Buyer Beware

A colleague recently handed me a flyer she had received and asked if I knew anything about the service. Here are some of the claims made in the flyer:

Important Elder Law Update
Congress has passed legislation that standardizes entitlement provisions for persons 60 and over. These laws provide the following benefits:

Seniors may apply to completely avoid all probate and estate taxes
I don't even know what that means. The way it reads, it implies that there are probate taxes. There are not. If they mean that you can "apply" to avoid probate, they are wrong. You can't "apply" to avoid probate. You can plan to avoid probate.

In 2009, unless your estate is over 3 million dollars, there won't be any estate taxes anyway. Again, there is no "application" to complete to avoid estate taxes. If you have to pay estate taxes, you may be able to minimize the tax liability through proper planning.

Exempt assets from collection by government or nursing home if ill (with no need for nursing home insurance!)
I assume they are talking about paying for nursing home care. The government does not collect assets. Neither will the nursing home.

If you do not have long term care insurance and you need nursing home care, you can either pay privately for your care, or you can apply for Medicaid assistance. If you apply for Medicaid assistance, certain assets, like a homestead up to a certain value or one vehicle of any value are considered "exempt" (This is the rule in Texas. Medicaid rules vary from state to state). If the state pays for your nursing home care, they do have the right to recover expenses from your estate, this is the Medicaid estate recovery program. With proper planning, it may be possible to avoid estate recovery. Even so, the state isn't going to take your assets. They will file a claim against your probate estate, just like any other creditor.

The key is proper planning, done by qualified professionals. Many elder law attorneys are well versed in Medicaid laws, as well as estate tax planning. You would probably not let an electrician work on your plumbing system, so why would you let a someone with no credentials or questionable credentials give you tax planning or Medicaid planning advice?

I would also be cautious getting advice from someone whose main business appears to be selling financial products. Sometimes annuities are a perfectly fine financial product, but if an annuity won't mature until you're 114 years old (I have seen this, really), then it may not be the best product for you.

When I went to the website listed on the flyer, annuities figured prominently, as well as other financial products. There was no information on the "advisors", so there was no way to tell if they were Certified Financial Planners or if they held any other certification or designation.

I just don't think you can be too cautious when it comes to doing research on the folks who are going to help you plan for your retirement. If you need an elder law attorney, you can find one at www.naela.org. If you need a financial planner, you can find one at www.cfp.net. Another resource for a financial planner is the National Association of Personal Financial Planners.

It may be hard spending a little money for the right advice, but in the long run it could save you a bundle.

To Keep or Not to Keep

Writing and keeping up with a blog is hard work. I find more often than not that I'll get an idea, even think about it for a bit, then just never get around to actually writing anything. I've been re-inspired this week, thanks to the daughter of a former client. She and I have had several emails about the blog, and networking, our facebook page, and networking, our website, and networking. But the thing she said that inspired me the most is that she feels the information I provide is easy to understand about practical topics.

Now that I'm inspired to write, what to write about...

...So, I'm going to muse a little bit about the issue of hoarding, because it's on my mind a lot lately, for more than one reason.

I learned a couple of years ago from my childhood best friend (I'll call her Ann) that her mother had become a hoarder. At the same time I also learned from Ann that her mother had been diagnosed with a rare form of cancer, and was not expected to live much longer. As we talked, I learned that Ann's mother, in an effort to control vermin, sprinkled Sevin dust everywhere in her house. Now, Sevin dust is a dangerous pesticide, and according to Ann, it was not possible to go anywhere in the home without coming into contact with Sevin dust, and her mother lived in it. It was no surprise to learn that the type of cancer her mother had has a strong correlation to chemical exposure. While no doctor had suggested the Sevin exposure caused the cancer, Ann, being in health care, firmly believed the exposure caused the cancer.

Around the same time I found out that a former neighbor also had a problem with hoarding. When her son went in and cleared out more than 20 trash bags full of her stuff, she basically disowned him. By her son's report, there wasn't even room on her bed for her to sleep, and her husband had all but left her.

I am currently working with a gentleman with similar issues, and his friends and family are struggling to help him deal with making the decision to move, which means sorting through a lifetime of belongings, and deciding what stays and what goes.

What I know about hoarding is that not enough is known about it. I went to a very informative presentation on hoarding at the American Society on Aging conference in March. The speakers reported that while hoarding has been commonly understood to be related to obsessive compulsive disorder, current research is finding a strong link to depression and dementia. Some researchers now believe that the changes in the brain that come with depression and dementia make it difficult for people to distinguish between "important" stuff and trash, so they just keep it all. Of course this is a major simplification, but it does make sense.

The other thing I learned is that for family to go in and just toss stuff out is often the worst way to deal with the problem, as my neighbor's son found out. Hoarders are often very attached to their stuff, even things that are obviously trash to the rest of us. When all that stuff is gone, the hoarder grieves, and I have heard of instances where psychiatric treatment was required, although that rarely repairs the damage done to the family relationships. We saw a film clip from the movie My Mother's Garden, which is a very poignant documentary about a family's struggle with this problem.

So how do you deal with it? It seems that often the best way to deal with the issue is to use a "good cop/bad cop" type of strategy.

The good cops are family members, friends, mental health professionals and other support systems. The bad cops can be code enforcement, law enforcement or Adult Protective Services (APS). Basically, the bad cops spell out why things need to be cleaned up and what will happen if it doesn't happen. The good cops then provide support, encouragement and assistance to help the hoarder maintain control of the situation while they clean things up. This is certainly a very labor intensive method, as my client's family and support system knows, but it can work.

Medicaid Unplugged

No, I don't know all the answers you might have about Medicaid. I'm just way more tuned into Medicaid now because I'm doing more with Medicaid right now. I'm actually helping clients with their applications (for readers who are these clients, don't fret, I have LOTS of supervision).

Even though I've been listening in on Medicaid consultations for over 2 years, like anything else, you don't really pay attention until you actually need the information. Like now. And Medicaid is really complicated.

I'm also looking at my own family's situation in a new light. I know my Mom is getting really tired of me telling her "If you ever have to apply for Medicaid...", but what I know is that I don't want to have to do her Medicaid application. It will be one of those hard ones, and not just because it's Mom.

I marvel at some of the families I work with when they get the list of all of the documentation that's needed: months worth of bank statements, sometimes from years ago, copies of checks, copies of legal documents, copies of life insurance policies, etc., and then they actually send it to me. I'm not sure I could find all that documentation for myself, much less for my Mom.

Mom announced over the weekend that she had old bank statements that she needed to shred, and I told her "Keep at least 5 year's worth, in case you need to apply for Medicaid". She's keeping 7 year's worth for the IRS; who cares about the IRS?

I guess my point is, Medicaid is such a complicated animal, that if you or a loved one has even an inkling that Medicaid might be needed in the future, it's worth a visit to your friendly, neighborhood Medicaid specialist to learn a little bit about it. I'm thick in the middle of Medicaid every day, and the thought of being on the client side of the table makes my head hurt, and I know about this stuff!

If Katten & Benson is too far away or too difficult to get to, call us anyway, because we can refer you to someone more convenient who we know will do a good job for you.

Happy sorting and filing!

Medication Reminders

Keeping track of medications can be hard, especially when you are on multiple medications, like so many older adults are. I wanted to make a couple of resources that I've learned about recently available.

For a lot of folks, pill minders aren't an option, because there isn't anyone to set the box up each week. I learned about this service, called DailyMedRx. They package all medications, including over the counter medications into pre-sorted into single dose packs. Each pack is then printed with the date and time the medication is to be taken. Now, I have not personally used the service, but it sounds like it could be a really great service for a lot of people.

Another useful site is e-pill Medication Reminders. They carry several different reminders, including ones that talk or vibrate. Again, these are great, but only as long as there is someone who can load them every week.

When choosing a medication reminder it's important to think about who will be using it. Someone told me recently about their client who had one of the really fancy ones, that's all computerized and has all the bells and whistles. This gentleman, who had dementia, had been an engineer, so of course he took the very expensive device apart, to see how it worked, and then he couldn't put it back together! I don't know what they ended up doing, but sometimes simpler is better.

There are also services that can provide monitoring, usually tied in with an emergency response system. One thing to remember with these is that you might know that the device opened at the proper time, and that the person even took the medications out, but you have no way of knowing that they actually took them.

These devices can be helpful for people in early stages of dementia, but as the dementia progresses they can often forget the purpose of the device. It's important to monitor how the person is understanding and using the reminder. I've actually seen a person take the pills out, say that they need to be taken, then put them on the table and forget about them.

Some of these products can be very helpful and can keep a person independent longer, just don't ever expect a device like these to be a substitute for real, live person.

Medically Complex Patients

There was a great article today in the New York Times, http://tinyurl.com/cttxvp. The article talks about some of the issues involved in treating patients with multiple medical conditions, many of whom are age 65 or older.

One of the basic issues, which I had not really thought of before, is that almost no research has been done on medications. Lots of research is done on, say, diabetes medications, when diabetes is the only medical condition being treated. There is little to know research on diabetes medications when they are taken along with medications for heart disease, Alzheimer's disease, blood pressure, and high cholesterol.

What we know is that the more medications a patient takes, the greater the possibility of serious side effects, and the higher the risk of serious drug interactions. The way our health delivery system is fragmented, there are many patients who have a cardiologist prescribing one set of drugs, an internist prescribing other drugs, and then maybe an endocrinologist or a gastroenterologist also prescribing drugs. This often means that no one doctor is looking at the patient as a whole. This is further complicated by the fact that so few doctors are trained in geriatric issues.

The article suggests that at this point, patients are pretty much on their own, and must take responsibility themselves to stay informed about their medications and be proactive when talking to their doctors.

Little Known Facts About Medical Scans

There was an interesting article in the New York Times http://tinyurl.com/bpl8fz today about medical scans. It seems that radiology centers are not required to be accredited, so there are no standards governing the quality of the scans being done.

According to the article, there is a great deal of discrepancy between good scans and bad scans, but insurers, including Medicare, pay the same price regardless of quality. In an example from the article, a woman had an MRI of her knee that was so bad the radiologist could not read it, but she went ahead and had surgery. The surgeon found no damage, and she still has knee pain. Her insurance company paid for the initial scan, but would not pay for a follow-up scan, and they paid for the unnecessary surgery.

Imaging centers can choose to be accredited by the American College of Radiology, which does requires that technicians be certified and provides standards for physicians. A new Medicare law was passed recently that will only allow Medicare to pay for scans at accredited centers, but this law does not go into effect until 2012.

Until there is more regulation, there is little for a health care consumer to do. The article does suggest however that consumers ask why the scan is needed, ask about the center's accreditation, ask about the technician's credentials, and ask how old the scanner is. Scanners more than 10 years old are much more likely to produce poor quality scans, because the technology has improved so much in the past 10 years.

Oops, Lost Again

I had to go see a client in the hospital earlier this week, and even for me it was a somewhat daunting experience. The hospital is in Dallas, and it's large. Now on this particular trip I did go right to the hospital, thanks to my GPS. In the past I can see it; it's really big, then I can't see it, turn down a one way street; oh, there it is, but it's behind me, I have to turn around....now, finally there! So, anyway, I got there without incident this week.

It's a large complex, with multiple buildings, but I did at least know which building I was going to. I actually found a parking lot, with empty spaces, right across the street. The signs to the parking lot were OK, not great. My big issue was with the signs at street level. Why do they put the names of buildings 40 feet up on the top or side of the building? OK, I know it's so you can see it from the car, but what about when you are on the sidewalk? While I knew I was right across the street from the correct building, the only entrance that looked promising had a big sign that said "Physician Referral Service Only/No Hospital Entrance", so I kept walking. The next building was definitely not the building I needed (signage 40 feet up, but readable), so I backtracked, and went in the Physician Referral door to ask how to get to the hospital. Well, guess what? In the foyer of the Physician Referral office was an elevator to...you guessed it...the Hospital!

I found my client fairly easily from there, although once I got to the unit, which seemed circular in design, there were no signs at the entrance to tell which way the numbering went, so I pretty much made the circle looking for the room.

On the way in, I had observed that there was a skywalk from the hospital to the building across the street, which was adjacent to the parking lot where I had parked. In the elevator the floor with the skywalk was labeled, so I decided to go that way. Big mistake. I got off on the right floor, saw a sign with an arrow to the skywalk--but then never saw another sign and never found the skywalk. I could see it....Anyway, I walked from one area that was clearly patient rooms, then into an area that looked like it should be off limits to the likes of me. All gray walls and office doors and people in lab coats, but no one stopped me, and then ahead I saw more patient rooms, so I just kept going. I finally found some more elevators, got to the ground floor and out of the building, and saw I was on the other side of the building. So I had to go back in, go through the lobby, then finally out the way I came in.

As I was doing all this traipsing around, I kept thinking about my client's 80-something year old husband, who takes himself there every day to be with his wife. I'm sure he parks in the same place every day and follows the route that he knows will get him to his wife. But what if that parking lot is full? What if that particular elevator is out of service? What if they move her? I'm pretty comfortable wandering around hospitals, and I can read small, ambiguous signs and usally figure them out, but not every 65 year old, or 85 year old can. I only had one hospital employee ask me if I needed help, even though I passed dozens.

It's not just the emergency room that needs to be redesigned to accommodate older adults. Hospitals are often huge complexes, with remote parking lots, and as our population continues to age, they are going to have to be more proactive in serving this older population. I didn't see much being done about it when I worked in hospitals, and I don't see much evidence of it now when I go to hospitals.

In a few weeks I'm going with some friends and colleagues to Las Vegas, where we are doing a presentation at the American Society on Aging conference. We are going to teach people how to teach age sensitivity to others. This is just a first step. I hope some of you will consider joining me on this trip toward better accessibility for everyone.