Wednesday, August 6, 2014

The Case for Adult Daycare Extends Beyond Costs

Adult Daycare provides a low cost alternative to nursing home care while maintaining the senior’s health and connection to home.

Somewhere between 25 - 35 percent of seniors will require nursing home level of care at some point during their retirement. Nursing home care costs approximately $77,000 per year. Most Americans cannot afford $77,000 per year in care costs even if they sell their homes and everything in them. This means Medicaid (the federal government entitlement program) will continue to fund the majority of nursing home care.
Photo by Univ. of the Fraser Valley. A happy participant at the Pleasantview Care Facility.

The Baby Boom Generation are starting to retire and many will require nursing home level care over the next 20 - 30 years. Even though there is a declining percentage of seniors in Medicaid funded nursing homes, we face a looming care funding crisis. The demand for elder care is expected to triple by 2050.

Enter adult day care. Full-time adult day care, 5 days / week for a year costs approximately $18,000. This is less than one quarter of the cost of nursing home care. If there were such a thing as 24 hr adult day care, it would still be less expensive than nursing home care by 10%.  Approximately, two-thirds of nursing homes are private, for-profit companies. The opposite is true with adult day care: just over one-quarter are private, for-profit organizations.

While the American Elder Care Research Organization focuses most of our research on costs and financial options, we believe that the reasons to consider an adult daycare program as an alternative care go beyond just the economic. Surveys show that over 90 percent of Americans want to grow old living at home, even if they require long term care. Adult day care allows them to do so. If not in their own homes, then in the homes of family members. The staff to patient ratios in adult day care and nursing homes are surprisingly similar; about 1 to 6 in both.  Adult day care also provides recreational activities and social interactions, both of which improve health outcomes and can further reduce the need for care.

Photo by Univ. of the Fraser Valley. One girl twirls around a senior in a wheelchair as part of the final dance at the Pleasantview Care Facility.
For help discovering financial assistance and adult daycare programs near you or to read about state Medicaid policies visit our page on Adult Daycare.

Friday, June 20, 2014

Calculating the Cost Savings of Walk In Tubs

Our organization is contacted regularly by individuals inquiring about walk in tubs and which government programs, if any, provide financial assistance for them.  We've written in depth on that subject here so we won't go into those details in this blog post.   However, for families struggling with the purchase decision and for program administrators and legislators, we want to examine the economic question of if and when there are care cost savings associated with the installation and usage of walk in bathtubs instead of showers.

There are two ways to look at this question.   The most obvious way is to look at the reduced need for personal care assistance.   If one is able to safely bathe themselves, then a family need not hire a home care professional to provide assistance.  The second, somewhat roundabout way of calculating cost savings, is to look at the medical costs associated with bath related falls.

When caring for a loved one at home for a period of one year or more, the purchase of a walk in tub is a sound economic decision. 

For families in the situation where they must hire outside assistance to help an elderly love one bathe, the calculation is fairly straightforward.  Let's assume an individual needs to bathe 5 times per week.  Family members can provide assistance on both days of the weekend which means on 3 weekdays outside assistance is required for approximately 1 hour / day (although realistically, one cannot hire home care assistance for just one hour.)  3 hours / week times the national average hourly rate for personal care ($20 / hour) equals $60 / week or $3,120 / year.  Basic walk-in tubs costs $2,000 - $3,000 and wheelchair accessible tubs cost $3,000 - $4,000.  Using this math, we can see that should one be caring for a loved one at home for a period of one year or longer, the installation of a walk in tub makes economic sense. 

The more complicated calculation for determining the cost savings of walk-in tubs is by looking at the reduced injury rate.  This question is of greater interest to program administrators when considering if and whether to include walk in tub installations as a covered benefit of their program.  Our methodology is clearly unscientific, however our "napkin numbers" make a clear case that on the whole including walk in tubs as a benefit of assistance or insurance programs is also a good economic decision.

The hospitalization costs of one fall can pay for 10 walk in tubs.

By combining the statistics from a variety of different studies, we estimate the following.  Each month there are approximately 12,000 falls experienced by American seniors in their bathrooms.  One third of which are serious enough to warrant a hospital visit.  The CDC finds the average hospitalization cost for a fall injury is almost $35,000.  Doing the math, we find that over $1.5B is spent annually on medical costs from bath related falls.  Since most seniors are insured by Medicare or Medicaid, both of which are government programs, it seems a no-brainer that walk in tubs should be a covered benefit for the frail elderly at risk who cannot bathe themselves otherwise. 

It is worth mentioning that this blog post strictly examines the walk in tub decision from an economic perspective and that there are other factors which can and should be considered.  Most importantly is the increased sense of self-reliance and dignity afforded by being able to manage one's own personal hygiene.

Friday, December 13, 2013

Options for Paying Family Members as Caregivers

Without question, the most common question our organization is asked is "can I get paid to provide care for my parents (or spouse)?".   On own website we maintain a list of programs that offer that option to family caregivers but as some new options have become available, we thought a blog post overview of all 5 different ways family members can be paid as caregivers of their elderly loved ones was in order. 

1) Medicaid Waivers
This is the most common and well known option.  Many states have Medicaid Waivers that allow participants to receive care at home instead of in a nursing home.  Some of these waivers allow for self-direction of care services.  This means the participant is free to select their care providers.  They can "hire" their adult children, other relatives or a few states, their spouses to provide them with personal care.  Relatives are paid the Medicaid hourly rate for home care.  Medicaid Waivers have enrollment caps, so only a limited number of individuals can participate through this option.

The exclusion of spouses in many states from being paid has lead to an unintended consequence of divorces.  While there are rules prohibiting spouses from being paid, there are no rules that prohibit former spouses. 

2) Medicaid Personal Care Services (PCS)
Approximately 50% of the states allow for personal care services in their Medicaid State Plans.  As with Medicaid Waivers, some of these programs allow for consumer direction of personal care providers enabling participants to hire friends and family members to provide them with personal care. 

These PCS programs differ from Medicaid Waivers in two key ways.  First, typically Medicaid Waivers have less restrictive financial eligibility requirements than PCS programs.  It is not uncommon for the monthly income limit for a Waiver to be approximately $2,130, while Medicaid PCS programs might be closer to $800 - $1,000 / month.  Second, because these programs are offered through the Medicaid State Plans, they are entitlements, unlike Medicaid Waivers which are not. 

3) State Based Non-Medicaid Programs
There are also non-Medicaid consumer directed care programs.  Unfortunately, a much fewer number of states offer these programs.  During our most recent survey, we found 12 states offer consumer direction in their non-Medicaid assistance programs for the elderly. 

4) Veterans Directed Home and Community Based Services
The 4th option is for veterans and their spouses only.  Similar to Medicaid Home and Community Based Services Waivers, there are Veterans Directed Home and Community Based Services.  Under these programs veterans, especially those living in rural areas, are given the flexibility to select what cares services they require and whom shall provide them.  Family members and friends can be hired to provide personal care.

5) Medicaid Life Settlements
Also referred to as Life Care Funding Plans, this is the newest way family members can receive payment for caregiving.  The approach is for holders of life insurance policies who require ongoing care and are considering Medicaid as a long term solution. 

Medicaid counts life insurance policies as assets and generally persons with these policies cannot qualify.  A Medicaid Life Settlement allows the individual to convert their life insurance policy into a dollar amount of care services.  That money is put into an account and used to pay for care for the policyholder.  It can be used for any type of care such as home care, assisted living or to make home modifications that help seniors maintain their independence (walk-in tubs, wheelchair ramps, stairglides etc.). 

It can also be used to pay family members for the care they provide.  For example, a spouse with Alzheimer's may require 24 hour supervision.  They might go to adult day care for 8 hours on weekdays and be looked after by their spouse for the remaining time.  The spouse could be paid the hourly Medicaid rate for the caregiving. 

The account that holds the money is a Medicaid qualified spend down, so when the funds are exhausted the individual is in a very strong position to qualify for Medicaid.

To learn more about each of this option and discover other sources of funding please explore our website. 

Friday, July 26, 2013

Life and Death in Assisted Living

The suggestive title of this new film about the assisted living industry has compelled us to do something we rarely do on this blog; express an opinion.  For those who are not aware, this film or "expose" on assisted living was created by ProPublica and airs on PBS FRONTLINE.  In summary, the film shows assisted living in a dark light.

Our organization has the utmost respect for both ProPublica and FRONTLINE.  However in this case, we feel sensationalism is rearing its less than pretty head.  While of course it is true that not every assisted living community does everything perfectly and one can always find examples of negligence and poor treatment in any service industry.  The vast majority of assisted living communities and their employees are hard working, dedicated individuals.  And yes, many assisted living communities are for-profit institutions, as are many hospitals and media outlets.  Being a for-profit does not necessarily make an organization bad, often times it just makes them more efficient.

For many individuals, assisted living offers a vastly improved quality of life for both the resident and their families.  No it is not perfect, nor is it the perfect solution for every family.  Certainly home care and nursing homes are imperfect solutions as well. 

Perhaps what we object to most is the promotional copy.   To paraphrase "months after checking into an assisted living facility, she was dead".  Really?  Is that surprising when the average age of an assisted living resident is in 80s and the average length of stay is only 22 months.

While what ProPublica has uncovered is important and there are problems within the assisted living industry, does that justify giving the entire industry a bad name?  It is like saying the Olympics are bad because some athletes use performance enhancing drugs.  Or perhaps more relevantly it is like saying documentaries are bad because certain films utilize sensationalistic, Hollywood practices in their promotion.   Why not just call the film "To Live and Die in AL"?

Monday, June 24, 2013

Understanding the differences between Medicare and Medicaid

For a seemingly simple question, this distinction causes an extraordinary amount of confusion.  The most simple answer is that Medicare is a health insurance program for all Americans age 65 and over.  Medicaid is a health insurance program for low income Americans with limited financial resources of any age.  Therefore for persons 65 and older, it is possible to be eligible for both Medicaid and Medicare.  Unlike many government programs, eligibility for these two programs is not mutually exclusive.  It is possible to be eligible for and concurrently receive benefits from both programs.

Other than the eligibility criteria, Medicaid and Medicare also differ in their benefits.  Both programs cover medical care and prescriptions drugs (to an extent), what sets them apart is their coverage of long term care. 

For nursing home care, Medicare will only pay for part of the cost for a period of 100 days.  Medicaid will cover the full cost of nursing home care indefinitely.

For assisted living care, adult foster care or other forms of residential care in which personal care and assistance with the activities of daily living is provided but not full medical care, Medicare does not pay anything.  Medicaid, on the other hand, does cover these forms of care though some explanation of how it does is helpful.  Medicaid offers elderly beneficiaries what are called HCBS or 1915 Waivers.  Waivers allow beneficiaries to receive care services outside of nursing homes.  Waivers are state-specific and some states have waivers specifically to pay for assisted living and others offer only partial payment of assisted living costs.

For non-medical, home care, Medicare again pays nothing.  Medicaid, similar to the way assisted living is covered, will pay for home care through Medicaid Waivers.

Hopefully this provides a quick and easily understandable answer to the question of the difference between Medicare and Medicaid.  We've published several other blog posts which address Medicaid's coverage of assisted living and home care

Thursday, May 2, 2013

Help Paying for Bathroom Safety, Power Wheelchairs and Incontinence Supplies

Our organization attempts to let our website audience drive the site's content.  By analyzing the questions we receive and we can determine our content development priorities.  We have long produced in-depth content about how to pay for home care supplies and durable medical equipment and the resources which are available as financial assistance.  While this information is valuable, we recently recognized that people visiting our website are more task driven.  Instead of wanting to understand the options available for home medical equipment, they want to know specifically if (for example) Medicare will pay for bathroom safety modifications or for a motorized wheelchair. 

To accommodate this task driven approach, we are trying a new approach to content development.  Recently we published three articles which attempt to answer very specific questions about home medical equipment, home modifications for aging in a place and home care supplies.  Available now on the website are our guides to paying for bathroom safety modifications, such as walk-in tubs, paying for motorized and manual wheelchairs and paying for adult diapers and other incontinence supplies

We are hoping this approach will provide families with faster answers to their questions.  However, we continue to press that families should consider the larger picture of how to manage caring for a loved one financially even while addressing problems which require immediate solutions.  Please don't hesitate to provide feedback both on the helpfulness of the articles we've published as well as the need for articles on subjects we have not yet published. 

Sunday, April 28, 2013

Adult Day Care: 5 Things Everyone Should Know

1) Adult day care is, by far, the most affordable form of elder care available.  In 2013, the average cost of adult day care across the US is $65 / day.   In some states, especially in the Southeastern USA, adult day care and adult day health care can be found for as little as $35 / day.   In the Northeast, the cost is slightly higher averaging in the $80 - $90 / day.  Learn about how to pay for adult day care.

2) Many seniors are resistant to the idea of adult day care, but end up liking it.   This is a rather common scenario perhaps due to an outdated idea of what senior care is or a failure to distinguish between nursing homes and day care.  Regardless of the reason, when seniors experience the diverse social activities and camaraderie which exists in adult day care, most end up liking it and looking forward to the days on which they will participate. 

3) Getting to and from adult day care is not that difficult.  Approximately 70% of adult day care centers offer transportation services for program participants.  There are also many volunteer services that offer transportation for the elderly and other programs which receive federal money to provide discounted transportation assistance. 

4) There is more than one kind of adult day care.  There are adult day care centers that provide personal care and there are more sophisticated adult day health care centers which offer nursing home level care.  There are also centers which specialize in helping individuals with Alzheimer's or dementia; referred to as Alzheimer's Day Care Centers.  Find adult day care that meets your loved one's needs.

5) Adult day care centers are licensed and regulated.  Each state has different guidelines but generally speaking, staff members are subject to background checks, there are minimum staff-to-patient ratios as well as minimum staff-on-premise requirements.

The most important thing to know about adult day care is that it can be very flexible.  Most families who bring a loved one to adult day care find that not only can they make it work, but that it works very well for their loved ones, their caregivers and themselves.  Families can try adult day care for a week without making any commitments and they can choose the hours and days which work for them.  

Learn more about paying for adult day care or find a adult day care center near you.

Friday, April 12, 2013

How Prescription Discount Cards Make Money? (and should you be concerned?)

We had a very interesting conversation recently that gave us a behind-the-scenes look at prescription discount cards and how they make money.  We were surprised to learn about the number of players involved and their motivations.  We were equally surprised by how much variation there is in the operational practices of the different cards.

To better understand discount drug cards, it helps to first identify all the players and learn some terminology.  There are five or sometimes six entities involved in each prescription purchase that involves a discount card. These are:

1.    Cardholder - the consumer
2.    Pharmacy - the retail outlet in which the purchase is made
3.    Pharmaceutical Company - the manufacturer of the medication
4.    Adjudicator - the organization that negotiates the discounts with the drug makers
5.    Card Marketer - the organization whose brand is on the card
6.    Card Marketer Affiliate - an organization that assists the Card Marketer in distribution

Each time a card is used there is a transaction fee applied to the purchase price.  That fee is split 3 or 4 ways (though perhaps not evenly) between the Pharmacy, the Adjudicator, the Card Marketer and their Affiliate.  This transaction fee comes at the Cardholder's expense.  However, usually the negotiated discount cost of the medication far exceeds the transaction fee so the Cardholder still wins.  For example, the retail price for a medication is $100.  The prescription discount card has negotiated a 40% discount, so the cost would be $60 but there is a $10 transaction fee.  So the Cardholder pays $70 instead of $100.  Of the $10 transaction fee, the Pharmacy might take $2, the Adjudicator $2 and the Card Marketer $6.  The Card Marketer might pay out $1 to their marketing affiliate. 

What's more is that transaction fees are not the only way the cards make money.  With each purchase there is valuable information gathered that the Card Marketers then sell to other marketing organizations.  Two types of information is gathered and sold.  Although only one of which should be of concern to the Cardholder, which is when their personal information, their name, address and the medications they've purchased is sold.  The other information gathered and sold is anonymous and in aggregate, such as 20% of persons buying a specific medication also purchased over-the-counter Vitamin C.  This information is still valuable to marketers but harmless to consumers.  It is worth noting that not all cards sell their members' personal information.

Finally, some prescription discount cards also charge annual, monthly or enrollment fees.  While these may seem minor, they may add up to as much as $100 / year.  As with selling personal information, not all cards engage in this practice.

Obviously, Card Marketers can generate a significant amount of revenue each time one of their cards is issued and even more when it is used.  This goes a long way to explaining the aggressive distribution tactics employed by those companies that issue prescription drug cards. 

On our website, we've published more detailed information about how consumers can select a drug card that maximizes their saving and protects their personal privacy

Wednesday, March 27, 2013

Medicaid vs. Veterans Pensions? Assisted Living vs. Nursing Home? Are these even the right questions?

We often let the volume of email questions we receive guide our content development priorities.  There are two questions we receive nearly every day and both of similar themes.  The first question is which is the better option financially Medicaid or VA Aid and Attendance?   The second question is which is the better option for a loved one assisted living or a nursing home?

These are difficult questions and there is no single answer for either.  In publishing our recent articles we have attempted to help families with these decisions in two ways.  First by presenting the facts about each option and second by presenting the consideration factors which need to be applied to their specific situation.  For example, for practical purposes Medicaid and the Aid and Attendance pension benefit are mutually exclusive options.  It is a choice, one option or the other.  Persons who could be eligible for both need to decide between them and a major factor that needs to be considered is the type of care they require or desire; assisted living, home care or nursing home care.  Another factor is the immediacy of need. Medicaid's approval process is relatively quick while veterans might wait as long as two years to begin receiving their pensions.  Fortunately, payments are retro-active once the application has been approved.

Our intent is not to reproduce the articles on this blog, so we will keep this post relatively short.  However there is one thing we should add which we don't stress in the articles.  Most people are asking "should I apply for Medicaid or a veteran's pension?"  We feel the question should be "how do I plan so I can be eligible for either?".  The same applies to the assisted living vs. nursing home question.  It is very likely that if one type of care is required, the other type will also be necessary at some point.  One should plan for both.

Friday, March 15, 2013

Waiting for Veteran's Benefits: 11 Things Every Applicant Should Know and Do

The Veterans Administration offers many different types of assistance to help aging and disabled veterans receive the care they require.  Included are programs and benefits such as Aid and Attendance, Disability Compensation, Survivor's Benefits, Housebound and the Improved Pension.  The problem with VA benefits is not the lack of assistance but in the bureaucratic backlog of claims processing.  As anyone who has filed a claim for assistance with the VA knows, the wait time is excruciating. 

By the Department of Veterans Affairs own admission, the average time to process a claim is 241 days.  For those whose require assistance, that is over 8 months worth of home care, assisted living or nursing home bills piling up.  For many veterans the experience is much worse.  Complicated claims, errors made by the VA or by the applicants and the appeals process can add months or even years to the wait.  It is not unheard of or even unusual for applicants to wait two years to begin receiving their full benefits. 

While it is interesting to know what is causing the problem (23 million aging veterans among other things) and what the administration is doing to fix it (quite a bit, actually), it is of little comfort to the veteran waiting for assistance.  The VAs proposed fixes are years away and even with those improvements wait times will still be 6 months.  This is not a problem that is going away any time soon.  So what should veterans know and do to speed up their claims?  How can we make the best of this bad situation?

1) Do it right the first time.  We cannot over-emphasize the importance of properly filling out an application.  Take the time to answer every question thoroughly and accurately. Don't skip questions or leave blanks because you don't understand the question or think it does not apply to you.  Get help when you need it.  The rejection and appeal cycle is not something that is going to benefit anyone.

2) Do your research.  Know the exact benefit type and amount for which you are applying.  Know the eligibility requirements and know why you qualify. Don't ask for benefits for which you think you might be eligible.  Know that you are eligible for certain before applying and have the evidence to prove it.

3) Recognize that the VA prioritizes, officially.  For example, a terminally ill veteran's first-time claim will be prioritized in front of an appeal for a higher benefit rate.  Present your case with the urgency it requires.

4) Recognize that the VA prioritizes, un-officially.  VA claims processors are human.  When presented with an overwhelming number of claims, they are going to choose the less complicated cases first; they are going to choose the thinner file folders.  Don't take the "everything and the kitchen sink" approach to providing evidence to back your claim.  Provide the exact evidence which is needed and nothing more. 

5) Keep copies of everything.  Lost paperwork, unsurprisingly, causes long delays.  Keep paper and digital copies of everything and be ready to fax or email anything which is requested immediately.  Don't waste time blaming the VA for losing paperwork, simply provide them with another copy. 

6) Don't put all your eggs in one basket.  For many veterans, Medicaid is a much faster alternative to receiving assistance.  Applications are usually processed within 45 - 60 days.  Learn more about Medicaid vs. Veterans Pensions or get help determining your Medicaid eligibility.

7) Don't put all your eggs in two baskets.  Many elderly veterans are or could be eligible for other, non-Medicaid  non-military, federal, state and non-profit assistance programs.  Use the Eldercare Resource Locator Tool to find public and private assistance options which are available to you.

8) Know How Long You'll Wait  Death, taxes and a long wait for VA benefits are sure things.  Expect to wait 9 -18 months to begin receiving assistance and plan for it.  The VA does a good job of publishing information on the backlog.  You can view the average wait time for each regional VA claims processing office here

9) Know that financial help is available.  One relatively new and very good option for aging veterans are eldercare loans.  These are loans designed specifically to assist veterans pay for the cost of home care or assisted living while they are waiting for their VA application to be approved.  The lender will even help with the application paperwork.  Learn more about eldercare loans for veterans.

10) Who do you know?  Though officially denied, all evidence points to the fact that knowing someone within the administration can speed up the veterans claims approval process.  Working with a veterans benefits consultant will undoubtedly reduce the time needed to gain approval.  If not because of who they know within the Department of Veterans Affairs, then because they help their clients to present an application that is complete, thorough and without errors, inaccuracies or missing data.  Read more about or find a veterans benefits advisor.

11) Find affordable care.  Veterans who pay for care out of pocket while waiting for a claim approval and reimbursement check should be aware of the vast difference in the cost of home care and assisted living.  Even within the same geographic area, the cost for the same care can vary by 50%, even 100%.  Veterans and their families should use one of the free services to help them find the most affordable care in their area.