seniors. Nearly every day, she visits the dolls in the home’s pretend nursery. Sometimes she changes their clothes or lays them down for a nap. One morning, she sang to them: You are my sunshine, my only sunshine. You make me happy when skies are gray.

No one knows whether she believes she is holding a doll or a real baby. What the staff at Sunrise Senior Living do know is that Vivian — who can get agitated and aggressive — is always calm when caring for the dolls.

Nursing homes and other senior facilities nationwide are using a controversial technique called doll therapy to ease anxiety among their residents with dementia. Senior care providers and experts say the dolls are an alternative to medication and help draw in elderly people who are no longer able to participate in many activities.

“Many people with Alzheimer’s are bored and may become depressed or agitated or unhappy because they aren’t engaged,” said Ruth Drew, director of family and information services at the Alzheimer’s Association.

Caregivers are not trying to make their residents believe the dolls are real infants, and they do not want to infantilize the seniors, Drew said. They are just “trying to meet them where they are and communicate with them in a way that makes sense to them.”

Other senior facilities that use the dolls include On Lok Lifeways in San Francisco and the Los Angeles Jewish Home in the LA suburb of Reseda. Some, including Texas-based Belmont Village Senior Living, eschew them, arguing that it can be demeaning for seniors to play with dolls.

“They are adults and we want to treat them like adults,” said Stephanie Zeverino, who works in community relations at Belmont Village Senior Living Westwood. “These are very well-educated residents.”

The facility prefers other types of therapy, including art and music, she said. And staff members there work with residents to play brain games that promote critical thinking.

“We want to provide a sense of dignity,” Zeverino said.

Studies on doll therapy are limited, but some research has shown it can reduce the need for medications, diminish anxiety and improve communication, according to Gary Mitchell, a nurse specialist at Four Seasons Health Care in the United Kingdom who has authored a new book about doll therapy.

However, Mitchell acknowledged it is possible that doll therapy, because it can infantilize adults, “perpetuates a lot of stigma with dementia care that we are trying to get away from.”

Some families worry about their relatives being laughed at when they engage in doll therapy, Mitchell noted. He said he understands those concerns, and even shared them when he worked at a senior residential center. But when one resident requested that he allow her to continue caring for a doll, he soon saw the positive impact of the therapy.

Mitchell said it can be very beneficial for some people — especially those who may get easily distressed or pace obsessively. “Having the doll … offers them an anchor or a sense of attachment in a time of uncertainty,” he said. “A lot of people associate the doll with their younger days and having to care for people.”

At Sunrise Beverly Hills, the nursery is set up like a baby’s room. A stuffed bear rests inside the wooden crib. On a shelf above are framed photos of Vivian and a few other women who regularly interact with the dolls. A few bottles, a swaddling blanket, a Dr. Seuss book and diapers sit on a nearby changing table.

The nursery is just one of several areas in the Sunrise centers designed to engage residents, said Rita Altman, senior vice president of memory care for Sunrise, which has facilities in the United States, Canada and the United Kingdom. There are also art centers, offices, gardens and kitchens where residents may find familiar objects from their past.

Altman said the nurseries tend to attract residents who have an instinct to care for babies. Some people, she said, may not be able to talk anymore but still find a sense of security with the dolls. “You can read it in their body language when they pick up the doll,” she said.

Sunrise caregivers also use the dolls to spark conversations by asking questions: How many children do you have? Was your first baby a boy or a girl? What are the best things about being a mom?

The executive director of the Beverly Hills facility, Jason Malone, said he was skeptical about the use of dolls when he first heard about them.

“I almost felt like we were being deceitful,” he said. “It didn’t feel like it was real.”

But he quickly changed his mind when he realized that staff could use the dolls respectfully.

“We don’t want to confuse treating our seniors as children,” Malone said. “That’s not what this activity is truly about.”

Vivian began caring for the dolls soon after moving into the facility. When asked what she likes about the dolls, she said, “I love babies. I have some very nice ones back where I live now.”

Vivian’s daughter, Carol, said her mother raised three children and volunteered extensively in Colorado and Mexico before being diagnosed with Alzheimer’s about five years ago. Carol said she doesn’t see any downside to her mother caring for the dolls. It is a “creative way of dealing with her where she is now,” she said.

“I always describe my mother as being … very similar [to] many of my young grandchildren in her cognitive skills,” Carol added.

For some residents, including 87-year-old Marilou, holding the dolls is one of the only times she interacts with the staff. Marilou is confined to a wheelchair and rarely speaks. She sleeps much of the day.

There is not much [Marilou] can participate in,” said Vladimir Kaplun, former coordinator of the secure memory floor. “When she spends some time with the dolls, she wakes up and she brightens up.”

On a recent day, caregiver Jessica Butler sat next to Marilou, who held a doll against her chest and patted her on the back. She kissed the doll twice.

“The baby is beautiful like you,” Butler said.

“It’s a boy,” Marilou said. “Five months.”

“Is the baby five months?” Butler asked. “You’re doing a good job holding the baby.”

Caring for the dolls is second nature to Marilou, who made a career of being a mom to five children and was involved with the PTA, Girl Scouts and other activities, according to her daughter, Ellen.

Ellen said it’s been difficult to watch the decline of her mother, who hasn’t called her by name in over a year. Watching her with the dolls helps, she said.

“To see the light in her eyes when she has a baby doll in her arms, I don’t care if it’s real or if it’s pretending,” she said. “If that gives her comfort, I am A-OK with it.”

New Medicare Law for a Patient Loophole

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Long-Term CareLast November, after a bad fall, 85-year old Elizabeth Cannon was taken to a hospital near Philadelphia for seven days of observation, followed by nearly five months in a nursing home for rehabilitation and skilled nursing care. The cost: more than $40,000.  

The hospital insisted that Elizabeth had never been formally admitted there as an inpatient, so under federal rules, Medicare would not pay for her nursing home stay. The money would have to come from her pocket.

The experience of Elizabeth and thousands like her inspired a new Medicare law — in force as of Saturday, August 6, 2016 — that requires hospitals to notify patients they may incur huge out-of-pocket costs if they stay more than 24 hours in the hospital without being formally admitted. Because of the Notice Act, passed by Congress last year [2015] with broad bipartisan support, patients can expect to start receiving the notice in January [2017].

“It was extremely distressful to my mother, who was frugal her whole life,” said Cynthia Morgan, Elizabeth’s daughter. Elizabeth had questioned why Medicare would not pay for her care after she paid into Medicare for so many years. Elizabeth died in April 2016.

Hospitals have been keeping patients like Elizabeth in limbo due to fear of being penalized by Medicare for inappropriate admissions. While under observation, patients can be liable for substantial hospital bills, and Medicare will not pay for subsequent nursing home care unless a person has spent three consecutive days in the hospital as an inpatient.

Time spent under observation does not count toward the three days, even though the patient may spend five or six nights in a hospital bed and receive extensive hospital services, including tests, treatment and medications ordered by a doctor.

Under the new law, the notice must be provided to “each individual who receives observation services as an outpatient” at a hospital for more than 24 hours. Medicare officials estimate that hospitals will have to issue 1.4 million notices a year.

“The financial consequences of observation stays can be devastating for seniors,” said Senator Susan Collins, Republican of Maine and the chairwoman of the Senate Special Committee on Aging.

Senator Benjamin Cardin, Democrat of Maryland, the chief sponsor of the Senate version of the legislation, said it would “save seniors from the sticker shock that comes after they are discharged from the hospital and realize that Medicare will not cover the cost of care in a skilled nursing facility.”

The median cost for a private room in a nursing home is roughly $92,000 a year, according to a survey by Genworth Financial. Medicare covers up to 100 days of skilled nursing home care at a time.

The text of the standard “Medicare outpatient observation notice” is subject to approval by the White House Office of Management and Budget. In its current form, the notice to beneficiaries says: “You are a hospital outpatient receiving observation services. You are not an inpatient.” And it explains that Medicare will cover care in a skilled nursing home only if the beneficiary has had an inpatient hospital stay of at least three days.

Patients can then consult their doctors and may ask to be reclassified as inpatients.

Hospitals have found themselves in a dilemma. They increased their use of “observation status” in response to close scrutiny of their billing practices by Medicare auditors — private companies hired by the government to review claims. In many cases, these companies challenged decisions by doctors to admit patients to a hospital, saying the services should have been provided on an outpatient basis. The auditors then tried to recover what they described as improper payments.

Doctors and hospitals said the auditors were like bounty hunters because they were allowed to keep a percentage of the funds they recovered.

But patients will now, at least, be better informed. The Senate Finance Committee explained the reason for the law this way:

“The number of Medicare beneficiaries receiving outpatient observation care over the last several years has been steadily increasing. Some beneficiaries are surprised to learn that although having received treatment overnight in a hospital bed, the beneficiary was never formally admitted as an inpatient but was instead a hospital outpatient.”

Federal officials acknowledged that Medicare beneficiaries sometimes had to pay more as outpatients under observation than they would have paid if they had been formally admitted to the hospital and received the same services as inpatients.

The administration issued rules to carry out the new law. The purpose, it said, is “to inform beneficiaries of costs they might not otherwise be aware.”

“Even if staying in a hospital overnight, the status might still be considered outpatient,” the administration said in a publication for beneficiaries.

Consumer advocates and nursing homes support the new requirement.

“Medicare beneficiaries are spending more and more time in the hospital without being formally admitted,” said Joyce Rogers, a senior vice president of AARP, the lobby for older Americans, adding that this “can expose beneficiaries to unexpectedly high out-of-pocket costs amounting to thousands of dollars.”

Mark Parkinson, the president and chief executive of the American Health Care Association, a trade group for nursing homes, said, “Patients often have no idea what their status is in a hospital and observation stays impose a significant financial burden on seniors increasing the likelihood of turning to Medicaid.”  

“The new law is an important first step, but Congress and the administration need to do more to protect beneficiaries,” said Judith Stein, the executive director of the nonprofit Center for Medicare Advocacy.

Under the law, hospitals can still keep Medicare patients in observation status, and some of the patients will be responsible for nursing home costs. Twenty-four senators and more than 120 House members are supporting bipartisan legislation to address that concern. Under that bill, time in a hospital under observation would count toward the three-day inpatient stay required for Medicare coverage of nursing home care.

Medicare Slow to Adopt Telemedicine

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Lady worried at laptop.jpgDonna Miles did not feel like getting dressed and driving to her physician’s office or to a hospital health clinic near her Cincinnati home. For several days she had a sore tongue that was discolored with raised white spots thinking that maybe it could be thrush, a painful mouth infection. 

So when Miles, 68, awoke on a wintry February morning and the pain had not subsided, she decided to see a doctor by simply turning on her computer and logging into www.livehealthonline.com, a service offered by her Medicare Advantage plan. She spoke to a physician, who used her computer’s camera to peer into her mouth and who then sent a prescription to her pharmacy. “This was so easy,” Miles said.

For Medicare patients, it’s also incredibly rare.

Nearly 20 years after such videoconferencing technology has been available for health services, it is used by fewer than 1 percent of Medicare beneficiaries. There are only two Medicare Advantage insurers offering the virtual visits, and the traditional Medicare program has tightly limited telemedicine payments to certain rural areas. And even there, the beneficiary must be present at a clinic, a rule that often defeats the goal of making care more convenient.

Congress has maintained such restrictions out of concern that the service might increase Medicare expenses. The Congressional Budget Office and other analysts have said giving seniors access to doctors online will encourage them to use more services, replacing what Congress says [in their opinion] would be more costly than visits to emergency rooms and urgent care centers.

In 2012, the latest year for which data is available, Medicare paid about $5 million for telemedicine services — barely a blip compared with the program’s total spending of $466 billion, according to a study in the journal Telemedicine.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel,”  a Rand Corporation analyst told a House Energy and Commerce subcommittee in 2014. “Telehealth may be ‘too convenient.’ ”

But the telemedicine industry says letting more beneficiaries get care online would reduce doctor visits and emergency care. Industry officials as well as the American Medical Association, the American Hospital Association and other health experts say it’s time for Congress to expand use of telemedicine in Medicare.

Popular Outside Medicare

“There is no question that telemedicine is going to be an increasingly important portal for doctors and other providers to stay connected with patients,” former Surgeon General Richard Carmona said in an interview.

Some health experts say it’s disappointing that most seniors can’t take advantage of the benefit used by many of their children who have coverage in pre-65 individual plans.

“Medicare beneficiaries are paying a huge price” for not having this benefit, said Jay Wolfson, a professor of public health at the University of South Florida in Tampa. For example, he said, telemedicine could help seniors with follow-up appointments that might be missed because of transportation problems.

Aetna and UnitedHealthcare cover telemedicine services for members younger than 65, regardless of whether enrollees live in the city or in the country. About 37 percent of large employers said that they expect to offer their employees a telemedicine benefit this year, according to a survey last year by Towers Watson, an employee benefits firm. About 800,000 online medical consultations were completed in 2015, according to the American Telemedicine Association.

Medicare’s tight lid on telemedicine is showing signs of changing. In addition to Medicare Advantage plans, several Medicare accountable care organizations, or ACOs — groups of doctors and hospitals that coordinate patient care for at least 5,000 enrollees — have begun using the service. Medicare Advantage plans have the option to offer telemedicine without the tight restrictions in the traditional Medicare program because they are paid a fixed amount by the federal government to care for seniors. As a result, Medicare is not directly paying for the telemedicine services; instead, the services are paid for through plan revenue.

Republicans and Democrats in Congress are also considering broadening the use of telemedicine; some of them tried unsuccessfully to add such provisions to a recent law.

This year, Medicare expanded telemedicine coverage for mental health services and annual wellness visits — when done in certain rural areas and when the patient is present at a doctor’s office or health clinic.

“Medicare . . . is still laboring under a number of limitations that disincentivize telemedicine use,” said Jonathan Neufeld, clinical director of the Upper Midwest Telehealth Resource Center, an Indiana-based consortium of organizations involved in telemedicine. “But ACOs and other alternative payment methods have the possibility of changing this dynamic.”

AARP wants Congress to allow all Medicare beneficiaries to have coverage for telemedicine services, said Andrew Scholnick, a senior legislative representative for the lobbying group. “We would like to see a broader use of this service,” he said. He stressed that AARP prefers that Medicare patients use telemedicine in conjunction with seeing their regular doctor.

The American Medical Association has endorsed congressional efforts to change Medicare’s policy on telemedicine, as has the American Academy of Family Physicians. “We see the potential for it . . . to improve quality and lower costs,” said Robert Wergin, president of the academy and a family doctor in Milford, Nebraska. He said such technology can help patients who are disabled or don’t have easy transportation to the doctor’s office.

Anthem, which provides its telemedicine option to about 350,000 Medicare Advantage members in 12 states, expects the system to improve care and make it more affordable. “It’s also about the consumer experience and giving consumers the convenience of being face to face with a doctor in less than 10 minutes, 365 days a year,” said John Jesser, an Anthem vice president. 

While seniors are more likely to have more complicated health issues, telemedicine for them is no riskier than for younger patients, said Mia Finkelston, a family physician in Leonardtown, Maryland, who works with American Well, a firm that provides the technology behind LivehealthOnline.com. That’s because the online doctors know when they can handle health issues and when to advise people to seek an in-person visit or head to the emergency room, she said.

“Our intent is not to replace their primary care physician, but to augment their care,” she said.

Alternatives To Lapsing A Life Insurance Policy

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Nest Eggs       More than 100 years ago, in its landmark, Grigsby v. Russell decision, the U.S. Supreme Court ruled that life insurance is personal property. It can be bought and sold like any other property owned.

This means your life insurance policy has value to you or your family right now, not just when you pass away. Unfortunately, the vast majority of people are unaware of this simple fact.

The problem arises when the policy owner concludes they just can’t afford those premiums anymore, perhaps because they’re now in their retirement years and living on a fixed income. Or maybe they decide they just don’t need the death benefit anymore now that their children are grown, have steady jobs and built families of their own.

So, in the absence of knowledge about any other alternatives, most policy owners in this situation just lapse or surrender the policy back to the insurance company, accepting whatever small amount of cash surrender value is available.

Research available to the Life Insurance Settlement Association indicates that more than 710,000 policies are lapsed or surrendered each year — with a combined face value of more than $57 billion — by American seniors over the age of 70.

It’s important to contact your trusted insurance advisor [since it is their fiduciary responsibility] who can inform you of your options and instill awareness of alternatives to lapsing or surrendering a policy. 

But aside from the fiduciary issue, there is a common-sense test: if a person could lapse a policy for its nominal cash surrender value of $20,000 or able to sell that same policy to an investor for $150,000, they should be entitled to this information.

So, if a person has decided they no longer need or can afford a life insurance policy, what are the alternatives to lapsing the policy and surrendering it back to the insurance company?

Here are the primary options that you should know:

  • Maintain the policy through loans, using the policy or its cash surrender value as collateral;
  • Seek an accelerated death benefit, if possible;
  • Convert the policy to a long-term care health insurance policy, if possible;
  • Assign the policy to someone else as a gift or to a non-profit organization as a charitable contribution;
  • If it is a “term” policy, attempt to convert it to permanent insurance;
  • Reduce the death benefit (a lower “face value”) and the premiums; and
  • Sell the policy to a third-party investor through a life settlement.

As with any financial planning decision, there is no “one size fits all” answer to which of these options is best. The one that makes the most sense for you will depend on the your unique needs and desires as the policy owner — and that is where your trusted advisor, can play an invaluable role to guide you to the wisest decision.

90 percent of seniors who lapse policies without knowing about a life settlement indicated they would have considered that option had they known about it; and that 79 percent feel their advisors should inform them about a life settlement option.

Consider this story: A car dealership owner originally purchased a $488,000 life insurance policy to fund a buy/sell agreement with his business partner. After the business dissolved, his family continued to pay the premiums, but eventually decided the coverage was no longer needed.

He was planning to surrender the policy back to the insurance company for $6,800, then learned he had another option: to sell his policy to a life settlement company for $80,000. That’s more than 10 times what he would have received from the insurance company. The proceeds were divided among his three children, which they used to supplement their income.

If your main motive is to obtain cash in your hands — for retirement needs, health care expenses or simply to invest into other assets — then a life settlement is likely the best alternative. As a life insurance policy owner, when you enter into a life settlement, you can realize an average of seven times the amount of the policy’s cash surrender value, based on an analysis of a 2010 survey by the U.S. Government Accountability Office.

Perhaps that’s why 90 percent of seniors who have lapsed a policy would have considered selling it if they had known a life settlement was an option, according to a survey prepared for the Insurance Studies Institute.

Regardless of what you choose to do, just make sure that you are informed of all options before you lapse that life insurance policy.

 

College Freshman Learns About Growing Old

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April Pearce

April Pearce is in the middle of her freshman year at UCLA, settling into life away from home for the first time. But instead of thinking about dorm food or exams, the 19-year-old is focused on something a little more abstract: old age. 

That’s because of a unique course April is taking called Frontiers in Human Aging, designed to teach first-year college students what it means to get old — physically, emotionally and financially.

April said that before, she barely noticed elderly people when she passed them on the street. Since being in the aging class, seeing them fills her mind with questions: Do they live alone? Will they develop dementia? Do they interact with anyone apart from relatives?

“It’s weird, I know,” she said. “But before, I didn’t have any knowledge really about aging. I didn’t even interact with any older people except for my grandmother. Now I’m learning so much.”

In addition to teaching students about aging, the professors have another goal in mind: inspiring them to pursue careers working with the elderly.

With more than 10,000 baby boomers turning 65 every day, there is a growing need, said Rita Effros, a professor at UCLA’s David Geffen School of Medicine who teaches both undergraduates and medical students.

People over 65 represented about 14 percent of the U.S. population in 2013, and that figure is expected to increase to nearly 22 percent by 2040. During that same time period, the number of people over 85 is expected to triple.

And jobs working with the elderly won’t just be in medicine but also in social work, psychiatry, technology and law, Effros said.

We try to make it clear that aging is going to be big business,” she said. “Whatever their interests are, they should think about serving the elderly.” The strategy seems to be working on many of the students, including April. She started UCLA in the fall of 2015 wanting to be a veterinarian and now is thinking about becoming a geriatrician.

The class, which has about 120 students, is taught jointly by Effros, an immunologist, Paul Hsu, an epidemiologist, and Lené Levy-Storms, a social welfare professor. UCLA started offering the course in 2001, but the professors said it is becoming increasingly important.

Throughout the year, students hear lectures about anxiety, genetics and dementia. They discuss ageism and read about Social Security. They stage debates on assisted suicide and watch films about growing old.

The course lasts from September to June, and students can go on to take other classes about aging, including ones that focus on diversity or public policy.

Effros said she wants the students to understand people don’t suddenly become old. Rather, the aging process starts when they are conceived. “A lot of life habits and choices they make as college students can affect them decades later,” she said.

During one guest lecture, UCLA medical school professor David Reuben explained how geriatricians evaluate patients and told students about some of the most common problems older people face — dementia, falls, sensory impairment.

He also described how the students’ own lives will change as they age. Instead of traveling the world, older people eventually become unable to travel out of their own bedrooms.

One student raised his hand and said being a geriatrician sounded gratifying, but also seemed heartbreaking. “You watch so many people decline … how do you handle that?”

Reuben responded that he does get sad and he does cry. “Nobody lives forever and nobody should live forever,” he said. “Death is part of the human experience.”

Michael Margolis, 17, said being in the class has made him think for the first time about his own mortality. “It’s not something we typically think about as teenagers,” he said.

One requirement of the class is that students spend a total of 20 hours volunteering with seniors.

Just after the New Year [2016], the students gathered in a large room on campus to meet representatives from several agencies that serve the elderly. Andres Gonzalez, a director at St. Barnabas Senior Center in Hollywood, told the students they could teach technology classes to active seniors or help deliver meals to homebound ones.

“Even that short interaction becomes very meaningful to the seniors,” Gonzalez said. “You might be the only person they see that day. And they get even more excited seeing younger people.”

April Pearce was assigned to Wise & Healthy Aging, which runs an adult day service center for seniors with dementia. Catherine Jonas, who previously directed the center, said the students bring a lot of energy to the center, and they often lead bingo games and exercises. They also have lengthy conversations with the seniors.

“What the older adults need is that dialogue,” Jonas said. And for students interested in learning about dementia, interacting with people affected by it “is so much better than what they get from a book,” she added.

One morning in early February [2016], the center was decorated for Valentine’s Day, with red and white streamers and cut-out hearts hanging from the ceiling.

One of the student volunteers, Julia Gierasimow, led the group as they rolled their shoulders, stretched their legs and tried to touch their toes. Julia, who is also considering a career in geriatrics, said all the seniors she’s met so far have interesting life stories.

“I don’t know if they remember me from week to week … but they are very friendly,” she said. “As bad as their dementia may be, they still give you a hug.”

After the physical exercises, April sat in a chair in the middle of the room, picked up a microphone and commenced with the mind exercises she’s led each visit. Today’s activity: a quiz game about football.

“Which team won the first Super Bowl ever?” she asked, smiling.

Several of the seniors shrugged. One man, 76-year-old Tracy Williams, yelled out the right answer: “Green Bay Packers!”

Williams, retired from the Air Force, said he enjoys when the college students come to visit — even though he never would have done the same at their age. “When I was young, I didn’t want to even be near an old person,” he recalled.

April said that in just a few weeks of volunteering, she is becoming more patient and is learning how to talk to people with dementia. “If they say it’s Tuesday, you’re supposed to go with it,” April said. The class has given her a new perspective on her own life, too. She is trying to eat less fast food and exercise more. And she tries not to worry so much about things like not doing well on an exam. “I’m going to have health problems later if I let the stress get to me,” she said.

April is also seeing her grandmother in a new light, especially after doing an in-depth interview with her for a class assignment.

She said she learned that her grandmother had undergone hip replacement surgery, a kidney transplant, and treatment for cancer. She also discovered her grandmother had loved to dance when she was younger, and was popular with the boys.

“I had never really thought about my grandmother as a young woman,” April said. “This class is making me appreciate her more.” .

 

A Surprise for Paramedic Responses

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Katie

After Katie Gurzi woke in the middle of the night with excruciating chest pains, paramedics rushed her to the hospital. That part went smoothly. Katie, 85, was pleased with the care she received and doctors determined she was not having a heart attack, just a spasm in her esophagus. 

 

But then, in January 2015, the city of La Habra, California sent her a $260 bill for “paramedic response” — after her insurers had already been billed for the November ambulance ride. That made Katie wonder.

It wasn’t just that she believed the city was trying to reach into her purse for money it couldn’t get from health insurers, it was that she was rebuffed nearly every step of the way as she contacted more than a dozen people from city bill collectors to her congressman. Some didn’t return her calls. Others refused to help. A few were just plain rude.

One city employee threatened to send her to collections, warning she wouldn’t ever be able to get a loan.

“I told her, ‘Honey, I’m 85. Do what you need to do… You can blacklist me all you want. I’ll be dead,” Katie said.

When she finally reached the La Habra mayor, Jim Gomez, he was nice enough but told her he didn’t have the authority to dismiss the fee.

“I thought, ‘you’re kind of a toothless mayor,’” she said.

Cases like Katie’s may become commonplace as more cities adopt 911 response fees, said Aileen Harper, executive director of Center for Health Care Rights, a government-funded nonprofit that helps Medicare beneficiaries.

Harper’s organization is helping Katie and three others with similar bills but she believes many more people have simply paid the bill or haven’t come forward.

The city of La Habra says the $260 fees are to help recoup expenses that aren’t sufficiently covered by insurers.

“It is a fee the city charges to offset some of the costs associated with emergency transports,” said Cindy Knapp, bureau manager for the city’s police department. “It is to offset general costs, not for a specific transport.”

Knapp said the money goes into the general fund but that she couldn’t answer exactly how it is spent.

Harper said the cities shouldn’t be billing people like Katie because the cities are already being paid by Medicare or other insurers.

It seems to me their underlying rationale is they don’t seem to be getting paid enough,” she said. “If that is the case, they need to take that up with Medicare and not move those costs to the beneficiaries.”

As in several cities around California, La Habra residents can avoid the fee by subscribing to a voluntary paramedic program, which charges an annual fee to cover emergency response. In La Habra, the fee for its FireMed program, as it is known, is $48 per year, up from $36 in 2009.

If they subscribe, Knapp said, they are protected from any out-of-pocket expenses related to the 911 transportation. The city bills the insurance company but accepts whatever is paid without charging the consumer for any unpaid balance, she said.

If they don’t subscribe, or they aren’t La Habra residents, Knapp said they have to pay $260 each time they are transported by an ambulance, in addition to what insurers cover.

Katie said she lives by some simple rules. Be honest. Treat people with respect. And when something isn’t right, speak up. True to her principles, she started a year-long campaign against the fee, keeping track of every conversation with a handwritten note. She became so frustrated at one point that she accused the city’s billing department of “senior harassment.”

When she contacted her congressman, Rep. Alan Lowenthal (D-Calif.), he responded that the matter was out of his jurisdiction but that he would forward the material to the city manager.

She also reached out to the Centers for Medicare & Medicaid Services, which oversees Medicare, and the Council on Aging in Orange County before she achieved some success with the Center for Health Care Rights. 

A 72-year-old man in Anaheim, California who had a stroke was billed $350 by the city for the 911 response, even though Medicare covered the ambulance ride, according to the center.

In response to an e-mail from the health care rights center, Medicare officials wrote back late last year saying the issue was forwarded to “program integrity” investigators.

Finally, Katie did receive some good news. La Habra officials told her that based on her low income, she could apply for a hardship exemption to get the fee waived. But that, Katie said, wouldn’t be honest. After all, she has enough money to pay the bill.

“This isn’t a hardship,” she said. “It’s inappropriate billing.”

So Katie is continuing to fight her bill, which the collections agency told her is now $271.47. She remains miffed that the city of La Habra lacked both “grace and compassion.”

“I think seniors deserve a little better,” she said.

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