Posts Tagged ‘long-term care’

(Elder) Figures Never Lie …


Discussions about the future of long-term care in the United States are obviously dependent on the current and projected extent of the need for care. While many working in the field have an intuitive feel for the frequency of use of nursing homes, the statistics can nonetheless be surprising.

Admission Rates

According to a 1991 article in the New England Journal of Medicine, 33% of men turning 65 in the prior year would spend at least some time in a nursing home. For women, that number grew to 52%.

While total admissions for women are significantly higher, short-term admissions are much less sex-dependent. Of that same 65-year-old group, 21% of women and 19% of men will be admitted for stays of less than one year. But for longer stays, women begin to dramatically outnumber men.

10% of men and 18% of women will spend between one and five years in the nursing home. Only 4% of the 65-year-old men will spend more than five years in the nursing home, while 13% of their female counterparts will do so.

Nursing Home Financing

According to the American Association of Retired Persons, over half of the cost of nursing home care is paid by the federal-state Medicaid program (ALTCS in Arizona). The actual figure is 51.7% of all nursing home costs, compared to 8.8% for the Medicare program and 2.2% for other public programs.

Long-term care insurance and medical insurance account for 2.4% of nursing home costs, with private programs (such as charities) provide 2.2%.

The remaining 33% of nursing home costs are paid by patients from their income and savings. It is not clear, however, whether the patients’ “share of cost” contributions to Medicaid coverage are included in this statistic.

1996 Medicare and Social Security Rates

Although numbers may change as the budget compromise takes final shape, 1996 numbers for Medicare and Social Security are currently in place. Until further changes, the following figures apply:

Medicare Part A

Hospital Deductible $736/illness
Daily Coinsurance (Hospital)
Days 1-60 $0
Days 61-90 $184
Lifetime Reserve $368
Daily Coinsurance (Skilled Nursing)
Days 1-20 $0
Days 21-100 $92
Premium (for those not otherwise qualified) $289/month

Medicare Part B

Premium $42.50/month
Deductible $100/year
20% of approved charge
Balance Billing
15% of approved charge

Social Security

Cost of Living Adjustment 2.6%
Retirement Earnings Limits
Age 65-69 $11,520/year ($960/month)
($1 in benefits withheld for every $3 of earnings over the limit)
Under 65 $8,280/year ($690/month)
($1 in benefits withheld for every $2 of earnings over the limit)
Maximum SSI Benefit
Individuals $470/month
Couples $705/month

Annual Increases Predicted for Medicare Premiums


Republicans in Congress have made it clear they hope to trim $270 billion from anticipated Medicare increases in future years, but have so far failed to explain how they intend to accomplish this result. It has become clear, however, that they expect about $60 billion of that savings to come from higher premiums charged to Medicare participants.

Currently, Medicare beneficiaries pay $46.10 per month for Part B. Usually, this premium is deducted from Social Security benefits. On average, this premium pays 31.5% of the government’s cost to provide Part B coverage.

Congressional Republicans have proposed indexing Medicare premiums so that the percentage of remains fixed at 31.5%. Based on best estimates of future Medicare costs, that means premiums would jump to $97.50 per month by 2002.

Medicare’s premium rates were originally set to cover 50% of the cost of the program, but rising costs led to a reduction in the percentage recovered through premiums in recent years. Current premium rates were set five years ago and were intended to provide 25% of the cost of coverage; since costs increased more slowly than expected, the premiums actually covered a larger share of the cost than intended.

The White House has proposed returning the premium level to 25% of the cost of Medicare. Under that proposal, beneficiaries could expect to pay about $77.40 per month by 2002. Clinton’s plan would only raise $16 billion to help reduce the anticipated Medicare shortfall in the next five years, but would save beneficiaries slightly more than $20 per month in premiums.

Restraints In Nursing Homes

About one of every five elderly nursing home residents will be restrained for some part of their nursing home stay. At least that is the estimate of Professor Marshall Kapp, recognized as a leading expert on long-term care issues.

Nursing home rights advocates have fought for reduction of the use of restraints for several years. Among the arguments Kapp makes:

  • Serious injuries are more common when mechanical restraints are used long-term. Residents are often hurt when they become agitated and attempt to escape from the restraints, or when staff fails to monitor and adjust restraints in time.
  • Facilities using restraints frequently provide inadequate training in how to use, monitor and adjust the devices.
  • Nursing homes have made more dramatic strides in reducing restraints than hospitals or other acute care facilities.

White House Conference on Aging (Cont’d)

APRIL 10, 1995 VOLUME 2, NUMBER 40

More proposals considered by Arizona delegates to the White House Conference on Aging (by topic area):

Health Care and Mental Health

  • Permit reimbursement for direct care provided by nurse practitioners and physician’s assistants, for home care, preventive care and wellness programs.
  • Reduce duplication and coordinate services, particularly for those who access special services such as Veteran’s programs, Indian Health Services and Medicaid.
  • Control prescription medication costs.
  • Avoid rationing of health care by caps on service reimbursement and cost-benefit analysis of the true value of high-cost medical procedures.
  • Use excess hospital capacity for alternative services, such as extended care and assisted living.
  • Share medical resources, particularly high-tech equipment.
  • Consider means-testing Medicare (though a strong minority voice opposed any discussion of such a step).
  • Expand health programs to include mental health services.
  • Promote greater patient involvement in medical decisions.
  • Deal more creatively with substance abuse and suicide among the elderly.
  • Encourage medical professionals to work in rural and under served populations.
  • Institute a single-payor national health program (though this one did not make it into the final report).

Long Term Care

  • Shift emphasis from long term care in medical institutions to home care.
  • Provide tax incentives for family caretakers.
  • Encourage innovation in state and local programs by granting federal program waivers.
  • Promote prevention practices, among both elderly and young.
  • Encourage seniors to volunteer in their communities, to help them stay vital and involved.
  • Develop a wellness check program for homebound seniors.
  • Provide loans and incentives for home repair and adaptation for the homebound elderly.
  • Increase recreational programs for the elderly.
  • Expand case management programs.
  • Provide respite care for family care givers.
  • Promote congregate housing alternatives to reduce care costs.
  • Promote family and community responsibility for the elderly.

These are just a few of the myriad of suggestions considered by Arizona delegates. Next issue, we will discuss “special populations” and “elder rights.”

White House Conference on Aging


The White House Conference on Aging will convene in Washington, D.C. on May 2, 1995. For four days, delegates from around the country will discuss issues of importance to an aging American population.

Among the delegates will be four Pima County residents: Elder Law Issues Publisher Robert Fleming, PCOA Executive Director Marian Lupu, Univ. of Arizona Professor Theodore Koff, and former Social Security Commissioner Charles Schottland.

In previous Elder Law Issues, we have described some of the issues Arizona delegates wrestled with during the Arizona conference in January. Beginning with this issue, we will give you some insight into the issues that Arizona delegates thought important for the national agenda.

Issues on the Agenda

The Arizona conference dealt with five areas of concern for aging Arizonans. Those topic areas (more thoroughly described in previous Elder Law Issues) included:

  • Financial and Income Security
  • Health Care and Mental Health
  • Elder Rights
  • Long Term Care
  • Special and Minority Aged Populations

Not surprisingly, many of the ideas and concerns developed by the Arizona conference had been discussed and debated in previous forums. A sampling of the Social Security proposals and recommendations from the Arizona conference:
Isolate Social Security from other budget items, to preserve the programs viability and deal with anticipated future demands.

Reduce the federal deficit or, in other words, improve the quality of Social Security investments by avoiding use of Social Security to subsidize debt costs.

Streamline the Social Security Administration itself as a way to cut costs.

Consider means testing Social Security, but only if absolutely necessary (two of five separate discussion groups at the Arizona conference adamantly opposed any consideration of means testing).

Raise the wage cap on taxable salaries to generate more revenues.

Educate Americans to the reality that Social Security is intended to be a supplement to other retirement programs.

Encourage healthy seniors to remain employed longer by removing the cap on earnings for recipients (one discussion group adamantly opposed this solution, believing that the program would be seriously hurt financially).

Next Issue

Beginning next issue, Elder Law Issues will capsulize conference recommendations in other areas.

Arizona White House Conference on Aging


The Arizona White House Conference on Aging held in Phoenix last month dealt with issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Long Term Care

Everyone knows that the proportion of elderly citizens is expected to grow dramatically in the next two decades. What many do not appreciate is that the greatest growth is projected for the “old old”; those over age 85. Currently one-quarter of all women (but only one-seventh of men) over age 85 live in nursing homes. Those who turn 65 in any given year have about a 40% chance of spending some portion of the rest of their lives in a nursing home. About 10% of those will spend five or more years there.

Another tremendous segment of the population requires long-term care, but receives care at home. About 70% of all long-term care of the elderly is provided solely by family and friends, without institutionalization.

For those who can be cared for at home, the cost of assistance may be prohibitive. Simply bringing an aide into the home three times a week for meal preparation and light housekeeping can easily cost in the range of about $600 per month. Since about 20% of Arizona’s elderly live at or near the federal poverty level, even such small assistance may be unaffordable.

For those placed in nursing homes in Arizona, the cost of care will typically vary from $30,000 to $40,000 per year. Many seniors expect Medicare to pay some portion of that cost; in fact, Medicare pays only about 3% of the total nursing home bill in this country. Private long-term care insurance (still a relative rarity) and Veteran’s benefits account for another percent or two each; the remaining portion of long-term care costs are paid roughly equally by Medicaid and patient’s private savings and income.

Although nursing homes care for less than one-fifth of those requiring long-term care, they are responsible for more than half of the cost of care. Seniors are reluctant to enter the nursing home, and much prefer to be cared for (and die) in their homes.

Cost effective alternatives to institutionalization exist, especially in urban areas. Adult day care, respite care, hospice and assisted housing programs can keep many nursing home candidates in less expensive settings and more comfortable. Unfortunately, such programs are too rare and are seldom funded by public dollars. Paradoxically, it becomes less expensive for most patients to move into the nursing home and qualify for Medicaid (ALTCS in Arizona) than to secure care at home or in a more home-like setting.

Recent Court Cases


Some recent court cases of note to those caring for or working with elders:

Assaultive Resident Can Not be Moved from Nursing Home

“E.R.” is a demented patient residing in a Washington State nursing home, Park West. E.R. sufered a stroke in 1991 which reduced his ability to control sexual impulses. E.R. repeatedly engaged in sexually assaultive behavior. Park West placed him on a “15-minute alert”, which required that staff members physically view E.R. at least every fifteen minutes. E.R. was also moved to a private room.

Nevertheless, E.R.’s behavior continued. Finally, Park West served E.R.’s guardian with a notice intended to require the guardian to find a new placement for E.R. The notice purported to require the guardian to move E.R. to another facility. It noted that E.R.’s needs could not be met at Park West, and that his conduct endangered the safety of other residents.

E.R.’s guardian opposed the transfer and requested an administrative hearing. The Administrative Law Judge ultimately ruled that Park West could not force the guardian to make the move. The ALJ ruled that E.R. had rights pursuant to OBRA93, the Fair Housing Amendments Act and the American’s with Disabilities Act, and that Park West did not have authority to order his removal unless he posed a danger to other residents that could not be eliminated by a plan of care. The Administrative Law Judge specifically found that E.R.’s supervision was “intermittent and inconsistently applied.” E.R. was permitted to remain at Park West and the facility required to develop and implement a care plan to deal with his actions. In re E.R., Washington State Office of Hearings and Appeals, DSHS, March 16, 1994. [Note that the result might well have been different if E.R. had lived in Arizona.]

Trust Available to Medicaid Applicant

When Pennsylvanian Louis Rosenberg died in January, 1976, his Will left $65,000 in a trust for his wife Mary. The trust required provided for income to be used for Mary, and also permitted use of principal for her medical and surgical expenses and other “unusual” needs.

In 1992, Mary Rosenberg (by then living in a nursing home) exhausted her personal assets. Her son (who was also one of the trustees of the trust) applied for Medicaid long-term benefits on her behalf. The state Medicaid agency denied eligibility, finding that the trust principal was “available” to Mary. Her son appealed on her behalf unsuccessfully.

Mary died shortly thereafter, and her estate sought judicial review of the denial. The court agreed with the Medicaid agency, finding that Louis had intended to make the funds available to pay for Mary’s medical bills, including nursing care. Rosenberg v. Dep’t. of Public Welfare, Penn. Commonwealth Court, June 13, 1994. [This case, with its unsurprising result, points out the importance of knowledgeable drafting of estate planning documents when long-term care is anticipated.]

Medicaid Liens in California

MARCH 14, 1994 VOLUME 1, NUMBER 17

A recent article in the Orange County Register indicated that many Medicaid recipients (and newspaper reporters) are likely to be surprised by the implementation of Medicaid estate recovery programs. The article (reprinted in the Arizona Republic as “Californians get surprise bills for care”) detailed the plights of several Californians whose spouses had died while receiving benefits from MediCal, California’s version of Medicaid.

Pursuant to August, 1993, changes in federal law, states are required to implement an aggressive program to recover assets from the estates of deceased recipients of Medicaid long-term care (known in Arizona as ALTCS). Among the measures already implemented in California is an automatic lien imposed on the residence of MediCal recipients, which may be collected upon the death of a surviving spouse or upon sale of the property.

Arizona has not yet complied with the new federal mandate, though changes are expected at any time. If California’s experience is any guide, seniors who seek ALTCS benefits for their spouses, and the children of ALTCS patients, are in for a surprise.

The Register article told of Edward F. Gunz, whose Parkinson’s disease required his nursing home placement in January, 1993. When he died in October, California authorities placed a $17,287.53 lien against his widow’s home.

Litigation Filed

Gunz’ widow is one of six plaintiffs in a class action seeking to invalidate the California lien program. Another plaintiff is Ralph Ainsworth, whose wife Virginia received $11,700 of MediCal care. When she died last September, Ainsworth received a form inquiring about assets and telling him there would be no lien against his home so long as he lived there. After the lien was filed, MediCal officials explained that he “got an old form” and that the new ones hadn’t been printed up at the time of her death.

Pat McGinnis, director of the California Advocates for Nursing Home Reform in San Francisco, is quoted as saying that “this is just a way to balance California’s budget on the backs of nursing-home residents and their families.” The article also notes that California’s share of long-term care costs is running about $1.5 billion per year. California has about 3 million citizens over age 65.

Other States

According to Linda DeRuvo-Keegan, vice president of American Health Care Association, other states are also taking advantage of the new federal mandate to collect money from estates. She indicates that she is unaware of any other lawsuits.

The California lawsuit alleges only that the surviving spouses were given inadequate notice of the liens, not that the liens are themselves illegal. California authorities are quick to point out that the liens will not be foreclosed so long as a surviving spouse resides in the home. Less clear is how the appreciation in real estate values between the deaths of the first and second spouse will be treated.


Arizona has not yet adopted an estate recovery program, although liens were extensively used by County eligibility offices prior to the enactment of ALTCS. One choice facing Arizona will be whether to use an expanded definition of “estate” authorized by federal law. If followed to the extreme, the new law might permit recovery against the families of patients who only owned a life estate–a right to use the property during the patient’s life.

ALTCS has not been quick to involve family members, lawyers or other advocates for the elderly or disabled in the planning process. We all eagerly await the final outcome.

Elder Care in the Workplace


Employers are increasingly likely to find that care of employees’ parents becomes a workplace issue. National studies indicate that about 15% of employees have responsibility for elder care today, and that number is expected to increase to 22% in the next four years.

According to Andrew Scharlach, a UC Berkeley professor specializing on aging issues, 37% of the U.S. work force in 2005 will be aged 40 to 54, the prime years for elder care issues to surface. By 2020, more than a third of the work force will be responsible for elder care.

As baby boomers age, the demographics will become even more compelling. The U.S. Census Bureau predicts that the number of people over 85 who rely on their children for care will nearly double by 2030 and more than triple by 2050. Families are expected to continue to provide 80% of needed long-term care.

The Current Problem

One large national employer, NationsBank, calculates that it loses about $1 million per year to absences for elder care. Dr. Scharlach estimates that the national bill for productivity lost to elder care is $17 billion.

While elder care problems are often compared to child care difficulties, there is one important difference. Child care usually is an issue for younger, newer employees. Elder care, however, is the province of more experienced and valuable employees.

What Companies are Doing

According to a Wall Street Journal article (February 16, 1994) on the problem, large companies are approaching the problem with a number of alternatives. Some have adopted flexible scheduling arrangements, including permitting employees to bring parents to the workplace for short periods at the beginning or end of the day.

Others promote or fund resource and referral programs, helping provide information to employees about nursing home alternatives, home safety issues, planning for incapacity and dealing with the problems of distant elders. Some provide referrals to Elder Law attorneys or case managers to work with employees.

Still other employers take a more simple approach, providing seminars for employee groups. Work/Family Directions, Inc., a Boston consulting firm, reports that it gave 575 elder-care seminars for employees in 1993, up 27% from the year before, on such topics as choosing a nursing home, paying for care and Elder Law issues.

Elder Issues in Eastern Europe

The former communist countries of Eastern Europe have many of the same demographic concerns. For two reasons, however, their elder care problems may be greater. After years of low fertility rates, Eastern European countries have much larger ratios of older citizens. The high mortality among young men in World War II also means that elderly women (who usually require more medical care) outnumber elderly men by even larger margins than in the rest of the world. The demographic difficulties are compounded by historically liberal pension benefits which will strain already thin budgets.

“Figures Never Lie …”


Coincidentally, the results of two different statistical studies crossed our desk this week. Because they seem to lead to opposite conclusions about the elderly, they are interesting and worth mentioning.

Everyone’s Poorer–Except the Elderly

The first study, conducted by the government itself, focused on the net worth of American families. Disturbingly, the average net worth of all families declined by about $5,000 between studies conducted in 1988 and 1991.

That bad news is not as bad for the elderly. On average, families headed by an individual older than 65 had a net worth of $88,192. That figure is sixteen times the average net worth of families headed by an individual under age 35–the study pegged that figure at $5,565.

Of course, the older families have three decades (or more) of additional earnings to add to net worth. Not surprisingly, the largest jump in net worth showed up in the 45-55 age group. Still, this study seemed to paint a picture of relative financial strength and security. We were reminded of recent news stories about the tremendous accumulated wealth of the oldest generation, which is about to be transferred to the “baby-boom” generation over the next decade or two.

Nursing Home Costs Exhaust Estates

The second study arrived the next day. Conducted by Brown University researchers, it focused on how long elderly patients are able to pay privately for long-term nursing care. This study found that 8.6% of private pay nursing home patients become Medicaid patients within six months of admission. Nearly one-fifth (19%) run out of private funds within the first year.

Among patients first admitted to the nursing home under Medicare, the figures are even more striking. While 13.4% become Medicaid patients within six months, 52% run out of both Medicare coverage and private funds in the first year.

What accounts for the difference in the focus of these two studies? Of course, the average net worth of $88,192 is not all that much when costs of care exceed $30,000 per year, but Social Security and pension income, coupled with increasingly common long-term care insurance coverage, ought to be taking care of a larger segment of the population for a longer time. Perhaps the difference can be explained by the likelihood that a recent nursing home admittee has suffered through a debilitating and expensive illness for some time prior to admission.

And what about the difference between Medicare and private pay admissions? Are Medicare patients poorer? Are wealthy individuals moving into nursing homes before they really need to for medical reasons? Have Medicare patients been sicker for longer, thus exhausting their reserves prior to the first admission? We don’t have the answers, but thought the questions (and the statistics) interesting enough to pass along.

Fiduciary Regulation

Senate Bill 1103, now pending in the Arizona Legislature, would require all private fiduciaries to be licensed and regulated by the Supreme Court. As proposed, this legislation would affect any person (or corporation) who charges a fee to serve as guardian or conservator for persons not related to the fiduciary.

SB 1103 has already passed through the State Senate and is now being considered by the House. We will keep you updated on its progress.

Health Care Reform


Much discussion has been heard about health care reform proposals. The administration’s plan, the “single payor” proposal, and the alternative plans of the Republican leadership, a bipartisan group of Senators and Congressmen, and Republican Nancy Kassebaum of Kansas have all been widely discussed.

Long Term Care

Most of the proposals deal with acute care, doctor and hospital visits and, in some cases, medications. Little attention has been paid to the long-term care component of our national health care costs.

Now two national coalitions of long-term care advocates have spoken up about the treatment of nursing care costs and services under each of the various proposals. The Long Term Care Campaign, consisting of 138 groups, and the Leadership Council of Aging Organizations, consisting of 35 groups, have given “passing” grades to only two of the proposals. According to the two advocacy groups, only Clinton’s health care plan and the “single payor” proposal of Rep. Jim McDermott (Dem.-Wash.) and Sen. Paul Wellstone (Dem.-Minn.) deal with the long-term care issue at all.

Alternative Proposals

According to the two coalitions, of the remaining proposals, only Sen. Kassebaum’s even addresses long-term care. That proposal would establish a commission to decide which long-term care costs would be covered in its basic benefits package. The bipartisan plan of Sen. John Breaux (Dem.-La.) and Rep. Jim Cooper (Dem.-Tenn.) was rated as a step backward because it would eliminate Medicaid, phase out long-term care funding altogether, and force states to pay for long-term care.

Of Interest

Curtailing Miss Daisy

(From Cooking Light, Nov/Dec 1993):

“Asking aging parents to give up their car keys is not easy, but it is a problem more sons and daughters will face as the population grows.

Statistics show that motor vehicle accidents cause the most injury-related deaths among 65 to 74 year olds and are second only to falls after age 75. Although people over age 75 drive less, their accident rates equal or surpass those of teenagers.

But allowing aging drivers to keep their independence is important, says Dave Carr, M.D., a geriatrician at St. John’s Mercy Medical Center in St. Louis. He advises adult children not to take lightly any attempt to restrict or eliminate a parent’s driving privilege. For one thing, elderly drivers often know their limits and restrict themselves by not driving at night, on highways, during rush hour, or in bad weather.

‘When older drivers fail to give up the road despite decreasing skills, it’s usually because their judgment is impaired,’ says Carr.”

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