Dying at Home

Most people (70%) want to die at home, in a familiar place surrounded by loved ones. However, only about 25% do. Nearly 50% of Americans die in a hospital, and another 20% die in a nursing home or long-term care facility.

The trend is for more people to die at home, with a 29.5 percent increase from 2000 to 2014, according to the Centers for Disease Control and Prevention. During the same time period, the percentage of deaths in hospitals, nursing homes and long-term care facilities has dropped.

Seven out of ten Americans die from chronic disease, and more than 90 million Americans are living with at least one chronic disease. The Centers for Disease Control (2007) listed the ten leading causes of death in America (in order):
1.
heart disease
2.
cancer
3.
stroke
4.
chronic lower respiratory disease
5.
accidents
6.
Alzheimer’s
7. diabetes
8.
influenza
9.
pneumonia
10.
kidney disease and sepsis.

Almost a third of Americans see ten or more physicians in the last six months of their life. And almost 30% of Medicare’s budget each year is spent on patients who are in the last 12 months of their lives.

According to LongTermCare.gov about 70% of Americans over age 65 will require long-term care. If a person has an extended illness requiring long-term care, long-term care insurance will help cover those expenses whether in a hospital or at home. Studies show that those with long-term care insurance stay at home longer because the insurance provides more money for care. This includes extra money for home modifications like a wheel-chair ramp, a medical alert system and a stair lift.

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It is often the lack of money that prevents people from staying at home when they need care. Who pays for long-term care? In some cases they will spend all their savings and now are forced to rely on Medicaid (welfare health care). With a Partnership asset-protection insurance policy you will be exempt from the Medicaid spend-down requirement, the exemption is based on the total benefits your policy has paid out for care.

More than 80% of patients with chronic diseases say they want to avoid being in a hospital or intensive care unit when they are dying. While dying at home is usually preferred by the patient, it can be difficult for the caregiver. Hospice services can help.

Hospice care is for those in the last six months of their lives. More than 88% of hospice patients are Medicare beneficiaries.

Traditionally, for a patient to qualify for Medicare-supported hospice, a doctor must certify that the patient has: a home, a diagnosis of six months or less to live, a full-time caregiver, and a willingness to give up curative care and receive only palliative care.

In 2016 the Medicare Care Choices Model began offering some patients “concurrent care”: the choice of continuing curative care while starting palliative care and hospice care. An evaluation of concurrent hospice in non-elderly patients showed this plan improves quality of life and reduces costs.

The Medicare hospice benefit emphasizes home care, with almost 60% of patients receiving their care at home as of 2014. Medicare coverage is limited, additional care would be paid for out-of-pocket. Do you really want to spend-down your hard-earned savings and investments leaving open the option that Medicaid will require your estate to repay Medicaid for your care costs? There are 30 states with a filial responsibility law that could require your family to reimburse Medicaid.

Home care is much less expensive. Inpatient hospice services are used when the patient’s pain and symptoms must be closely monitored in order to be controlled, when medical intervention is required to control pain or symptoms, or when the family needs a rest from the stress of care giving.

A hospice team arranges for doctors, nursing care, medical equipment like wheelchairs and walkers, medical supplies, prescription drugs, hospice aide and homemaker services, physical and occupational therapy, speech-language pathology services, social workers, dietary counseling, grief and loss counseling for the patient and family, short-term inpatient care, and short-term respite care.

After evaluation by a doctor, a patient can enroll in hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit extensions. A patient can decide to stop hospice care at any time.

A recently proposed bill, The Patient Choice and Quality Care Act of 2017 (H.R. 2797), aims to give patients and families living with advanced and life-limiting illnesses the information and services they need.

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Have You Had The Conversation?

The Conversation Project is dedicated to helping people talk about their wishes for end of life care. They offer a collection of “Conversation Starter Kits” that you can download for free.

Talking with loved ones openly and honestly, before a medical crisis happens, ensures that everyone understands what matters most to each individual at the end of life. You can use a starter kit for yourself, or to help others communicate their wishes.

conversation2There are several different kits: for families and loved ones of people with Alzheimer’s or other dementias; how to choose a health care proxy and how to be a health care proxy; how to talk to your doctor or nurse about your wishes; and one for parents of a seriously ill child.

There are starter kits in English, Spanish, Mandarin, French, Hebrew, Korean, Russian, Vietnamese, and Hindi.

Organizations can purchase printed copies to distribute and add their logos.

The cost of care can be devastating, the national average is over $7,000 per month. To plan means to be insured before needing care, even before the diagnosis and not everyone can health-qualify for insurance (Can You Qualify?).

To find out more about long term care insurance see the Guide To Long Term Care

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Assisted suicide in nursing homes creates moral and ethical dilemmas

A court in Switzerland has ordered a nursing home to perform assisted suicide for those patients who want it. Switzerland legalized assisted suicide and has become a destination for suicide tourists – 611 from 2008 to 2012 – since passing the law, including 21 patients from the United States.

The nursing home, run by Christian charity The Salvation Army, claims its religious beliefs forbid helping patients commit suicide. But the court denied The Salvation Army’s appeal.

There is one way the nursing home can avoid helping patients kill themselves: giving up its charitable status and state subsidies.

One concern about assisted suicide is that some people who do not have a terminal illness are choosing to end their lives. Also, there is a risk that elderly people may be pressured into “voluntary” suicide by family members, or their own concerns about the cost of their care.

Find out about long term care insurance in America at Guide To Long Term Care.


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Why are some long term care insurance rates going up so much?

Group rates for long term care insurance will rise steeply in November.

  • Federal LTCI premiums will rise an average of 83%
  • CNA recently raised premiums nearly 100% for some group policies for employers, unions, and associations.
  • John Hancock Financial raised premiums as much as 126% on group policies for federal employees and retirees.

Policy holders, many of them angry, are wanting to know the reason for the sudden rise in rates.

Some blame the Office of Personnel Management. OPM oversees government insurance programs and must approve any rise in premiums.

Some say that the government keeping oil prices down produced the shortfall.

Others blame John Hancock, the only insurance company to bid on the federal program this year. John Hancock pays about $13 million a month in federal long term care insurance claims. Since 2002 the federal program has paid out more than $700 million for long term care.

ltc cost1

Part of the reason for the rise in premiums is that insurers originally set prices too low, underestimating how long people would live and need care. Insurance companies must balance the need for affordable rates with the responsibility to pay claims when they come in. Fourteen years ago, 102 companies offered long term care insurance. In 2016, only 12 to 14 companies are still in the business.

Insurance companies earn some of their money in interest on premiums; they make investments that help pay for claims. The recession unexpectedly brought interest rates down below 8%. Around the world, interest rates are near zero, and in some places have even become negative. The low interest rates are one of the main reasons insurance companies must raise premiums.

Because of the low earnings, some insurers have struggled to pay dividends to their shareholders. The Federal Reserve Board held down interest rates on Treasury bonds to prevent another recession.

A law passed in 2012 was supposed to protect consumers from steep increases in insurance rates. Insurers need permission from regulators in most states before premiums can be increased. However, since state insurance regulators still have not issued the final rules, insurance companies can raise rates on some policies without regulatory approval. Group coverage, while it offers discount rates, does not have the same regulatory protections as individual coverage. New regulations are being discussed.

ltc cost2

The National Active and Retired Federal Employees Association and some members of Congress are calling for hearings on the premium increases. But Congress will have little time for action before September 30 when enrollees must decide whether to keep their policies; so hearings will probably take place after the premiums have already gone up.

For those who enrolled in a policy before August 2015, premium increases will begin on November 1.

Policy holders must choose to either keep their policy and pay higher premiums, scale back coverage, or discontinue the policy and consider getting a different policy. Some enrollees can switch to an option in which they pay no more premiums but have a much lower benefit.

For some people, it may be possible to find a better policy in the private market. If the policy holder is in good health and bought the policy within the last few years, it may be possible to get a new policy with better rates. However, if the original policy was bought many years ago, a new policy will probably not cost less – and may have no guarantee that its premium will not rise.

Premiums are based on the insured’s age at the time of purchase. Each year the purchaser waits to buy a policy, premiums can rise 5% to 12%. The risk of being denied coverage for medical reasons also increases with age. And newer policies are regulated more strictly, which makes them more expensive than those issued years ago. Genworth 2015 Cost of Long-Term Care Survey ChartWays to lower the cost of a policy include reducing the benefit period, reducing the daily or monthly benefit, extending the waiting period before benefits apply, or changing the inflation protection. People who have policies with lifetime coverage could save a lot by reducing the benefit period to three or five years. Most long term care claims are for three years or less.

Policy holders should not wait until the last minute to look at the alternatives. If you decide to switch to another company, make sure your application has been approved before ending your existing coverage.

Many policy owners bought their policy before their state had approved the Partnership asset protection program. Some policyholders may choose to buy a smaller second policy just to get the Partnership.

Despite the proposed rate hike, long term care insurance is still the most cost effective way to protect yourself from the high risk that you will need expensive long term care.

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Nursing home social media abuse

The ubiquity of cameras and cell phones has created a new problem in nursing homes: nursing home workers taking inappropriate photos and videos of residents and posting them on social media, often without the residents’ knowledge or permission.

Abuses include recording cognitively impaired patients in embarrassing situations, including one where a nursing assistant posted a photo of a resident naked and lying in bed surrounded by feces. Some of these postings document abuse. There are even images of dead patients.

In response to an exposé by ProPublica, The Centers for Medicare and Medicaid Services issued a memo, “Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings” to state health departments, making it clear that releasing inappropriate photos and videos is abuse, and nursing homes must have rules to prevent it.

The memo states: “Each nursing home must provide training on abuse prohibition policies for all staff who provide care and services to residents, including prohibiting staff from using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings of residents that are demeaning or humiliating.”

And: “Nursing homes must establish an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident’s sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s).  Federal nursing home regulations require that each nursing home provides care and services in a person-centered environment in which all individuals are treated as human beings.”

The laws vary from state to state, but nursing homes that do not comply with federal requirements to prevent abuse can be cited, fined, and possibly removed from the Medicare program. Senator Charles Grassley, R-Iowa, called on the U.S. Department of Justice and the Office for Civil Rights to review their policies.

At least 70% of people over age 65 require long term care at some point.

A long term care insurance plan can provide for options ranging from home care to nursing homes.

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Too many Alzheimer’s patients end up in the hospital

An analysis of Medicare claims presented in July at the Alzheimer’s Association International Conference found that many Alzheimer’s patients have been hospitalized for conditions that could have been treated in outpatient care.alz

Researchers from Tufts Medical Center in Boston looked at 2013 Medicare claims data of over 2.7 million people with Alzheimer’s diseases and related dementias (ADRDs), and found that 280,000 had at least one avoidable hospitalization.

Examples of hospital admissions that could have been avoided include those for uncontrolled diabetes, asthma, high blood pressure, bacterial pneumonia, heart failure, angina without cardiac procedure, chronic obstructive pulmonary disease, urinary tract infections, and dehydration. With adequate care, these medical problems could be kept under control.

alz-vs-normal

However, Alzheimer’s and dementia patients are less likely to be aware of their medical problems, and less likely to follow through with lifestyle recommendations such as diet, exercise, and rest. Some Alzheimer’s and dementia patients need help with things like scheduling doctor visits, taking medications, monitoring blood pressure and glycemic levels, and taking care of wounds.alz101b

The researchers estimated that each hospital stay cost Medicare $7,000. Counting 369,000 avoidable visits, the costs came to $2.6 billion a year. In addition to costs in money, hospitalization increases the risk to patients, who may be confused by being in a strange place, and possibly exposed to infections in the hospital.

Doctors and caregivers of ADRD patients need to be
aware of common medical problems that may arise, and treat them right away so the problems can be resolved without hospitalization.

“By allocating nothing for long term care, you allocate everything”– Harley Gordon, Esq.
Founding member the National Academy of Elder Law Attorneys

For more information on Alzheimer’s and dementia care, see Guide To Long Term Care – Alzheimer’s.

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5 things state lawmakers want to do about long-term care insurance

Legislators are wrestling with purchasing incentives, benefits options and rate stability

State lawmakers have a huge stake in improving private long-term care planning.

genworth nursing cost 2016States now spend about $100 billion per year, or about 6 percent of their $1.7 trillion in annual revenue, on Medicaid nursing home benefits and other Medicaid long-term care benefits for the poor, and for residents who have used “Medicaid planning” to protect their assets.

The share of state revenue going to fund Medicaid long-term care benefits could rise sharply starting around 2031, when the baby boomers begin to flow into the 85-and-older age category.

Read Rest of Story Here


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