Posts Tagged ‘Parkinson’s’

Long Term Care Insurance: Who Needs It? Which Policy?

JANUARY 27, 1997 VOLUME 4, NUMBER 30

With nursing home costs approaching $40,000 per year for most residents, the government’s Medicaid program has for decades been the “safety net” for families with long-term care needs. In recent years, escalating Medicaid costs and increases in the portion of national nursing home bill paid by the program have resulted in Congressional efforts to reduce Medicaid eligibility and coverage. Prudent elders should be considering other ways to ensure that nursing home stays can be paid for if needed.

A relative handful of individuals have long-term care available from religious or service group affiliations. Another small portion of the population can rely on government programs other than Medicaid, but for most elders the only alternatives are to accumulate substantial personal wealth (a common goal, though sometimes difficult to realize) or purchase long-term care insurance (LTCI).

A recent review of LTCI purchasing strategies by Elder Law Forum (a newsletter published by Legal Counsel for the Elderly, Inc., and sponsored by AARP) points out some of the considerations for typical buyers. The review makes several points for the “typical” LTCI buyer:

  • About half of 65-year-old women and a third of the men will spend some time in a nursing home.
  • Most nursing home stays will be short, with the median length of institutionalization being slightly less than one year.
  • LTCI premiums currently average about $1,000 per year for 60-year-olds, and rise to $1,500 for 65-year-olds and $2,000 for 70-year-olds.

If you (or a relative or client) are concerned about long-term care costs, some pertinent questions to consider include:

  • When should you buy? The average age of new policyholders is currently 67. Many employers now offer group plans, and a few younger people may buy policies. But for most people, waiting until age 60 to make the purchase is probably reasonable.
  • Should both a husband and wife buy policies? In many cases, one spouse or the other may be uninsurable due to illness or age. The “well” spouse should particularly consider LTCI, since she (most commonly) is likely to survive the “ill” spouse, and therefore have no spouse to care for her. Of course, this is another way of saying that the well spouse is likely to spend some considerable time providing care for the ill, uninsurable spouse, as well.
  • Does family history matter? If a potential LTCI buyer has a family history of strokes, high blood pressure, dementia, Parkinson’s or other conditions likely to require long-term care, insurance is more strongly indicated. Such persons should make the initial purchase at younger ages, since the onset of disability will usually make them uninsurable.
  • Does net worth make a difference? Couples with a net worth of less than $100,000 (not counting the family home), and individuals worth less than $50,000, may not need to consider LTCI, since (current) Medicaid rules will permit them to receive government assistance within a year or two of nursing home admission. Prospective LTCI buyers with large estates may not need the insurance, particularly if their estates generate $40,000 in annual income over and above their (or their spouse’s) other living expenses. In other words, LTCI is primarily of interest to the middle-class elderly.
  • How important are individual policy provisions? Very. Some policies provide excellent coverage for home health care, while others do not; a policy without home care provisions might unnecessarily force the owner into an institution.

A checklist for comparison shoppers can help frame some of the issues. For a helpful checklist, contact FLEMING & CURTI at the fax, e-mail or street address below.
330 N. Granada Avenue, Tucson, Arizona 85701
520-622-0400 / FAX: 520-203-0240

Frequency of Dementia Varies By Age, Diagnosis, Placement

JULY 15, 1996 VOLUME 4, NUMBER 3

The common usage of “dementia” usually refers to loss of intellectual functioning or diminished mental capacity. Frequently, the term is used to describe any of a wide variety of illnesses or conditions, without distinguishing among the possible causes.

In a similar way, “Alzheimer’s” is commonly used to describe almost all demented individuals, regardless of the actual reason for the diminution of capacity. It is commonly understood that Alzheimer’s Disease is a diagnosis of exclusion; other than autopsy, it is usually impossible to definitively diagnosis Alzheimer’s, and the diagnosis is reached by excluding all other possible diseases.

For many purposes, the difference between a diagnosis of Alzheimer’s and, for example, vascular dementia is unimportant. Most dementias are irreversible, and there is little evidence to suggest that the progress of many dementing illnesses can be slowed. Still, it is both important and interesting to know what different illnesses might cause dementia, and the relative frequency of each.

In their 1992 book “Dementia: A Clinical Approach,” medical researchers Jeffrey L. Cummings and D. Frank Benson survey the existing literature about dementia. Among demented patients, the frequency of each cause varies according to the researcher. Cummings and Benson caution that the estimates of Alzheimer’s disease, in particular, are almost certainly overstated, but the research suggests the following frequencies:

  • Alzheimer’s Disease–25-50%
  • Vascular (multi-infarct) Dementia–10-25%
  • Depression and other psychiatric disorders–10-20%
  • Alcoholic Dementia–2-12%

Other causes, each accounting for between one or two percent and ten percent of all dementias, include metabolic conditions, infections, toxic conditions, Huntington’s and Parkinson’s diseases and other, less frequent causes.

Clearly, Alzheimer’s Disease is the most common dementing condition, but other causes collectively account for more dementia. The very fact that Alzheimer’s is a diagnosis of exclusion operates to inflate its reported frequency, since unidentified dementias will usually be lumped into that category.

Cummings and Benson also report several studies about the frequency of dementia in various groups. Among those 65 or over, approximately 6% can be expected to suffer from severe dementia, and another 10% to 15% evidence mild to moderate impairment.

The frequency of dementia, not surprisingly, increases with age. The percentage of demented individuals can be expected to double for each five-year increment in age, so that about 20% of those over age 75 will show severe symptoms of dementia.

Dementia should be expected to appear more frequently in more restrictive medical facilities, and that expectation is borne out by the research. About 54% of state hospital patients demonstrate severe dementia, while 30% of nursing home residents and 15% of retirement community residents are severely demented. Mild dementia (or worse) can be expected in 94% of state hospital patients, 87% of nursing home residents and 80% of retirement community residents.

What do these figures mean for the treatment or care of demented patients? The high frequency of dementia other than Alzheimer’s Disease suggests the importance of differential diagnosis of dementing illnesses. While most dementia is irreversible, some (such as metabolic conditions and infection) may be treated, and the progress of others (notably vascular dementia) may be slowed by drug therapy and/or diet. And diagnosis and treatment regimens become more important with age and type of treatment facility.

Lifetime Transfers By Elderly Patient Upheld After Death

APRIL 8, 1996 VOLUME 3, NUMBER 41

Stories about relatives and friends taking advantage of the elderly are widespread. Several cases reported in Elder Law Issues involve courts setting aside transfers by vulnerable adults to caregivers, family members or others. But what about the capable adult who, though elderly, truly wishes to make a gift?

Ohioan Harold Hawkins was diagnosed as suffering from Parkinson’s disease ten years before his wife’s death in 1991. After her death, Minnie Nash and her husband Ples, friends of the Hawkins’, moved in with Mr. Hawkins to help take care of him.

Nearly from the beginning, Hawkins and the Nashes had an understanding about the assistance. Mr. Hawkins would provide a home for the three of them, Mr. and Mrs. Nash would provide care for Mr. Hawkins and necessary upkeep and repairs, and Mr. Hawkins would transfer his interest in the property to the Nashes. In March, 1992, Mr. Hawkins signed a power of attorney naming Mrs. Nash as his agent, and a month later he quit-claimed his home to the Nashes. At about the same time, he also changed the beneficiary on his VA life insurance to name the Nashes.

Mr. Hawkins died a little more than a year later. His sister, Clover Elliott, brought an action to set aside the transfers and to recover the property and VA insurance benefits.

Many cases establish the principle that such transfers are suspect, based on the “confidential relationship” between Mr. Hawkins and Mrs. Nash. In this case the trial judge acknowledged that the Nashes had the burden of proving the transfers valid. Still, the court noted that they could show Mr. Hawkins knew what he wanted to do and acted out of his own volition.

At trial, the Nashes introduced evidence that Mr. Hawkins was lucid and alert right up until his death. The trial judge ruled (and the Court of Appeals later agreed) that the Nashes had shown “competent and credible evidence showing the quit-claim deed and the VA Change of Beneficiary Form were executed pursuant to decedent’s declarations and wishes.” The Nashes prevailed, and Mr. Hawkins’ wishes were upheld. Elliott v. Hawkins, Ohio Court of Appeals, December 28, 1995.

Perspectives on Death and Dying

According to a recent article in the Journal of the American Medical Association, different ethnic groups may have distinctly different views of medical care issues at the end of life. The article reports on a University of Southern California of 800 elderly patients.

Study results indicate that immigrants from South Korea and Mexico are particularly likely to differ from the more common views of European-Americans and African-Americans. While the latter groups (and the legal system) focus on a patient self-determination model, the immigrant groups were much more likely to rely on family consensus and less inclined to permit patients to make their own decisions.

A second study reports on Do Not Resuscitate orders among terminally ill AIDS patients. Perhaps surprisingly, the study reveals that about 2/3 of such patients would want to be resuscitated. About half of even those who rated their own prognosis as poor wanted resuscitation.

Nursing Home May Not Bill After Refusing to Honor Living Will

JULY 31, 1995 VOLUME 3, NUMBER 5

Lawrence Rettinger suffered from Parkinson’s disease and was concerned about being kept alive by machines after he was no longer able to communicate. Like millions of other Americans, he executed a Living Will.

In January, 1990, Mr. Rettinger was admitted to a North Carolina nursing home. His wife Nell provided a copy of his Living Will to the home at the time of admission. One year later, he contracted pneumonia and a nasogastric tube was inserted.

For several months, Mr. Rettinger received medications, food and fluid through his nasogastric tube. Finally, his wife requested that the nursing home remove the tube and enter a Do Not Resuscitate order.

The nursing home required that Mr. Rettinger’s physician and his wife comply with North Carolina statutes requiring a certification that Mr. Rettinger’s condition was terminal. On June 25, 1991, the physician signed the appropriate form and entered the Do Not Resuscitate order.

When the nursing home still did not remove the tube, Mrs. Rettinger sued to compel compliance with Mr. Rettinger’s Living Will. On September 12, a trial judge ordered that the tube be removed; Mr. Rettinger died two weeks after the removal was completed.

Two years later the nursing home brought suit against Mrs. Rettinger for $14,458 in unpaid nursing home bills. Mrs. Rettinger refused to pay, arguing that the services had been rejected by her and by her husband (because of his Living Will). The nursing home responded that the attending physician never signed the form expressly directing removal of the nasogastric tube, as the home’s reading of the North Carolina statute required.

The trial court granted a summary judgment in favor of the nursing home, finding that Mrs. Rettinger’s defense was invalid even if true. Mrs. Rettinger appealed.

The North Carolina Court of Appeals reversed the trial court and sent the case back for trial. The Court of Appeals found that the statute (which provides that treatment such as a nasogastric tube “may be withheld or discontinued upon the direction and under the supervision of the attending physician”) does not require that the physician personally direct removal of the tube.

At trial, Mrs. Rettinger will have to show that the statute’s requirements were met. If she is able to do so, the Court ruled, she will not be responsible for nursing home bills incurred after the date her husband would have been expected to die if his instructions had been followed. First Healthcare v. Rettinger, N.C. Ct. of App., May 2, 1995).

[Ed. note–this case is expected to be appealed to the North Carolina Supreme Court. A New York court recently ruled exactly opposite to North Carolina on very similar facts.]

Elder Law Court Cases

JULY 24, 1995 VOLUME 3, NUMBER 4

Recent Court cases of interest to providers and advocates for seniors:

Daughter, Limited in Visits to Mother, Sues

Barbara Miller claimed that she just wanted to visit her mother in her Ohio nursing home. But, she alleged, the nursing home hid her mother from her on at least three occasions when she attempted to visit, and interfered with her mail and telephone calls to her mother. In one instance, the nursing home even had her arrested when she visited.

Ms. Miller sued the nursing home and her brother. She alleged four different causes of action: interference with a family relationship, defamation, malicious prosecution and intentional infliction of emotional distress. The federal trial court dismissed all four claims.

In March, the Sixth Circuit Court of Appeals reversed the dismissal. The Court of Appeals ruled that Ms. Miller could pursue her claim of intentional infliction of emotional distress, although they upheld the dismissal of the other three causes of action. The effect of the ruling: Ms. Miller will now get to make her case before the trial court. Miller v. Currie, Sixth Circuit, March 22, 1995.

Court-Ordered Child Support Not a Deduction

Alan Tarin, age 47, suffers from Parkinson’s. When placement in a Massachusetts nursing home was imminent, his wife divorced him and secured an award of child support for their two children.

Unfortunately, Mr. Tarin’s child support was not deducted from his income for Medicaid purposes. As a result, Mr. Tarin’s “turnover amount” (the amount he is required to pay toward his nursing care) was not reduced for the child support payments. Tarin v. Bullen, Mass. Super. Ct., April 1, 1995.

Generalizations About Generations, Part II

Last week Elder Law Issues invited readers to suggest some of the formative events that might have shaped the attitudes of those born before the Depression. Several responses are thought-provoking, even if not particularly precise science.

One contributor suggests that a key difference between those born before the Depression and the so-called “Depression Babies” (those born between 1929 and the early 1940s) may account for some attitude differences. While “Depression Babies” were born into a world of shortages and hardships, their immediate predecessors were born into a period of relative wealth and stability. Many were in their early teens or young adulthood when they lost everything and watched their friends and neighbors suffer as well. They may be even more unlikely to make gifts or spend money on themselves than those born into the Depression.

One correspondent also points out that it was uncommon for pre-Depression workers to be supervised by bosses younger than themselves. By contrast, post-World War II work environments made such situations more common. As a result, the older generation may be more sanguine about the shortcomings of Baby Boomers and Baby Busters in the workplace than their successors.

But remember: generalizations can be dangerous.

Recent Cases Involving Estate Recovery Issues

JUNE 19, 1995 VOLUME 2, NUMBER 50

Two recent cases from other states illustrate some of the trends in Medicaid financing. In one,Estate of Budney, a Wisconsin Circuit Court case from February, 1995, the state sought to recover Medicaid expenses from the patient’s husband after his death. In the other, Coye v. Hope, a California Court of Appeals case also from February, the state sought to recover Medicaid benefits from the patient’s revocable trust after her death.

Grace Budney received Medicaid benefits prior to her September, 1993, death. Her husband Paul died six months later. Although no estate recovery proceeding was commenced after Grace’s death (all the assets presumably went to Paul), Minnesota’s Department of Health and Human Services made a claim against Paul Budney’s estate for $54,000. DHHS cited a Minnesota statute that appears to permit the recovery. The Circuit Court ruled that federal law controls, and that recovery against spouses’ estates is not permitted. Minnesota’s statute was invalid.

Ed. note: Arizona does not have a similar statute, so the controversy should not arise here. Unless, that is, the Arizona legislature chooses to follow the lead of Minnesota and Oregon, which have adopted such statutes.

In the California case, Myrtle Hope had signed a revocable living trust prior to going into the nursing home. After her death, the California Department of Health Services filed a claim against her trust, noting that the claim would have been permitted if her estate had gone through the probate process. Her trustee objected, pointing out that there were no probate proceedings; that is the nature of trusts.

The Court of Appeals ruled that the state could recover Medicaid benefits from Ms. Hope’s trust. Although there is no clear state statute permitting the action, the Court reads the federal law to permit the action, noting that “the purposes of the act will be better achieved” thereby.

Ed. note: Arizona has expressly defined “estate” for estate recovery purposes to include only the probate estate, so this case should not directly apply. Still, changes may be in the works.

Abandonment of Spouse Leads to Criminal Charges

Wallace Johnson suffered from Parkinson’s disease; his wife provided care in their home. In November of 1993, Mr. Johnson fell in the home and called out for help. Mrs. Johnson first ignored his calls, then punched and kicked her husband and ultimately left the house without summoning help. Mr. Johnson was able to call 911, but died three months later.

Mrs. Johnson was charged with assault and neglect. Her attorney argued that she was not her husband’s guardian, and could not legally “neglect” him. The Iowa Supreme Court disagreed, holding that the law applied whenever one “may be charged with the care and control of another.”

Ed. note: Arizona law already specifically creates a duty of spouses to provide support. A.R.S. §§13-3610 and 13-3611 make it a Class 6 Felony to fail to provide for a spouse’s personal or medical needs.

Local Alzheimer’s Support Project

SEPTEMBER 12, 1994 VOLUME 2, NUMBER 10

Tucson’s Jewish Family and Children’s Service Center and the Southern Arizona Chapter of the Alzheimer’s Association have announced the receipt of a $46,809 grant from the Flinn Foundation. The grant money will be used to establish a program to provide relief for family caregivers of dementia, Parkinson’s and stroke patients.

The program will utilize volunteers to provide respite care. Volunteer recruitment, supervision and retention will be the responsibility of the Jewish Family and Children’s Service Center, and the Alzheimer’s Association will develop a training program for the volunteer caregivers.

Once established, the program will provide volunteer relief caregivers for some families. There will be no fee, but families will be permitted to make contributions toward the cost of the program.

State Medicaid Waivers Challenged

States may have a more difficult time securing federal waivers to permit experimental Medicaid programs in the future. A lawsuit filed by a group of community health clinics against state plans in Tennessee and Oregon challenges the use of such waivers.

Under federal Medicaid administrative rules, states must secure specific waivers before implementing variations on Medicaid funding or service delivery structures. Arizona has operated under such a waiver since the establishment of its AHCCCS program.

The Clinton administration has indicated its intention to permit state experimentation by making the waiver process easier for states to navigate. The Tennessee experiment, for example, would transfer Medicaid recipients into health maintenance organizations and other discount-price networks of health providers. Similar waivers have already been granted to Hawaii and Rhode Island, and another half dozen states have either applied for waivers or are considering doing so.

The lawsuit alleges that the effect of the waivers is to permit state-by-state health care reform, rather than to encourage Medicaid improvement. The clinics also claim that low-income patients are hurt by placing them in HMOs, because they need health education and encouragement to seek care. Since HMOs are rewarded when patients make fewer visits to the doctor’s office, they are not a good way to deliver care to the poor, according to the suit.

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